White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SPLENECTOMY

Facility

$8,884.69

Service Code	APR-DRG 6502
Min. Negotiated Rate	$8,376.79
Max. Negotiated Rate	$8,884.69
Rate for Payer: Amerigroup CHIP/Medicaid	$8,376.79
Rate for Payer: Cigna Medicaid	$8,376.79
Rate for Payer: Molina CHIP/Medicaid	$8,376.79
Rate for Payer: Parkland Medicaid	$8,376.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,884.69

SPLENECTOMY

Facility

$6,224.00

Service Code	APR-DRG 6501
Min. Negotiated Rate	$5,868.20
Max. Negotiated Rate	$6,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,868.20
Rate for Payer: Cigna Medicaid	$5,868.20
Rate for Payer: Molina CHIP/Medicaid	$5,868.20
Rate for Payer: Parkland Medicaid	$5,868.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,224.00

SPLENECTOMY W CC

Facility

$50,511.50

Service Code	MSDRG 800
Min. Negotiated Rate	$22,590.48
Max. Negotiated Rate	$50,511.50
Rate for Payer: BCBS of TX Blue Advantage	$22,590.48
Rate for Payer: BCBS of TX Blue Essentials	$27,105.95
Rate for Payer: BCBS of TX PPO	$30,118.89

SPLENECTOMY WITH CC

Facility

$50,511.50

Service Code	MSDRG 800
Min. Negotiated Rate	$22,590.48
Max. Negotiated Rate	$50,511.50
Rate for Payer: Multiplan Auto	$50,511.50
Rate for Payer: Multiplan Commercial	$50,511.50
Rate for Payer: Multiplan Workers Comp	$50,511.50
Rate for Payer: Scott and White EPO/PPO	$23,261.88

SPLENECTOMY WITH MCC

Facility

$98,946.30

Service Code	MSDRG 799
Min. Negotiated Rate	$37,952.50
Max. Negotiated Rate	$98,946.30
Rate for Payer: Multiplan Auto	$98,946.30
Rate for Payer: Multiplan Commercial	$98,946.30
Rate for Payer: Multiplan Workers Comp	$98,946.30
Rate for Payer: Scott and White EPO/PPO	$45,567.38

SPLENECTOMY WITHOUT CC/MCC

Facility

$34,124.00

Service Code	MSDRG 801
Min. Negotiated Rate	$13,384.18
Max. Negotiated Rate	$34,124.00
Rate for Payer: Multiplan Auto	$34,124.00
Rate for Payer: Multiplan Commercial	$34,124.00
Rate for Payer: Multiplan Workers Comp	$34,124.00
Rate for Payer: Scott and White EPO/PPO	$15,715.00

SPLENECTOMY W MCC

Facility

$98,946.30

Service Code	MSDRG 799
Min. Negotiated Rate	$37,952.50
Max. Negotiated Rate	$98,946.30
Rate for Payer: BCBS of TX Blue Advantage	$40,433.76
Rate for Payer: BCBS of TX Blue Essentials	$48,515.81
Rate for Payer: BCBS of TX PPO	$53,908.55

SPLENECTOMY W/O CC/MCC

Facility

$34,124.00

Service Code	MSDRG 801
Min. Negotiated Rate	$13,384.18
Max. Negotiated Rate	$34,124.00
Rate for Payer: BCBS of TX Blue Advantage	$13,384.18
Rate for Payer: BCBS of TX Blue Essentials	$16,059.46
Rate for Payer: BCBS of TX PPO	$17,844.54

SPLENIC PROCEDURES WITH CC

Facility

$50,511.50

Service Code	MSDRG 800
Min. Negotiated Rate	$22,590.48
Max. Negotiated Rate	$50,511.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25,350.23
Rate for Payer: Amerigroup Medicare	$25,350.23
Rate for Payer: BCBS of TX Medicare	$25,350.23
Rate for Payer: Cigna Commercial	$36,185.07
Rate for Payer: Cigna Medicare	$25,350.23
Rate for Payer: Employer Direct Commercial	$25,350.23
Rate for Payer: Humana Medicare/TRICARE	$25,350.23
Rate for Payer: Molina Dual Medicare/Medicaid	$25,350.23
Rate for Payer: Molina Medicare	$25,350.23
Rate for Payer: Scott and White Medicare	$25,350.23
Rate for Payer: Superior Health Plan EPO	$25,350.23
Rate for Payer: Superior Health Plan Medicare	$25,350.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$25,350.23
Rate for Payer: Universal American Medicare	$25,350.23
Rate for Payer: Wellcare Medicare	$25,350.23
Rate for Payer: Wellmed Medicare	$25,350.23

SPLENIC PROCEDURES WITH MCC

Facility

$98,946.30

Service Code	MSDRG 799
Min. Negotiated Rate	$37,952.50
Max. Negotiated Rate	$98,946.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37,952.50
Rate for Payer: Amerigroup Medicare	$37,952.50
Rate for Payer: BCBS of TX Medicare	$37,952.50
Rate for Payer: Cigna Commercial	$58,332.23
Rate for Payer: Cigna Medicare	$37,952.50
Rate for Payer: Employer Direct Commercial	$37,952.50
Rate for Payer: Humana Medicare/TRICARE	$37,952.50
Rate for Payer: Molina Dual Medicare/Medicaid	$37,952.50
Rate for Payer: Molina Medicare	$37,952.50
Rate for Payer: Scott and White Medicare	$37,952.50
Rate for Payer: Superior Health Plan EPO	$37,952.50
Rate for Payer: Superior Health Plan Medicare	$37,952.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$37,952.50
Rate for Payer: Universal American Medicare	$37,952.50
Rate for Payer: Wellcare Medicare	$37,952.50
Rate for Payer: Wellmed Medicare	$37,952.50

SPLENIC PROCEDURES WITHOUT CC/MCC

Facility

$34,124.00

Service Code	MSDRG 801
Min. Negotiated Rate	$13,384.18
Max. Negotiated Rate	$34,124.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,750.46
Rate for Payer: Amerigroup Medicare	$18,750.46
Rate for Payer: BCBS of TX Medicare	$18,750.46
Rate for Payer: Cigna Commercial	$24,586.63
Rate for Payer: Cigna Medicare	$18,750.46
Rate for Payer: Employer Direct Commercial	$18,750.46
Rate for Payer: Humana Medicare/TRICARE	$18,750.46
Rate for Payer: Molina Dual Medicare/Medicaid	$18,750.46
Rate for Payer: Molina Medicare	$18,750.46
Rate for Payer: Scott and White Medicare	$18,750.46
Rate for Payer: Superior Health Plan EPO	$18,750.46
Rate for Payer: Superior Health Plan Medicare	$18,750.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,750.46
Rate for Payer: Universal American Medicare	$18,750.46
Rate for Payer: Wellcare Medicare	$18,750.46
Rate for Payer: Wellmed Medicare	$18,750.46

SPLINT, 12 3-PANEL KNEE

Facility

$53.98

Hospital Charge Code	993366
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.71

SPLINT, 12 3-PANEL KNEE

Facility

$53.98

Hospital Charge Code	993366
Hospital Revenue Code	270
Min. Negotiated Rate	$4.86
Max. Negotiated Rate	$38.87
Rate for Payer: Amerigroup CHIP/Medicaid	$4.86
Rate for Payer: BCBS of TX Blue Advantage	$16.19
Rate for Payer: BCBS of TX Blue Essentials	$19.43
Rate for Payer: BCBS of TX PPO	$21.59
Rate for Payer: Cash Price	$36.71
Rate for Payer: Cigna Medicaid	$38.87
Rate for Payer: Molina CHIP/Medicaid	$38.87
Rate for Payer: Multiplan Auto	$35.09
Rate for Payer: Multiplan Commercial	$35.09
Rate for Payer: Multiplan Workers Comp	$35.09
Rate for Payer: Parkland Medicaid	$38.87
Rate for Payer: Scott and White EPO/PPO	$26.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.87
Rate for Payer: Superior Health Plan EPO	$7.34

SPLINT, KNEE, BASIC, 20', UNIVERSAL

Facility

$63.15

Hospital Charge Code	993917
Hospital Revenue Code	274
Min. Negotiated Rate	$15.79
Max. Negotiated Rate	$31.57
Rate for Payer: Cash Price	$42.94
Rate for Payer: Cigna Commercial	$15.79
Rate for Payer: Multiplan Auto	$31.57
Rate for Payer: Multiplan Commercial	$31.57
Rate for Payer: Multiplan Workers Comp	$31.57
Rate for Payer: Scott and White EPO/PPO	$31.57

SPLINT, KNEE, BASIC, 20', UNIVERSAL

Facility

$63.15

Hospital Charge Code	993917
Hospital Revenue Code	274
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$45.47
Rate for Payer: Amerigroup CHIP/Medicaid	$5.68
Rate for Payer: BCBS of TX Blue Advantage	$18.95
Rate for Payer: BCBS of TX Blue Essentials	$22.73
Rate for Payer: BCBS of TX PPO	$25.26
Rate for Payer: Cash Price	$42.94
Rate for Payer: Cigna Medicaid	$45.47
Rate for Payer: Molina CHIP/Medicaid	$45.47
Rate for Payer: Multiplan Auto	$31.57
Rate for Payer: Multiplan Commercial	$31.57
Rate for Payer: Multiplan Workers Comp	$31.57
Rate for Payer: Parkland Medicaid	$45.47
Rate for Payer: Scott and White EPO/PPO	$31.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45.47
Rate for Payer: Superior Health Plan EPO	$8.59

SPLINT, PLASTERS, 5' X 30'

Facility

$1.78

Hospital Charge Code	993981
Hospital Revenue Code	271
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$1.28
Rate for Payer: Amerigroup CHIP/Medicaid	$0.16
Rate for Payer: BCBS of TX Blue Advantage	$0.53
Rate for Payer: BCBS of TX Blue Essentials	$0.64
Rate for Payer: BCBS of TX PPO	$0.71
Rate for Payer: Cash Price	$1.21
Rate for Payer: Cigna Medicaid	$1.28
Rate for Payer: Molina CHIP/Medicaid	$1.28
Rate for Payer: Multiplan Auto	$1.16
Rate for Payer: Multiplan Commercial	$1.16
Rate for Payer: Multiplan Workers Comp	$1.16
Rate for Payer: Parkland Medicaid	$1.28
Rate for Payer: Scott and White EPO/PPO	$0.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.28
Rate for Payer: Superior Health Plan EPO	$0.24

SPLINT, PLASTERS, 5' X 30'

Facility

$1.78

Hospital Charge Code	993981
Hospital Revenue Code	271
Rate for Payer: Cash Price	$1.21

SPLIT GRAFT FACE, NECK, FEET

Facility

$12,523.00

Service Code	HCPCS 15120
Hospital Charge Code	9900123
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,515.64

SPLIT GRAFT FACE, NECK, FEET

Facility

$12,523.00

Service Code	HCPCS 15120
Hospital Charge Code	9900123
Hospital Revenue Code	360
Min. Negotiated Rate	$1,457.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$8,515.64
Rate for Payer: Cash Price	$8,515.64
Rate for Payer: Cash Price	$8,515.64
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicaid	$9,016.56
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina CHIP/Medicaid	$9,016.56
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$9,016.56
Rate for Payer: Scott and White EPO/PPO	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,016.56
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

SPLIT GRAFT FACE, NECK, FEET

Facility

$10,000.00

Service Code	CPT 15120
Hospital Charge Code	36015120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,457.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm

Facility

$7,316.92

Service Code	HCPCS 15101
Hospital Charge Code	994166
Hospital Revenue Code	361
Min. Negotiated Rate	$658.52
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$658.52
Rate for Payer: BCBS of TX Blue Advantage	$2,195.08
Rate for Payer: BCBS of TX Blue Essentials	$2,634.09
Rate for Payer: BCBS of TX PPO	$2,926.77
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,658.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$995.10

Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm

Facility

$7,316.92

Service Code	HCPCS 15101
Hospital Charge Code	994166
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)

Facility

$7,316.92

Service Code	HCPCS 15100
Hospital Charge Code	991328
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,975.51

Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)

Facility

$7,316.92

Service Code	HCPCS 15100
Hospital Charge Code	991328
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

SPLNT IMOBL SHLD -- DHF

Facility

$284.49

Hospital Charge Code	81145757
Hospital Revenue Code	270
Rate for Payer: Cash Price	$193.45

Know your out-of-pocket cost for care.

All Charges