White Rock Medical Center

All Charges

Charge

Type

Setting

Price

US Upper Ext Venous Duplex Left

Facility

$1,906.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	994147
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,296.08

US Upper Ext Venous Duplex Left

Facility

$1,906.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	994147
Hospital Revenue Code	921
Min. Negotiated Rate	$171.54
Max. Negotiated Rate	$1,372.32
Rate for Payer: Amerigroup CHIP/Medicaid	$171.54
Rate for Payer: BCBS of TX Blue Advantage	$571.80
Rate for Payer: BCBS of TX Blue Essentials	$686.16
Rate for Payer: BCBS of TX PPO	$762.40
Rate for Payer: Cash Price	$1,296.08
Rate for Payer: Cash Price	$1,296.08
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,372.32
Rate for Payer: Molina CHIP/Medicaid	$1,372.32
Rate for Payer: Multiplan Auto	$1,238.90
Rate for Payer: Multiplan Commercial	$1,238.90
Rate for Payer: Multiplan Workers Comp	$1,238.90
Rate for Payer: Parkland Medicaid	$1,372.32
Rate for Payer: Scott and White EPO/PPO	$953.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,372.32
Rate for Payer: Superior Health Plan EPO	$259.22

US Upper Ext Venous Duplex Right

Facility

$1,906.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	994148
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,296.08

US Upper Ext Venous Duplex Right

Facility

$1,906.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	994148
Hospital Revenue Code	921
Min. Negotiated Rate	$171.54
Max. Negotiated Rate	$1,372.32
Rate for Payer: Amerigroup CHIP/Medicaid	$171.54
Rate for Payer: BCBS of TX Blue Advantage	$571.80
Rate for Payer: BCBS of TX Blue Essentials	$686.16
Rate for Payer: BCBS of TX PPO	$762.40
Rate for Payer: Cash Price	$1,296.08
Rate for Payer: Cash Price	$1,296.08
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,372.32
Rate for Payer: Molina CHIP/Medicaid	$1,372.32
Rate for Payer: Multiplan Auto	$1,238.90
Rate for Payer: Multiplan Commercial	$1,238.90
Rate for Payer: Multiplan Workers Comp	$1,238.90
Rate for Payer: Parkland Medicaid	$1,372.32
Rate for Payer: Scott and White EPO/PPO	$953.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,372.32
Rate for Payer: Superior Health Plan EPO	$259.22

UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC

Facility

$34,861.20

Service Code	MSDRG 742
Min. Negotiated Rate	$14,740.40
Max. Negotiated Rate	$34,861.20
Rate for Payer: BCBS of TX Blue Advantage	$14,740.40
Rate for Payer: BCBS of TX Blue Essentials	$17,686.77
Rate for Payer: BCBS of TX PPO	$19,652.72

UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC

Facility

$23,573.30

Service Code	MSDRG 743
Min. Negotiated Rate	$9,594.16
Max. Negotiated Rate	$23,573.30
Rate for Payer: BCBS of TX Blue Advantage	$9,594.16
Rate for Payer: BCBS of TX Blue Essentials	$11,511.88
Rate for Payer: BCBS of TX PPO	$12,791.47

UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC

Facility

$34,382.40

Service Code	MSDRG 740
Min. Negotiated Rate	$14,988.94
Max. Negotiated Rate	$34,382.40
Rate for Payer: BCBS of TX Blue Advantage	$14,988.94
Rate for Payer: BCBS of TX Blue Essentials	$17,984.99
Rate for Payer: BCBS of TX PPO	$19,984.09

UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC

Facility

$66,999.70

Service Code	MSDRG 739
Min. Negotiated Rate	$30,855.12
Max. Negotiated Rate	$66,999.70
Rate for Payer: BCBS of TX Blue Advantage	$30,940.22
Rate for Payer: BCBS of TX Blue Essentials	$37,124.67
Rate for Payer: BCBS of TX PPO	$41,251.23

UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC/MCC

Facility

$27,095.90

Service Code	MSDRG 741
Min. Negotiated Rate	$11,419.08
Max. Negotiated Rate	$27,095.90
Rate for Payer: BCBS of TX Blue Advantage	$11,419.08
Rate for Payer: BCBS of TX Blue Essentials	$13,701.57
Rate for Payer: BCBS of TX PPO	$15,224.55

UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W CC

Facility

$39,151.40

Service Code	MSDRG 737
Min. Negotiated Rate	$17,470.04
Max. Negotiated Rate	$39,151.40
Rate for Payer: BCBS of TX Blue Advantage	$17,470.04
Rate for Payer: BCBS of TX Blue Essentials	$20,962.02
Rate for Payer: BCBS of TX PPO	$23,292.03

UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W MCC

Facility

$67,915.50

Service Code	MSDRG 736
Min. Negotiated Rate	$30,957.69
Max. Negotiated Rate	$67,915.50
Rate for Payer: BCBS of TX Blue Advantage	$34,663.16
Rate for Payer: BCBS of TX Blue Essentials	$41,591.76
Rate for Payer: BCBS of TX PPO	$46,214.86

UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC

Facility

$27,901.50

Service Code	MSDRG 738
Min. Negotiated Rate	$11,973.78
Max. Negotiated Rate	$27,901.50
Rate for Payer: BCBS of TX Blue Advantage	$11,973.78
Rate for Payer: BCBS of TX Blue Essentials	$14,367.14
Rate for Payer: BCBS of TX PPO	$15,964.11

UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA

Facility

$4,879.69

Service Code	APR-DRG 5192
Min. Negotiated Rate	$4,600.75
Max. Negotiated Rate	$4,879.69
Rate for Payer: Amerigroup CHIP/Medicaid	$4,600.75
Rate for Payer: Cigna Medicaid	$4,600.75
Rate for Payer: Molina CHIP/Medicaid	$4,600.75
Rate for Payer: Parkland Medicaid	$4,600.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,879.69

UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA

Facility

$3,979.72

Service Code	APR-DRG 5191
Min. Negotiated Rate	$3,752.22
Max. Negotiated Rate	$3,979.72
Rate for Payer: Amerigroup CHIP/Medicaid	$3,752.22
Rate for Payer: Cigna Medicaid	$3,752.22
Rate for Payer: Molina CHIP/Medicaid	$3,752.22
Rate for Payer: Parkland Medicaid	$3,752.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,979.72

UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA

Facility

$18,833.42

Service Code	APR-DRG 5194
Min. Negotiated Rate	$17,756.81
Max. Negotiated Rate	$18,833.42
Rate for Payer: Amerigroup CHIP/Medicaid	$17,756.81
Rate for Payer: Cigna Medicaid	$17,756.81
Rate for Payer: Molina CHIP/Medicaid	$17,756.81
Rate for Payer: Parkland Medicaid	$17,756.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,833.42

UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA

Facility

$8,384.91

Service Code	APR-DRG 5193
Min. Negotiated Rate	$7,905.59
Max. Negotiated Rate	$8,384.91
Rate for Payer: Amerigroup CHIP/Medicaid	$7,905.59
Rate for Payer: Cigna Medicaid	$7,905.59
Rate for Payer: Molina CHIP/Medicaid	$7,905.59
Rate for Payer: Parkland Medicaid	$7,905.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,384.91

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA

Facility

$4,040.45

Service Code	APR-DRG 5131
Min. Negotiated Rate	$3,809.48
Max. Negotiated Rate	$4,040.45
Rate for Payer: Amerigroup CHIP/Medicaid	$3,809.48
Rate for Payer: Cigna Medicaid	$3,809.48
Rate for Payer: Molina CHIP/Medicaid	$3,809.48
Rate for Payer: Parkland Medicaid	$3,809.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,040.45

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA

Facility

$4,727.31

Service Code	APR-DRG 5132
Min. Negotiated Rate	$4,457.07
Max. Negotiated Rate	$4,727.31
Rate for Payer: Amerigroup CHIP/Medicaid	$4,457.07
Rate for Payer: Cigna Medicaid	$4,457.07
Rate for Payer: Molina CHIP/Medicaid	$4,457.07
Rate for Payer: Parkland Medicaid	$4,457.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,727.31

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA

Facility

$8,693.07

Service Code	APR-DRG 5133
Min. Negotiated Rate	$8,196.14
Max. Negotiated Rate	$8,693.07
Rate for Payer: Amerigroup CHIP/Medicaid	$8,196.14
Rate for Payer: Cigna Medicaid	$8,196.14
Rate for Payer: Molina CHIP/Medicaid	$8,196.14
Rate for Payer: Parkland Medicaid	$8,196.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,693.07

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA

Facility

$27,200.98

Service Code	APR-DRG 5134
Min. Negotiated Rate	$25,646.04
Max. Negotiated Rate	$27,200.98
Rate for Payer: Amerigroup CHIP/Medicaid	$25,646.04
Rate for Payer: Cigna Medicaid	$25,646.04
Rate for Payer: Molina CHIP/Medicaid	$25,646.04
Rate for Payer: Parkland Medicaid	$25,646.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,200.98

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC

Facility

$34,861.20

Service Code	MSDRG 742
Min. Negotiated Rate	$14,740.40
Max. Negotiated Rate	$34,861.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,207.37
Rate for Payer: Amerigroup Medicare	$18,207.37
Rate for Payer: BCBS of TX Medicare	$18,207.37
Rate for Payer: Cigna Commercial	$23,632.22
Rate for Payer: Cigna Medicare	$18,207.37
Rate for Payer: Employer Direct Commercial	$18,207.37
Rate for Payer: Humana Medicare/TRICARE	$18,207.37
Rate for Payer: Molina Dual Medicare/Medicaid	$18,207.37
Rate for Payer: Molina Medicare	$18,207.37
Rate for Payer: Multiplan Auto	$34,861.20
Rate for Payer: Multiplan Commercial	$34,861.20
Rate for Payer: Multiplan Workers Comp	$34,861.20
Rate for Payer: Scott and White EPO/PPO	$16,054.50
Rate for Payer: Scott and White Medicare	$18,207.37
Rate for Payer: Superior Health Plan EPO	$18,207.37
Rate for Payer: Superior Health Plan Medicare	$18,207.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,207.37
Rate for Payer: Universal American Medicare	$18,207.37
Rate for Payer: Wellcare Medicare	$18,207.37
Rate for Payer: Wellmed Medicare	$18,207.37

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC

Facility

$23,573.30

Service Code	MSDRG 743
Min. Negotiated Rate	$9,594.16
Max. Negotiated Rate	$23,573.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,853.21
Rate for Payer: Amerigroup Medicare	$13,853.21
Rate for Payer: BCBS of TX Medicare	$13,853.21
Rate for Payer: Cigna Commercial	$15,980.22
Rate for Payer: Cigna Medicare	$13,853.21
Rate for Payer: Employer Direct Commercial	$13,853.21
Rate for Payer: Humana Medicare/TRICARE	$13,853.21
Rate for Payer: Molina Dual Medicare/Medicaid	$13,853.21
Rate for Payer: Molina Medicare	$13,853.21
Rate for Payer: Multiplan Auto	$23,573.30
Rate for Payer: Multiplan Commercial	$23,573.30
Rate for Payer: Multiplan Workers Comp	$23,573.30
Rate for Payer: Scott and White EPO/PPO	$10,856.12
Rate for Payer: Scott and White Medicare	$13,853.21
Rate for Payer: Superior Health Plan EPO	$13,853.21
Rate for Payer: Superior Health Plan Medicare	$13,853.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,853.21
Rate for Payer: Universal American Medicare	$13,853.21
Rate for Payer: Wellcare Medicare	$13,853.21
Rate for Payer: Wellmed Medicare	$13,853.21

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY

Facility

$22,393.33

Service Code	APR-DRG 5124
Min. Negotiated Rate	$21,113.22
Max. Negotiated Rate	$22,393.33
Rate for Payer: Amerigroup CHIP/Medicaid	$21,113.22
Rate for Payer: Cigna Medicaid	$21,113.22
Rate for Payer: Molina CHIP/Medicaid	$21,113.22
Rate for Payer: Parkland Medicaid	$21,113.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,393.33

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY

Facility

$7,206.20

Service Code	APR-DRG 5122
Min. Negotiated Rate	$6,794.25
Max. Negotiated Rate	$7,206.20
Rate for Payer: Amerigroup CHIP/Medicaid	$6,794.25
Rate for Payer: Cigna Medicaid	$6,794.25
Rate for Payer: Molina CHIP/Medicaid	$6,794.25
Rate for Payer: Parkland Medicaid	$6,794.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,206.20

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY

Facility

$6,429.94

Service Code	APR-DRG 5121
Min. Negotiated Rate	$6,062.37
Max. Negotiated Rate	$6,429.94
Rate for Payer: Amerigroup CHIP/Medicaid	$6,062.37
Rate for Payer: Cigna Medicaid	$6,062.37
Rate for Payer: Molina CHIP/Medicaid	$6,062.37
Rate for Payer: Parkland Medicaid	$6,062.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,429.94

Know your out-of-pocket cost for care.

All Charges