White Rock Medical Center

All Charges

Charge

Type

Setting

Price

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY

Facility

$12,501.18

Service Code	APR-DRG 5113
Min. Negotiated Rate	$11,786.55
Max. Negotiated Rate	$12,501.18
Rate for Payer: Amerigroup CHIP/Medicaid	$11,786.55
Rate for Payer: Cigna Medicaid	$11,786.55
Rate for Payer: Molina CHIP/Medicaid	$11,786.55
Rate for Payer: Parkland Medicaid	$11,786.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,501.18

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY

Facility

$5,478.29

Service Code	APR-DRG 5111
Min. Negotiated Rate	$5,165.13
Max. Negotiated Rate	$5,478.29
Rate for Payer: Amerigroup CHIP/Medicaid	$5,165.13
Rate for Payer: Cigna Medicaid	$5,165.13
Rate for Payer: Molina CHIP/Medicaid	$5,165.13
Rate for Payer: Parkland Medicaid	$5,165.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,478.29

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY

Facility

$6,730.94

Service Code	APR-DRG 5112
Min. Negotiated Rate	$6,346.16
Max. Negotiated Rate	$6,730.94
Rate for Payer: Amerigroup CHIP/Medicaid	$6,346.16
Rate for Payer: Cigna Medicaid	$6,346.16
Rate for Payer: Molina CHIP/Medicaid	$6,346.16
Rate for Payer: Parkland Medicaid	$6,346.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,730.94

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY

Facility

$25,832.92

Service Code	APR-DRG 5114
Min. Negotiated Rate	$24,356.18
Max. Negotiated Rate	$25,832.92
Rate for Payer: Amerigroup CHIP/Medicaid	$24,356.18
Rate for Payer: Cigna Medicaid	$24,356.18
Rate for Payer: Molina CHIP/Medicaid	$24,356.18
Rate for Payer: Parkland Medicaid	$24,356.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,832.92

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC

Facility

$38,446.50

Service Code	MSDRG 737
Min. Negotiated Rate	$17,470.04
Max. Negotiated Rate	$38,446.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,862.27
Rate for Payer: Amerigroup Medicare	$19,862.27
Rate for Payer: BCBS of TX Medicare	$19,862.27
Rate for Payer: Cigna Commercial	$26,540.53
Rate for Payer: Cigna Medicare	$19,862.27
Rate for Payer: Employer Direct Commercial	$19,862.27
Rate for Payer: Humana Medicare/TRICARE	$19,862.27
Rate for Payer: Molina Dual Medicare/Medicaid	$19,862.27
Rate for Payer: Molina Medicare	$19,862.27
Rate for Payer: Multiplan Auto	$38,446.50
Rate for Payer: Multiplan Commercial	$38,446.50
Rate for Payer: Multiplan Workers Comp	$38,446.50
Rate for Payer: Scott and White EPO/PPO	$17,705.62
Rate for Payer: Scott and White Medicare	$19,862.27
Rate for Payer: Superior Health Plan EPO	$19,862.27
Rate for Payer: Superior Health Plan Medicare	$19,862.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,862.27
Rate for Payer: Universal American Medicare	$19,862.27
Rate for Payer: Wellcare Medicare	$19,862.27
Rate for Payer: Wellmed Medicare	$19,862.27

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC

Facility

$81,038.80

Service Code	MSDRG 736
Min. Negotiated Rate	$30,957.69
Max. Negotiated Rate	$81,038.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$30,957.69
Rate for Payer: Amerigroup Medicare	$30,957.69
Rate for Payer: BCBS of TX Medicare	$30,957.69
Rate for Payer: Cigna Commercial	$46,039.56
Rate for Payer: Cigna Medicare	$30,957.69
Rate for Payer: Employer Direct Commercial	$30,957.69
Rate for Payer: Humana Medicare/TRICARE	$30,957.69
Rate for Payer: Molina Dual Medicare/Medicaid	$30,957.69
Rate for Payer: Molina Medicare	$30,957.69
Rate for Payer: Multiplan Auto	$81,038.80
Rate for Payer: Multiplan Commercial	$81,038.80
Rate for Payer: Multiplan Workers Comp	$81,038.80
Rate for Payer: Scott and White EPO/PPO	$37,320.50
Rate for Payer: Scott and White Medicare	$30,957.69
Rate for Payer: Superior Health Plan EPO	$30,957.69
Rate for Payer: Superior Health Plan Medicare	$30,957.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$30,957.69
Rate for Payer: Universal American Medicare	$30,957.69
Rate for Payer: Wellcare Medicare	$30,957.69
Rate for Payer: Wellmed Medicare	$30,957.69

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$26,672.20

Service Code	MSDRG 738
Min. Negotiated Rate	$11,973.78
Max. Negotiated Rate	$26,672.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,522.77
Rate for Payer: Amerigroup Medicare	$15,522.77
Rate for Payer: BCBS of TX Medicare	$15,522.77
Rate for Payer: Cigna Commercial	$18,914.28
Rate for Payer: Cigna Medicare	$15,522.77
Rate for Payer: Employer Direct Commercial	$15,522.77
Rate for Payer: Humana Medicare/TRICARE	$15,522.77
Rate for Payer: Molina Dual Medicare/Medicaid	$15,522.77
Rate for Payer: Molina Medicare	$15,522.77
Rate for Payer: Multiplan Auto	$26,672.20
Rate for Payer: Multiplan Commercial	$26,672.20
Rate for Payer: Multiplan Workers Comp	$26,672.20
Rate for Payer: Scott and White EPO/PPO	$12,283.25
Rate for Payer: Scott and White Medicare	$15,522.77
Rate for Payer: Superior Health Plan EPO	$15,522.77
Rate for Payer: Superior Health Plan Medicare	$15,522.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,522.77
Rate for Payer: Universal American Medicare	$15,522.77
Rate for Payer: Wellcare Medicare	$15,522.77
Rate for Payer: Wellmed Medicare	$15,522.77

VAC-U-MIX -- DHF

Facility

$1,218.97

Hospital Charge Code	81779001
Hospital Revenue Code	272
Rate for Payer: Cash Price	$828.90

VAC-U-MIX -- DHF

Facility

$1,218.97

Hospital Charge Code	81779001
Hospital Revenue Code	272
Min. Negotiated Rate	$109.71
Max. Negotiated Rate	$877.66
Rate for Payer: Amerigroup CHIP/Medicaid	$109.71
Rate for Payer: BCBS of TX Blue Advantage	$365.69
Rate for Payer: BCBS of TX Blue Essentials	$438.83
Rate for Payer: BCBS of TX PPO	$487.59
Rate for Payer: Cash Price	$828.90
Rate for Payer: Cigna Medicaid	$877.66
Rate for Payer: Molina CHIP/Medicaid	$877.66
Rate for Payer: Multiplan Auto	$792.33
Rate for Payer: Multiplan Commercial	$792.33
Rate for Payer: Multiplan Workers Comp	$792.33
Rate for Payer: Parkland Medicaid	$877.66
Rate for Payer: Scott and White EPO/PPO	$609.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$877.66
Rate for Payer: Superior Health Plan EPO	$165.78

VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC

Facility

$29,704.60

Service Code	MSDRG 746
Min. Negotiated Rate	$13,679.75
Max. Negotiated Rate	$29,704.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,491.34
Rate for Payer: Amerigroup Medicare	$17,491.34
Rate for Payer: BCBS of TX Medicare	$17,491.34
Rate for Payer: Cigna Commercial	$22,373.85
Rate for Payer: Cigna Medicare	$17,491.34
Rate for Payer: Employer Direct Commercial	$17,491.34
Rate for Payer: Humana Medicare/TRICARE	$17,491.34
Rate for Payer: Molina Dual Medicare/Medicaid	$17,491.34
Rate for Payer: Molina Medicare	$17,491.34
Rate for Payer: Multiplan Auto	$29,704.60
Rate for Payer: Multiplan Commercial	$29,704.60
Rate for Payer: Multiplan Workers Comp	$29,704.60
Rate for Payer: Scott and White EPO/PPO	$13,679.75
Rate for Payer: Scott and White Medicare	$17,491.34
Rate for Payer: Superior Health Plan EPO	$17,491.34
Rate for Payer: Superior Health Plan Medicare	$17,491.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,491.34
Rate for Payer: Universal American Medicare	$17,491.34
Rate for Payer: Wellcare Medicare	$17,491.34
Rate for Payer: Wellmed Medicare	$17,491.34

VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC

Facility

$18,593.40

Service Code	MSDRG 747
Min. Negotiated Rate	$8,240.52
Max. Negotiated Rate	$18,593.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,060.85
Rate for Payer: Amerigroup Medicare	$11,060.85
Rate for Payer: BCBS of TX Medicare	$11,060.85
Rate for Payer: Cigna Commercial	$10,812.76
Rate for Payer: Cigna Medicare	$11,060.85
Rate for Payer: Employer Direct Commercial	$11,060.85
Rate for Payer: Humana Medicare/TRICARE	$11,060.85
Rate for Payer: Molina Dual Medicare/Medicaid	$11,060.85
Rate for Payer: Molina Medicare	$11,060.85
Rate for Payer: Multiplan Auto	$18,593.40
Rate for Payer: Multiplan Commercial	$18,593.40
Rate for Payer: Multiplan Workers Comp	$18,593.40
Rate for Payer: Scott and White EPO/PPO	$8,562.75
Rate for Payer: Scott and White Medicare	$11,060.85
Rate for Payer: Superior Health Plan EPO	$11,060.85
Rate for Payer: Superior Health Plan Medicare	$11,060.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,060.85
Rate for Payer: Universal American Medicare	$11,060.85
Rate for Payer: Wellcare Medicare	$11,060.85
Rate for Payer: Wellmed Medicare	$11,060.85

VAGINA, CERVIX & VULVA PROCEDURES W CC/MCC

Facility

$29,704.60

Service Code	MSDRG 746
Min. Negotiated Rate	$13,679.75
Max. Negotiated Rate	$29,704.60
Rate for Payer: BCBS of TX Blue Advantage	$14,428.22
Rate for Payer: BCBS of TX Blue Essentials	$17,312.19
Rate for Payer: BCBS of TX PPO	$19,236.51

VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC

Facility

$18,593.40

Service Code	MSDRG 747
Min. Negotiated Rate	$8,240.52
Max. Negotiated Rate	$18,593.40
Rate for Payer: BCBS of TX Blue Advantage	$8,240.52
Rate for Payer: BCBS of TX Blue Essentials	$9,887.67
Rate for Payer: BCBS of TX PPO	$10,986.72

VAGINAL DELIVERY

Facility

$1,412.95

Service Code	APR-DRG 5601
Min. Negotiated Rate	$1,332.18
Max. Negotiated Rate	$1,412.95
Rate for Payer: Amerigroup CHIP/Medicaid	$1,332.18
Rate for Payer: Cigna Medicaid	$1,332.18
Rate for Payer: Molina CHIP/Medicaid	$1,332.18
Rate for Payer: Parkland Medicaid	$1,332.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,412.95

VAGINAL DELIVERY

Facility

$2,211.08

Service Code	APR-DRG 5603
Min. Negotiated Rate	$2,084.69
Max. Negotiated Rate	$2,211.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,084.69
Rate for Payer: Cigna Medicaid	$2,084.69
Rate for Payer: Molina CHIP/Medicaid	$2,084.69
Rate for Payer: Parkland Medicaid	$2,084.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,211.08

VAGINAL DELIVERY

Facility

$3,766.61

Service Code	APR-DRG 5604
Min. Negotiated Rate	$3,551.29
Max. Negotiated Rate	$3,766.61
Rate for Payer: Amerigroup CHIP/Medicaid	$3,551.29
Rate for Payer: Cigna Medicaid	$3,551.29
Rate for Payer: Molina CHIP/Medicaid	$3,551.29
Rate for Payer: Parkland Medicaid	$3,551.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,766.61

VAGINAL DELIVERY

Facility

$1,609.47

Service Code	APR-DRG 5602
Min. Negotiated Rate	$1,517.46
Max. Negotiated Rate	$1,609.47
Rate for Payer: Amerigroup CHIP/Medicaid	$1,517.46
Rate for Payer: Cigna Medicaid	$1,517.46
Rate for Payer: Molina CHIP/Medicaid	$1,517.46
Rate for Payer: Parkland Medicaid	$1,517.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,609.47

Vaginal Delivery Charge -> Complex

Facility

$4,890.00

Hospital Charge Code	300053
Hospital Revenue Code	720
Rate for Payer: Cash Price	$3,325.20

Vaginal Delivery Charge -> Complex

Facility

$4,890.00

Hospital Charge Code	300053
Hospital Revenue Code	720
Min. Negotiated Rate	$440.10
Max. Negotiated Rate	$3,520.80
Rate for Payer: Amerigroup CHIP/Medicaid	$440.10
Rate for Payer: BCBS of TX Blue Advantage	$1,467.00
Rate for Payer: BCBS of TX Blue Essentials	$1,760.40
Rate for Payer: BCBS of TX PPO	$1,956.00
Rate for Payer: Cash Price	$3,325.20
Rate for Payer: Cigna Medicaid	$3,520.80
Rate for Payer: Molina CHIP/Medicaid	$3,520.80
Rate for Payer: Multiplan Auto	$3,178.50
Rate for Payer: Multiplan Commercial	$3,178.50
Rate for Payer: Multiplan Workers Comp	$3,178.50
Rate for Payer: Parkland Medicaid	$3,520.80
Rate for Payer: Scott and White EPO/PPO	$2,445.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,520.80
Rate for Payer: Superior Health Plan EPO	$665.04

Vaginal Delivery Charge -> Simple

Facility

$3,760.00

Hospital Charge Code	300046
Hospital Revenue Code	720
Min. Negotiated Rate	$338.40
Max. Negotiated Rate	$2,707.20
Rate for Payer: Amerigroup CHIP/Medicaid	$338.40
Rate for Payer: BCBS of TX Blue Advantage	$1,128.00
Rate for Payer: BCBS of TX Blue Essentials	$1,353.60
Rate for Payer: BCBS of TX PPO	$1,504.00
Rate for Payer: Cash Price	$2,556.80
Rate for Payer: Cigna Medicaid	$2,707.20
Rate for Payer: Molina CHIP/Medicaid	$2,707.20
Rate for Payer: Multiplan Auto	$2,444.00
Rate for Payer: Multiplan Commercial	$2,444.00
Rate for Payer: Multiplan Workers Comp	$2,444.00
Rate for Payer: Parkland Medicaid	$2,707.20
Rate for Payer: Scott and White EPO/PPO	$1,880.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,707.20
Rate for Payer: Superior Health Plan EPO	$511.36

Vaginal Delivery Charge -> Simple

Facility

$3,760.00

Hospital Charge Code	300046
Hospital Revenue Code	720
Rate for Payer: Cash Price	$2,556.80

VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C

Facility

$3,223.08

Service Code	APR-DRG 5423
Min. Negotiated Rate	$3,038.83
Max. Negotiated Rate	$3,223.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,038.83
Rate for Payer: Cigna Medicaid	$3,038.83
Rate for Payer: Molina CHIP/Medicaid	$3,038.83
Rate for Payer: Parkland Medicaid	$3,038.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,223.08

VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C

Facility

$2,041.35

Service Code	APR-DRG 5422
Min. Negotiated Rate	$1,924.65
Max. Negotiated Rate	$2,041.35
Rate for Payer: Amerigroup CHIP/Medicaid	$1,924.65
Rate for Payer: Cigna Medicaid	$1,924.65
Rate for Payer: Molina CHIP/Medicaid	$1,924.65
Rate for Payer: Parkland Medicaid	$1,924.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,041.35

VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C

Facility

$7,669.01

Service Code	APR-DRG 5424
Min. Negotiated Rate	$7,230.61
Max. Negotiated Rate	$7,669.01
Rate for Payer: Amerigroup CHIP/Medicaid	$7,230.61
Rate for Payer: Cigna Medicaid	$7,230.61
Rate for Payer: Molina CHIP/Medicaid	$7,230.61
Rate for Payer: Parkland Medicaid	$7,230.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,669.01

VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C

Facility

$1,759.96

Service Code	APR-DRG 5421
Min. Negotiated Rate	$1,659.36
Max. Negotiated Rate	$1,759.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1,659.36
Rate for Payer: Cigna Medicaid	$1,659.36
Rate for Payer: Molina CHIP/Medicaid	$1,659.36
Rate for Payer: Parkland Medicaid	$1,659.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,759.96

Know your out-of-pocket cost for care.

All Charges