White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

$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

$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

$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

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

Facility

$20,360.40

Service Code	MSDRG 768
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$20,360.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,613.87
Rate for Payer: Amerigroup Medicare	$12,613.87
Rate for Payer: BCBS of TX Medicare	$12,613.87
Rate for Payer: Cigna Commercial	$4,586.00
Rate for Payer: Cigna Medicare	$12,613.87
Rate for Payer: Employer Direct Commercial	$12,613.87
Rate for Payer: Humana Medicare/TRICARE	$12,613.87
Rate for Payer: Molina Dual Medicare/Medicaid	$12,613.87
Rate for Payer: Molina Medicare	$12,613.87
Rate for Payer: Multiplan Auto	$20,360.40
Rate for Payer: Multiplan Commercial	$20,360.40
Rate for Payer: Multiplan Workers Comp	$20,360.40
Rate for Payer: Scott and White EPO/PPO	$9,376.50
Rate for Payer: Scott and White Medicare	$12,613.87
Rate for Payer: Superior Health Plan EPO	$12,613.87
Rate for Payer: Superior Health Plan Medicare	$12,613.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,613.87
Rate for Payer: Universal American Medicare	$12,613.87
Rate for Payer: Wellcare Medicare	$12,613.87
Rate for Payer: Wellmed Medicare	$12,613.87

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC

Facility

$14,326.00

Service Code	MSDRG 806
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$14,326.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,286.16
Rate for Payer: Amerigroup Medicare	$10,286.16
Rate for Payer: BCBS of TX Medicare	$10,286.16
Rate for Payer: Cigna Commercial	$4,586.00
Rate for Payer: Cigna Medicare	$10,286.16
Rate for Payer: Employer Direct Commercial	$10,286.16
Rate for Payer: Humana Medicare/TRICARE	$10,286.16
Rate for Payer: Molina Dual Medicare/Medicaid	$10,286.16
Rate for Payer: Molina Medicare	$10,286.16
Rate for Payer: Multiplan Auto	$14,326.00
Rate for Payer: Multiplan Commercial	$14,326.00
Rate for Payer: Multiplan Workers Comp	$14,326.00
Rate for Payer: Scott and White EPO/PPO	$6,597.50
Rate for Payer: Scott and White Medicare	$10,286.16
Rate for Payer: Superior Health Plan EPO	$10,286.16
Rate for Payer: Superior Health Plan Medicare	$10,286.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,286.16
Rate for Payer: Universal American Medicare	$10,286.16
Rate for Payer: Wellcare Medicare	$10,286.16
Rate for Payer: Wellmed Medicare	$10,286.16

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC

Facility

$20,504.80

Service Code	MSDRG 805
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$20,504.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,669.56
Rate for Payer: Amerigroup Medicare	$12,669.56
Rate for Payer: BCBS of TX Medicare	$12,669.56
Rate for Payer: Cigna Commercial	$4,586.00
Rate for Payer: Cigna Medicare	$12,669.56
Rate for Payer: Employer Direct Commercial	$12,669.56
Rate for Payer: Humana Medicare/TRICARE	$12,669.56
Rate for Payer: Molina Dual Medicare/Medicaid	$12,669.56
Rate for Payer: Molina Medicare	$12,669.56
Rate for Payer: Multiplan Auto	$20,504.80
Rate for Payer: Multiplan Commercial	$20,504.80
Rate for Payer: Multiplan Workers Comp	$20,504.80
Rate for Payer: Scott and White EPO/PPO	$9,443.00
Rate for Payer: Scott and White Medicare	$12,669.56
Rate for Payer: Superior Health Plan EPO	$12,669.56
Rate for Payer: Superior Health Plan Medicare	$12,669.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,669.56
Rate for Payer: Universal American Medicare	$12,669.56
Rate for Payer: Wellcare Medicare	$12,669.56
Rate for Payer: Wellmed Medicare	$12,669.56

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC

Facility

$12,809.80

Service Code	MSDRG 807
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$12,809.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,701.31
Rate for Payer: Amerigroup Medicare	$9,701.31
Rate for Payer: BCBS of TX Medicare	$9,701.31
Rate for Payer: Cigna Commercial	$4,586.00
Rate for Payer: Cigna Medicare	$9,701.31
Rate for Payer: Employer Direct Commercial	$9,701.31
Rate for Payer: Humana Medicare/TRICARE	$9,701.31
Rate for Payer: Molina Dual Medicare/Medicaid	$9,701.31
Rate for Payer: Molina Medicare	$9,701.31
Rate for Payer: Multiplan Auto	$12,809.80
Rate for Payer: Multiplan Commercial	$12,809.80
Rate for Payer: Multiplan Workers Comp	$12,809.80
Rate for Payer: Scott and White EPO/PPO	$5,899.25
Rate for Payer: Scott and White Medicare	$9,701.31
Rate for Payer: Superior Health Plan EPO	$9,701.31
Rate for Payer: Superior Health Plan Medicare	$9,701.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,701.31
Rate for Payer: Universal American Medicare	$9,701.31
Rate for Payer: Wellcare Medicare	$9,701.31
Rate for Payer: Wellmed Medicare	$9,701.31

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C

Facility

$2,576.20

Service Code	APR-DRG 5412
Min. Negotiated Rate	$2,428.93
Max. Negotiated Rate	$2,576.20
Rate for Payer: Amerigroup CHIP/Medicaid	$2,428.93
Rate for Payer: Cigna Medicaid	$2,428.93
Rate for Payer: Molina CHIP/Medicaid	$2,428.93
Rate for Payer: Parkland Medicaid	$2,428.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,576.20

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C

Facility

$2,296.70

Service Code	APR-DRG 5411
Min. Negotiated Rate	$2,165.41
Max. Negotiated Rate	$2,296.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2,165.41
Rate for Payer: Cigna Medicaid	$2,165.41
Rate for Payer: Molina CHIP/Medicaid	$2,165.41
Rate for Payer: Parkland Medicaid	$2,165.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,296.70

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C

Facility

$7,872.31

Service Code	APR-DRG 5414
Min. Negotiated Rate	$7,422.29
Max. Negotiated Rate	$7,872.31
Rate for Payer: Amerigroup CHIP/Medicaid	$7,422.29
Rate for Payer: Cigna Medicaid	$7,422.29
Rate for Payer: Molina CHIP/Medicaid	$7,422.29
Rate for Payer: Parkland Medicaid	$7,422.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,872.31

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C

Facility

$2,855.70

Service Code	APR-DRG 5413
Min. Negotiated Rate	$2,692.45
Max. Negotiated Rate	$2,855.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2,692.45
Rate for Payer: Cigna Medicaid	$2,692.45
Rate for Payer: Molina CHIP/Medicaid	$2,692.45
Rate for Payer: Parkland Medicaid	$2,692.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,855.70

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC

Facility

$19,007.60

Service Code	MSDRG 797
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$19,007.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,092.05
Rate for Payer: Amerigroup Medicare	$12,092.05
Rate for Payer: BCBS of TX Medicare	$12,092.05
Rate for Payer: Cigna Commercial	$4,586.00
Rate for Payer: Cigna Medicare	$12,092.05
Rate for Payer: Employer Direct Commercial	$12,092.05
Rate for Payer: Humana Medicare/TRICARE	$12,092.05
Rate for Payer: Molina Dual Medicare/Medicaid	$12,092.05
Rate for Payer: Molina Medicare	$12,092.05
Rate for Payer: Multiplan Auto	$19,007.60
Rate for Payer: Multiplan Commercial	$19,007.60
Rate for Payer: Multiplan Workers Comp	$19,007.60
Rate for Payer: Scott and White EPO/PPO	$8,753.50
Rate for Payer: Scott and White Medicare	$12,092.05
Rate for Payer: Superior Health Plan EPO	$12,092.05
Rate for Payer: Superior Health Plan Medicare	$12,092.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,092.05
Rate for Payer: Universal American Medicare	$12,092.05
Rate for Payer: Wellcare Medicare	$12,092.05
Rate for Payer: Wellmed Medicare	$12,092.05

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC

Facility

$22,173.00

Service Code	MSDRG 796
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$22,173.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,313.05
Rate for Payer: Amerigroup Medicare	$13,313.05
Rate for Payer: BCBS of TX Medicare	$13,313.05
Rate for Payer: Cigna Commercial	$4,586.00
Rate for Payer: Cigna Medicare	$13,313.05
Rate for Payer: Employer Direct Commercial	$13,313.05
Rate for Payer: Humana Medicare/TRICARE	$13,313.05
Rate for Payer: Molina Dual Medicare/Medicaid	$13,313.05
Rate for Payer: Molina Medicare	$13,313.05
Rate for Payer: Multiplan Auto	$22,173.00
Rate for Payer: Multiplan Commercial	$22,173.00
Rate for Payer: Multiplan Workers Comp	$22,173.00
Rate for Payer: Scott and White EPO/PPO	$10,211.25
Rate for Payer: Scott and White Medicare	$13,313.05
Rate for Payer: Superior Health Plan EPO	$13,313.05
Rate for Payer: Superior Health Plan Medicare	$13,313.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,313.05
Rate for Payer: Universal American Medicare	$13,313.05
Rate for Payer: Wellcare Medicare	$13,313.05
Rate for Payer: Wellmed Medicare	$13,313.05

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC

Facility

$18,184.90

Service Code	MSDRG 798
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$18,184.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,774.70
Rate for Payer: Amerigroup Medicare	$11,774.70
Rate for Payer: BCBS of TX Medicare	$11,774.70
Rate for Payer: Cigna Commercial	$4,586.00
Rate for Payer: Cigna Medicare	$11,774.70
Rate for Payer: Employer Direct Commercial	$11,774.70
Rate for Payer: Humana Medicare/TRICARE	$11,774.70
Rate for Payer: Molina Dual Medicare/Medicaid	$11,774.70
Rate for Payer: Molina Medicare	$11,774.70
Rate for Payer: Multiplan Auto	$18,184.90
Rate for Payer: Multiplan Commercial	$18,184.90
Rate for Payer: Multiplan Workers Comp	$18,184.90
Rate for Payer: Scott and White EPO/PPO	$8,374.62
Rate for Payer: Scott and White Medicare	$11,774.70
Rate for Payer: Superior Health Plan EPO	$11,774.70
Rate for Payer: Superior Health Plan Medicare	$11,774.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,774.70
Rate for Payer: Universal American Medicare	$11,774.70
Rate for Payer: Wellcare Medicare	$11,774.70
Rate for Payer: Wellmed Medicare	$11,774.70

VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C

Facility

$20,360.40

Service Code	MSDRG 768
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$20,360.40
Rate for Payer: BCBS of TX Blue Advantage	$9,730.04
Rate for Payer: BCBS of TX Blue Essentials	$11,674.92
Rate for Payer: BCBS of TX PPO	$12,972.63

VAGINAL DELIVERY W/O STERILIZATION/D&C W CC

Facility

$14,326.00

Service Code	MSDRG 806
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$14,326.00
Rate for Payer: BCBS of TX Blue Advantage	$6,083.64
Rate for Payer: BCBS of TX Blue Essentials	$7,299.66
Rate for Payer: BCBS of TX PPO	$8,111.05

VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC

Facility

$20,504.80

Service Code	MSDRG 805
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$20,504.80
Rate for Payer: BCBS of TX Blue Advantage	$8,799.52
Rate for Payer: BCBS of TX Blue Essentials	$10,558.40
Rate for Payer: BCBS of TX PPO	$11,732.01

VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC

Facility

$12,809.80

Service Code	MSDRG 807
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$12,809.80
Rate for Payer: BCBS of TX Blue Advantage	$5,280.40
Rate for Payer: BCBS of TX Blue Essentials	$6,335.87
Rate for Payer: BCBS of TX PPO	$7,040.12

VAGINAL DELIVERY W STERILIZATION/D&C W CC

Facility

$19,007.60

Service Code	MSDRG 797
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$19,007.60
Rate for Payer: BCBS of TX Blue Advantage	$7,283.34
Rate for Payer: BCBS of TX Blue Essentials	$8,739.16
Rate for Payer: BCBS of TX PPO	$9,710.56

VAGINAL DELIVERY W STERILIZATION/D&C W MCC

Facility

$22,173.00

Service Code	MSDRG 796
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$22,173.00
Rate for Payer: BCBS of TX Blue Advantage	$12,626.52
Rate for Payer: BCBS of TX Blue Essentials	$15,150.36
Rate for Payer: BCBS of TX PPO	$16,834.38

VAGINAL DELIVERY W STERILIZATION/D&C WO CC/MCC

Facility

$18,184.90

Service Code	MSDRG 798
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$18,184.90
Rate for Payer: BCBS of TX Blue Advantage	$7,283.34
Rate for Payer: BCBS of TX Blue Essentials	$8,739.16
Rate for Payer: BCBS of TX PPO	$9,710.56

valACYclovir 500 mg Tab

Facility

$54.45

Service Code	HCPCS J8499
Hospital Charge Code	77868406
Hospital Revenue Code	636
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$39.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.90
Rate for Payer: BCBS of TX Blue Advantage	$16.34
Rate for Payer: BCBS of TX Blue Essentials	$19.60
Rate for Payer: BCBS of TX PPO	$21.78
Rate for Payer: Cash Price	$37.03
Rate for Payer: Cigna Medicaid	$39.20
Rate for Payer: Molina CHIP/Medicaid	$39.20
Rate for Payer: Multiplan Auto	$35.39
Rate for Payer: Multiplan Commercial	$35.39
Rate for Payer: Multiplan Workers Comp	$35.39
Rate for Payer: Parkland Medicaid	$39.20
Rate for Payer: Scott and White EPO/PPO	$27.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.20
Rate for Payer: Superior Health Plan EPO	$7.41

valACYclovir 500 mg Tab

Facility

$54.45

Service Code	HCPCS J8499
Hospital Charge Code	77868406
Hospital Revenue Code	636
Min. Negotiated Rate	$13.61
Max. Negotiated Rate	$27.23
Rate for Payer: Cash Price	$37.03
Rate for Payer: Cigna Commercial	$13.61
Rate for Payer: Scott and White EPO/PPO	$27.23

VALOR 9.0MMX250 STEPPED REAM

Facility

$1,893.18

Hospital Charge Code	993420
Hospital Revenue Code	272
Min. Negotiated Rate	$170.39
Max. Negotiated Rate	$1,363.09
Rate for Payer: Amerigroup CHIP/Medicaid	$170.39
Rate for Payer: BCBS of TX Blue Advantage	$567.95
Rate for Payer: BCBS of TX Blue Essentials	$681.54
Rate for Payer: BCBS of TX PPO	$757.27
Rate for Payer: Cash Price	$1,287.36
Rate for Payer: Cigna Medicaid	$1,363.09
Rate for Payer: Molina CHIP/Medicaid	$1,363.09
Rate for Payer: Multiplan Auto	$1,230.57
Rate for Payer: Multiplan Commercial	$1,230.57
Rate for Payer: Multiplan Workers Comp	$1,230.57
Rate for Payer: Parkland Medicaid	$1,363.09
Rate for Payer: Scott and White EPO/PPO	$946.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,363.09
Rate for Payer: Superior Health Plan EPO	$257.47

Know your out-of-pocket cost for care.

All Charges