White Rock Medical Center

All Charges

Charge

Type

Setting

Price

COMPRESSION SLEEVE MED/LG VP501M/VP501L

Facility

$39.91

Hospital Charge Code	145251
Hospital Revenue Code	270
Rate for Payer: Cash Price	$27.14

COMPRESSION SLEEVE MED/LG VP501M/VP501L

Facility

$39.91

Hospital Charge Code	145251
Hospital Revenue Code	270
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$28.74
Rate for Payer: Amerigroup CHIP/Medicaid	$3.59
Rate for Payer: BCBS of TX Blue Advantage	$11.97
Rate for Payer: BCBS of TX Blue Essentials	$14.37
Rate for Payer: BCBS of TX PPO	$15.96
Rate for Payer: Cash Price	$27.14
Rate for Payer: Cigna Medicaid	$28.74
Rate for Payer: Molina CHIP/Medicaid	$28.74
Rate for Payer: Multiplan Auto	$25.94
Rate for Payer: Multiplan Commercial	$25.94
Rate for Payer: Multiplan Workers Comp	$25.94
Rate for Payer: Parkland Medicaid	$28.74
Rate for Payer: Scott and White EPO/PPO	$19.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.74
Rate for Payer: Superior Health Plan EPO	$5.43

Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology

Facility

$1,744.12

Service Code	HCPCS 75572
Hospital Charge Code	994105
Hospital Revenue Code	359
Rate for Payer: Cash Price	$1,186.00

Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology

Facility

$1,744.12

Service Code	HCPCS 75572
Hospital Charge Code	994105
Hospital Revenue Code	359
Min. Negotiated Rate	$175.06
Max. Negotiated Rate	$1,255.77
Rate for Payer: Amerigroup CHIP/Medicaid	$175.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
Rate for Payer: BCBS of TX Blue Advantage	$300.30
Rate for Payer: BCBS of TX Blue Essentials	$360.36
Rate for Payer: BCBS of TX Medicare	$350.46
Rate for Payer: BCBS of TX PPO	$402.22
Rate for Payer: Cash Price	$1,186.00
Rate for Payer: Cash Price	$1,186.00
Rate for Payer: Cash Price	$1,186.00
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$1,255.77
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$1,255.77
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$1,133.68
Rate for Payer: Multiplan Commercial	$1,133.68
Rate for Payer: Multiplan Workers Comp	$1,133.68
Rate for Payer: Parkland Medicaid	$1,255.77
Rate for Payer: Scott and White EPO/PPO	$288.21
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,255.77
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

Computer-assisted surgical navigational procedure for musculoskeletal procedures,

Facility

$323.48

Service Code	HCPCS 20985
Hospital Charge Code	991245
Hospital Revenue Code	360
Min. Negotiated Rate	$29.11
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$29.11
Rate for Payer: BCBS of TX Blue Advantage	$97.04
Rate for Payer: BCBS of TX Blue Essentials	$116.45
Rate for Payer: BCBS of TX PPO	$129.39
Rate for Payer: Cash Price	$219.97
Rate for Payer: Cash Price	$219.97
Rate for Payer: Cigna Medicaid	$232.91
Rate for Payer: Molina CHIP/Medicaid	$232.91
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	$232.91
Rate for Payer: Scott and White EPO/PPO	$161.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$232.91
Rate for Payer: Superior Health Plan EPO	$43.99

Computer-assisted surgical navigational procedure for musculoskeletal procedures,

Facility

$323.48

Service Code	HCPCS 20985
Hospital Charge Code	991245
Hospital Revenue Code	360
Rate for Payer: Cash Price	$219.97

Computer Crossmatch Interp -> Computer XM OK

Facility

$198.00

Service Code	HCPCS 86923
Hospital Charge Code	1600001
Hospital Revenue Code	300
Min. Negotiated Rate	$17.82
Max. Negotiated Rate	$361.78
Rate for Payer: Amerigroup CHIP/Medicaid	$17.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$171.15
Rate for Payer: Amerigroup Medicare	$171.15
Rate for Payer: BCBS of TX Blue Advantage	$59.40
Rate for Payer: BCBS of TX Blue Essentials	$71.28
Rate for Payer: BCBS of TX Medicare	$171.15
Rate for Payer: BCBS of TX PPO	$79.20
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$361.78
Rate for Payer: Cigna Medicaid	$142.56
Rate for Payer: Cigna Medicare	$171.15
Rate for Payer: Employer Direct Commercial	$171.15
Rate for Payer: Humana Medicare/TRICARE	$171.15
Rate for Payer: Molina CHIP/Medicaid	$142.56
Rate for Payer: Molina Dual Medicare/Medicaid	$171.15
Rate for Payer: Molina Medicare	$171.15
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Parkland Medicaid	$142.56
Rate for Payer: Scott and White EPO/PPO	$234.31
Rate for Payer: Scott and White Medicare	$171.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$142.56
Rate for Payer: Superior Health Plan EPO	$171.15
Rate for Payer: Superior Health Plan Medicare	$171.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$171.15
Rate for Payer: Universal American Medicare	$171.15
Rate for Payer: Wellcare Medicare	$171.15
Rate for Payer: Wellmed Medicare	$171.15

Computer Crossmatch Interp -> Computer XM OK

Facility

$198.00

Service Code	HCPCS 86923
Hospital Charge Code	1600001
Hospital Revenue Code	300
Rate for Payer: Cash Price	$134.64

.Concentration SO

Facility

$90.69

Service Code	HCPCS 87015
Hospital Charge Code	9058995
Hospital Revenue Code	306
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$65.30
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.68
Rate for Payer: Amerigroup Medicare	$6.68
Rate for Payer: BCBS of TX Blue Advantage	$27.21
Rate for Payer: BCBS of TX Blue Essentials	$32.65
Rate for Payer: BCBS of TX Medicare	$6.68
Rate for Payer: BCBS of TX PPO	$36.28
Rate for Payer: Cash Price	$61.67
Rate for Payer: Cash Price	$61.67
Rate for Payer: Cigna Medicaid	$65.30
Rate for Payer: Cigna Medicare	$6.68
Rate for Payer: Employer Direct Commercial	$6.68
Rate for Payer: Humana Medicare/TRICARE	$6.68
Rate for Payer: Molina CHIP/Medicaid	$65.30
Rate for Payer: Molina Dual Medicare/Medicaid	$6.68
Rate for Payer: Molina Medicare	$6.68
Rate for Payer: Multiplan Auto	$58.95
Rate for Payer: Multiplan Commercial	$58.95
Rate for Payer: Multiplan Workers Comp	$58.95
Rate for Payer: Parkland Medicaid	$65.30
Rate for Payer: Scott and White EPO/PPO	$8.35
Rate for Payer: Scott and White Medicare	$6.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.30
Rate for Payer: Superior Health Plan EPO	$6.68
Rate for Payer: Superior Health Plan Medicare	$6.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.68
Rate for Payer: Universal American Medicare	$6.68
Rate for Payer: Wellcare Medicare	$6.68
Rate for Payer: Wellmed Medicare	$6.68

.Concentration SO

Facility

$90.69

Service Code	HCPCS 87015
Hospital Charge Code	9058995
Hospital Revenue Code	306
Rate for Payer: Cash Price	$61.67

CONCHA COLUMN -- DHF

Facility

$60.77

Hospital Charge Code	82020959
Hospital Revenue Code	270
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$43.75
Rate for Payer: Amerigroup CHIP/Medicaid	$5.47
Rate for Payer: BCBS of TX Blue Advantage	$18.23
Rate for Payer: BCBS of TX Blue Essentials	$21.88
Rate for Payer: BCBS of TX PPO	$24.31
Rate for Payer: Cash Price	$41.32
Rate for Payer: Cigna Medicaid	$43.75
Rate for Payer: Molina CHIP/Medicaid	$43.75
Rate for Payer: Multiplan Auto	$39.50
Rate for Payer: Multiplan Commercial	$39.50
Rate for Payer: Multiplan Workers Comp	$39.50
Rate for Payer: Parkland Medicaid	$43.75
Rate for Payer: Scott and White EPO/PPO	$30.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.75
Rate for Payer: Superior Health Plan EPO	$8.26

CONCHA COLUMN -- DHF

Facility

$60.77

Hospital Charge Code	82020959
Hospital Revenue Code	270
Rate for Payer: Cash Price	$41.32

CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES

Facility

$140,058.41

Service Code	MSDRG 212
Min. Negotiated Rate	$84,456.65
Max. Negotiated Rate	$140,058.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$84,456.65
Rate for Payer: Amerigroup Medicare	$84,456.65
Rate for Payer: BCBS of TX Medicare	$84,456.65
Rate for Payer: Cigna Commercial	$140,058.41
Rate for Payer: Cigna Medicare	$84,456.65
Rate for Payer: Employer Direct Commercial	$84,456.65
Rate for Payer: Humana Medicare/TRICARE	$84,456.65
Rate for Payer: Molina Dual Medicare/Medicaid	$84,456.65
Rate for Payer: Molina Medicare	$84,456.65
Rate for Payer: Scott and White Medicare	$84,456.65
Rate for Payer: Superior Health Plan EPO	$84,456.65
Rate for Payer: Superior Health Plan Medicare	$84,456.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$84,456.65
Rate for Payer: Universal American Medicare	$84,456.65
Rate for Payer: Wellcare Medicare	$84,456.65
Rate for Payer: Wellmed Medicare	$84,456.65

CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION

Facility

$86,122.12

Service Code	MSDRG 317
Min. Negotiated Rate	$53,765.61
Max. Negotiated Rate	$86,122.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$53,765.61
Rate for Payer: Amerigroup Medicare	$53,765.61
Rate for Payer: BCBS of TX Medicare	$53,765.61
Rate for Payer: Cigna Commercial	$86,122.12
Rate for Payer: Cigna Medicare	$53,765.61
Rate for Payer: Employer Direct Commercial	$53,765.61
Rate for Payer: Humana Medicare/TRICARE	$53,765.61
Rate for Payer: Molina Dual Medicare/Medicaid	$53,765.61
Rate for Payer: Molina Medicare	$53,765.61
Rate for Payer: Scott and White Medicare	$53,765.61
Rate for Payer: Superior Health Plan EPO	$53,765.61
Rate for Payer: Superior Health Plan Medicare	$53,765.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$53,765.61
Rate for Payer: Universal American Medicare	$53,765.61
Rate for Payer: Wellcare Medicare	$53,765.61
Rate for Payer: Wellmed Medicare	$53,765.61

CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA

Facility

$7,371.40

Service Code	APR-DRG 0573
Min. Negotiated Rate	$6,950.02
Max. Negotiated Rate	$7,371.40
Rate for Payer: Amerigroup CHIP/Medicaid	$6,950.02
Rate for Payer: Cigna Medicaid	$6,950.02
Rate for Payer: Molina CHIP/Medicaid	$6,950.02
Rate for Payer: Parkland Medicaid	$6,950.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,371.40

CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA

Facility

$3,859.02

Service Code	APR-DRG 0572
Min. Negotiated Rate	$3,638.42
Max. Negotiated Rate	$3,859.02
Rate for Payer: Amerigroup CHIP/Medicaid	$3,638.42
Rate for Payer: Cigna Medicaid	$3,638.42
Rate for Payer: Molina CHIP/Medicaid	$3,638.42
Rate for Payer: Parkland Medicaid	$3,638.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,859.02

CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA

Facility

$2,185.43

Service Code	APR-DRG 0571
Min. Negotiated Rate	$2,060.50
Max. Negotiated Rate	$2,185.43
Rate for Payer: Amerigroup CHIP/Medicaid	$2,060.50
Rate for Payer: Cigna Medicaid	$2,060.50
Rate for Payer: Molina CHIP/Medicaid	$2,060.50
Rate for Payer: Parkland Medicaid	$2,060.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,185.43

CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA

Facility

$18,401.54

Service Code	APR-DRG 0574
Min. Negotiated Rate	$17,349.62
Max. Negotiated Rate	$18,401.54
Rate for Payer: Amerigroup CHIP/Medicaid	$17,349.62
Rate for Payer: Cigna Medicaid	$17,349.62
Rate for Payer: Molina CHIP/Medicaid	$17,349.62
Rate for Payer: Parkland Medicaid	$17,349.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,401.54

CONCUSSION W CC

Facility

$22,186.30

Service Code	MSDRG 089
Min. Negotiated Rate	$9,180.50
Max. Negotiated Rate	$22,186.30
Rate for Payer: BCBS of TX Blue Advantage	$9,180.50
Rate for Payer: BCBS of TX Blue Essentials	$11,015.53
Rate for Payer: BCBS of TX PPO	$12,239.95

CONCUSSION WITH CC

Facility

$22,186.30

Service Code	MSDRG 089
Min. Negotiated Rate	$9,180.50
Max. Negotiated Rate	$22,186.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,811.75
Rate for Payer: Amerigroup Medicare	$12,811.75
Rate for Payer: BCBS of TX Medicare	$12,811.75
Rate for Payer: Cigna Commercial	$14,149.97
Rate for Payer: Cigna Medicare	$12,811.75
Rate for Payer: Employer Direct Commercial	$12,811.75
Rate for Payer: Humana Medicare/TRICARE	$12,811.75
Rate for Payer: Molina Dual Medicare/Medicaid	$12,811.75
Rate for Payer: Molina Medicare	$12,811.75
Rate for Payer: Multiplan Auto	$22,186.30
Rate for Payer: Multiplan Commercial	$22,186.30
Rate for Payer: Multiplan Workers Comp	$22,186.30
Rate for Payer: Scott and White EPO/PPO	$10,217.38
Rate for Payer: Scott and White Medicare	$12,811.75
Rate for Payer: Superior Health Plan EPO	$12,811.75
Rate for Payer: Superior Health Plan Medicare	$12,811.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,811.75
Rate for Payer: Universal American Medicare	$12,811.75
Rate for Payer: Wellcare Medicare	$12,811.75
Rate for Payer: Wellmed Medicare	$12,811.75

CONCUSSION WITH MCC

Facility

$29,949.70

Service Code	MSDRG 088
Min. Negotiated Rate	$12,724.56
Max. Negotiated Rate	$29,949.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,667.46
Rate for Payer: Amerigroup Medicare	$14,667.46
Rate for Payer: BCBS of TX Medicare	$14,667.46
Rate for Payer: Cigna Commercial	$17,411.18
Rate for Payer: Cigna Medicare	$14,667.46
Rate for Payer: Employer Direct Commercial	$14,667.46
Rate for Payer: Humana Medicare/TRICARE	$14,667.46
Rate for Payer: Molina Dual Medicare/Medicaid	$14,667.46
Rate for Payer: Molina Medicare	$14,667.46
Rate for Payer: Multiplan Auto	$29,949.70
Rate for Payer: Multiplan Commercial	$29,949.70
Rate for Payer: Multiplan Workers Comp	$29,949.70
Rate for Payer: Scott and White EPO/PPO	$13,792.62
Rate for Payer: Scott and White Medicare	$14,667.46
Rate for Payer: Superior Health Plan EPO	$14,667.46
Rate for Payer: Superior Health Plan Medicare	$14,667.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,667.46
Rate for Payer: Universal American Medicare	$14,667.46
Rate for Payer: Wellcare Medicare	$14,667.46
Rate for Payer: Wellmed Medicare	$14,667.46

CONCUSSION WITHOUT CC/MCC

Facility

$15,638.90

Service Code	MSDRG 090
Min. Negotiated Rate	$6,823.24
Max. Negotiated Rate	$15,638.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,793.33
Rate for Payer: Amerigroup Medicare	$10,793.33
Rate for Payer: BCBS of TX Medicare	$10,793.33
Rate for Payer: Cigna Commercial	$10,602.82
Rate for Payer: Cigna Medicare	$10,793.33
Rate for Payer: Employer Direct Commercial	$10,793.33
Rate for Payer: Humana Medicare/TRICARE	$10,793.33
Rate for Payer: Molina Dual Medicare/Medicaid	$10,793.33
Rate for Payer: Molina Medicare	$10,793.33
Rate for Payer: Multiplan Auto	$15,638.90
Rate for Payer: Multiplan Commercial	$15,638.90
Rate for Payer: Multiplan Workers Comp	$15,638.90
Rate for Payer: Scott and White EPO/PPO	$7,202.12
Rate for Payer: Scott and White Medicare	$10,793.33
Rate for Payer: Superior Health Plan EPO	$10,793.33
Rate for Payer: Superior Health Plan Medicare	$10,793.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,793.33
Rate for Payer: Universal American Medicare	$10,793.33
Rate for Payer: Wellcare Medicare	$10,793.33
Rate for Payer: Wellmed Medicare	$10,793.33

CONCUSSION W MCC

Facility

$29,949.70

Service Code	MSDRG 088
Min. Negotiated Rate	$12,724.56
Max. Negotiated Rate	$29,949.70
Rate for Payer: BCBS of TX Blue Advantage	$12,724.56
Rate for Payer: BCBS of TX Blue Essentials	$15,267.99
Rate for Payer: BCBS of TX PPO	$16,965.09

CONCUSSION W/O CC/MCC

Facility

$15,638.90

Service Code	MSDRG 090
Min. Negotiated Rate	$6,823.24
Max. Negotiated Rate	$15,638.90
Rate for Payer: BCBS of TX Blue Advantage	$6,823.24
Rate for Payer: BCBS of TX Blue Essentials	$8,187.09
Rate for Payer: BCBS of TX PPO	$9,097.12

CONFIRM CARDIAC MONITOR DM3500

Facility

$20,199.00

Service Code	HCPCS C1833
Hospital Charge Code	8550485
Hospital Revenue Code	278
Min. Negotiated Rate	$5,049.75
Max. Negotiated Rate	$10,099.50
Rate for Payer: Cash Price	$13,735.32
Rate for Payer: Cigna Commercial	$5,049.75
Rate for Payer: Multiplan Auto	$10,099.50
Rate for Payer: Multiplan Commercial	$10,099.50
Rate for Payer: Multiplan Workers Comp	$10,099.50
Rate for Payer: Scott and White EPO/PPO	$10,099.50

Know your out-of-pocket cost for care.

All Charges