White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CONFIRM CARDIAC MONITOR DM3500

Facility

$20,199.00

Service Code	HCPCS C1833
Hospital Charge Code	146573
Hospital Revenue Code	278
Min. Negotiated Rate	$761.25
Max. Negotiated Rate	$14,543.28
Rate for Payer: Amerigroup CHIP/Medicaid	$1,817.91
Rate for Payer: BCBS of TX Blue Advantage	$761.25
Rate for Payer: BCBS of TX Blue Essentials	$913.50
Rate for Payer: BCBS of TX PPO	$1,013.25
Rate for Payer: Cash Price	$13,735.32
Rate for Payer: Cash Price	$13,735.32
Rate for Payer: Cigna Medicaid	$14,543.28
Rate for Payer: Molina CHIP/Medicaid	$14,543.28
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: Parkland Medicaid	$14,543.28
Rate for Payer: Scott and White EPO/PPO	$10,099.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,543.28
Rate for Payer: Superior Health Plan EPO	$2,747.06

CONFIRM CARDIAC MONITOR DM3500

Facility

$20,199.00

Service Code	HCPCS C1833
Hospital Charge Code	8550485
Hospital Revenue Code	278
Min. Negotiated Rate	$761.25
Max. Negotiated Rate	$14,543.28
Rate for Payer: Amerigroup CHIP/Medicaid	$1,817.91
Rate for Payer: BCBS of TX Blue Advantage	$761.25
Rate for Payer: BCBS of TX Blue Essentials	$913.50
Rate for Payer: BCBS of TX PPO	$1,013.25
Rate for Payer: Cash Price	$13,735.32
Rate for Payer: Cash Price	$13,735.32
Rate for Payer: Cigna Medicaid	$14,543.28
Rate for Payer: Molina CHIP/Medicaid	$14,543.28
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: Parkland Medicaid	$14,543.28
Rate for Payer: Scott and White EPO/PPO	$10,099.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,543.28
Rate for Payer: Superior Health Plan EPO	$2,747.06

CONFIRM CARDIAC MONITOR DM3500

Facility

$20,199.00

Service Code	HCPCS C1833
Hospital Charge Code	146573
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

Conjunctivoplasty, reconstruction cul-de-sac with conjunctival graft or extensive rearrangement

Facility

$10,000.00

Service Code	CPT 68326
Hospital Charge Code	36068326
Hospital Revenue Code	360
Min. Negotiated Rate	$1,103.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,103.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Amerigroup Medicare	$3,949.31
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,949.31
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cigna Commercial	$8,348.12
Rate for Payer: Cigna Medicare	$3,949.31
Rate for Payer: Employer Direct Commercial	$3,949.31
Rate for Payer: Humana Medicare/TRICARE	$3,949.31
Rate for Payer: Molina Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Molina Medicare	$3,949.31
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	$6,541.58
Rate for Payer: Scott and White Medicare	$3,949.31
Rate for Payer: Superior Health Plan EPO	$3,949.31
Rate for Payer: Superior Health Plan Medicare	$3,949.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Universal American Medicare	$3,949.31
Rate for Payer: Wellcare Medicare	$3,949.31
Rate for Payer: Wellmed Medicare	$3,949.31

Conjunctivoplasty, reconstruction cul-de-sac with conjunctival graft or extensive rearrangement

Facility

$9,089.99

Service Code	HCPCS 68326
Hospital Charge Code	9900881
Hospital Revenue Code	360
Min. Negotiated Rate	$1,103.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,103.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Amerigroup Medicare	$3,949.31
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,949.31
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cash Price	$6,181.19
Rate for Payer: Cash Price	$6,181.19
Rate for Payer: Cash Price	$6,181.19
Rate for Payer: Cigna Commercial	$8,348.12
Rate for Payer: Cigna Medicaid	$6,544.79
Rate for Payer: Cigna Medicare	$3,949.31
Rate for Payer: Employer Direct Commercial	$3,949.31
Rate for Payer: Humana Medicare/TRICARE	$3,949.31
Rate for Payer: Molina CHIP/Medicaid	$6,544.79
Rate for Payer: Molina Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Molina Medicare	$3,949.31
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	$6,544.79
Rate for Payer: Scott and White EPO/PPO	$6,541.58
Rate for Payer: Scott and White Medicare	$3,949.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,544.79
Rate for Payer: Superior Health Plan EPO	$3,949.31
Rate for Payer: Superior Health Plan Medicare	$3,949.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,949.31
Rate for Payer: Universal American Medicare	$3,949.31
Rate for Payer: Wellcare Medicare	$3,949.31
Rate for Payer: Wellmed Medicare	$3,949.31

Conjunctivoplasty, reconstruction cul-de-sac with conjunctival graft or extensive rearrangement

Facility

$9,089.99

Service Code	HCPCS 68326
Hospital Charge Code	9900881
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,181.19

CONNECTING NUT

Facility

$122.58

Hospital Charge Code	993242
Hospital Revenue Code	272
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$88.26
Rate for Payer: Amerigroup CHIP/Medicaid	$11.03
Rate for Payer: BCBS of TX Blue Advantage	$36.77
Rate for Payer: BCBS of TX Blue Essentials	$44.13
Rate for Payer: BCBS of TX PPO	$49.03
Rate for Payer: Cash Price	$83.35
Rate for Payer: Cigna Medicaid	$88.26
Rate for Payer: Molina CHIP/Medicaid	$88.26
Rate for Payer: Multiplan Auto	$79.68
Rate for Payer: Multiplan Commercial	$79.68
Rate for Payer: Multiplan Workers Comp	$79.68
Rate for Payer: Parkland Medicaid	$88.26
Rate for Payer: Scott and White EPO/PPO	$61.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.26
Rate for Payer: Superior Health Plan EPO	$16.67

CONNECTING NUT

Facility

$122.58

Hospital Charge Code	993242
Hospital Revenue Code	272
Rate for Payer: Cash Price	$83.35

CONNECTING NUT - SHORT - M8 X 6 mm

Facility

$122.58

Hospital Charge Code	993422
Hospital Revenue Code	272
Rate for Payer: Cash Price	$83.35

CONNECTING NUT - SHORT - M8 X 6 mm

Facility

$122.58

Hospital Charge Code	993422
Hospital Revenue Code	272
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$88.26
Rate for Payer: Amerigroup CHIP/Medicaid	$11.03
Rate for Payer: BCBS of TX Blue Advantage	$36.77
Rate for Payer: BCBS of TX Blue Essentials	$44.13
Rate for Payer: BCBS of TX PPO	$49.03
Rate for Payer: Cash Price	$83.35
Rate for Payer: Cigna Medicaid	$88.26
Rate for Payer: Molina CHIP/Medicaid	$88.26
Rate for Payer: Multiplan Auto	$79.68
Rate for Payer: Multiplan Commercial	$79.68
Rate for Payer: Multiplan Workers Comp	$79.68
Rate for Payer: Parkland Medicaid	$88.26
Rate for Payer: Scott and White EPO/PPO	$61.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.26
Rate for Payer: Superior Health Plan EPO	$16.67

CONNECTIVE TISSUE DISORDERS

Facility

$25,325.60

Service Code	APR-DRG 3464
Min. Negotiated Rate	$23,877.86
Max. Negotiated Rate	$25,325.60
Rate for Payer: Amerigroup CHIP/Medicaid	$23,877.86
Rate for Payer: Cigna Medicaid	$23,877.86
Rate for Payer: Molina CHIP/Medicaid	$23,877.86
Rate for Payer: Parkland Medicaid	$23,877.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,325.60

CONNECTIVE TISSUE DISORDERS

Facility

$10,815.89

Service Code	APR-DRG 3463
Min. Negotiated Rate	$10,197.60
Max. Negotiated Rate	$10,815.89
Rate for Payer: Amerigroup CHIP/Medicaid	$10,197.60
Rate for Payer: Cigna Medicaid	$10,197.60
Rate for Payer: Molina CHIP/Medicaid	$10,197.60
Rate for Payer: Parkland Medicaid	$10,197.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,815.89

CONNECTIVE TISSUE DISORDERS

Facility

$5,519.78

Service Code	APR-DRG 3462
Min. Negotiated Rate	$5,204.25
Max. Negotiated Rate	$5,519.78
Rate for Payer: Amerigroup CHIP/Medicaid	$5,204.25
Rate for Payer: Cigna Medicaid	$5,204.25
Rate for Payer: Molina CHIP/Medicaid	$5,204.25
Rate for Payer: Parkland Medicaid	$5,204.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,519.78

CONNECTIVE TISSUE DISORDERS

Facility

$4,186.04

Service Code	APR-DRG 3461
Min. Negotiated Rate	$3,946.75
Max. Negotiated Rate	$4,186.04
Rate for Payer: Amerigroup CHIP/Medicaid	$3,946.75
Rate for Payer: Cigna Medicaid	$3,946.75
Rate for Payer: Molina CHIP/Medicaid	$3,946.75
Rate for Payer: Parkland Medicaid	$3,946.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,186.04

CONNECTIVE TISSUE DISORDERS W CC

Facility

$22,906.40

Service Code	MSDRG 546
Min. Negotiated Rate	$10,443.84
Max. Negotiated Rate	$22,906.40
Rate for Payer: BCBS of TX Blue Advantage	$10,443.84
Rate for Payer: BCBS of TX Blue Essentials	$12,531.39
Rate for Payer: BCBS of TX PPO	$13,924.31

CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$22,906.40

Service Code	MSDRG 546
Min. Negotiated Rate	$10,443.84
Max. Negotiated Rate	$22,906.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,213.37
Rate for Payer: Amerigroup Medicare	$13,213.37
Rate for Payer: BCBS of TX Medicare	$13,213.37
Rate for Payer: Cigna Commercial	$14,855.79
Rate for Payer: Cigna Medicare	$13,213.37
Rate for Payer: Employer Direct Commercial	$13,213.37
Rate for Payer: Humana Medicare/TRICARE	$13,213.37
Rate for Payer: Molina Dual Medicare/Medicaid	$13,213.37
Rate for Payer: Molina Medicare	$13,213.37
Rate for Payer: Multiplan Auto	$22,906.40
Rate for Payer: Multiplan Commercial	$22,906.40
Rate for Payer: Multiplan Workers Comp	$22,906.40
Rate for Payer: Scott and White EPO/PPO	$10,549.00
Rate for Payer: Scott and White Medicare	$13,213.37
Rate for Payer: Superior Health Plan EPO	$13,213.37
Rate for Payer: Superior Health Plan Medicare	$13,213.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,213.37
Rate for Payer: Universal American Medicare	$13,213.37
Rate for Payer: Wellcare Medicare	$13,213.37
Rate for Payer: Wellmed Medicare	$13,213.37

CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$47,663.40

Service Code	MSDRG 545
Min. Negotiated Rate	$21,320.26
Max. Negotiated Rate	$47,663.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,948.52
Rate for Payer: Amerigroup Medicare	$22,948.52
Rate for Payer: BCBS of TX Medicare	$22,948.52
Rate for Payer: Cigna Commercial	$31,964.30
Rate for Payer: Cigna Medicare	$22,948.52
Rate for Payer: Employer Direct Commercial	$22,948.52
Rate for Payer: Humana Medicare/TRICARE	$22,948.52
Rate for Payer: Molina Dual Medicare/Medicaid	$22,948.52
Rate for Payer: Molina Medicare	$22,948.52
Rate for Payer: Multiplan Auto	$47,663.40
Rate for Payer: Multiplan Commercial	$47,663.40
Rate for Payer: Multiplan Workers Comp	$47,663.40
Rate for Payer: Scott and White EPO/PPO	$21,950.25
Rate for Payer: Scott and White Medicare	$22,948.52
Rate for Payer: Superior Health Plan EPO	$22,948.52
Rate for Payer: Superior Health Plan Medicare	$22,948.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,948.52
Rate for Payer: Universal American Medicare	$22,948.52
Rate for Payer: Wellcare Medicare	$22,948.52
Rate for Payer: Wellmed Medicare	$22,948.52

CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$17,381.20

Service Code	MSDRG 547
Min. Negotiated Rate	$7,375.36
Max. Negotiated Rate	$17,381.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,888.60
Rate for Payer: Amerigroup Medicare	$10,888.60
Rate for Payer: BCBS of TX Medicare	$10,888.60
Rate for Payer: Cigna Commercial	$10,770.26
Rate for Payer: Cigna Medicare	$10,888.60
Rate for Payer: Employer Direct Commercial	$10,888.60
Rate for Payer: Humana Medicare/TRICARE	$10,888.60
Rate for Payer: Molina Dual Medicare/Medicaid	$10,888.60
Rate for Payer: Molina Medicare	$10,888.60
Rate for Payer: Multiplan Auto	$17,381.20
Rate for Payer: Multiplan Commercial	$17,381.20
Rate for Payer: Multiplan Workers Comp	$17,381.20
Rate for Payer: Scott and White EPO/PPO	$8,004.50
Rate for Payer: Scott and White Medicare	$10,888.60
Rate for Payer: Superior Health Plan EPO	$10,888.60
Rate for Payer: Superior Health Plan Medicare	$10,888.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,888.60
Rate for Payer: Universal American Medicare	$10,888.60
Rate for Payer: Wellcare Medicare	$10,888.60
Rate for Payer: Wellmed Medicare	$10,888.60

CONNECTIVE TISSUE DISORDERS W MCC

Facility

$47,663.40

Service Code	MSDRG 545
Min. Negotiated Rate	$21,320.26
Max. Negotiated Rate	$47,663.40
Rate for Payer: BCBS of TX Blue Advantage	$21,320.26
Rate for Payer: BCBS of TX Blue Essentials	$25,581.83
Rate for Payer: BCBS of TX PPO	$28,425.36

CONNECTIVE TISSUE DISORDERS W/O CC/MCC

Facility

$17,381.20

Service Code	MSDRG 547
Min. Negotiated Rate	$7,375.36
Max. Negotiated Rate	$17,381.20
Rate for Payer: BCBS of TX Blue Advantage	$7,375.36
Rate for Payer: BCBS of TX Blue Essentials	$8,849.57
Rate for Payer: BCBS of TX PPO	$9,833.24

CONNECTOR 5-7MM TBG COUPLES O2

Facility

$9.08

Hospital Charge Code	993605
Hospital Revenue Code	270
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$6.54
Rate for Payer: Amerigroup CHIP/Medicaid	$0.82
Rate for Payer: BCBS of TX Blue Advantage	$2.72
Rate for Payer: BCBS of TX Blue Essentials	$3.27
Rate for Payer: BCBS of TX PPO	$3.63
Rate for Payer: Cash Price	$6.17
Rate for Payer: Cigna Medicaid	$6.54
Rate for Payer: Molina CHIP/Medicaid	$6.54
Rate for Payer: Multiplan Auto	$5.90
Rate for Payer: Multiplan Commercial	$5.90
Rate for Payer: Multiplan Workers Comp	$5.90
Rate for Payer: Parkland Medicaid	$6.54
Rate for Payer: Scott and White EPO/PPO	$4.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.54
Rate for Payer: Superior Health Plan EPO	$1.23

CONNECTOR 5-7MM TBG COUPLES O2

Facility

$9.08

Hospital Charge Code	993605
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.17

CONNECTOR CAP UNIV MALE FEMALE W/LUER LCK

Facility

$13.33

Hospital Charge Code	993293
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$9.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1.20
Rate for Payer: BCBS of TX Blue Advantage	$4.00
Rate for Payer: BCBS of TX Blue Essentials	$4.80
Rate for Payer: BCBS of TX PPO	$5.33
Rate for Payer: Cash Price	$9.06
Rate for Payer: Cigna Medicaid	$9.60
Rate for Payer: Molina CHIP/Medicaid	$9.60
Rate for Payer: Multiplan Auto	$8.66
Rate for Payer: Multiplan Commercial	$8.66
Rate for Payer: Multiplan Workers Comp	$8.66
Rate for Payer: Parkland Medicaid	$9.60
Rate for Payer: Scott and White EPO/PPO	$6.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.60
Rate for Payer: Superior Health Plan EPO	$1.81

CONNECTOR CAP UNIV MALE FEMALE W/LUER LCK

Facility

$13.33

Hospital Charge Code	993293
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9.06

CONNECTOR SWIVEL OXYGEN CLEAR NON STERILE

Facility

$9.38

Hospital Charge Code	993523
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.38

Know your out-of-pocket cost for care.

All Charges