White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR CENTRAL CATHETER KIT

Facility

$291.92

Service Code	HCPCS C1751
Hospital Charge Code	8082230
Hospital Revenue Code	278
Min. Negotiated Rate	$26.27
Max. Negotiated Rate	$145.96
Rate for Payer: Aetna Commercial	$87.58
Rate for Payer: Amerigroup CHIP/Medicaid	$26.27
Rate for Payer: BCBS of TX Blue Advantage	$87.58
Rate for Payer: BCBS of TX Blue Essentials	$105.09
Rate for Payer: BCBS of TX PPO	$116.77
Rate for Payer: Cash Price	$256.89
Rate for Payer: Multiplan Auto	$145.96
Rate for Payer: Multiplan Commercial	$145.96
Rate for Payer: Multiplan Workers Comp	$145.96
Rate for Payer: Scott and White EPO/PPO	$145.96
Rate for Payer: Superior Health Plan EPO	$39.70

CHWR CENTRAL CATHETER KIT

Facility

$291.92

Service Code	HCPCS C1751
Hospital Charge Code	8082230
Hospital Revenue Code	278
Min. Negotiated Rate	$72.98
Max. Negotiated Rate	$145.96
Rate for Payer: Aetna Commercial	$87.58
Rate for Payer: Cash Price	$256.89
Rate for Payer: Cigna Commercial	$72.98
Rate for Payer: Multiplan Auto	$145.96
Rate for Payer: Multiplan Commercial	$145.96
Rate for Payer: Multiplan Workers Comp	$145.96
Rate for Payer: Scott and White EPO/PPO	$145.96

CHWR CENTRAL CATHETER KIT BCE

Facility

$291.92

Service Code	HCPCS C1751
Hospital Charge Code	8082230
Hospital Revenue Code	278
Min. Negotiated Rate	$26.27
Max. Negotiated Rate	$145.96
Rate for Payer: Aetna Commercial	$87.58
Rate for Payer: Amerigroup CHIP/Medicaid	$26.27
Rate for Payer: BCBS of TX Blue Advantage	$87.58
Rate for Payer: BCBS of TX Blue Essentials	$105.09
Rate for Payer: BCBS of TX PPO	$116.77
Rate for Payer: Cash Price	$256.89
Rate for Payer: Multiplan Auto	$145.96
Rate for Payer: Multiplan Commercial	$145.96
Rate for Payer: Multiplan Workers Comp	$145.96
Rate for Payer: Scott and White EPO/PPO	$145.96
Rate for Payer: Superior Health Plan EPO	$39.70

CHWR CENTRAL CATHETER KIT BCE

Facility

$291.92

Service Code	HCPCS C1751
Hospital Charge Code	8082230
Hospital Revenue Code	278
Min. Negotiated Rate	$72.98
Max. Negotiated Rate	$145.96
Rate for Payer: Aetna Commercial	$87.58
Rate for Payer: Cash Price	$256.89
Rate for Payer: Cigna Commercial	$72.98
Rate for Payer: Multiplan Auto	$145.96
Rate for Payer: Multiplan Commercial	$145.96
Rate for Payer: Multiplan Workers Comp	$145.96
Rate for Payer: Scott and White EPO/PPO	$145.96

CHWR CHIBA NEEDLES ALL

Facility

$76.00

Hospital Charge Code	8032780
Hospital Revenue Code	272
Rate for Payer: Cash Price	$66.88

CHWR CHIBA NEEDLES ALL

Facility

$76.00

Hospital Charge Code	8032780
Hospital Revenue Code	272
Min. Negotiated Rate	$6.84
Max. Negotiated Rate	$49.40
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Amerigroup CHIP/Medicaid	$6.84
Rate for Payer: BCBS of TX Blue Advantage	$22.80
Rate for Payer: BCBS of TX Blue Essentials	$27.36
Rate for Payer: BCBS of TX PPO	$30.40
Rate for Payer: Cash Price	$66.88
Rate for Payer: Multiplan Auto	$49.40
Rate for Payer: Multiplan Commercial	$49.40
Rate for Payer: Multiplan Workers Comp	$49.40
Rate for Payer: Scott and White EPO/PPO	$38.00
Rate for Payer: Superior Health Plan EPO	$10.34

CHWR COBAN WRAP

Facility

$45.82

Hospital Charge Code	8024031
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

CHWR COBAN WRAP BCE

Facility

$45.82

Hospital Charge Code	8024031
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

CHWR COBAN WRAP BCE

Facility

$45.82

Hospital Charge Code	8024031
Hospital Revenue Code	270
Rate for Payer: Cash Price	$40.32

CHWR CONNECTING TUBE

Facility

$66.89

Hospital Charge Code	8177545
Hospital Revenue Code	270
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$43.48
Rate for Payer: Aetna Commercial	$36.79
Rate for Payer: Amerigroup CHIP/Medicaid	$6.02
Rate for Payer: BCBS of TX Blue Advantage	$20.07
Rate for Payer: BCBS of TX Blue Essentials	$24.08
Rate for Payer: BCBS of TX PPO	$26.76
Rate for Payer: Cash Price	$58.86
Rate for Payer: Multiplan Auto	$43.48
Rate for Payer: Multiplan Commercial	$43.48
Rate for Payer: Multiplan Workers Comp	$43.48
Rate for Payer: Scott and White EPO/PPO	$33.44
Rate for Payer: Superior Health Plan EPO	$9.10

CHWR CONNECTING TUBE BCE

Facility

$66.89

Hospital Charge Code	8177545
Hospital Revenue Code	270
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$43.48
Rate for Payer: Aetna Commercial	$36.79
Rate for Payer: Amerigroup CHIP/Medicaid	$6.02
Rate for Payer: BCBS of TX Blue Advantage	$20.07
Rate for Payer: BCBS of TX Blue Essentials	$24.08
Rate for Payer: BCBS of TX PPO	$26.76
Rate for Payer: Cash Price	$58.86
Rate for Payer: Multiplan Auto	$43.48
Rate for Payer: Multiplan Commercial	$43.48
Rate for Payer: Multiplan Workers Comp	$43.48
Rate for Payer: Scott and White EPO/PPO	$33.44
Rate for Payer: Superior Health Plan EPO	$9.10

CHWR CONNECTING TUBE BCE

Facility

$66.89

Hospital Charge Code	8177545
Hospital Revenue Code	270
Rate for Payer: Cash Price	$58.86

CHWR CONNECTION TUBING

Facility

$87.80

Hospital Charge Code	8185585
Hospital Revenue Code	272
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$57.07
Rate for Payer: Aetna Commercial	$48.29
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$77.26
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan EPO	$11.94

CHWR CONNECTION TUBING BCE

Facility

$87.80

Hospital Charge Code	8185585
Hospital Revenue Code	272
Rate for Payer: Cash Price	$77.26

CHWR CONNECTION TUBING BCE

Facility

$87.80

Hospital Charge Code	8185585
Hospital Revenue Code	272
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$57.07
Rate for Payer: Aetna Commercial	$48.29
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$77.26
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan EPO	$11.94

CHWR CT GUIDE NEEDLE PLACEMENT

Facility

$4,508.00

Service Code	CPT 77012
Hospital Charge Code	5056361
Hospital Revenue Code	350
Min. Negotiated Rate	$108.13
Max. Negotiated Rate	$2,930.20
Rate for Payer: Aetna Commercial	$108.13
Rate for Payer: Amerigroup CHIP/Medicaid	$405.72
Rate for Payer: BCBS of TX Blue Advantage	$129.03
Rate for Payer: BCBS of TX Blue Essentials	$154.84
Rate for Payer: BCBS of TX PPO	$172.82
Rate for Payer: Cash Price	$3,967.04
Rate for Payer: Cash Price	$3,967.04
Rate for Payer: Multiplan Auto	$2,930.20
Rate for Payer: Multiplan Commercial	$2,930.20
Rate for Payer: Multiplan Workers Comp	$2,930.20
Rate for Payer: Scott and White EPO/PPO	$2,254.00
Rate for Payer: Superior Health Plan EPO	$613.09

CHWR CT GUIDE NEEDLE PLACEMENT BCE

Facility

$4,508.00

Service Code	CPT 77012
Hospital Charge Code	5056361
Hospital Revenue Code	350
Min. Negotiated Rate	$108.13
Max. Negotiated Rate	$2,930.20
Rate for Payer: Aetna Commercial	$108.13
Rate for Payer: Amerigroup CHIP/Medicaid	$405.72
Rate for Payer: BCBS of TX Blue Advantage	$129.03
Rate for Payer: BCBS of TX Blue Essentials	$154.84
Rate for Payer: BCBS of TX PPO	$172.82
Rate for Payer: Cash Price	$3,967.04
Rate for Payer: Cash Price	$3,967.04
Rate for Payer: Multiplan Auto	$2,930.20
Rate for Payer: Multiplan Commercial	$2,930.20
Rate for Payer: Multiplan Workers Comp	$2,930.20
Rate for Payer: Scott and White EPO/PPO	$2,254.00
Rate for Payer: Superior Health Plan EPO	$613.09

CHWR CT GUIDE NEEDLE PLACEMENT BCE

Facility

$4,508.00

Service Code	CPT 77012
Hospital Charge Code	5056361
Hospital Revenue Code	350
Rate for Payer: Cash Price	$3,967.04

CHWR CT GUIDE PERC DRAIN ABSCESS W CATH

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	5055990
Hospital Revenue Code	320
Min. Negotiated Rate	$88.25
Max. Negotiated Rate	$2,063.10
Rate for Payer: Aetna Commercial	$88.25
Rate for Payer: Amerigroup CHIP/Medicaid	$285.66
Rate for Payer: BCBS of TX Blue Advantage	$105.25
Rate for Payer: BCBS of TX Blue Essentials	$126.30
Rate for Payer: BCBS of TX PPO	$140.98
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Multiplan Auto	$2,063.10
Rate for Payer: Multiplan Commercial	$2,063.10
Rate for Payer: Multiplan Workers Comp	$2,063.10
Rate for Payer: Scott and White EPO/PPO	$1,587.00
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR CT GUIDE PERC DRAIN ABSCESS W CATH BCE

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	5055990
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,793.12

CHWR CT GUIDE PERC DRAIN ABSCESS W CATH BCE

Facility

$3,174.00

Service Code	CPT 75989
Hospital Charge Code	5055990
Hospital Revenue Code	320
Min. Negotiated Rate	$88.25
Max. Negotiated Rate	$2,063.10
Rate for Payer: Aetna Commercial	$88.25
Rate for Payer: Amerigroup CHIP/Medicaid	$285.66
Rate for Payer: BCBS of TX Blue Advantage	$105.25
Rate for Payer: BCBS of TX Blue Essentials	$126.30
Rate for Payer: BCBS of TX PPO	$140.98
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Cash Price	$2,793.12
Rate for Payer: Multiplan Auto	$2,063.10
Rate for Payer: Multiplan Commercial	$2,063.10
Rate for Payer: Multiplan Workers Comp	$2,063.10
Rate for Payer: Scott and White EPO/PPO	$1,587.00
Rate for Payer: Superior Health Plan EPO	$431.66

CHWR DILATOR ANY SIZE

Facility

$77.63

Hospital Charge Code	8174035
Hospital Revenue Code	272
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$50.46
Rate for Payer: Aetna Commercial	$42.70
Rate for Payer: Amerigroup CHIP/Medicaid	$6.99
Rate for Payer: BCBS of TX Blue Advantage	$23.29
Rate for Payer: BCBS of TX Blue Essentials	$27.95
Rate for Payer: BCBS of TX PPO	$31.05
Rate for Payer: Cash Price	$68.31
Rate for Payer: Multiplan Auto	$50.46
Rate for Payer: Multiplan Commercial	$50.46
Rate for Payer: Multiplan Workers Comp	$50.46
Rate for Payer: Scott and White EPO/PPO	$38.82
Rate for Payer: Superior Health Plan EPO	$10.56

CHWR DILATOR ANY SIZE BCE

Facility

$77.63

Hospital Charge Code	8174035
Hospital Revenue Code	272
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$50.46
Rate for Payer: Aetna Commercial	$42.70
Rate for Payer: Amerigroup CHIP/Medicaid	$6.99
Rate for Payer: BCBS of TX Blue Advantage	$23.29
Rate for Payer: BCBS of TX Blue Essentials	$27.95
Rate for Payer: BCBS of TX PPO	$31.05
Rate for Payer: Cash Price	$68.31
Rate for Payer: Multiplan Auto	$50.46
Rate for Payer: Multiplan Commercial	$50.46
Rate for Payer: Multiplan Workers Comp	$50.46
Rate for Payer: Scott and White EPO/PPO	$38.82
Rate for Payer: Superior Health Plan EPO	$10.56

CHWR DILATOR ANY SIZE BCE

Facility

$77.63

Hospital Charge Code	8174035
Hospital Revenue Code	272
Rate for Payer: Cash Price	$68.31

CHWR DOBHOFF TUBE FEEDING TUBE

Facility

$64.05

Hospital Charge Code	8034690
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$41.63
Rate for Payer: Aetna Commercial	$35.23
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$19.22
Rate for Payer: BCBS of TX Blue Essentials	$23.06
Rate for Payer: BCBS of TX PPO	$25.62
Rate for Payer: Cash Price	$56.36
Rate for Payer: Multiplan Auto	$41.63
Rate for Payer: Multiplan Commercial	$41.63
Rate for Payer: Multiplan Workers Comp	$41.63
Rate for Payer: Scott and White EPO/PPO	$32.02
Rate for Payer: Superior Health Plan EPO	$8.71

Know your out-of-pocket cost for care.

All Charges