White Rock Medical Center

All Charges

Charge

Type

Setting

Price

carvedilol 3.125 mg Tab

Facility

$9.30

Service Code	HCPCS J3490
Hospital Charge Code	78422803
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.79
Rate for Payer: BCBS of TX Blue Essentials	$3.35
Rate for Payer: BCBS of TX PPO	$3.72
Rate for Payer: Cash Price	$6.32
Rate for Payer: Cigna Medicaid	$6.70
Rate for Payer: Molina CHIP/Medicaid	$6.70
Rate for Payer: Multiplan Auto	$6.04
Rate for Payer: Multiplan Commercial	$6.04
Rate for Payer: Multiplan Workers Comp	$6.04
Rate for Payer: Parkland Medicaid	$6.70
Rate for Payer: Scott and White EPO/PPO	$4.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.70
Rate for Payer: Superior Health Plan EPO	$1.26

carvedilol 3.125 mg Tab

Facility

$9.30

Service Code	HCPCS J3490
Hospital Charge Code	78422803
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.32

carvedilol 6.25 mg Tab

Facility

$9.30

Service Code	HCPCS J3490
Hospital Charge Code	78404151
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.32

carvedilol 6.25 mg Tab

Facility

$9.30

Service Code	HCPCS J3490
Hospital Charge Code	78404151
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.79
Rate for Payer: BCBS of TX Blue Essentials	$3.35
Rate for Payer: BCBS of TX PPO	$3.72
Rate for Payer: Cash Price	$6.32
Rate for Payer: Cigna Medicaid	$6.70
Rate for Payer: Molina CHIP/Medicaid	$6.70
Rate for Payer: Multiplan Auto	$6.04
Rate for Payer: Multiplan Commercial	$6.04
Rate for Payer: Multiplan Workers Comp	$6.04
Rate for Payer: Parkland Medicaid	$6.70
Rate for Payer: Scott and White EPO/PPO	$4.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.70
Rate for Payer: Superior Health Plan EPO	$1.26

cassettes

Facility

$20.34

Hospital Charge Code	992581
Hospital Revenue Code	272
Rate for Payer: Cash Price	$13.83

cassettes

Facility

$20.34

Hospital Charge Code	992581
Hospital Revenue Code	272
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$14.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1.83
Rate for Payer: BCBS of TX Blue Advantage	$6.10
Rate for Payer: BCBS of TX Blue Essentials	$7.32
Rate for Payer: BCBS of TX PPO	$8.14
Rate for Payer: Cash Price	$13.83
Rate for Payer: Cigna Medicaid	$14.64
Rate for Payer: Molina CHIP/Medicaid	$14.64
Rate for Payer: Multiplan Auto	$13.22
Rate for Payer: Multiplan Commercial	$13.22
Rate for Payer: Multiplan Workers Comp	$13.22
Rate for Payer: Parkland Medicaid	$14.64
Rate for Payer: Scott and White EPO/PPO	$10.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.64
Rate for Payer: Superior Health Plan EPO	$2.77

Cassettes for NX Sterrad Sterilizer

Facility

$29.75

Hospital Charge Code	992589
Hospital Revenue Code	272
Rate for Payer: Cash Price	$20.23

Cassettes for NX Sterrad Sterilizer

Facility

$29.75

Hospital Charge Code	992589
Hospital Revenue Code	272
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$21.42
Rate for Payer: Amerigroup CHIP/Medicaid	$2.68
Rate for Payer: BCBS of TX Blue Advantage	$8.93
Rate for Payer: BCBS of TX Blue Essentials	$10.71
Rate for Payer: BCBS of TX PPO	$11.90
Rate for Payer: Cash Price	$20.23
Rate for Payer: Cigna Medicaid	$21.42
Rate for Payer: Molina CHIP/Medicaid	$21.42
Rate for Payer: Multiplan Auto	$19.34
Rate for Payer: Multiplan Commercial	$19.34
Rate for Payer: Multiplan Workers Comp	$19.34
Rate for Payer: Parkland Medicaid	$21.42
Rate for Payer: Scott and White EPO/PPO	$14.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.42
Rate for Payer: Superior Health Plan EPO	$4.05

CASSETTE VAC VERALINK ULTLNK0500.S

Facility

$237.22

Hospital Charge Code	122725
Hospital Revenue Code	272
Min. Negotiated Rate	$21.35
Max. Negotiated Rate	$170.80
Rate for Payer: Amerigroup CHIP/Medicaid	$21.35
Rate for Payer: BCBS of TX Blue Advantage	$71.17
Rate for Payer: BCBS of TX Blue Essentials	$85.40
Rate for Payer: BCBS of TX PPO	$94.89
Rate for Payer: Cash Price	$161.31
Rate for Payer: Cigna Medicaid	$170.80
Rate for Payer: Molina CHIP/Medicaid	$170.80
Rate for Payer: Multiplan Auto	$154.19
Rate for Payer: Multiplan Commercial	$154.19
Rate for Payer: Multiplan Workers Comp	$154.19
Rate for Payer: Parkland Medicaid	$170.80
Rate for Payer: Scott and White EPO/PPO	$118.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$170.80
Rate for Payer: Superior Health Plan EPO	$32.26

CASSETTE VAC VERALINK ULTLNK0500.S

Facility

$237.22

Hospital Charge Code	122725
Hospital Revenue Code	272
Rate for Payer: Cash Price	$161.31

Catecholamines Ur Free 24 Hr SO

Facility

$193.00

Service Code	HCPCS 82384
Hospital Charge Code	1701945
Hospital Revenue Code	301
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$138.96
Rate for Payer: Amerigroup CHIP/Medicaid	$9.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25.25
Rate for Payer: Amerigroup Medicare	$25.25
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$25.25
Rate for Payer: BCBS of TX PPO	$77.20
Rate for Payer: Cash Price	$131.24
Rate for Payer: Cash Price	$131.24
Rate for Payer: Cigna Medicaid	$138.96
Rate for Payer: Cigna Medicare	$25.25
Rate for Payer: Employer Direct Commercial	$25.25
Rate for Payer: Humana Medicare/TRICARE	$25.25
Rate for Payer: Molina CHIP/Medicaid	$138.96
Rate for Payer: Molina Dual Medicare/Medicaid	$25.25
Rate for Payer: Molina Medicare	$25.25
Rate for Payer: Multiplan Auto	$125.45
Rate for Payer: Multiplan Commercial	$125.45
Rate for Payer: Multiplan Workers Comp	$125.45
Rate for Payer: Parkland Medicaid	$138.96
Rate for Payer: Scott and White EPO/PPO	$31.56
Rate for Payer: Scott and White Medicare	$25.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$138.96
Rate for Payer: Superior Health Plan EPO	$25.25
Rate for Payer: Superior Health Plan Medicare	$25.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$25.25
Rate for Payer: Universal American Medicare	$25.25
Rate for Payer: Wellcare Medicare	$25.25
Rate for Payer: Wellmed Medicare	$25.25

Catecholamines Ur Free 24 Hr SO

Facility

$193.00

Service Code	HCPCS 82384
Hospital Charge Code	1701945
Hospital Revenue Code	301
Rate for Payer: Cash Price	$131.24

CATH ABL BLAZER 4MM

Facility

$2,465.00

Service Code	HCPCS C1888
Hospital Charge Code	8494508
Hospital Revenue Code	278
Min. Negotiated Rate	$616.25
Max. Negotiated Rate	$1,232.50
Rate for Payer: Cash Price	$1,676.20
Rate for Payer: Cigna Commercial	$616.25
Rate for Payer: Multiplan Auto	$1,232.50
Rate for Payer: Multiplan Commercial	$1,232.50
Rate for Payer: Multiplan Workers Comp	$1,232.50
Rate for Payer: Scott and White EPO/PPO	$1,232.50

CATH ABL BLAZER 4MM

Facility

$2,465.00

Service Code	HCPCS C1888
Hospital Charge Code	8494508
Hospital Revenue Code	278
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$1,774.80
Rate for Payer: Amerigroup CHIP/Medicaid	$221.85
Rate for Payer: BCBS of TX Blue Advantage	$739.50
Rate for Payer: BCBS of TX Blue Essentials	$887.40
Rate for Payer: BCBS of TX PPO	$986.00
Rate for Payer: Cash Price	$1,676.20
Rate for Payer: Cigna Medicaid	$1,774.80
Rate for Payer: Molina CHIP/Medicaid	$1,774.80
Rate for Payer: Multiplan Auto	$1,232.50
Rate for Payer: Multiplan Commercial	$1,232.50
Rate for Payer: Multiplan Workers Comp	$1,232.50
Rate for Payer: Parkland Medicaid	$1,774.80
Rate for Payer: Scott and White EPO/PPO	$1,232.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,774.80
Rate for Payer: Superior Health Plan EPO	$335.24

CATH ABL NAVISTR DEFL TI -- DHF

Facility

$12,289.72

Hospital Charge Code	82406455
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8,357.01

CATH ABL NAVISTR DEFL TI -- DHF

Facility

$12,289.72

Hospital Charge Code	82406455
Hospital Revenue Code	272
Min. Negotiated Rate	$1,106.07
Max. Negotiated Rate	$8,848.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,106.07
Rate for Payer: BCBS of TX Blue Advantage	$3,686.92
Rate for Payer: BCBS of TX Blue Essentials	$4,424.30
Rate for Payer: BCBS of TX PPO	$4,915.89
Rate for Payer: Cash Price	$8,357.01
Rate for Payer: Cigna Medicaid	$8,848.60
Rate for Payer: Molina CHIP/Medicaid	$8,848.60
Rate for Payer: Multiplan Auto	$7,988.32
Rate for Payer: Multiplan Commercial	$7,988.32
Rate for Payer: Multiplan Workers Comp	$7,988.32
Rate for Payer: Parkland Medicaid	$8,848.60
Rate for Payer: Scott and White EPO/PPO	$6,144.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,848.60
Rate for Payer: Superior Health Plan EPO	$1,671.40

CATH ANGIO -- DHF

Facility

$72.64

Hospital Charge Code	80560147
Hospital Revenue Code	272
Rate for Payer: Cash Price	$49.40

CATH ANGIO -- DHF

Facility

$72.64

Hospital Charge Code	80560147
Hospital Revenue Code	272
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$52.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6.54
Rate for Payer: BCBS of TX Blue Advantage	$21.79
Rate for Payer: BCBS of TX Blue Essentials	$26.15
Rate for Payer: BCBS of TX PPO	$29.06
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cigna Medicaid	$52.30
Rate for Payer: Molina CHIP/Medicaid	$52.30
Rate for Payer: Multiplan Auto	$47.22
Rate for Payer: Multiplan Commercial	$47.22
Rate for Payer: Multiplan Workers Comp	$47.22
Rate for Payer: Parkland Medicaid	$52.30
Rate for Payer: Scott and White EPO/PPO	$36.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.30
Rate for Payer: Superior Health Plan EPO	$9.88

CATH, ANGIOPLASTY BLL EUP2030X

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992540
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATH, ANGIOPLASTY BLL EUP2030X

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992540
Hospital Revenue Code	272
Min. Negotiated Rate	$69.46
Max. Negotiated Rate	$555.70
Rate for Payer: Amerigroup CHIP/Medicaid	$69.46
Rate for Payer: BCBS of TX Blue Advantage	$231.54
Rate for Payer: BCBS of TX Blue Essentials	$277.85
Rate for Payer: BCBS of TX PPO	$308.72
Rate for Payer: Cash Price	$524.82
Rate for Payer: Cigna Medicaid	$555.70
Rate for Payer: Molina CHIP/Medicaid	$555.70
Rate for Payer: Multiplan Auto	$501.67
Rate for Payer: Multiplan Commercial	$501.67
Rate for Payer: Multiplan Workers Comp	$501.67
Rate for Payer: Parkland Medicaid	$555.70
Rate for Payer: Scott and White EPO/PPO	$385.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$555.70
Rate for Payer: Superior Health Plan EPO	$104.96

CATH ANGIOSPRV TRQ HCOAT -- DHF

Facility

$302.07

Hospital Charge Code	80560212
Hospital Revenue Code	272
Min. Negotiated Rate	$27.19
Max. Negotiated Rate	$217.49
Rate for Payer: Amerigroup CHIP/Medicaid	$27.19
Rate for Payer: BCBS of TX Blue Advantage	$90.62
Rate for Payer: BCBS of TX Blue Essentials	$108.75
Rate for Payer: BCBS of TX PPO	$120.83
Rate for Payer: Cash Price	$205.41
Rate for Payer: Cigna Medicaid	$217.49
Rate for Payer: Molina CHIP/Medicaid	$217.49
Rate for Payer: Multiplan Auto	$196.35
Rate for Payer: Multiplan Commercial	$196.35
Rate for Payer: Multiplan Workers Comp	$196.35
Rate for Payer: Parkland Medicaid	$217.49
Rate for Payer: Scott and White EPO/PPO	$151.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$217.49
Rate for Payer: Superior Health Plan EPO	$41.08

CATH ANGIOSPRV TRQ HCOAT -- DHF

Facility

$302.07

Hospital Charge Code	80560212
Hospital Revenue Code	272
Rate for Payer: Cash Price	$205.41

CATH ANG QUICK-CROSS -- DHF

Facility

$797.00

Service Code	HCPCS C1713
Hospital Charge Code	82400292
Hospital Revenue Code	278
Min. Negotiated Rate	$71.73
Max. Negotiated Rate	$573.84
Rate for Payer: Amerigroup CHIP/Medicaid	$71.73
Rate for Payer: BCBS of TX Blue Advantage	$239.10
Rate for Payer: BCBS of TX Blue Essentials	$286.92
Rate for Payer: BCBS of TX PPO	$318.80
Rate for Payer: Cash Price	$541.96
Rate for Payer: Cigna Medicaid	$573.84
Rate for Payer: Molina CHIP/Medicaid	$573.84
Rate for Payer: Multiplan Auto	$398.50
Rate for Payer: Multiplan Commercial	$398.50
Rate for Payer: Multiplan Workers Comp	$398.50
Rate for Payer: Parkland Medicaid	$573.84
Rate for Payer: Scott and White EPO/PPO	$398.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$573.84
Rate for Payer: Superior Health Plan EPO	$108.39

CATH ANG QUICK-CROSS -- DHF

Facility

$797.00

Service Code	HCPCS C1713
Hospital Charge Code	82400292
Hospital Revenue Code	278
Min. Negotiated Rate	$199.25
Max. Negotiated Rate	$398.50
Rate for Payer: Cash Price	$541.96
Rate for Payer: Cigna Commercial	$199.25
Rate for Payer: Multiplan Auto	$398.50
Rate for Payer: Multiplan Commercial	$398.50
Rate for Payer: Multiplan Workers Comp	$398.50
Rate for Payer: Scott and White EPO/PPO	$398.50

CATH ARMADA BALLOON 35

Facility

$861.00

Service Code	HCPCS C1726
Hospital Charge Code	82401258
Hospital Revenue Code	278
Min. Negotiated Rate	$215.25
Max. Negotiated Rate	$430.50
Rate for Payer: Cash Price	$585.48
Rate for Payer: Cigna Commercial	$215.25
Rate for Payer: Multiplan Auto	$430.50
Rate for Payer: Multiplan Commercial	$430.50
Rate for Payer: Multiplan Workers Comp	$430.50
Rate for Payer: Scott and White EPO/PPO	$430.50

Know your out-of-pocket cost for care.

All Charges