White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

CATH ASPIRATION EXPORTAP -- DHF

Facility

$2,518.00

Service Code	HCPCS C1757
Hospital Charge Code	80560527
Hospital Revenue Code	278
Min. Negotiated Rate	$629.50
Max. Negotiated Rate	$1,259.00
Rate for Payer: Cash Price	$1,712.24
Rate for Payer: Cigna Commercial	$629.50
Rate for Payer: Multiplan Auto	$1,259.00
Rate for Payer: Multiplan Commercial	$1,259.00
Rate for Payer: Multiplan Workers Comp	$1,259.00
Rate for Payer: Scott and White EPO/PPO	$1,259.00

CATH ASPIRATION EXPORTAP -- DHF

Facility

$2,518.00

Service Code	HCPCS C1757
Hospital Charge Code	80560527
Hospital Revenue Code	278
Min. Negotiated Rate	$226.62
Max. Negotiated Rate	$1,812.96
Rate for Payer: Amerigroup CHIP/Medicaid	$226.62
Rate for Payer: BCBS of TX Blue Advantage	$755.40
Rate for Payer: BCBS of TX Blue Essentials	$906.48
Rate for Payer: BCBS of TX PPO	$1,007.20
Rate for Payer: Cash Price	$1,712.24
Rate for Payer: Cigna Medicaid	$1,812.96
Rate for Payer: Molina CHIP/Medicaid	$1,812.96
Rate for Payer: Multiplan Auto	$1,259.00
Rate for Payer: Multiplan Commercial	$1,259.00
Rate for Payer: Multiplan Workers Comp	$1,259.00
Rate for Payer: Parkland Medicaid	$1,812.96
Rate for Payer: Scott and White EPO/PPO	$1,259.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,812.96
Rate for Payer: Superior Health Plan EPO	$342.45

CATH ATRIAL PACING

Facility

$3,198.00

Service Code	HCPCS 93610
Hospital Charge Code	4613551
Hospital Revenue Code	481
Rate for Payer: Cash Price	$2,174.64

CATH ATRIAL PACING

Facility

$3,198.00

Service Code	HCPCS 93610
Hospital Charge Code	4613551
Hospital Revenue Code	481
Min. Negotiated Rate	$287.82
Max. Negotiated Rate	$16,562.21
Rate for Payer: Amerigroup CHIP/Medicaid	$287.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Amerigroup Medicare	$7,835.21
Rate for Payer: BCBS of TX Blue Advantage	$9,829.14
Rate for Payer: BCBS of TX Blue Essentials	$11,771.42
Rate for Payer: BCBS of TX Medicare	$7,835.21
Rate for Payer: BCBS of TX PPO	$14,831.99
Rate for Payer: Cash Price	$2,174.64
Rate for Payer: Cash Price	$2,174.64
Rate for Payer: Cash Price	$2,174.64
Rate for Payer: Cigna Commercial	$16,562.21
Rate for Payer: Cigna Medicaid	$2,302.56
Rate for Payer: Cigna Medicare	$7,835.21
Rate for Payer: Employer Direct Commercial	$7,835.21
Rate for Payer: Humana Medicare/TRICARE	$7,835.21
Rate for Payer: Molina CHIP/Medicaid	$2,302.56
Rate for Payer: Molina Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Molina Medicare	$7,835.21
Rate for Payer: Multiplan Auto	$2,078.70
Rate for Payer: Multiplan Commercial	$2,078.70
Rate for Payer: Multiplan Workers Comp	$2,078.70
Rate for Payer: Parkland Medicaid	$2,302.56
Rate for Payer: Scott and White EPO/PPO	$1,599.00
Rate for Payer: Scott and White Medicare	$7,835.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,302.56
Rate for Payer: Superior Health Plan EPO	$7,835.21
Rate for Payer: Superior Health Plan Medicare	$7,835.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,835.21
Rate for Payer: Universal American Medicare	$7,835.21
Rate for Payer: Wellcare Medicare	$7,835.21
Rate for Payer: Wellmed Medicare	$7,835.21

CATH BALLN NC EUPH NCEUP2008X

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992538
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 BALLN NC EUPH NCEUP2008X

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992538
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATH BALLN NC EUPH NCEUP3008X

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992539
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATH BALLN NC EUPH NCEUP3008X

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992539
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 BLN BVCS618

Facility

$449.46

Hospital Charge Code	8504477
Hospital Revenue Code	272
Rate for Payer: Cash Price	$305.63

CATH BLN BVCS618

Facility

$449.46

Hospital Charge Code	8504477
Hospital Revenue Code	272
Min. Negotiated Rate	$40.45
Max. Negotiated Rate	$323.61
Rate for Payer: Amerigroup CHIP/Medicaid	$40.45
Rate for Payer: BCBS of TX Blue Advantage	$134.84
Rate for Payer: BCBS of TX Blue Essentials	$161.81
Rate for Payer: BCBS of TX PPO	$179.78
Rate for Payer: Cash Price	$305.63
Rate for Payer: Cigna Medicaid	$323.61
Rate for Payer: Molina CHIP/Medicaid	$323.61
Rate for Payer: Multiplan Auto	$292.15
Rate for Payer: Multiplan Commercial	$292.15
Rate for Payer: Multiplan Workers Comp	$292.15
Rate for Payer: Parkland Medicaid	$323.61
Rate for Payer: Scott and White EPO/PPO	$224.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$323.61
Rate for Payer: Superior Health Plan EPO	$61.13

CATH BLN DIL 4MM VIATRAC

Facility

$703.70

Hospital Charge Code	8504480
Hospital Revenue Code	272
Rate for Payer: Cash Price	$478.52

CATH BLN DIL 4MM VIATRAC

Facility

$703.70

Hospital Charge Code	8504480
Hospital Revenue Code	272
Min. Negotiated Rate	$63.33
Max. Negotiated Rate	$506.66
Rate for Payer: Amerigroup CHIP/Medicaid	$63.33
Rate for Payer: BCBS of TX Blue Advantage	$211.11
Rate for Payer: BCBS of TX Blue Essentials	$253.33
Rate for Payer: BCBS of TX PPO	$281.48
Rate for Payer: Cash Price	$478.52
Rate for Payer: Cigna Medicaid	$506.66
Rate for Payer: Molina CHIP/Medicaid	$506.66
Rate for Payer: Multiplan Auto	$457.40
Rate for Payer: Multiplan Commercial	$457.40
Rate for Payer: Multiplan Workers Comp	$457.40
Rate for Payer: Parkland Medicaid	$506.66
Rate for Payer: Scott and White EPO/PPO	$351.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$506.66
Rate for Payer: Superior Health Plan EPO	$95.70

CATH BLN DIL CRE FX WIRE -- DHF

Facility

$1,036.00

Service Code	HCPCS C1726
Hospital Charge Code	82400714
Hospital Revenue Code	278
Min. Negotiated Rate	$93.24
Max. Negotiated Rate	$745.92
Rate for Payer: Amerigroup CHIP/Medicaid	$93.24
Rate for Payer: BCBS of TX Blue Advantage	$310.80
Rate for Payer: BCBS of TX Blue Essentials	$372.96
Rate for Payer: BCBS of TX PPO	$414.40
Rate for Payer: Cash Price	$704.48
Rate for Payer: Cigna Medicaid	$745.92
Rate for Payer: Molina CHIP/Medicaid	$745.92
Rate for Payer: Multiplan Auto	$518.00
Rate for Payer: Multiplan Commercial	$518.00
Rate for Payer: Multiplan Workers Comp	$518.00
Rate for Payer: Parkland Medicaid	$745.92
Rate for Payer: Scott and White EPO/PPO	$518.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$745.92
Rate for Payer: Superior Health Plan EPO	$140.90

CATH BLN DIL CRE FX WIRE -- DHF

Facility

$1,036.00

Service Code	HCPCS C1726
Hospital Charge Code	82400714
Hospital Revenue Code	278
Min. Negotiated Rate	$259.00
Max. Negotiated Rate	$518.00
Rate for Payer: Cash Price	$704.48
Rate for Payer: Cigna Commercial	$259.00
Rate for Payer: Multiplan Auto	$518.00
Rate for Payer: Multiplan Commercial	$518.00
Rate for Payer: Multiplan Workers Comp	$518.00
Rate for Payer: Scott and White EPO/PPO	$518.00

CATH BLN DIL MARSHAL -- DHF

Facility

$2,030.00

Service Code	HCPCS C1726
Hospital Charge Code	82400706
Hospital Revenue Code	278
Min. Negotiated Rate	$507.50
Max. Negotiated Rate	$1,015.00
Rate for Payer: Cash Price	$1,380.40
Rate for Payer: Cigna Commercial	$507.50
Rate for Payer: Multiplan Auto	$1,015.00
Rate for Payer: Multiplan Commercial	$1,015.00
Rate for Payer: Multiplan Workers Comp	$1,015.00
Rate for Payer: Scott and White EPO/PPO	$1,015.00

CATH BLN DIL MARSHAL -- DHF

Facility

$2,030.00

Service Code	HCPCS C1726
Hospital Charge Code	82400706
Hospital Revenue Code	278
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$1,461.60
Rate for Payer: Amerigroup CHIP/Medicaid	$182.70
Rate for Payer: BCBS of TX Blue Advantage	$609.00
Rate for Payer: BCBS of TX Blue Essentials	$730.80
Rate for Payer: BCBS of TX PPO	$812.00
Rate for Payer: Cash Price	$1,380.40
Rate for Payer: Cigna Medicaid	$1,461.60
Rate for Payer: Molina CHIP/Medicaid	$1,461.60
Rate for Payer: Multiplan Auto	$1,015.00
Rate for Payer: Multiplan Commercial	$1,015.00
Rate for Payer: Multiplan Workers Comp	$1,015.00
Rate for Payer: Parkland Medicaid	$1,461.60
Rate for Payer: Scott and White EPO/PPO	$1,015.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,461.60
Rate for Payer: Superior Health Plan EPO	$276.08

CATH BLN DIL MINI TREK -- DHF

Facility

$736.00

Service Code	HCPCS C1726
Hospital Charge Code	80517261
Hospital Revenue Code	278
Min. Negotiated Rate	$66.24
Max. Negotiated Rate	$529.92
Rate for Payer: Amerigroup CHIP/Medicaid	$66.24
Rate for Payer: BCBS of TX Blue Advantage	$220.80
Rate for Payer: BCBS of TX Blue Essentials	$264.96
Rate for Payer: BCBS of TX PPO	$294.40
Rate for Payer: Cash Price	$500.48
Rate for Payer: Cigna Medicaid	$529.92
Rate for Payer: Molina CHIP/Medicaid	$529.92
Rate for Payer: Multiplan Auto	$368.00
Rate for Payer: Multiplan Commercial	$368.00
Rate for Payer: Multiplan Workers Comp	$368.00
Rate for Payer: Parkland Medicaid	$529.92
Rate for Payer: Scott and White EPO/PPO	$368.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$529.92
Rate for Payer: Superior Health Plan EPO	$100.10

CATH BLN DIL MINI TREK -- DHF

Facility

$736.00

Service Code	HCPCS C1726
Hospital Charge Code	80517261
Hospital Revenue Code	278
Min. Negotiated Rate	$184.00
Max. Negotiated Rate	$368.00
Rate for Payer: Cash Price	$500.48
Rate for Payer: Cigna Commercial	$184.00
Rate for Payer: Multiplan Auto	$368.00
Rate for Payer: Multiplan Commercial	$368.00
Rate for Payer: Multiplan Workers Comp	$368.00
Rate for Payer: Scott and White EPO/PPO	$368.00

CATH BLN DIL NONVASCULAR -- DHF

Facility

$1,523.00

Service Code	HCPCS C1726
Hospital Charge Code	82400748
Hospital Revenue Code	278
Min. Negotiated Rate	$137.07
Max. Negotiated Rate	$1,096.56
Rate for Payer: Amerigroup CHIP/Medicaid	$137.07
Rate for Payer: BCBS of TX Blue Advantage	$456.90
Rate for Payer: BCBS of TX Blue Essentials	$548.28
Rate for Payer: BCBS of TX PPO	$609.20
Rate for Payer: Cash Price	$1,035.64
Rate for Payer: Cigna Medicaid	$1,096.56
Rate for Payer: Molina CHIP/Medicaid	$1,096.56
Rate for Payer: Multiplan Auto	$761.50
Rate for Payer: Multiplan Commercial	$761.50
Rate for Payer: Multiplan Workers Comp	$761.50
Rate for Payer: Parkland Medicaid	$1,096.56
Rate for Payer: Scott and White EPO/PPO	$761.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,096.56
Rate for Payer: Superior Health Plan EPO	$207.13

CATH BLN DIL NONVASCULAR -- DHF

Facility

$1,523.00

Service Code	HCPCS C1726
Hospital Charge Code	82400748
Hospital Revenue Code	278
Min. Negotiated Rate	$380.75
Max. Negotiated Rate	$761.50
Rate for Payer: Cash Price	$1,035.64
Rate for Payer: Cigna Commercial	$380.75
Rate for Payer: Multiplan Auto	$761.50
Rate for Payer: Multiplan Commercial	$761.50
Rate for Payer: Multiplan Workers Comp	$761.50
Rate for Payer: Scott and White EPO/PPO	$761.50

CATH BLN DIL OTW -- DHF

Facility

$3,986.00

Service Code	HCPCS C1726
Hospital Charge Code	80550825
Hospital Revenue Code	278
Min. Negotiated Rate	$996.50
Max. Negotiated Rate	$1,993.00
Rate for Payer: Cash Price	$2,710.48
Rate for Payer: Cigna Commercial	$996.50
Rate for Payer: Multiplan Auto	$1,993.00
Rate for Payer: Multiplan Commercial	$1,993.00
Rate for Payer: Multiplan Workers Comp	$1,993.00
Rate for Payer: Scott and White EPO/PPO	$1,993.00

CATH BLN DIL OTW -- DHF

Facility

$3,986.00

Service Code	HCPCS C1726
Hospital Charge Code	80550825
Hospital Revenue Code	278
Min. Negotiated Rate	$358.74
Max. Negotiated Rate	$2,869.92
Rate for Payer: Amerigroup CHIP/Medicaid	$358.74
Rate for Payer: BCBS of TX Blue Advantage	$1,195.80
Rate for Payer: BCBS of TX Blue Essentials	$1,434.96
Rate for Payer: BCBS of TX PPO	$1,594.40
Rate for Payer: Cash Price	$2,710.48
Rate for Payer: Cigna Medicaid	$2,869.92
Rate for Payer: Molina CHIP/Medicaid	$2,869.92
Rate for Payer: Multiplan Auto	$1,993.00
Rate for Payer: Multiplan Commercial	$1,993.00
Rate for Payer: Multiplan Workers Comp	$1,993.00
Rate for Payer: Parkland Medicaid	$2,869.92
Rate for Payer: Scott and White EPO/PPO	$1,993.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,869.92
Rate for Payer: Superior Health Plan EPO	$542.10

CATH BLN PTA POWERFLX P3 -- DHF

Facility

$948.00

Service Code	HCPCS C1726
Hospital Charge Code	82452400
Hospital Revenue Code	278
Min. Negotiated Rate	$237.00
Max. Negotiated Rate	$474.00
Rate for Payer: Cash Price	$644.64
Rate for Payer: Cigna Commercial	$237.00
Rate for Payer: Multiplan Auto	$474.00
Rate for Payer: Multiplan Commercial	$474.00
Rate for Payer: Multiplan Workers Comp	$474.00
Rate for Payer: Scott and White EPO/PPO	$474.00

CATH BLN PTA POWERFLX P3 -- DHF

Facility

$948.00

Service Code	HCPCS C1726
Hospital Charge Code	82452400
Hospital Revenue Code	278
Min. Negotiated Rate	$85.32
Max. Negotiated Rate	$682.56
Rate for Payer: Amerigroup CHIP/Medicaid	$85.32
Rate for Payer: BCBS of TX Blue Advantage	$284.40
Rate for Payer: BCBS of TX Blue Essentials	$341.28
Rate for Payer: BCBS of TX PPO	$379.20
Rate for Payer: Cash Price	$644.64
Rate for Payer: Cigna Medicaid	$682.56
Rate for Payer: Molina CHIP/Medicaid	$682.56
Rate for Payer: Multiplan Auto	$474.00
Rate for Payer: Multiplan Commercial	$474.00
Rate for Payer: Multiplan Workers Comp	$474.00
Rate for Payer: Parkland Medicaid	$682.56
Rate for Payer: Scott and White EPO/PPO	$474.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$682.56
Rate for Payer: Superior Health Plan EPO	$128.93

Know your out-of-pocket cost for care.

All Charges