White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATH DIAMONDBACK SYS-SOLID DBP-EX-125SOL145

Facility

$16,775.30

Hospital Charge Code	145243
Hospital Revenue Code	272
Min. Negotiated Rate	$1,509.78
Max. Negotiated Rate	$12,078.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,509.78
Rate for Payer: BCBS of TX Blue Advantage	$5,032.59
Rate for Payer: BCBS of TX Blue Essentials	$6,039.11
Rate for Payer: BCBS of TX PPO	$6,710.12
Rate for Payer: Cash Price	$11,407.20
Rate for Payer: Cigna Medicaid	$12,078.22
Rate for Payer: Molina CHIP/Medicaid	$12,078.22
Rate for Payer: Multiplan Auto	$10,903.94
Rate for Payer: Multiplan Commercial	$10,903.94
Rate for Payer: Multiplan Workers Comp	$10,903.94
Rate for Payer: Parkland Medicaid	$12,078.22
Rate for Payer: Scott and White EPO/PPO	$8,387.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,078.22
Rate for Payer: Superior Health Plan EPO	$2,281.44

CATH DIAMOND BACK SYS-SOLID DBP-EX-150SOL145

Facility

$16,775.30

Hospital Charge Code	144465
Hospital Revenue Code	272
Min. Negotiated Rate	$1,509.78
Max. Negotiated Rate	$12,078.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,509.78
Rate for Payer: BCBS of TX Blue Advantage	$5,032.59
Rate for Payer: BCBS of TX Blue Essentials	$6,039.11
Rate for Payer: BCBS of TX PPO	$6,710.12
Rate for Payer: Cash Price	$11,407.20
Rate for Payer: Cigna Medicaid	$12,078.22
Rate for Payer: Molina CHIP/Medicaid	$12,078.22
Rate for Payer: Multiplan Auto	$10,903.94
Rate for Payer: Multiplan Commercial	$10,903.94
Rate for Payer: Multiplan Workers Comp	$10,903.94
Rate for Payer: Parkland Medicaid	$12,078.22
Rate for Payer: Scott and White EPO/PPO	$8,387.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,078.22
Rate for Payer: Superior Health Plan EPO	$2,281.44

CATH DIAMOND BACK SYS-SOLID DBP-EX-150SOL145

Facility

$16,775.30

Hospital Charge Code	144465
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11,407.20

CATH DIAMOND BACK SYS-SOLID DBP-EX-200SOL145

Facility

$16,775.30

Hospital Charge Code	144466
Hospital Revenue Code	272
Min. Negotiated Rate	$1,509.78
Max. Negotiated Rate	$12,078.22
Rate for Payer: Amerigroup CHIP/Medicaid	$1,509.78
Rate for Payer: BCBS of TX Blue Advantage	$5,032.59
Rate for Payer: BCBS of TX Blue Essentials	$6,039.11
Rate for Payer: BCBS of TX PPO	$6,710.12
Rate for Payer: Cash Price	$11,407.20
Rate for Payer: Cigna Medicaid	$12,078.22
Rate for Payer: Molina CHIP/Medicaid	$12,078.22
Rate for Payer: Multiplan Auto	$10,903.94
Rate for Payer: Multiplan Commercial	$10,903.94
Rate for Payer: Multiplan Workers Comp	$10,903.94
Rate for Payer: Parkland Medicaid	$12,078.22
Rate for Payer: Scott and White EPO/PPO	$8,387.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,078.22
Rate for Payer: Superior Health Plan EPO	$2,281.44

CATH DIAMOND BACK SYS-SOLID DBP-EX-200SOL145

Facility

$16,775.30

Hospital Charge Code	144466
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11,407.20

CATH DRAINAGE 2 -- DHF

Facility

$295.00

Service Code	HCPCS C1729
Hospital Charge Code	82400839
Hospital Revenue Code	278
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$212.40
Rate for Payer: Amerigroup CHIP/Medicaid	$26.55
Rate for Payer: BCBS of TX Blue Advantage	$88.50
Rate for Payer: BCBS of TX Blue Essentials	$106.20
Rate for Payer: BCBS of TX PPO	$118.00
Rate for Payer: Cash Price	$200.60
Rate for Payer: Cigna Medicaid	$212.40
Rate for Payer: Molina CHIP/Medicaid	$212.40
Rate for Payer: Multiplan Auto	$147.50
Rate for Payer: Multiplan Commercial	$147.50
Rate for Payer: Multiplan Workers Comp	$147.50
Rate for Payer: Parkland Medicaid	$212.40
Rate for Payer: Scott and White EPO/PPO	$147.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.40
Rate for Payer: Superior Health Plan EPO	$40.12

CATH DRAINAGE 2 -- DHF

Facility

$295.00

Service Code	HCPCS C1729
Hospital Charge Code	8240082
Hospital Revenue Code	278
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$212.40
Rate for Payer: Amerigroup CHIP/Medicaid	$26.55
Rate for Payer: BCBS of TX Blue Advantage	$88.50
Rate for Payer: BCBS of TX Blue Essentials	$106.20
Rate for Payer: BCBS of TX PPO	$118.00
Rate for Payer: Cash Price	$200.60
Rate for Payer: Cigna Medicaid	$212.40
Rate for Payer: Molina CHIP/Medicaid	$212.40
Rate for Payer: Multiplan Auto	$147.50
Rate for Payer: Multiplan Commercial	$147.50
Rate for Payer: Multiplan Workers Comp	$147.50
Rate for Payer: Parkland Medicaid	$212.40
Rate for Payer: Scott and White EPO/PPO	$147.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$212.40
Rate for Payer: Superior Health Plan EPO	$40.12

CATH DRAINAGE 2 -- DHF

Facility

$295.00

Service Code	HCPCS C1729
Hospital Charge Code	8240082
Hospital Revenue Code	278
Min. Negotiated Rate	$73.75
Max. Negotiated Rate	$147.50
Rate for Payer: Cash Price	$200.60
Rate for Payer: Cigna Commercial	$73.75
Rate for Payer: Multiplan Auto	$147.50
Rate for Payer: Multiplan Commercial	$147.50
Rate for Payer: Multiplan Workers Comp	$147.50
Rate for Payer: Scott and White EPO/PPO	$147.50

CATH DRAINAGE 2 -- DHF

Facility

$295.00

Service Code	HCPCS C1729
Hospital Charge Code	82400839
Hospital Revenue Code	278
Min. Negotiated Rate	$73.75
Max. Negotiated Rate	$147.50
Rate for Payer: Cash Price	$200.60
Rate for Payer: Cigna Commercial	$73.75
Rate for Payer: Multiplan Auto	$147.50
Rate for Payer: Multiplan Commercial	$147.50
Rate for Payer: Multiplan Workers Comp	$147.50
Rate for Payer: Scott and White EPO/PPO	$147.50

CATH DRAINAGE 3

Facility

$209.92

Hospital Charge Code	8430488
Hospital Revenue Code	272
Min. Negotiated Rate	$18.89
Max. Negotiated Rate	$151.14
Rate for Payer: Amerigroup CHIP/Medicaid	$18.89
Rate for Payer: BCBS of TX Blue Advantage	$62.98
Rate for Payer: BCBS of TX Blue Essentials	$75.57
Rate for Payer: BCBS of TX PPO	$83.97
Rate for Payer: Cash Price	$142.75
Rate for Payer: Cigna Medicaid	$151.14
Rate for Payer: Molina CHIP/Medicaid	$151.14
Rate for Payer: Multiplan Auto	$136.45
Rate for Payer: Multiplan Commercial	$136.45
Rate for Payer: Multiplan Workers Comp	$136.45
Rate for Payer: Parkland Medicaid	$151.14
Rate for Payer: Scott and White EPO/PPO	$104.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.14
Rate for Payer: Superior Health Plan EPO	$28.55

CATH DRAINAGE 3

Facility

$209.92

Hospital Charge Code	8430488
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.75

CATH DRAINAGE -- DHF

Facility

$430.00

Service Code	HCPCS C1729
Hospital Charge Code	82400821
Hospital Revenue Code	278
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$309.60
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: BCBS of TX Blue Advantage	$129.00
Rate for Payer: BCBS of TX Blue Essentials	$154.80
Rate for Payer: BCBS of TX PPO	$172.00
Rate for Payer: Cash Price	$292.40
Rate for Payer: Cigna Medicaid	$309.60
Rate for Payer: Molina CHIP/Medicaid	$309.60
Rate for Payer: Multiplan Auto	$215.00
Rate for Payer: Multiplan Commercial	$215.00
Rate for Payer: Multiplan Workers Comp	$215.00
Rate for Payer: Parkland Medicaid	$309.60
Rate for Payer: Scott and White EPO/PPO	$215.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$309.60
Rate for Payer: Superior Health Plan EPO	$58.48

CATH DRAINAGE -- DHF

Facility

$430.00

Service Code	HCPCS C1729
Hospital Charge Code	82400821
Hospital Revenue Code	278
Min. Negotiated Rate	$107.50
Max. Negotiated Rate	$215.00
Rate for Payer: Cash Price	$292.40
Rate for Payer: Cigna Commercial	$107.50
Rate for Payer: Multiplan Auto	$215.00
Rate for Payer: Multiplan Commercial	$215.00
Rate for Payer: Multiplan Workers Comp	$215.00
Rate for Payer: Scott and White EPO/PPO	$215.00

CATH EMBL 3FR 40CM FGRTY ART STRL 120403FP

Facility

$144.53

Service Code	HCPCS C1757
Hospital Charge Code	992513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$98.28

CATH EMBL 3FR 40CM FGRTY ART STRL 120403FP

Facility

$144.53

Service Code	HCPCS C1757
Hospital Charge Code	992513
Hospital Revenue Code	272
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$104.06
Rate for Payer: Amerigroup CHIP/Medicaid	$13.01
Rate for Payer: BCBS of TX Blue Advantage	$43.36
Rate for Payer: BCBS of TX Blue Essentials	$52.03
Rate for Payer: BCBS of TX PPO	$57.81
Rate for Payer: Cash Price	$98.28
Rate for Payer: Cigna Medicaid	$104.06
Rate for Payer: Molina CHIP/Medicaid	$104.06
Rate for Payer: Multiplan Auto	$93.94
Rate for Payer: Multiplan Commercial	$93.94
Rate for Payer: Multiplan Workers Comp	$93.94
Rate for Payer: Parkland Medicaid	$104.06
Rate for Payer: Scott and White EPO/PPO	$72.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$104.06
Rate for Payer: Superior Health Plan EPO	$19.66

CATH EMBL 3FR 80CM FGRTY ART STRL 120803FP

Facility

$144.53

Service Code	HCPCS C1757
Hospital Charge Code	992515
Hospital Revenue Code	272
Rate for Payer: Cash Price	$98.28

CATH EMBL 3FR 80CM FGRTY ART STRL 120803FP

Facility

$144.53

Service Code	HCPCS C1757
Hospital Charge Code	992515
Hospital Revenue Code	272
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$104.06
Rate for Payer: Amerigroup CHIP/Medicaid	$13.01
Rate for Payer: BCBS of TX Blue Advantage	$43.36
Rate for Payer: BCBS of TX Blue Essentials	$52.03
Rate for Payer: BCBS of TX PPO	$57.81
Rate for Payer: Cash Price	$98.28
Rate for Payer: Cigna Medicaid	$104.06
Rate for Payer: Molina CHIP/Medicaid	$104.06
Rate for Payer: Multiplan Auto	$93.94
Rate for Payer: Multiplan Commercial	$93.94
Rate for Payer: Multiplan Workers Comp	$93.94
Rate for Payer: Parkland Medicaid	$104.06
Rate for Payer: Scott and White EPO/PPO	$72.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$104.06
Rate for Payer: Superior Health Plan EPO	$19.66

CATH EMBL 5FR 80CM FGRTY ART STRL 120805FP

Facility

$494.00

Service Code	HCPCS C1757
Hospital Charge Code	992516
Hospital Revenue Code	272
Rate for Payer: Cash Price	$335.92

CATH EMBL 5FR 80CM FGRTY ART STRL 120805FP

Facility

$494.00

Service Code	HCPCS C1757
Hospital Charge Code	992516
Hospital Revenue Code	272
Min. Negotiated Rate	$44.46
Max. Negotiated Rate	$355.68
Rate for Payer: Amerigroup CHIP/Medicaid	$44.46
Rate for Payer: BCBS of TX Blue Advantage	$148.20
Rate for Payer: BCBS of TX Blue Essentials	$177.84
Rate for Payer: BCBS of TX PPO	$197.60
Rate for Payer: Cash Price	$335.92
Rate for Payer: Cigna Medicaid	$355.68
Rate for Payer: Molina CHIP/Medicaid	$355.68
Rate for Payer: Multiplan Auto	$321.10
Rate for Payer: Multiplan Commercial	$321.10
Rate for Payer: Multiplan Workers Comp	$321.10
Rate for Payer: Parkland Medicaid	$355.68
Rate for Payer: Scott and White EPO/PPO	$247.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$355.68
Rate for Payer: Superior Health Plan EPO	$67.18

CATH EMBOLECTOMY OCC E2103-36

Facility

$1,584.46

Service Code	HCPCS C1757
Hospital Charge Code	992718
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,077.43

CATH EMBOLECTOMY OCC E2103-36

Facility

$1,584.46

Service Code	HCPCS C1757
Hospital Charge Code	992718
Hospital Revenue Code	270
Min. Negotiated Rate	$142.60
Max. Negotiated Rate	$1,140.81
Rate for Payer: Amerigroup CHIP/Medicaid	$142.60
Rate for Payer: BCBS of TX Blue Advantage	$475.34
Rate for Payer: BCBS of TX Blue Essentials	$570.41
Rate for Payer: BCBS of TX PPO	$633.78
Rate for Payer: Cash Price	$1,077.43
Rate for Payer: Cigna Medicaid	$1,140.81
Rate for Payer: Molina CHIP/Medicaid	$1,140.81
Rate for Payer: Multiplan Auto	$1,029.90
Rate for Payer: Multiplan Commercial	$1,029.90
Rate for Payer: Multiplan Workers Comp	$1,029.90
Rate for Payer: Parkland Medicaid	$1,140.81
Rate for Payer: Scott and White EPO/PPO	$792.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,140.81
Rate for Payer: Superior Health Plan EPO	$215.49

CATH EMBOLECTOMY OCC E2103-36

Facility

$1,584.46

Service Code	HCPCS C1757
Hospital Charge Code	80563182
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,077.43

CATH EMBOLECTOMY OCC E2103-36

Facility

$1,584.46

Service Code	HCPCS C1757
Hospital Charge Code	80563182
Hospital Revenue Code	270
Min. Negotiated Rate	$142.60
Max. Negotiated Rate	$1,140.81
Rate for Payer: Amerigroup CHIP/Medicaid	$142.60
Rate for Payer: BCBS of TX Blue Advantage	$475.34
Rate for Payer: BCBS of TX Blue Essentials	$570.41
Rate for Payer: BCBS of TX PPO	$633.78
Rate for Payer: Cash Price	$1,077.43
Rate for Payer: Cigna Medicaid	$1,140.81
Rate for Payer: Molina CHIP/Medicaid	$1,140.81
Rate for Payer: Multiplan Auto	$1,029.90
Rate for Payer: Multiplan Commercial	$1,029.90
Rate for Payer: Multiplan Workers Comp	$1,029.90
Rate for Payer: Parkland Medicaid	$1,140.81
Rate for Payer: Scott and White EPO/PPO	$792.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,140.81
Rate for Payer: Superior Health Plan EPO	$215.49

CATH EMBOLECTOMY OCC E2103-56

Facility

$1,584.46

Service Code	HCPCS C1757
Hospital Charge Code	992717
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,077.43

CATH EMBOLECTOMY OCC E2103-56

Facility

$1,584.46

Service Code	HCPCS C1757
Hospital Charge Code	992717
Hospital Revenue Code	270
Min. Negotiated Rate	$142.60
Max. Negotiated Rate	$1,140.81
Rate for Payer: Amerigroup CHIP/Medicaid	$142.60
Rate for Payer: BCBS of TX Blue Advantage	$475.34
Rate for Payer: BCBS of TX Blue Essentials	$570.41
Rate for Payer: BCBS of TX PPO	$633.78
Rate for Payer: Cash Price	$1,077.43
Rate for Payer: Cigna Medicaid	$1,140.81
Rate for Payer: Molina CHIP/Medicaid	$1,140.81
Rate for Payer: Multiplan Auto	$1,029.90
Rate for Payer: Multiplan Commercial	$1,029.90
Rate for Payer: Multiplan Workers Comp	$1,029.90
Rate for Payer: Parkland Medicaid	$1,140.81
Rate for Payer: Scott and White EPO/PPO	$792.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,140.81
Rate for Payer: Superior Health Plan EPO	$215.49

Know your out-of-pocket cost for care.

All Charges