White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATHETER ART 7FR 110CM 4 LUM TD SG

Facility

$317.80

Hospital Charge Code	80567654
Hospital Revenue Code	272
Rate for Payer: Cash Price	$216.10

catheter arthmy dmd back exchangable 1.25mm

Facility

$16,775.30

Hospital Charge Code	8684559
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

catheter arthmy dmd back exchangable 1.25mm

Facility

$16,775.30

Hospital Charge Code	8684559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11,407.20

CATHETER ASPIRATION 50CM CATD KIT

Facility

$16,084.00

Service Code	HCPCS C1757
Hospital Charge Code	8598514
Hospital Revenue Code	278
Min. Negotiated Rate	$4,021.00
Max. Negotiated Rate	$8,042.00
Rate for Payer: Cash Price	$10,937.12
Rate for Payer: Cigna Commercial	$4,021.00
Rate for Payer: Multiplan Auto	$8,042.00
Rate for Payer: Multiplan Commercial	$8,042.00
Rate for Payer: Multiplan Workers Comp	$8,042.00
Rate for Payer: Scott and White EPO/PPO	$8,042.00

CATHETER ASPIRATION 50CM CATD KIT

Facility

$16,084.00

Service Code	HCPCS C1757
Hospital Charge Code	8598514
Hospital Revenue Code	278
Min. Negotiated Rate	$1,447.56
Max. Negotiated Rate	$11,580.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,447.56
Rate for Payer: BCBS of TX Blue Advantage	$4,825.20
Rate for Payer: BCBS of TX Blue Essentials	$5,790.24
Rate for Payer: BCBS of TX PPO	$6,433.60
Rate for Payer: Cash Price	$10,937.12
Rate for Payer: Cigna Medicaid	$11,580.48
Rate for Payer: Molina CHIP/Medicaid	$11,580.48
Rate for Payer: Multiplan Auto	$8,042.00
Rate for Payer: Multiplan Commercial	$8,042.00
Rate for Payer: Multiplan Workers Comp	$8,042.00
Rate for Payer: Parkland Medicaid	$11,580.48
Rate for Payer: Scott and White EPO/PPO	$8,042.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,580.48
Rate for Payer: Superior Health Plan EPO	$2,187.42

CATHETER ASPIRATION LIGHTING CAT12

Facility

$40,783.00

Service Code	HCPCS C1757
Hospital Charge Code	8568958
Hospital Revenue Code	278
Min. Negotiated Rate	$10,195.75
Max. Negotiated Rate	$20,391.50
Rate for Payer: Cash Price	$27,732.44
Rate for Payer: Cigna Commercial	$10,195.75
Rate for Payer: Multiplan Auto	$20,391.50
Rate for Payer: Multiplan Commercial	$20,391.50
Rate for Payer: Multiplan Workers Comp	$20,391.50
Rate for Payer: Scott and White EPO/PPO	$20,391.50

CATHETER ASPIRATION LIGHTING CAT12

Facility

$40,783.00

Service Code	HCPCS C1757
Hospital Charge Code	8568958
Hospital Revenue Code	278
Min. Negotiated Rate	$3,670.47
Max. Negotiated Rate	$29,363.76
Rate for Payer: Amerigroup CHIP/Medicaid	$3,670.47
Rate for Payer: BCBS of TX Blue Advantage	$12,234.90
Rate for Payer: BCBS of TX Blue Essentials	$14,681.88
Rate for Payer: BCBS of TX PPO	$16,313.20
Rate for Payer: Cash Price	$27,732.44
Rate for Payer: Cigna Medicaid	$29,363.76
Rate for Payer: Molina CHIP/Medicaid	$29,363.76
Rate for Payer: Multiplan Auto	$20,391.50
Rate for Payer: Multiplan Commercial	$20,391.50
Rate for Payer: Multiplan Workers Comp	$20,391.50
Rate for Payer: Parkland Medicaid	$29,363.76
Rate for Payer: Scott and White EPO/PPO	$20,391.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,363.76
Rate for Payer: Superior Health Plan EPO	$5,546.49

CATHETER ASPIRATION LIGHTNING CAT 7

Facility

$33,554.00

Service Code	HCPCS C1757
Hospital Charge Code	8598515
Hospital Revenue Code	278
Min. Negotiated Rate	$8,388.50
Max. Negotiated Rate	$16,777.00
Rate for Payer: Cash Price	$22,816.72
Rate for Payer: Cigna Commercial	$8,388.50
Rate for Payer: Multiplan Auto	$16,777.00
Rate for Payer: Multiplan Commercial	$16,777.00
Rate for Payer: Multiplan Workers Comp	$16,777.00
Rate for Payer: Scott and White EPO/PPO	$16,777.00

CATHETER ASPIRATION LIGHTNING CAT 7

Facility

$33,554.00

Service Code	HCPCS C1757
Hospital Charge Code	8598515
Hospital Revenue Code	278
Min. Negotiated Rate	$3,019.86
Max. Negotiated Rate	$24,158.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3,019.86
Rate for Payer: BCBS of TX Blue Advantage	$10,066.20
Rate for Payer: BCBS of TX Blue Essentials	$12,079.44
Rate for Payer: BCBS of TX PPO	$13,421.60
Rate for Payer: Cash Price	$22,816.72
Rate for Payer: Cigna Medicaid	$24,158.88
Rate for Payer: Molina CHIP/Medicaid	$24,158.88
Rate for Payer: Multiplan Auto	$16,777.00
Rate for Payer: Multiplan Commercial	$16,777.00
Rate for Payer: Multiplan Workers Comp	$16,777.00
Rate for Payer: Parkland Medicaid	$24,158.88
Rate for Payer: Scott and White EPO/PPO	$16,777.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,158.88
Rate for Payer: Superior Health Plan EPO	$4,563.34

CATHETER ATHRCMY 1.25MM 30UM DMD BCK

Facility

$15,413.30

Service Code	HCPCS C1724
Hospital Charge Code	992638
Hospital Revenue Code	272
Min. Negotiated Rate	$1,387.20
Max. Negotiated Rate	$11,097.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,387.20
Rate for Payer: BCBS of TX Blue Advantage	$4,623.99
Rate for Payer: BCBS of TX Blue Essentials	$5,548.79
Rate for Payer: BCBS of TX PPO	$6,165.32
Rate for Payer: Cash Price	$10,481.04
Rate for Payer: Cigna Medicaid	$11,097.58
Rate for Payer: Molina CHIP/Medicaid	$11,097.58
Rate for Payer: Multiplan Auto	$10,018.65
Rate for Payer: Multiplan Commercial	$10,018.65
Rate for Payer: Multiplan Workers Comp	$10,018.65
Rate for Payer: Parkland Medicaid	$11,097.58
Rate for Payer: Scott and White EPO/PPO	$7,706.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,097.58
Rate for Payer: Superior Health Plan EPO	$2,096.21

CATHETER ATHRCMY 1.25MM 30UM DMD BCK

Facility

$15,413.30

Service Code	HCPCS C1724
Hospital Charge Code	992638
Hospital Revenue Code	272
Rate for Payer: Cash Price	$10,481.04

CATHETER ATHRCMY 1.5MM 145CM CLSC CRWN DMDBCK

Facility

$15,413.30

Service Code	HCPCS C1724
Hospital Charge Code	992639
Hospital Revenue Code	272
Rate for Payer: Cash Price	$10,481.04

CATHETER ATHRCMY 1.5MM 145CM CLSC CRWN DMDBCK

Facility

$15,413.30

Service Code	HCPCS C1724
Hospital Charge Code	992639
Hospital Revenue Code	272
Min. Negotiated Rate	$1,387.20
Max. Negotiated Rate	$11,097.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,387.20
Rate for Payer: BCBS of TX Blue Advantage	$4,623.99
Rate for Payer: BCBS of TX Blue Essentials	$5,548.79
Rate for Payer: BCBS of TX PPO	$6,165.32
Rate for Payer: Cash Price	$10,481.04
Rate for Payer: Cigna Medicaid	$11,097.58
Rate for Payer: Molina CHIP/Medicaid	$11,097.58
Rate for Payer: Multiplan Auto	$10,018.65
Rate for Payer: Multiplan Commercial	$10,018.65
Rate for Payer: Multiplan Workers Comp	$10,018.65
Rate for Payer: Parkland Medicaid	$11,097.58
Rate for Payer: Scott and White EPO/PPO	$7,706.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,097.58
Rate for Payer: Superior Health Plan EPO	$2,096.21

CATHETER ATHRCMY 1.5MM 145CM SLD CRWN DMDBCK

Facility

$15,413.30

Service Code	HCPCS C1724
Hospital Charge Code	992640
Hospital Revenue Code	272
Min. Negotiated Rate	$1,387.20
Max. Negotiated Rate	$11,097.58
Rate for Payer: Amerigroup CHIP/Medicaid	$1,387.20
Rate for Payer: BCBS of TX Blue Advantage	$4,623.99
Rate for Payer: BCBS of TX Blue Essentials	$5,548.79
Rate for Payer: BCBS of TX PPO	$6,165.32
Rate for Payer: Cash Price	$10,481.04
Rate for Payer: Cigna Medicaid	$11,097.58
Rate for Payer: Molina CHIP/Medicaid	$11,097.58
Rate for Payer: Multiplan Auto	$10,018.65
Rate for Payer: Multiplan Commercial	$10,018.65
Rate for Payer: Multiplan Workers Comp	$10,018.65
Rate for Payer: Parkland Medicaid	$11,097.58
Rate for Payer: Scott and White EPO/PPO	$7,706.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,097.58
Rate for Payer: Superior Health Plan EPO	$2,096.21

CATHETER ATHRCMY 1.5MM 145CM SLD CRWN DMDBCK

Facility

$15,413.30

Service Code	HCPCS C1724
Hospital Charge Code	992640
Hospital Revenue Code	272
Rate for Payer: Cash Price	$10,481.04

Catheter, balloon dilatation, non-vascular

Facility

$6,895.06

Service Code	HCPCS C1726
Hospital Charge Code	990976
Hospital Revenue Code	272
Min. Negotiated Rate	$620.56
Max. Negotiated Rate	$4,964.44
Rate for Payer: Amerigroup CHIP/Medicaid	$620.56
Rate for Payer: BCBS of TX Blue Advantage	$2,068.52
Rate for Payer: BCBS of TX Blue Essentials	$2,482.22
Rate for Payer: BCBS of TX PPO	$2,758.02
Rate for Payer: Cash Price	$4,688.64
Rate for Payer: Cigna Medicaid	$4,964.44
Rate for Payer: Molina CHIP/Medicaid	$4,964.44
Rate for Payer: Multiplan Auto	$4,481.79
Rate for Payer: Multiplan Commercial	$4,481.79
Rate for Payer: Multiplan Workers Comp	$4,481.79
Rate for Payer: Parkland Medicaid	$4,964.44
Rate for Payer: Scott and White EPO/PPO	$3,447.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,964.44
Rate for Payer: Superior Health Plan EPO	$937.73

Catheter, balloon dilatation, non-vascular

Facility

$6,895.06

Service Code	HCPCS C1726
Hospital Charge Code	990976
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,688.64

CATHETER, BALLOON NC EUPHORA 3.5MM X 8MM L

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992541
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

CATHETER, BALLOON NC EUPHORA 3.5MM X 8MM L

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992541
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BALLOON RELIANT

Facility

$2,020.30

Hospital Charge Code	8484498
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,373.80

CATHETER BALLOON RELIANT

Facility

$2,020.30

Hospital Charge Code	8484498
Hospital Revenue Code	272
Min. Negotiated Rate	$181.83
Max. Negotiated Rate	$1,454.62
Rate for Payer: Amerigroup CHIP/Medicaid	$181.83
Rate for Payer: BCBS of TX Blue Advantage	$606.09
Rate for Payer: BCBS of TX Blue Essentials	$727.31
Rate for Payer: BCBS of TX PPO	$808.12
Rate for Payer: Cash Price	$1,373.80
Rate for Payer: Cigna Medicaid	$1,454.62
Rate for Payer: Molina CHIP/Medicaid	$1,454.62
Rate for Payer: Multiplan Auto	$1,313.19
Rate for Payer: Multiplan Commercial	$1,313.19
Rate for Payer: Multiplan Workers Comp	$1,313.19
Rate for Payer: Parkland Medicaid	$1,454.62
Rate for Payer: Scott and White EPO/PPO	$1,010.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,454.62
Rate for Payer: Superior Health Plan EPO	$274.76

CATHETER BLN 10MMX4X80CM PERPH DRADO

Facility

$976.00

Service Code	HCPCS C1726
Hospital Charge Code	107836
Hospital Revenue Code	278
Min. Negotiated Rate	$87.84
Max. Negotiated Rate	$702.72
Rate for Payer: Amerigroup CHIP/Medicaid	$87.84
Rate for Payer: BCBS of TX Blue Advantage	$292.80
Rate for Payer: BCBS of TX Blue Essentials	$351.36
Rate for Payer: BCBS of TX PPO	$390.40
Rate for Payer: Cash Price	$663.68
Rate for Payer: Cigna Medicaid	$702.72
Rate for Payer: Molina CHIP/Medicaid	$702.72
Rate for Payer: Multiplan Auto	$488.00
Rate for Payer: Multiplan Commercial	$488.00
Rate for Payer: Multiplan Workers Comp	$488.00
Rate for Payer: Parkland Medicaid	$702.72
Rate for Payer: Scott and White EPO/PPO	$488.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$702.72
Rate for Payer: Superior Health Plan EPO	$132.74

CATHETER BLN 10MMX4X80CM PERPH DRADO

Facility

$976.00

Service Code	HCPCS C1726
Hospital Charge Code	107836
Hospital Revenue Code	278
Min. Negotiated Rate	$244.00
Max. Negotiated Rate	$488.00
Rate for Payer: Cash Price	$663.68
Rate for Payer: Cigna Commercial	$244.00
Rate for Payer: Multiplan Auto	$488.00
Rate for Payer: Multiplan Commercial	$488.00
Rate for Payer: Multiplan Workers Comp	$488.00
Rate for Payer: Scott and White EPO/PPO	$488.00

CATHETER BLN 7MMX4X80CM PERPH DRADO

Facility

$1,355.00

Service Code	HCPCS C1726
Hospital Charge Code	107844
Hospital Revenue Code	278
Min. Negotiated Rate	$121.95
Max. Negotiated Rate	$975.60
Rate for Payer: Amerigroup CHIP/Medicaid	$121.95
Rate for Payer: BCBS of TX Blue Advantage	$406.50
Rate for Payer: BCBS of TX Blue Essentials	$487.80
Rate for Payer: BCBS of TX PPO	$542.00
Rate for Payer: Cash Price	$921.40
Rate for Payer: Cigna Medicaid	$975.60
Rate for Payer: Molina CHIP/Medicaid	$975.60
Rate for Payer: Multiplan Auto	$677.50
Rate for Payer: Multiplan Commercial	$677.50
Rate for Payer: Multiplan Workers Comp	$677.50
Rate for Payer: Parkland Medicaid	$975.60
Rate for Payer: Scott and White EPO/PPO	$677.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$975.60
Rate for Payer: Superior Health Plan EPO	$184.28

CATHETER BLN 7MMX4X80CM PERPH DRADO

Facility

$1,355.00

Service Code	HCPCS C1726
Hospital Charge Code	107844
Hospital Revenue Code	278
Min. Negotiated Rate	$338.75
Max. Negotiated Rate	$677.50
Rate for Payer: Cash Price	$921.40
Rate for Payer: Cigna Commercial	$338.75
Rate for Payer: Multiplan Auto	$677.50
Rate for Payer: Multiplan Commercial	$677.50
Rate for Payer: Multiplan Workers Comp	$677.50
Rate for Payer: Scott and White EPO/PPO	$677.50

Know your out-of-pocket cost for care.

All Charges