White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATHETER BLN 8X40X80CM PERPH DRADO

Facility

$1,355.42

Hospital Charge Code	108183
Hospital Revenue Code	272
Rate for Payer: Cash Price	$921.69

CATHETER BLN 8X40X80CM PERPH DRADO

Facility

$1,355.42

Hospital Charge Code	108183
Hospital Revenue Code	272
Min. Negotiated Rate	$121.99
Max. Negotiated Rate	$975.90
Rate for Payer: Amerigroup CHIP/Medicaid	$121.99
Rate for Payer: BCBS of TX Blue Advantage	$406.63
Rate for Payer: BCBS of TX Blue Essentials	$487.95
Rate for Payer: BCBS of TX PPO	$542.17
Rate for Payer: Cash Price	$921.69
Rate for Payer: Cigna Medicaid	$975.90
Rate for Payer: Molina CHIP/Medicaid	$975.90
Rate for Payer: Multiplan Auto	$881.02
Rate for Payer: Multiplan Commercial	$881.02
Rate for Payer: Multiplan Workers Comp	$881.02
Rate for Payer: Parkland Medicaid	$975.90
Rate for Payer: Scott and White EPO/PPO	$677.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$975.90
Rate for Payer: Superior Health Plan EPO	$184.34

CATHETER BLN 9X40X80CM PERPH DRADO

Facility

$1,355.00

Service Code	HCPCS C1726
Hospital Charge Code	82401266
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

CATHETER BLN 9X40X80CM PERPH DRADO

Facility

$1,355.00

Service Code	HCPCS C1726
Hospital Charge Code	82401266
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 DIL 2.5X10MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992527
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 BLN DIL 2.5X10MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992527
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 2.5X12MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992528
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 2.5X12MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992528
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 BLN DIL 2.5X15MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992529
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 BLN DIL 2.5X15MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992529
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 2.5X20MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992530
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 BLN DIL 2.5X20MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992530
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 2.5X30MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992531
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 BLN DIL 2.5X30MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992531
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 2.5X8MM RX NC EPHR

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992537
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 2.5X8MM RX NC EPHR

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992537
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 BLN DIL 2X15MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992525
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 2X15MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992525
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 BLN DIL 2X20MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992526
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 BLN DIL 2X20MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992526
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 3.5X12MM RX NC EPHR

Facility

$602.00

Service Code	HCPCS C1726
Hospital Charge Code	80560949
Hospital Revenue Code	278
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$301.00
Rate for Payer: Cash Price	$409.36
Rate for Payer: Cigna Commercial	$150.50
Rate for Payer: Multiplan Auto	$301.00
Rate for Payer: Multiplan Commercial	$301.00
Rate for Payer: Multiplan Workers Comp	$301.00
Rate for Payer: Scott and White EPO/PPO	$301.00

CATHETER BLN DIL 3.5X12MM RX NC EPHR

Facility

$602.00

Service Code	HCPCS C1726
Hospital Charge Code	80560949
Hospital Revenue Code	278
Min. Negotiated Rate	$54.18
Max. Negotiated Rate	$433.44
Rate for Payer: Amerigroup CHIP/Medicaid	$54.18
Rate for Payer: BCBS of TX Blue Advantage	$180.60
Rate for Payer: BCBS of TX Blue Essentials	$216.72
Rate for Payer: BCBS of TX PPO	$240.80
Rate for Payer: Cash Price	$409.36
Rate for Payer: Cigna Medicaid	$433.44
Rate for Payer: Molina CHIP/Medicaid	$433.44
Rate for Payer: Multiplan Auto	$301.00
Rate for Payer: Multiplan Commercial	$301.00
Rate for Payer: Multiplan Workers Comp	$301.00
Rate for Payer: Parkland Medicaid	$433.44
Rate for Payer: Scott and White EPO/PPO	$301.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.44
Rate for Payer: Superior Health Plan EPO	$81.87

CATHETER BLN DIL 3.5X20MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992536
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 3.5X20MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992536
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 BLN DIL 3X12MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992532
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

Know your out-of-pocket cost for care.

All Charges