White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATHETER BLN DIL 3X12MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992532
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 3X15MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992533
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 3X15MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992533
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 3X20MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992534
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 3X20MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992534
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 3X30MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992535
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER BLN DIL 3X30MM RX EUPHORA

Facility

$771.80

Service Code	HCPCS C1726
Hospital Charge Code	992535
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 BLNDIL 9X40MMX75CM MSTNG

Facility

$1,145.00

Service Code	HCPCS C1726
Hospital Charge Code	108501
Hospital Revenue Code	278
Min. Negotiated Rate	$103.05
Max. Negotiated Rate	$824.40
Rate for Payer: Amerigroup CHIP/Medicaid	$103.05
Rate for Payer: BCBS of TX Blue Advantage	$343.50
Rate for Payer: BCBS of TX Blue Essentials	$412.20
Rate for Payer: BCBS of TX PPO	$458.00
Rate for Payer: Cash Price	$778.60
Rate for Payer: Cigna Medicaid	$824.40
Rate for Payer: Molina CHIP/Medicaid	$824.40
Rate for Payer: Multiplan Auto	$572.50
Rate for Payer: Multiplan Commercial	$572.50
Rate for Payer: Multiplan Workers Comp	$572.50
Rate for Payer: Parkland Medicaid	$824.40
Rate for Payer: Scott and White EPO/PPO	$572.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$824.40
Rate for Payer: Superior Health Plan EPO	$155.72

CATHETER BLNDIL 9X40MMX75CM MSTNG

Facility

$1,145.00

Service Code	HCPCS C1726
Hospital Charge Code	108501
Hospital Revenue Code	278
Min. Negotiated Rate	$286.25
Max. Negotiated Rate	$572.50
Rate for Payer: Cash Price	$778.60
Rate for Payer: Cigna Commercial	$286.25
Rate for Payer: Multiplan Auto	$572.50
Rate for Payer: Multiplan Commercial	$572.50
Rate for Payer: Multiplan Workers Comp	$572.50
Rate for Payer: Scott and White EPO/PPO	$572.50

CATHETER BLN DIL CRE ENDOSCOPI 110CM 18-20MM

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145521
Hospital Revenue Code	278
Min. Negotiated Rate	$535.25
Max. Negotiated Rate	$1,070.50
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Commercial	$535.25
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Scott and White EPO/PPO	$1,070.50

CATHETER BLN DIL CRE ENDOSCOPI 110CM 18-20MM

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145521
Hospital Revenue Code	278
Min. Negotiated Rate	$192.69
Max. Negotiated Rate	$1,541.52
Rate for Payer: Amerigroup CHIP/Medicaid	$192.69
Rate for Payer: BCBS of TX Blue Advantage	$642.30
Rate for Payer: BCBS of TX Blue Essentials	$770.76
Rate for Payer: BCBS of TX PPO	$856.40
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Medicaid	$1,541.52
Rate for Payer: Molina CHIP/Medicaid	$1,541.52
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Parkland Medicaid	$1,541.52
Rate for Payer: Scott and White EPO/PPO	$1,070.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,541.52
Rate for Payer: Superior Health Plan EPO	$291.18

CATHETER BLN DIL CRE ENDOSCOPIC 110CM 15-18MM

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145520
Hospital Revenue Code	278
Min. Negotiated Rate	$535.25
Max. Negotiated Rate	$1,070.50
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Commercial	$535.25
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Scott and White EPO/PPO	$1,070.50

CATHETER BLN DIL CRE ENDOSCOPIC 110CM 15-18MM

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145520
Hospital Revenue Code	278
Min. Negotiated Rate	$192.69
Max. Negotiated Rate	$1,541.52
Rate for Payer: Amerigroup CHIP/Medicaid	$192.69
Rate for Payer: BCBS of TX Blue Advantage	$642.30
Rate for Payer: BCBS of TX Blue Essentials	$770.76
Rate for Payer: BCBS of TX PPO	$856.40
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Medicaid	$1,541.52
Rate for Payer: Molina CHIP/Medicaid	$1,541.52
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Parkland Medicaid	$1,541.52
Rate for Payer: Scott and White EPO/PPO	$1,070.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,541.52
Rate for Payer: Superior Health Plan EPO	$291.18

CATHETER BLN DIL CRE ENDOSCOPIC 110CM 8-10 X3

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145522
Hospital Revenue Code	278
Min. Negotiated Rate	$192.69
Max. Negotiated Rate	$1,541.52
Rate for Payer: Amerigroup CHIP/Medicaid	$192.69
Rate for Payer: BCBS of TX Blue Advantage	$642.30
Rate for Payer: BCBS of TX Blue Essentials	$770.76
Rate for Payer: BCBS of TX PPO	$856.40
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Medicaid	$1,541.52
Rate for Payer: Molina CHIP/Medicaid	$1,541.52
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Parkland Medicaid	$1,541.52
Rate for Payer: Scott and White EPO/PPO	$1,070.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,541.52
Rate for Payer: Superior Health Plan EPO	$291.18

CATHETER BLN DIL CRE ENDOSCOPIC 110CM 8-10 X3

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145522
Hospital Revenue Code	278
Min. Negotiated Rate	$535.25
Max. Negotiated Rate	$1,070.50
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Commercial	$535.25
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Scott and White EPO/PPO	$1,070.50

CATHETER BLN DIL CRE ENDOSCOPIC 110 CSM 12-15MM X3

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145524
Hospital Revenue Code	278
Min. Negotiated Rate	$192.69
Max. Negotiated Rate	$1,541.52
Rate for Payer: Amerigroup CHIP/Medicaid	$192.69
Rate for Payer: BCBS of TX Blue Advantage	$642.30
Rate for Payer: BCBS of TX Blue Essentials	$770.76
Rate for Payer: BCBS of TX PPO	$856.40
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Medicaid	$1,541.52
Rate for Payer: Molina CHIP/Medicaid	$1,541.52
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Parkland Medicaid	$1,541.52
Rate for Payer: Scott and White EPO/PPO	$1,070.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,541.52
Rate for Payer: Superior Health Plan EPO	$291.18

CATHETER BLN DIL CRE ENDOSCOPIC 110 CSM 12-15MM X3

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145524
Hospital Revenue Code	278
Min. Negotiated Rate	$535.25
Max. Negotiated Rate	$1,070.50
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Commercial	$535.25
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Scott and White EPO/PPO	$1,070.50

CATHETER BLN DIL CRE ENDSCOPIC 110CM 12-15MM

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145519
Hospital Revenue Code	278
Min. Negotiated Rate	$535.25
Max. Negotiated Rate	$1,070.50
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Commercial	$535.25
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Scott and White EPO/PPO	$1,070.50

CATHETER BLN DIL CRE ENDSCOPIC 110CM 12-15MM

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145519
Hospital Revenue Code	278
Min. Negotiated Rate	$192.69
Max. Negotiated Rate	$1,541.52
Rate for Payer: Amerigroup CHIP/Medicaid	$192.69
Rate for Payer: BCBS of TX Blue Advantage	$642.30
Rate for Payer: BCBS of TX Blue Essentials	$770.76
Rate for Payer: BCBS of TX PPO	$856.40
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Medicaid	$1,541.52
Rate for Payer: Molina CHIP/Medicaid	$1,541.52
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Parkland Medicaid	$1,541.52
Rate for Payer: Scott and White EPO/PPO	$1,070.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,541.52
Rate for Payer: Superior Health Plan EPO	$291.18

CATHETER BLN DIL CRE ENOSCOPIC 110CM 10-12 X3

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145523
Hospital Revenue Code	278
Min. Negotiated Rate	$192.69
Max. Negotiated Rate	$1,541.52
Rate for Payer: Amerigroup CHIP/Medicaid	$192.69
Rate for Payer: BCBS of TX Blue Advantage	$642.30
Rate for Payer: BCBS of TX Blue Essentials	$770.76
Rate for Payer: BCBS of TX PPO	$856.40
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Medicaid	$1,541.52
Rate for Payer: Molina CHIP/Medicaid	$1,541.52
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Parkland Medicaid	$1,541.52
Rate for Payer: Scott and White EPO/PPO	$1,070.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,541.52
Rate for Payer: Superior Health Plan EPO	$291.18

CATHETER BLN DIL CRE ENOSCOPIC 110CM 10-12 X3

Facility

$2,141.00

Service Code	HCPCS C1726
Hospital Charge Code	145523
Hospital Revenue Code	278
Min. Negotiated Rate	$535.25
Max. Negotiated Rate	$1,070.50
Rate for Payer: Cash Price	$1,455.88
Rate for Payer: Cigna Commercial	$535.25
Rate for Payer: Multiplan Auto	$1,070.50
Rate for Payer: Multiplan Commercial	$1,070.50
Rate for Payer: Multiplan Workers Comp	$1,070.50
Rate for Payer: Scott and White EPO/PPO	$1,070.50

CATHETER BLNOCC 6FR ASP XPRT

Facility

$1,816.00

Service Code	HCPCS C1726
Hospital Charge Code	992524
Hospital Revenue Code	272
Min. Negotiated Rate	$163.44
Max. Negotiated Rate	$1,307.52
Rate for Payer: Amerigroup CHIP/Medicaid	$163.44
Rate for Payer: BCBS of TX Blue Advantage	$544.80
Rate for Payer: BCBS of TX Blue Essentials	$653.76
Rate for Payer: BCBS of TX PPO	$726.40
Rate for Payer: Cash Price	$1,234.88
Rate for Payer: Cigna Medicaid	$1,307.52
Rate for Payer: Molina CHIP/Medicaid	$1,307.52
Rate for Payer: Multiplan Auto	$1,180.40
Rate for Payer: Multiplan Commercial	$1,180.40
Rate for Payer: Multiplan Workers Comp	$1,180.40
Rate for Payer: Parkland Medicaid	$1,307.52
Rate for Payer: Scott and White EPO/PPO	$908.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,307.52
Rate for Payer: Superior Health Plan EPO	$246.98

CATHETER BLNOCC 6FR ASP XPRT

Facility

$1,816.00

Service Code	HCPCS C1726
Hospital Charge Code	992524
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,234.88

CATHETER BLN PASEO 35 9X60X130

Facility

$544.80

Hospital Charge Code	145424
Hospital Revenue Code	272
Rate for Payer: Cash Price	$370.46

CATHETER BLN PASEO 35 9X60X130

Facility

$544.80

Hospital Charge Code	145424
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$370.46
Rate for Payer: Cigna Medicaid	$392.26
Rate for Payer: Molina CHIP/Medicaid	$392.26
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Parkland Medicaid	$392.26
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$392.26
Rate for Payer: Superior Health Plan EPO	$74.09

Know your out-of-pocket cost for care.

All Charges