White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATHETER, CURL, PERITONEAL, 2CUFF

Facility

$1,558.13

Service Code	HCPCS C1750
Hospital Charge Code	992521
Hospital Revenue Code	270
Min. Negotiated Rate	$140.23
Max. Negotiated Rate	$1,121.85
Rate for Payer: Amerigroup CHIP/Medicaid	$140.23
Rate for Payer: BCBS of TX Blue Advantage	$467.44
Rate for Payer: BCBS of TX Blue Essentials	$560.93
Rate for Payer: BCBS of TX PPO	$623.25
Rate for Payer: Cash Price	$1,059.53
Rate for Payer: Cigna Medicaid	$1,121.85
Rate for Payer: Molina CHIP/Medicaid	$1,121.85
Rate for Payer: Multiplan Auto	$1,012.78
Rate for Payer: Multiplan Commercial	$1,012.78
Rate for Payer: Multiplan Workers Comp	$1,012.78
Rate for Payer: Parkland Medicaid	$1,121.85
Rate for Payer: Scott and White EPO/PPO	$779.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,121.85
Rate for Payer: Superior Health Plan EPO	$211.91

CATHETER, CURL, PERITONEAL, 2CUFF

Facility

$1,558.13

Service Code	HCPCS C1750
Hospital Charge Code	992521
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,059.53

CATHETER DIL 3.5X12MM COR RX TREK

Facility

$771.80

Service Code	HCPCS C1714
Hospital Charge Code	992582
Hospital Revenue Code	272
Rate for Payer: Cash Price	$524.82

CATHETER DIL 3.5X12MM COR RX TREK

Facility

$771.80

Service Code	HCPCS C1714
Hospital Charge Code	992582
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 dilation bakri occlusion

Facility

$1,180.04

Hospital Charge Code	8690512
Hospital Revenue Code	272
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$849.63
Rate for Payer: Amerigroup CHIP/Medicaid	$106.20
Rate for Payer: BCBS of TX Blue Advantage	$354.01
Rate for Payer: BCBS of TX Blue Essentials	$424.81
Rate for Payer: BCBS of TX PPO	$472.02
Rate for Payer: Cash Price	$802.43
Rate for Payer: Cigna Medicaid	$849.63
Rate for Payer: Molina CHIP/Medicaid	$849.63
Rate for Payer: Multiplan Auto	$767.03
Rate for Payer: Multiplan Commercial	$767.03
Rate for Payer: Multiplan Workers Comp	$767.03
Rate for Payer: Parkland Medicaid	$849.63
Rate for Payer: Scott and White EPO/PPO	$590.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$849.63
Rate for Payer: Superior Health Plan EPO	$160.49

catheter dilation bakri occlusion

Facility

$1,180.04

Hospital Charge Code	8690512
Hospital Revenue Code	272
Rate for Payer: Cash Price	$802.43

CATHETER EMBL 4FR 40CM FGRTY ART STRL

Facility

$144.53

Service Code	HCPCS C1757
Hospital Charge Code	992514
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

CATHETER EMBL 4FR 40CM FGRTY ART STRL

Facility

$144.53

Service Code	HCPCS C1757
Hospital Charge Code	992514
Hospital Revenue Code	272
Rate for Payer: Cash Price	$98.28

CATHETER EMBOLECTOMY 4FR 80CM FOGARTY ARTERIAL STERILE

Facility

$1,445.31

Service Code	HCPCS C1757
Hospital Charge Code	992512
Hospital Revenue Code	272
Min. Negotiated Rate	$130.08
Max. Negotiated Rate	$1,040.62
Rate for Payer: Amerigroup CHIP/Medicaid	$130.08
Rate for Payer: BCBS of TX Blue Advantage	$433.59
Rate for Payer: BCBS of TX Blue Essentials	$520.31
Rate for Payer: BCBS of TX PPO	$578.12
Rate for Payer: Cash Price	$982.81
Rate for Payer: Cigna Medicaid	$1,040.62
Rate for Payer: Molina CHIP/Medicaid	$1,040.62
Rate for Payer: Multiplan Auto	$939.45
Rate for Payer: Multiplan Commercial	$939.45
Rate for Payer: Multiplan Workers Comp	$939.45
Rate for Payer: Parkland Medicaid	$1,040.62
Rate for Payer: Scott and White EPO/PPO	$722.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,040.62
Rate for Payer: Superior Health Plan EPO	$196.56

CATHETER EMBOLECTOMY 4FR 80CM FOGARTY ARTERIAL STERILE

Facility

$1,445.31

Service Code	HCPCS C1757
Hospital Charge Code	992512
Hospital Revenue Code	272
Rate for Payer: Cash Price	$982.81

CATHETER, EMBOLECTOMY, ARTERIAL, 80C

Facility

$494.00

Service Code	HCPCS C1757
Hospital Charge Code	992517
Hospital Revenue Code	272
Rate for Payer: Cash Price	$335.92

CATHETER, EMBOLECTOMY, ARTERIAL, 80C

Facility

$494.00

Service Code	HCPCS C1757
Hospital Charge Code	992517
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

CATHETER, EMBOLECTOMY, FOGARTY, 40CM, 4F

Facility

$494.00

Service Code	HCPCS C1757
Hospital Charge Code	992518
Hospital Revenue Code	272
Rate for Payer: Cash Price	$335.92

CATHETER, EMBOLECTOMY, FOGARTY, 40CM, 4F

Facility

$494.00

Service Code	HCPCS C1757
Hospital Charge Code	992518
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

CATHETER EP BIOSENSE DECAPOLAR 7F 2.3MM X 110CM

Facility

$5,833.90

Hospital Charge Code	8556477
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,967.05

CATHETER EP BIOSENSE DECAPOLAR 7F 2.3MM X 110CM

Facility

$5,833.90

Hospital Charge Code	8556477
Hospital Revenue Code	272
Min. Negotiated Rate	$525.05
Max. Negotiated Rate	$4,200.41
Rate for Payer: Amerigroup CHIP/Medicaid	$525.05
Rate for Payer: BCBS of TX Blue Advantage	$1,750.17
Rate for Payer: BCBS of TX Blue Essentials	$2,100.20
Rate for Payer: BCBS of TX PPO	$2,333.56
Rate for Payer: Cash Price	$3,967.05
Rate for Payer: Cigna Medicaid	$4,200.41
Rate for Payer: Molina CHIP/Medicaid	$4,200.41
Rate for Payer: Multiplan Auto	$3,792.03
Rate for Payer: Multiplan Commercial	$3,792.03
Rate for Payer: Multiplan Workers Comp	$3,792.03
Rate for Payer: Parkland Medicaid	$4,200.41
Rate for Payer: Scott and White EPO/PPO	$2,916.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,200.41
Rate for Payer: Superior Health Plan EPO	$793.41

CATHETER EXTERNAL, FEMALE, PUREWICK, LF

Facility

$36.15

Service Code	HCPCS C1758
Hospital Charge Code	992510
Hospital Revenue Code	270
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$26.03
Rate for Payer: Amerigroup CHIP/Medicaid	$3.25
Rate for Payer: BCBS of TX Blue Advantage	$10.85
Rate for Payer: BCBS of TX Blue Essentials	$13.01
Rate for Payer: BCBS of TX PPO	$14.46
Rate for Payer: Cash Price	$24.58
Rate for Payer: Cigna Medicaid	$26.03
Rate for Payer: Molina CHIP/Medicaid	$26.03
Rate for Payer: Multiplan Auto	$23.50
Rate for Payer: Multiplan Commercial	$23.50
Rate for Payer: Multiplan Workers Comp	$23.50
Rate for Payer: Parkland Medicaid	$26.03
Rate for Payer: Scott and White EPO/PPO	$18.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.03
Rate for Payer: Superior Health Plan EPO	$4.92

CATHETER EXTERNAL, FEMALE, PUREWICK, LF

Facility

$36.15

Service Code	HCPCS C1758
Hospital Charge Code	992510
Hospital Revenue Code	270
Rate for Payer: Cash Price	$24.58

catheter extractor pro xl retrieval blln 9-12mm

Facility

$596.00

Service Code	HCPCS C1726
Hospital Charge Code	116306
Hospital Revenue Code	278
Min. Negotiated Rate	$149.00
Max. Negotiated Rate	$298.00
Rate for Payer: Cash Price	$405.28
Rate for Payer: Cigna Commercial	$149.00
Rate for Payer: Multiplan Auto	$298.00
Rate for Payer: Multiplan Commercial	$298.00
Rate for Payer: Multiplan Workers Comp	$298.00
Rate for Payer: Scott and White EPO/PPO	$298.00

catheter extractor pro xl retrieval blln 9-12mm

Facility

$596.00

Service Code	HCPCS C1726
Hospital Charge Code	116306
Hospital Revenue Code	278
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$429.12
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$178.80
Rate for Payer: BCBS of TX Blue Essentials	$214.56
Rate for Payer: BCBS of TX PPO	$238.40
Rate for Payer: Cash Price	$405.28
Rate for Payer: Cigna Medicaid	$429.12
Rate for Payer: Molina CHIP/Medicaid	$429.12
Rate for Payer: Multiplan Auto	$298.00
Rate for Payer: Multiplan Commercial	$298.00
Rate for Payer: Multiplan Workers Comp	$298.00
Rate for Payer: Parkland Medicaid	$429.12
Rate for Payer: Scott and White EPO/PPO	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$429.12
Rate for Payer: Superior Health Plan EPO	$81.06

CATHETER, FOLEY LTX ULTRA

Facility

$13.44

Service Code	HCPCS C1758
Hospital Charge Code	992508
Hospital Revenue Code	270
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$9.68
Rate for Payer: Amerigroup CHIP/Medicaid	$1.21
Rate for Payer: BCBS of TX Blue Advantage	$4.03
Rate for Payer: BCBS of TX Blue Essentials	$4.84
Rate for Payer: BCBS of TX PPO	$5.38
Rate for Payer: Cash Price	$9.14
Rate for Payer: Cigna Medicaid	$9.68
Rate for Payer: Molina CHIP/Medicaid	$9.68
Rate for Payer: Multiplan Auto	$8.74
Rate for Payer: Multiplan Commercial	$8.74
Rate for Payer: Multiplan Workers Comp	$8.74
Rate for Payer: Parkland Medicaid	$9.68
Rate for Payer: Scott and White EPO/PPO	$6.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.68
Rate for Payer: Superior Health Plan EPO	$1.83

CATHETER, FOLEY LTX ULTRA

Facility

$13.44

Service Code	HCPCS C1758
Hospital Charge Code	992508
Hospital Revenue Code	270
Rate for Payer: Cash Price	$9.14

CATHETER FOLEY SURESTEP KIT 16FR

Facility

$29.20

Service Code	HCPCS C1758
Hospital Charge Code	992509
Hospital Revenue Code	270
Rate for Payer: Cash Price	$19.86

CATHETER FOLEY SURESTEP KIT 16FR

Facility

$29.20

Service Code	HCPCS C1758
Hospital Charge Code	992509
Hospital Revenue Code	270
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$21.02
Rate for Payer: Amerigroup CHIP/Medicaid	$2.63
Rate for Payer: BCBS of TX Blue Advantage	$8.76
Rate for Payer: BCBS of TX Blue Essentials	$10.51
Rate for Payer: BCBS of TX PPO	$11.68
Rate for Payer: Cash Price	$19.86
Rate for Payer: Cigna Medicaid	$21.02
Rate for Payer: Molina CHIP/Medicaid	$21.02
Rate for Payer: Multiplan Auto	$18.98
Rate for Payer: Multiplan Commercial	$18.98
Rate for Payer: Multiplan Workers Comp	$18.98
Rate for Payer: Parkland Medicaid	$21.02
Rate for Payer: Scott and White EPO/PPO	$14.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.02
Rate for Payer: Superior Health Plan EPO	$3.97

CATHETER GD AL1 6FR 100CM COR LNCHR

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992421
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

Know your out-of-pocket cost for care.

All Charges