White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATHETER IMG COR EE PLTN 5FR STD TIP

Facility

$6,583.00

Hospital Charge Code	80565468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,476.44

CATHETER INFS 5FR 10X65CM CRGG MCNAM

Facility

$390.44

Service Code	HCPCS C1887
Hospital Charge Code	992417
Hospital Revenue Code	272
Min. Negotiated Rate	$35.14
Max. Negotiated Rate	$281.12
Rate for Payer: Amerigroup CHIP/Medicaid	$35.14
Rate for Payer: BCBS of TX Blue Advantage	$117.13
Rate for Payer: BCBS of TX Blue Essentials	$140.56
Rate for Payer: BCBS of TX PPO	$156.18
Rate for Payer: Cash Price	$265.50
Rate for Payer: Cigna Medicaid	$281.12
Rate for Payer: Molina CHIP/Medicaid	$281.12
Rate for Payer: Multiplan Auto	$253.79
Rate for Payer: Multiplan Commercial	$253.79
Rate for Payer: Multiplan Workers Comp	$253.79
Rate for Payer: Parkland Medicaid	$281.12
Rate for Payer: Scott and White EPO/PPO	$195.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$281.12
Rate for Payer: Superior Health Plan EPO	$53.10

CATHETER INFS 5FR 10X65CM CRGG MCNAM

Facility

$390.44

Service Code	HCPCS C1887
Hospital Charge Code	992417
Hospital Revenue Code	272
Rate for Payer: Cash Price	$265.50

CATHETER INFS 5FR 20X135CM CRGG MCNAM

Facility

$404.06

Service Code	HCPCS C1887
Hospital Charge Code	992419
Hospital Revenue Code	272
Min. Negotiated Rate	$36.37
Max. Negotiated Rate	$290.92
Rate for Payer: Amerigroup CHIP/Medicaid	$36.37
Rate for Payer: BCBS of TX Blue Advantage	$121.22
Rate for Payer: BCBS of TX Blue Essentials	$145.46
Rate for Payer: BCBS of TX PPO	$161.62
Rate for Payer: Cash Price	$274.76
Rate for Payer: Cigna Medicaid	$290.92
Rate for Payer: Molina CHIP/Medicaid	$290.92
Rate for Payer: Multiplan Auto	$262.64
Rate for Payer: Multiplan Commercial	$262.64
Rate for Payer: Multiplan Workers Comp	$262.64
Rate for Payer: Parkland Medicaid	$290.92
Rate for Payer: Scott and White EPO/PPO	$202.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$290.92
Rate for Payer: Superior Health Plan EPO	$54.95

CATHETER INFS 5FR 20X135CM CRGG MCNAM

Facility

$404.06

Service Code	HCPCS C1887
Hospital Charge Code	992419
Hospital Revenue Code	272
Rate for Payer: Cash Price	$274.76

CATHETER INFS 5FR 20X65CM CRGG MCNAM

Facility

$381.36

Service Code	HCPCS C1887
Hospital Charge Code	992418
Hospital Revenue Code	272
Min. Negotiated Rate	$34.32
Max. Negotiated Rate	$274.58
Rate for Payer: Amerigroup CHIP/Medicaid	$34.32
Rate for Payer: BCBS of TX Blue Advantage	$114.41
Rate for Payer: BCBS of TX Blue Essentials	$137.29
Rate for Payer: BCBS of TX PPO	$152.54
Rate for Payer: Cash Price	$259.32
Rate for Payer: Cigna Medicaid	$274.58
Rate for Payer: Molina CHIP/Medicaid	$274.58
Rate for Payer: Multiplan Auto	$247.88
Rate for Payer: Multiplan Commercial	$247.88
Rate for Payer: Multiplan Workers Comp	$247.88
Rate for Payer: Parkland Medicaid	$274.58
Rate for Payer: Scott and White EPO/PPO	$190.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$274.58
Rate for Payer: Superior Health Plan EPO	$51.86

CATHETER INFS 5FR 20X65CM CRGG MCNAM

Facility

$381.36

Service Code	HCPCS C1887
Hospital Charge Code	992418
Hospital Revenue Code	272
Rate for Payer: Cash Price	$259.32

CATHETER INFS 5FR 30X135CM CRGG MCNAM

Facility

$608.36

Service Code	HCPCS C1887
Hospital Charge Code	992420
Hospital Revenue Code	272
Min. Negotiated Rate	$54.75
Max. Negotiated Rate	$438.02
Rate for Payer: Amerigroup CHIP/Medicaid	$54.75
Rate for Payer: BCBS of TX Blue Advantage	$182.51
Rate for Payer: BCBS of TX Blue Essentials	$219.01
Rate for Payer: BCBS of TX PPO	$243.34
Rate for Payer: Cash Price	$413.68
Rate for Payer: Cigna Medicaid	$438.02
Rate for Payer: Molina CHIP/Medicaid	$438.02
Rate for Payer: Multiplan Auto	$395.43
Rate for Payer: Multiplan Commercial	$395.43
Rate for Payer: Multiplan Workers Comp	$395.43
Rate for Payer: Parkland Medicaid	$438.02
Rate for Payer: Scott and White EPO/PPO	$304.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$438.02
Rate for Payer: Superior Health Plan EPO	$82.74

CATHETER INFS 5FR 30X135CM CRGG MCNAM

Facility

$608.36

Service Code	HCPCS C1887
Hospital Charge Code	992420
Hospital Revenue Code	272
Rate for Payer: Cash Price	$413.68

CATHETER, INTERMITTENT VINYL FEMALE LENGTH PVC -- DHF

Facility

$50.69

Hospital Charge Code	80412026
Hospital Revenue Code	272
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$36.50
Rate for Payer: Amerigroup CHIP/Medicaid	$4.56
Rate for Payer: BCBS of TX Blue Advantage	$15.21
Rate for Payer: BCBS of TX Blue Essentials	$18.25
Rate for Payer: BCBS of TX PPO	$20.28
Rate for Payer: Cash Price	$34.47
Rate for Payer: Cigna Medicaid	$36.50
Rate for Payer: Molina CHIP/Medicaid	$36.50
Rate for Payer: Multiplan Auto	$32.95
Rate for Payer: Multiplan Commercial	$32.95
Rate for Payer: Multiplan Workers Comp	$32.95
Rate for Payer: Parkland Medicaid	$36.50
Rate for Payer: Scott and White EPO/PPO	$25.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.50
Rate for Payer: Superior Health Plan EPO	$6.89

CATHETER, INTERMITTENT VINYL FEMALE LENGTH PVC -- DHF

Facility

$50.69

Hospital Charge Code	80412026
Hospital Revenue Code	272
Rate for Payer: Cash Price	$34.47

CATHETER, INTRAUTERINE MANIP HNDL ARCH TP 2.5CM -- DHF

Facility

$477.51

Hospital Charge Code	80565252
Hospital Revenue Code	272
Rate for Payer: Cash Price	$324.71

CATHETER, INTRAUTERINE MANIP HNDL ARCH TP 2.5CM -- DHF

Facility

$477.51

Hospital Charge Code	80565252
Hospital Revenue Code	272
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$343.81
Rate for Payer: Amerigroup CHIP/Medicaid	$42.98
Rate for Payer: BCBS of TX Blue Advantage	$143.25
Rate for Payer: BCBS of TX Blue Essentials	$171.90
Rate for Payer: BCBS of TX PPO	$191.00
Rate for Payer: Cash Price	$324.71
Rate for Payer: Cigna Medicaid	$343.81
Rate for Payer: Molina CHIP/Medicaid	$343.81
Rate for Payer: Multiplan Auto	$310.38
Rate for Payer: Multiplan Commercial	$310.38
Rate for Payer: Multiplan Workers Comp	$310.38
Rate for Payer: Parkland Medicaid	$343.81
Rate for Payer: Scott and White EPO/PPO	$238.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$343.81
Rate for Payer: Superior Health Plan EPO	$64.94

CATHETER INTRAUTERINE MANIP HNDL ARCH TP 3.5CM

Facility

$1,449.20

Service Code	HCPCS C1759
Hospital Charge Code	992505
Hospital Revenue Code	270
Min. Negotiated Rate	$130.43
Max. Negotiated Rate	$1,043.42
Rate for Payer: Amerigroup CHIP/Medicaid	$130.43
Rate for Payer: BCBS of TX Blue Advantage	$434.76
Rate for Payer: BCBS of TX Blue Essentials	$521.71
Rate for Payer: BCBS of TX PPO	$579.68
Rate for Payer: Cash Price	$985.46
Rate for Payer: Cigna Medicaid	$1,043.42
Rate for Payer: Molina CHIP/Medicaid	$1,043.42
Rate for Payer: Multiplan Auto	$941.98
Rate for Payer: Multiplan Commercial	$941.98
Rate for Payer: Multiplan Workers Comp	$941.98
Rate for Payer: Parkland Medicaid	$1,043.42
Rate for Payer: Scott and White EPO/PPO	$724.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,043.42
Rate for Payer: Superior Health Plan EPO	$197.09

CATHETER INTRAUTERINE MANIP HNDL ARCH TP 3.5CM

Facility

$1,449.20

Service Code	HCPCS C1759
Hospital Charge Code	992505
Hospital Revenue Code	270
Rate for Payer: Cash Price	$985.46

CATHETER, IV, AUTOGUARD, INSYTE 20GX1.88

Facility

$7.35

Hospital Charge Code	993185
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.00

CATHETER, IV, AUTOGUARD, INSYTE 20GX1.88

Facility

$7.35

Hospital Charge Code	993185
Hospital Revenue Code	270
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$5.29
Rate for Payer: Amerigroup CHIP/Medicaid	$0.66
Rate for Payer: BCBS of TX Blue Advantage	$2.21
Rate for Payer: BCBS of TX Blue Essentials	$2.65
Rate for Payer: BCBS of TX PPO	$2.94
Rate for Payer: Cash Price	$5.00
Rate for Payer: Cigna Medicaid	$5.29
Rate for Payer: Molina CHIP/Medicaid	$5.29
Rate for Payer: Multiplan Auto	$4.78
Rate for Payer: Multiplan Commercial	$4.78
Rate for Payer: Multiplan Workers Comp	$4.78
Rate for Payer: Parkland Medicaid	$5.29
Rate for Payer: Scott and White EPO/PPO	$3.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.29
Rate for Payer: Superior Health Plan EPO	$1.00

CATHETER, IV INTROCAN SAFETY TFLN 14G X 2' STERILE -- DHF

Facility

$57.27

Hospital Charge Code	54201504
Hospital Revenue Code	270
Min. Negotiated Rate	$5.15
Max. Negotiated Rate	$41.23
Rate for Payer: Amerigroup CHIP/Medicaid	$5.15
Rate for Payer: BCBS of TX Blue Advantage	$17.18
Rate for Payer: BCBS of TX Blue Essentials	$20.62
Rate for Payer: BCBS of TX PPO	$22.91
Rate for Payer: Cash Price	$38.94
Rate for Payer: Cigna Medicaid	$41.23
Rate for Payer: Molina CHIP/Medicaid	$41.23
Rate for Payer: Multiplan Auto	$37.23
Rate for Payer: Multiplan Commercial	$37.23
Rate for Payer: Multiplan Workers Comp	$37.23
Rate for Payer: Parkland Medicaid	$41.23
Rate for Payer: Scott and White EPO/PPO	$28.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.23
Rate for Payer: Superior Health Plan EPO	$7.79

CATHETER, IV INTROCAN SAFETY TFLN 14G X 2' STERILE -- DHF

Facility

$57.27

Hospital Charge Code	54201504
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.94

CATHETER, IV SAFETY W/BLOOD CONTROL 20G X 1.25'

Facility

$9.28

Hospital Charge Code	993250
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.31

CATHETER, IV SAFETY W/BLOOD CONTROL 20G X 1.25'

Facility

$9.28

Hospital Charge Code	993250
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.68
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.78
Rate for Payer: BCBS of TX Blue Essentials	$3.34
Rate for Payer: BCBS of TX PPO	$3.71
Rate for Payer: Cash Price	$6.31
Rate for Payer: Cigna Medicaid	$6.68
Rate for Payer: Molina CHIP/Medicaid	$6.68
Rate for Payer: Multiplan Auto	$6.03
Rate for Payer: Multiplan Commercial	$6.03
Rate for Payer: Multiplan Workers Comp	$6.03
Rate for Payer: Parkland Medicaid	$6.68
Rate for Payer: Scott and White EPO/PPO	$4.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.68
Rate for Payer: Superior Health Plan EPO	$1.26

CATHETER IVUS -- DHF

Facility

$3,246.10

Hospital Charge Code	80565427
Hospital Revenue Code	272
Min. Negotiated Rate	$292.15
Max. Negotiated Rate	$2,337.19
Rate for Payer: Amerigroup CHIP/Medicaid	$292.15
Rate for Payer: BCBS of TX Blue Advantage	$973.83
Rate for Payer: BCBS of TX Blue Essentials	$1,168.60
Rate for Payer: BCBS of TX PPO	$1,298.44
Rate for Payer: Cash Price	$2,207.35
Rate for Payer: Cigna Medicaid	$2,337.19
Rate for Payer: Molina CHIP/Medicaid	$2,337.19
Rate for Payer: Multiplan Auto	$2,109.97
Rate for Payer: Multiplan Commercial	$2,109.97
Rate for Payer: Multiplan Workers Comp	$2,109.97
Rate for Payer: Parkland Medicaid	$2,337.19
Rate for Payer: Scott and White EPO/PPO	$1,623.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,337.19
Rate for Payer: Superior Health Plan EPO	$441.47

CATHETER IVUS -- DHF

Facility

$3,246.10

Hospital Charge Code	80565427
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,207.35

CATHETER MOLDING & OCCLUSION MOB37

Facility

$2,528.78

Hospital Charge Code	141584
Hospital Revenue Code	272
Min. Negotiated Rate	$227.59
Max. Negotiated Rate	$1,820.72
Rate for Payer: Amerigroup CHIP/Medicaid	$227.59
Rate for Payer: BCBS of TX Blue Advantage	$758.63
Rate for Payer: BCBS of TX Blue Essentials	$910.36
Rate for Payer: BCBS of TX PPO	$1,011.51
Rate for Payer: Cash Price	$1,719.57
Rate for Payer: Cigna Medicaid	$1,820.72
Rate for Payer: Molina CHIP/Medicaid	$1,820.72
Rate for Payer: Multiplan Auto	$1,643.71
Rate for Payer: Multiplan Commercial	$1,643.71
Rate for Payer: Multiplan Workers Comp	$1,643.71
Rate for Payer: Parkland Medicaid	$1,820.72
Rate for Payer: Scott and White EPO/PPO	$1,264.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,820.72
Rate for Payer: Superior Health Plan EPO	$343.91

CATHETER MOLDING & OCCLUSION MOB37

Facility

$2,528.78

Hospital Charge Code	141584
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,719.57

Know your out-of-pocket cost for care.

All Charges