White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATH GUIDING -- DHF

Facility

$1,306.00

Service Code	HCPCS C1887
Hospital Charge Code	82400961
Hospital Revenue Code	278
Min. Negotiated Rate	$326.50
Max. Negotiated Rate	$653.00
Rate for Payer: Cash Price	$888.08
Rate for Payer: Cigna Commercial	$326.50
Rate for Payer: Multiplan Auto	$653.00
Rate for Payer: Multiplan Commercial	$653.00
Rate for Payer: Multiplan Workers Comp	$653.00
Rate for Payer: Scott and White EPO/PPO	$653.00

CATH GUIDING LNCH LA6AL30SH

Facility

$195.22

Service Code	HCPCS C1766
Hospital Charge Code	992485
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

CATH GUIDING LNCH LA6AL30SH

Facility

$195.22

Service Code	HCPCS C1766
Hospital Charge Code	992485
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

CATH GUIDING LNCH LA6JR30

Facility

$195.22

Service Code	HCPCS C1766
Hospital Charge Code	992484
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

CATH GUIDING LNCH LA6JR30

Facility

$195.22

Service Code	HCPCS C1766
Hospital Charge Code	992484
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

CATH GUIDING LNCH LA6JR45

Facility

$227.00

Service Code	HCPCS C1766
Hospital Charge Code	992482
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

CATH GUIDING LNCH LA6JR45

Facility

$227.00

Service Code	HCPCS C1766
Hospital Charge Code	992482
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$30.87

CATH GUIDING LNCH LA6JR45SH

Facility

$195.22

Service Code	HCPCS C1766
Hospital Charge Code	992483
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

CATH GUIDING LNCH LA6JR45SH

Facility

$195.22

Service Code	HCPCS C1766
Hospital Charge Code	992483
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

CATH INF PICC DL PWR -- DHF

Facility

$742.00

Service Code	HCPCS C1751
Hospital Charge Code	82457532
Hospital Revenue Code	278
Min. Negotiated Rate	$66.78
Max. Negotiated Rate	$534.24
Rate for Payer: Amerigroup CHIP/Medicaid	$66.78
Rate for Payer: BCBS of TX Blue Advantage	$222.60
Rate for Payer: BCBS of TX Blue Essentials	$267.12
Rate for Payer: BCBS of TX PPO	$296.80
Rate for Payer: Cash Price	$504.56
Rate for Payer: Cigna Medicaid	$534.24
Rate for Payer: Molina CHIP/Medicaid	$534.24
Rate for Payer: Multiplan Auto	$371.00
Rate for Payer: Multiplan Commercial	$371.00
Rate for Payer: Multiplan Workers Comp	$371.00
Rate for Payer: Parkland Medicaid	$534.24
Rate for Payer: Scott and White EPO/PPO	$371.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$534.24
Rate for Payer: Superior Health Plan EPO	$100.91

CATH INF PICC DL PWR -- DHF

Facility

$742.00

Service Code	HCPCS C1751
Hospital Charge Code	82457532
Hospital Revenue Code	278
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$371.00
Rate for Payer: Cash Price	$504.56
Rate for Payer: Cigna Commercial	$185.50
Rate for Payer: Multiplan Auto	$371.00
Rate for Payer: Multiplan Commercial	$371.00
Rate for Payer: Multiplan Workers Comp	$371.00
Rate for Payer: Scott and White EPO/PPO	$371.00

CATH INFUSION VALVED 41052-01

Facility

$590.20

Service Code	HCPCS C1714
Hospital Charge Code	992584
Hospital Revenue Code	272
Min. Negotiated Rate	$53.12
Max. Negotiated Rate	$424.94
Rate for Payer: Amerigroup CHIP/Medicaid	$53.12
Rate for Payer: BCBS of TX Blue Advantage	$177.06
Rate for Payer: BCBS of TX Blue Essentials	$212.47
Rate for Payer: BCBS of TX PPO	$236.08
Rate for Payer: Cash Price	$401.34
Rate for Payer: Cigna Medicaid	$424.94
Rate for Payer: Molina CHIP/Medicaid	$424.94
Rate for Payer: Multiplan Auto	$383.63
Rate for Payer: Multiplan Commercial	$383.63
Rate for Payer: Multiplan Workers Comp	$383.63
Rate for Payer: Parkland Medicaid	$424.94
Rate for Payer: Scott and White EPO/PPO	$295.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.94
Rate for Payer: Superior Health Plan EPO	$80.27

CATH INFUSION VALVED 41052-01

Facility

$590.20

Service Code	HCPCS C1714
Hospital Charge Code	992584
Hospital Revenue Code	272
Rate for Payer: Cash Price	$401.34

CATH INFUSION VALVED 41054-01

Facility

$590.20

Service Code	HCPCS C1714
Hospital Charge Code	992585
Hospital Revenue Code	272
Rate for Payer: Cash Price	$401.34

CATH INFUSION VALVED 41054-01

Facility

$590.20

Service Code	HCPCS C1714
Hospital Charge Code	992585
Hospital Revenue Code	272
Min. Negotiated Rate	$53.12
Max. Negotiated Rate	$424.94
Rate for Payer: Amerigroup CHIP/Medicaid	$53.12
Rate for Payer: BCBS of TX Blue Advantage	$177.06
Rate for Payer: BCBS of TX Blue Essentials	$212.47
Rate for Payer: BCBS of TX PPO	$236.08
Rate for Payer: Cash Price	$401.34
Rate for Payer: Cigna Medicaid	$424.94
Rate for Payer: Molina CHIP/Medicaid	$424.94
Rate for Payer: Multiplan Auto	$383.63
Rate for Payer: Multiplan Commercial	$383.63
Rate for Payer: Multiplan Workers Comp	$383.63
Rate for Payer: Parkland Medicaid	$424.94
Rate for Payer: Scott and White EPO/PPO	$295.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$424.94
Rate for Payer: Superior Health Plan EPO	$80.27

CATH INFUSION VALVED 41060-01

Facility

$608.36

Service Code	HCPCS C1714
Hospital Charge Code	992583
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

CATH INFUSION VALVED 41060-01

Facility

$608.36

Service Code	HCPCS C1714
Hospital Charge Code	992583
Hospital Revenue Code	272
Rate for Payer: Cash Price	$413.68

CATH INFUSION VALVED 41060-01

Facility

$608.36

Service Code	HCPCS C1714
Hospital Charge Code	992586
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

CATH INFUSION VALVED 41060-01

Facility

$608.36

Service Code	HCPCS C1714
Hospital Charge Code	992586
Hospital Revenue Code	272
Rate for Payer: Cash Price	$413.68

CATH IV 16X1-1/4 -- DHF

Facility

$72.12

Hospital Charge Code	54201447
Hospital Revenue Code	270
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$51.93
Rate for Payer: Amerigroup CHIP/Medicaid	$6.49
Rate for Payer: BCBS of TX Blue Advantage	$21.64
Rate for Payer: BCBS of TX Blue Essentials	$25.96
Rate for Payer: BCBS of TX PPO	$28.85
Rate for Payer: Cash Price	$49.04
Rate for Payer: Cigna Medicaid	$51.93
Rate for Payer: Molina CHIP/Medicaid	$51.93
Rate for Payer: Multiplan Auto	$46.88
Rate for Payer: Multiplan Commercial	$46.88
Rate for Payer: Multiplan Workers Comp	$46.88
Rate for Payer: Parkland Medicaid	$51.93
Rate for Payer: Scott and White EPO/PPO	$36.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.93
Rate for Payer: Superior Health Plan EPO	$9.81

CATH IV 16X1-1/4 -- DHF

Facility

$72.12

Hospital Charge Code	54201447
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.04

CATH IV 18X1-1/4 -- DHF

Facility

$72.12

Service Code	HCPCS A4649
Hospital Charge Code	54201454
Hospital Revenue Code	270
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$51.93
Rate for Payer: Amerigroup CHIP/Medicaid	$6.49
Rate for Payer: BCBS of TX Blue Advantage	$21.64
Rate for Payer: BCBS of TX Blue Essentials	$25.96
Rate for Payer: BCBS of TX PPO	$28.85
Rate for Payer: Cash Price	$49.04
Rate for Payer: Cigna Medicaid	$51.93
Rate for Payer: Molina CHIP/Medicaid	$51.93
Rate for Payer: Multiplan Auto	$46.88
Rate for Payer: Multiplan Commercial	$46.88
Rate for Payer: Multiplan Workers Comp	$46.88
Rate for Payer: Parkland Medicaid	$51.93
Rate for Payer: Scott and White EPO/PPO	$36.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.93
Rate for Payer: Superior Health Plan EPO	$9.81

CATH IV 18X1-1/4 -- DHF

Facility

$72.12

Service Code	HCPCS A4649
Hospital Charge Code	54201454
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.04

CATH IV 20X1-1/4 -- DHF

Facility

$57.27

Hospital Charge Code	54201496
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

CATH IV 20X1-1/4 -- DHF

Facility

$57.27

Hospital Charge Code	54201496
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.94

Know your out-of-pocket cost for care.

All Charges