White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Cath iv inssyte-n 24gx.56

Facility

$10.03

Hospital Charge Code	8616505
Hospital Revenue Code	272
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$7.22
Rate for Payer: Amerigroup CHIP/Medicaid	$0.90
Rate for Payer: BCBS of TX Blue Advantage	$3.01
Rate for Payer: BCBS of TX Blue Essentials	$3.61
Rate for Payer: BCBS of TX PPO	$4.01
Rate for Payer: Cash Price	$6.82
Rate for Payer: Cigna Medicaid	$7.22
Rate for Payer: Molina CHIP/Medicaid	$7.22
Rate for Payer: Multiplan Auto	$6.52
Rate for Payer: Multiplan Commercial	$6.52
Rate for Payer: Multiplan Workers Comp	$6.52
Rate for Payer: Parkland Medicaid	$7.22
Rate for Payer: Scott and White EPO/PPO	$5.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.22
Rate for Payer: Superior Health Plan EPO	$1.36

Cath iv inssyte-n 24gx.56

Facility

$10.03

Hospital Charge Code	8616505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.82

CATH IV PLCMNT -- DHF

Facility

$82.72

Hospital Charge Code	54201959
Hospital Revenue Code	270
Rate for Payer: Cash Price	$56.25

CATH IV PLCMNT -- DHF

Facility

$82.72

Hospital Charge Code	54201959
Hospital Revenue Code	270
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$59.56
Rate for Payer: Amerigroup CHIP/Medicaid	$7.44
Rate for Payer: BCBS of TX Blue Advantage	$24.82
Rate for Payer: BCBS of TX Blue Essentials	$29.78
Rate for Payer: BCBS of TX PPO	$33.09
Rate for Payer: Cash Price	$56.25
Rate for Payer: Cigna Medicaid	$59.56
Rate for Payer: Molina CHIP/Medicaid	$59.56
Rate for Payer: Multiplan Auto	$53.77
Rate for Payer: Multiplan Commercial	$53.77
Rate for Payer: Multiplan Workers Comp	$53.77
Rate for Payer: Parkland Medicaid	$59.56
Rate for Payer: Scott and White EPO/PPO	$41.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.56
Rate for Payer: Superior Health Plan EPO	$11.25

CATH IVUS DIGITL PV.035 -- DHF

Facility

$4,313.00

Hospital Charge Code	80565435
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,932.84

CATH IVUS DIGITL PV.035 -- DHF

Facility

$4,313.00

Hospital Charge Code	80565435
Hospital Revenue Code	272
Min. Negotiated Rate	$388.17
Max. Negotiated Rate	$3,105.36
Rate for Payer: Amerigroup CHIP/Medicaid	$388.17
Rate for Payer: BCBS of TX Blue Advantage	$1,293.90
Rate for Payer: BCBS of TX Blue Essentials	$1,552.68
Rate for Payer: BCBS of TX PPO	$1,725.20
Rate for Payer: Cash Price	$2,932.84
Rate for Payer: Cigna Medicaid	$3,105.36
Rate for Payer: Molina CHIP/Medicaid	$3,105.36
Rate for Payer: Multiplan Auto	$2,803.45
Rate for Payer: Multiplan Commercial	$2,803.45
Rate for Payer: Multiplan Workers Comp	$2,803.45
Rate for Payer: Parkland Medicaid	$3,105.36
Rate for Payer: Scott and White EPO/PPO	$2,156.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,105.36
Rate for Payer: Superior Health Plan EPO	$586.57

CATH KIT SURESTEP FOLEY

Facility

$94.97

Hospital Charge Code	8504483
Hospital Revenue Code	272
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$68.38
Rate for Payer: Amerigroup CHIP/Medicaid	$8.55
Rate for Payer: BCBS of TX Blue Advantage	$28.49
Rate for Payer: BCBS of TX Blue Essentials	$34.19
Rate for Payer: BCBS of TX PPO	$37.99
Rate for Payer: Cash Price	$64.58
Rate for Payer: Cigna Medicaid	$68.38
Rate for Payer: Molina CHIP/Medicaid	$68.38
Rate for Payer: Multiplan Auto	$61.73
Rate for Payer: Multiplan Commercial	$61.73
Rate for Payer: Multiplan Workers Comp	$61.73
Rate for Payer: Parkland Medicaid	$68.38
Rate for Payer: Scott and White EPO/PPO	$47.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$68.38
Rate for Payer: Superior Health Plan EPO	$12.92

CATH KIT SURESTEP FOLEY

Facility

$94.97

Hospital Charge Code	8504483
Hospital Revenue Code	272
Rate for Payer: Cash Price	$64.58

CATH L HRT ARTERY/VENTR

Facility

$21,615.00

Service Code	HCPCS 93458
Hospital Charge Code	2320527
Hospital Revenue Code	481
Min. Negotiated Rate	$1,262.79
Max. Negotiated Rate	$15,562.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,945.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Amerigroup Medicare	$3,256.70
Rate for Payer: BCBS of TX Blue Advantage	$4,759.42
Rate for Payer: BCBS of TX Blue Essentials	$5,699.90
Rate for Payer: BCBS of TX Medicare	$3,256.70
Rate for Payer: BCBS of TX PPO	$7,181.87
Rate for Payer: Cash Price	$14,698.20
Rate for Payer: Cash Price	$14,698.20
Rate for Payer: Cash Price	$14,698.20
Rate for Payer: Cigna Commercial	$6,884.08
Rate for Payer: Cigna Medicaid	$15,562.80
Rate for Payer: Cigna Medicare	$3,256.70
Rate for Payer: Employer Direct Commercial	$3,256.70
Rate for Payer: Humana Medicare/TRICARE	$3,256.70
Rate for Payer: Molina CHIP/Medicaid	$15,562.80
Rate for Payer: Molina Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Molina Medicare	$3,256.70
Rate for Payer: Multiplan Auto	$14,049.75
Rate for Payer: Multiplan Commercial	$14,049.75
Rate for Payer: Multiplan Workers Comp	$14,049.75
Rate for Payer: Parkland Medicaid	$15,562.80
Rate for Payer: Scott and White EPO/PPO	$1,262.79
Rate for Payer: Scott and White Medicare	$3,256.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,562.80
Rate for Payer: Superior Health Plan EPO	$3,256.70
Rate for Payer: Superior Health Plan Medicare	$3,256.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Universal American Medicare	$3,256.70
Rate for Payer: Wellcare Medicare	$3,256.70
Rate for Payer: Wellmed Medicare	$3,256.70

CATH L HRT ARTERY/VENTR

Facility

$21,615.00

Service Code	HCPCS 93458
Hospital Charge Code	2320527
Hospital Revenue Code	481
Rate for Payer: Cash Price	$14,698.20

CATH L VENTRICAL/ATRIAL

Facility

$2,166.00

Service Code	HCPCS 93565
Hospital Charge Code	4613566
Hospital Revenue Code	481
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$1,559.52
Rate for Payer: Amerigroup CHIP/Medicaid	$194.94
Rate for Payer: BCBS of TX Blue Advantage	$649.80
Rate for Payer: BCBS of TX Blue Essentials	$779.76
Rate for Payer: BCBS of TX PPO	$866.40
Rate for Payer: Cash Price	$1,472.88
Rate for Payer: Cash Price	$1,472.88
Rate for Payer: Cigna Medicaid	$1,559.52
Rate for Payer: Molina CHIP/Medicaid	$1,559.52
Rate for Payer: Multiplan Auto	$1,407.90
Rate for Payer: Multiplan Commercial	$1,407.90
Rate for Payer: Multiplan Workers Comp	$1,407.90
Rate for Payer: Parkland Medicaid	$1,559.52
Rate for Payer: Scott and White EPO/PPO	$32.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,559.52
Rate for Payer: Superior Health Plan EPO	$294.58

CATH L VENTRICAL/ATRIAL

Facility

$2,166.00

Service Code	HCPCS 93565
Hospital Charge Code	4613566
Hospital Revenue Code	481
Rate for Payer: Cash Price	$1,472.88

CATH MUSTANG BLN DIL 6X100X135

Facility

$1,145.00

Service Code	HCPCS C1726
Hospital Charge Code	108493
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

CATH MUSTANG BLN DIL 6X100X135

Facility

$1,145.00

Service Code	HCPCS C1726
Hospital Charge Code	108493
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

CATH OTW PTA 5.0MM X 120MM X 135CM

Facility

$649.22

Service Code	HCPCS C1726
Hospital Charge Code	993809
Hospital Revenue Code	279
Min. Negotiated Rate	$58.43
Max. Negotiated Rate	$467.44
Rate for Payer: Amerigroup CHIP/Medicaid	$58.43
Rate for Payer: BCBS of TX Blue Advantage	$194.77
Rate for Payer: BCBS of TX Blue Essentials	$233.72
Rate for Payer: BCBS of TX PPO	$259.69
Rate for Payer: Cash Price	$441.47
Rate for Payer: Cigna Medicaid	$467.44
Rate for Payer: Molina CHIP/Medicaid	$467.44
Rate for Payer: Multiplan Auto	$421.99
Rate for Payer: Multiplan Commercial	$421.99
Rate for Payer: Multiplan Workers Comp	$421.99
Rate for Payer: Parkland Medicaid	$467.44
Rate for Payer: Scott and White EPO/PPO	$324.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$467.44
Rate for Payer: Superior Health Plan EPO	$88.29

CATH OTW PTA 5.0MM X 120MM X 135CM

Facility

$649.22

Service Code	HCPCS C1726
Hospital Charge Code	993809
Hospital Revenue Code	279
Rate for Payer: Cash Price	$441.47

CATH PERI DIALYSIS -- DHF

Facility

$220.32

Hospital Charge Code	80566458
Hospital Revenue Code	272
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$158.63
Rate for Payer: Amerigroup CHIP/Medicaid	$19.83
Rate for Payer: BCBS of TX Blue Advantage	$66.10
Rate for Payer: BCBS of TX Blue Essentials	$79.32
Rate for Payer: BCBS of TX PPO	$88.13
Rate for Payer: Cash Price	$149.82
Rate for Payer: Cigna Medicaid	$158.63
Rate for Payer: Molina CHIP/Medicaid	$158.63
Rate for Payer: Multiplan Auto	$143.21
Rate for Payer: Multiplan Commercial	$143.21
Rate for Payer: Multiplan Workers Comp	$143.21
Rate for Payer: Parkland Medicaid	$158.63
Rate for Payer: Scott and White EPO/PPO	$110.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$158.63
Rate for Payer: Superior Health Plan EPO	$29.96

CATH PERI DIALYSIS -- DHF

Facility

$220.32

Hospital Charge Code	80566458
Hospital Revenue Code	272
Rate for Payer: Cash Price	$149.82

CATH PICC BARD GROSHONG -- DHF

Facility

$1,565.00

Service Code	HCPCS C1751
Hospital Charge Code	82458506
Hospital Revenue Code	278
Min. Negotiated Rate	$140.85
Max. Negotiated Rate	$1,126.80
Rate for Payer: Amerigroup CHIP/Medicaid	$140.85
Rate for Payer: BCBS of TX Blue Advantage	$469.50
Rate for Payer: BCBS of TX Blue Essentials	$563.40
Rate for Payer: BCBS of TX PPO	$626.00
Rate for Payer: Cash Price	$1,064.20
Rate for Payer: Cigna Medicaid	$1,126.80
Rate for Payer: Molina CHIP/Medicaid	$1,126.80
Rate for Payer: Multiplan Auto	$782.50
Rate for Payer: Multiplan Commercial	$782.50
Rate for Payer: Multiplan Workers Comp	$782.50
Rate for Payer: Parkland Medicaid	$1,126.80
Rate for Payer: Scott and White EPO/PPO	$782.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,126.80
Rate for Payer: Superior Health Plan EPO	$212.84

CATH PICC BARD GROSHONG -- DHF

Facility

$1,565.00

Service Code	HCPCS C1751
Hospital Charge Code	82458506
Hospital Revenue Code	278
Min. Negotiated Rate	$391.25
Max. Negotiated Rate	$782.50
Rate for Payer: Cash Price	$1,064.20
Rate for Payer: Cigna Commercial	$391.25
Rate for Payer: Multiplan Auto	$782.50
Rate for Payer: Multiplan Commercial	$782.50
Rate for Payer: Multiplan Workers Comp	$782.50
Rate for Payer: Scott and White EPO/PPO	$782.50

CATH PLC IN BYPASS GRAFT ANGIOGRAPH

Facility

$21,165.00

Service Code	HCPCS 93455
Hospital Charge Code	2320524
Hospital Revenue Code	481
Rate for Payer: Cash Price	$14,392.20

CATH PLC IN BYPASS GRAFT ANGIOGRAPH

Facility

$21,165.00

Service Code	HCPCS 93455
Hospital Charge Code	2320524
Hospital Revenue Code	481
Min. Negotiated Rate	$1,223.08
Max. Negotiated Rate	$15,238.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,904.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Amerigroup Medicare	$3,256.70
Rate for Payer: BCBS of TX Blue Advantage	$4,759.42
Rate for Payer: BCBS of TX Blue Essentials	$5,699.90
Rate for Payer: BCBS of TX Medicare	$3,256.70
Rate for Payer: BCBS of TX PPO	$7,181.87
Rate for Payer: Cash Price	$14,392.20
Rate for Payer: Cash Price	$14,392.20
Rate for Payer: Cash Price	$14,392.20
Rate for Payer: Cigna Commercial	$6,884.08
Rate for Payer: Cigna Medicaid	$15,238.80
Rate for Payer: Cigna Medicare	$3,256.70
Rate for Payer: Employer Direct Commercial	$3,256.70
Rate for Payer: Humana Medicare/TRICARE	$3,256.70
Rate for Payer: Molina CHIP/Medicaid	$15,238.80
Rate for Payer: Molina Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Molina Medicare	$3,256.70
Rate for Payer: Multiplan Auto	$13,757.25
Rate for Payer: Multiplan Commercial	$13,757.25
Rate for Payer: Multiplan Workers Comp	$13,757.25
Rate for Payer: Parkland Medicaid	$15,238.80
Rate for Payer: Scott and White EPO/PPO	$1,223.08
Rate for Payer: Scott and White Medicare	$3,256.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,238.80
Rate for Payer: Superior Health Plan EPO	$3,256.70
Rate for Payer: Superior Health Plan Medicare	$3,256.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,256.70
Rate for Payer: Universal American Medicare	$3,256.70
Rate for Payer: Wellcare Medicare	$3,256.70
Rate for Payer: Wellmed Medicare	$3,256.70

CATH POST ERGOTR STDY

Facility

$2,649.00

Service Code	HCPCS 93024
Hospital Charge Code	4613552
Hospital Revenue Code	482
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$1,907.28
Rate for Payer: Amerigroup CHIP/Medicaid	$238.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$448.76
Rate for Payer: Amerigroup Medicare	$448.76
Rate for Payer: BCBS of TX Blue Advantage	$794.70
Rate for Payer: BCBS of TX Blue Essentials	$953.64
Rate for Payer: BCBS of TX Medicare	$448.76
Rate for Payer: BCBS of TX PPO	$1,059.60
Rate for Payer: Cash Price	$1,801.32
Rate for Payer: Cash Price	$1,801.32
Rate for Payer: Cash Price	$1,801.32
Rate for Payer: Cigna Commercial	$948.59
Rate for Payer: Cigna Medicaid	$1,907.28
Rate for Payer: Cigna Medicare	$448.76
Rate for Payer: Employer Direct Commercial	$448.76
Rate for Payer: Humana Medicare/TRICARE	$448.76
Rate for Payer: Molina CHIP/Medicaid	$1,907.28
Rate for Payer: Molina Dual Medicare/Medicaid	$448.76
Rate for Payer: Molina Medicare	$448.76
Rate for Payer: Multiplan Auto	$1,721.85
Rate for Payer: Multiplan Commercial	$1,721.85
Rate for Payer: Multiplan Workers Comp	$1,721.85
Rate for Payer: Parkland Medicaid	$1,907.28
Rate for Payer: Scott and White EPO/PPO	$137.90
Rate for Payer: Scott and White Medicare	$448.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,907.28
Rate for Payer: Superior Health Plan EPO	$448.76
Rate for Payer: Superior Health Plan Medicare	$448.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$448.76
Rate for Payer: Universal American Medicare	$448.76
Rate for Payer: Wellcare Medicare	$448.76
Rate for Payer: Wellmed Medicare	$448.76

CATH POST ERGOTR STDY

Facility

$2,649.00

Service Code	HCPCS 93024
Hospital Charge Code	4613552
Hospital Revenue Code	482
Rate for Payer: Cash Price	$1,801.32

CATH RADIAL ART -- DHF

Facility

$54.48

Hospital Charge Code	80566854
Hospital Revenue Code	272
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$39.23
Rate for Payer: Amerigroup CHIP/Medicaid	$4.90
Rate for Payer: BCBS of TX Blue Advantage	$16.34
Rate for Payer: BCBS of TX Blue Essentials	$19.61
Rate for Payer: BCBS of TX PPO	$21.79
Rate for Payer: Cash Price	$37.05
Rate for Payer: Cigna Medicaid	$39.23
Rate for Payer: Molina CHIP/Medicaid	$39.23
Rate for Payer: Multiplan Auto	$35.41
Rate for Payer: Multiplan Commercial	$35.41
Rate for Payer: Multiplan Workers Comp	$35.41
Rate for Payer: Parkland Medicaid	$39.23
Rate for Payer: Scott and White EPO/PPO	$27.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.23
Rate for Payer: Superior Health Plan EPO	$7.41

Know your out-of-pocket cost for care.

All Charges