White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATH TEMPO SF PIG 90CM 5SH

Facility

$61.97

Service Code	HCPCS C2623
Hospital Charge Code	992413
Hospital Revenue Code	272
Rate for Payer: Cash Price	$42.14

CATH TEMPO SF PIG 90CM 5SH

Facility

$61.97

Service Code	HCPCS C2623
Hospital Charge Code	992413
Hospital Revenue Code	272
Min. Negotiated Rate	$5.58
Max. Negotiated Rate	$44.62
Rate for Payer: Amerigroup CHIP/Medicaid	$5.58
Rate for Payer: BCBS of TX Blue Advantage	$18.59
Rate for Payer: BCBS of TX Blue Essentials	$22.31
Rate for Payer: BCBS of TX PPO	$24.79
Rate for Payer: Cash Price	$42.14
Rate for Payer: Cigna Medicaid	$44.62
Rate for Payer: Molina CHIP/Medicaid	$44.62
Rate for Payer: Multiplan Auto	$40.28
Rate for Payer: Multiplan Commercial	$40.28
Rate for Payer: Multiplan Workers Comp	$40.28
Rate for Payer: Parkland Medicaid	$44.62
Rate for Payer: Scott and White EPO/PPO	$30.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.62
Rate for Payer: Superior Health Plan EPO	$8.43

CATH TEMPO SF SHK 1.0 65CM

Facility

$61.97

Service Code	HCPCS C2623
Hospital Charge Code	992416
Hospital Revenue Code	272
Min. Negotiated Rate	$5.58
Max. Negotiated Rate	$44.62
Rate for Payer: Amerigroup CHIP/Medicaid	$5.58
Rate for Payer: BCBS of TX Blue Advantage	$18.59
Rate for Payer: BCBS of TX Blue Essentials	$22.31
Rate for Payer: BCBS of TX PPO	$24.79
Rate for Payer: Cash Price	$42.14
Rate for Payer: Cigna Medicaid	$44.62
Rate for Payer: Molina CHIP/Medicaid	$44.62
Rate for Payer: Multiplan Auto	$40.28
Rate for Payer: Multiplan Commercial	$40.28
Rate for Payer: Multiplan Workers Comp	$40.28
Rate for Payer: Parkland Medicaid	$44.62
Rate for Payer: Scott and White EPO/PPO	$30.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.62
Rate for Payer: Superior Health Plan EPO	$8.43

CATH TEMPO SF SHK 1.0 65CM

Facility

$61.97

Service Code	HCPCS C2623
Hospital Charge Code	992416
Hospital Revenue Code	272
Rate for Payer: Cash Price	$42.14

cathter extractor pro xl retrieval bln 15-18mm

Facility

$2,708.00

Service Code	HCPCS C1726
Hospital Charge Code	116308
Hospital Revenue Code	278
Min. Negotiated Rate	$677.00
Max. Negotiated Rate	$1,354.00
Rate for Payer: Cash Price	$1,841.44
Rate for Payer: Cigna Commercial	$677.00
Rate for Payer: Multiplan Auto	$1,354.00
Rate for Payer: Multiplan Commercial	$1,354.00
Rate for Payer: Multiplan Workers Comp	$1,354.00
Rate for Payer: Scott and White EPO/PPO	$1,354.00

cathter extractor pro xl retrieval bln 15-18mm

Facility

$2,708.00

Service Code	HCPCS C1726
Hospital Charge Code	116308
Hospital Revenue Code	278
Min. Negotiated Rate	$243.72
Max. Negotiated Rate	$1,949.76
Rate for Payer: Amerigroup CHIP/Medicaid	$243.72
Rate for Payer: BCBS of TX Blue Advantage	$812.40
Rate for Payer: BCBS of TX Blue Essentials	$974.88
Rate for Payer: BCBS of TX PPO	$1,083.20
Rate for Payer: Cash Price	$1,841.44
Rate for Payer: Cigna Medicaid	$1,949.76
Rate for Payer: Molina CHIP/Medicaid	$1,949.76
Rate for Payer: Multiplan Auto	$1,354.00
Rate for Payer: Multiplan Commercial	$1,354.00
Rate for Payer: Multiplan Workers Comp	$1,354.00
Rate for Payer: Parkland Medicaid	$1,949.76
Rate for Payer: Scott and White EPO/PPO	$1,354.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,949.76
Rate for Payer: Superior Health Plan EPO	$368.29

CATH URETERAL -- DHF

Facility

$445.91

Hospital Charge Code	80412513
Hospital Revenue Code	272
Min. Negotiated Rate	$40.13
Max. Negotiated Rate	$321.06
Rate for Payer: Amerigroup CHIP/Medicaid	$40.13
Rate for Payer: BCBS of TX Blue Advantage	$133.77
Rate for Payer: BCBS of TX Blue Essentials	$160.53
Rate for Payer: BCBS of TX PPO	$178.36
Rate for Payer: Cash Price	$303.22
Rate for Payer: Cigna Medicaid	$321.06
Rate for Payer: Molina CHIP/Medicaid	$321.06
Rate for Payer: Multiplan Auto	$289.84
Rate for Payer: Multiplan Commercial	$289.84
Rate for Payer: Multiplan Workers Comp	$289.84
Rate for Payer: Parkland Medicaid	$321.06
Rate for Payer: Scott and White EPO/PPO	$222.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$321.06
Rate for Payer: Superior Health Plan EPO	$60.64

CATH URETERAL -- DHF

Facility

$445.91

Hospital Charge Code	80412513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$303.22

CATH VESL UMBLCL -- DHF

Facility

$636.00

Hospital Charge Code	80568256
Hospital Revenue Code	272
Rate for Payer: Cash Price	$432.48

CATH VESL UMBLCL -- DHF

Facility

$636.00

Hospital Charge Code	80568256
Hospital Revenue Code	272
Min. Negotiated Rate	$57.24
Max. Negotiated Rate	$457.92
Rate for Payer: Amerigroup CHIP/Medicaid	$57.24
Rate for Payer: BCBS of TX Blue Advantage	$190.80
Rate for Payer: BCBS of TX Blue Essentials	$228.96
Rate for Payer: BCBS of TX PPO	$254.40
Rate for Payer: Cash Price	$432.48
Rate for Payer: Cigna Medicaid	$457.92
Rate for Payer: Molina CHIP/Medicaid	$457.92
Rate for Payer: Multiplan Auto	$413.40
Rate for Payer: Multiplan Commercial	$413.40
Rate for Payer: Multiplan Workers Comp	$413.40
Rate for Payer: Parkland Medicaid	$457.92
Rate for Payer: Scott and White EPO/PPO	$318.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$457.92
Rate for Payer: Superior Health Plan EPO	$86.50

CAT TOURNIQUET ORANGE

Facility

$1,027.31

Hospital Charge Code	993783
Hospital Revenue Code	271
Min. Negotiated Rate	$92.46
Max. Negotiated Rate	$739.66
Rate for Payer: Amerigroup CHIP/Medicaid	$92.46
Rate for Payer: BCBS of TX Blue Advantage	$308.19
Rate for Payer: BCBS of TX Blue Essentials	$369.83
Rate for Payer: BCBS of TX PPO	$410.92
Rate for Payer: Cash Price	$698.57
Rate for Payer: Cigna Medicaid	$739.66
Rate for Payer: Molina CHIP/Medicaid	$739.66
Rate for Payer: Multiplan Auto	$667.75
Rate for Payer: Multiplan Commercial	$667.75
Rate for Payer: Multiplan Workers Comp	$667.75
Rate for Payer: Parkland Medicaid	$739.66
Rate for Payer: Scott and White EPO/PPO	$513.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$739.66
Rate for Payer: Superior Health Plan EPO	$139.71

CAT TOURNIQUET ORANGE

Facility

$1,027.31

Hospital Charge Code	993783
Hospital Revenue Code	271
Rate for Payer: Cash Price	$698.57

CAUT COAG SUCT -- DHF

Facility

$413.28

Hospital Charge Code	81814105
Hospital Revenue Code	272
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$297.56
Rate for Payer: Amerigroup CHIP/Medicaid	$37.20
Rate for Payer: BCBS of TX Blue Advantage	$123.98
Rate for Payer: BCBS of TX Blue Essentials	$148.78
Rate for Payer: BCBS of TX PPO	$165.31
Rate for Payer: Cash Price	$281.03
Rate for Payer: Cigna Medicaid	$297.56
Rate for Payer: Molina CHIP/Medicaid	$297.56
Rate for Payer: Multiplan Auto	$268.63
Rate for Payer: Multiplan Commercial	$268.63
Rate for Payer: Multiplan Workers Comp	$268.63
Rate for Payer: Parkland Medicaid	$297.56
Rate for Payer: Scott and White EPO/PPO	$206.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$297.56
Rate for Payer: Superior Health Plan EPO	$56.21

CAUT COAG SUCT -- DHF

Facility

$413.28

Hospital Charge Code	81814105
Hospital Revenue Code	272
Rate for Payer: Cash Price	$281.03

CAUT EYESTAT -- DHF

Facility

$722.01

Hospital Charge Code	81814204
Hospital Revenue Code	272
Min. Negotiated Rate	$64.98
Max. Negotiated Rate	$519.85
Rate for Payer: Amerigroup CHIP/Medicaid	$64.98
Rate for Payer: BCBS of TX Blue Advantage	$216.60
Rate for Payer: BCBS of TX Blue Essentials	$259.92
Rate for Payer: BCBS of TX PPO	$288.80
Rate for Payer: Cash Price	$490.97
Rate for Payer: Cigna Medicaid	$519.85
Rate for Payer: Molina CHIP/Medicaid	$519.85
Rate for Payer: Multiplan Auto	$469.31
Rate for Payer: Multiplan Commercial	$469.31
Rate for Payer: Multiplan Workers Comp	$469.31
Rate for Payer: Parkland Medicaid	$519.85
Rate for Payer: Scott and White EPO/PPO	$361.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$519.85
Rate for Payer: Superior Health Plan EPO	$98.19

CAUT EYESTAT -- DHF

Facility

$722.01

Hospital Charge Code	81814204
Hospital Revenue Code	272
Rate for Payer: Cash Price	$490.97

CAUT PEN+TIP -- DHF

Facility

$23.22

Hospital Charge Code	81814402
Hospital Revenue Code	272
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$16.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2.09
Rate for Payer: BCBS of TX Blue Advantage	$6.97
Rate for Payer: BCBS of TX Blue Essentials	$8.36
Rate for Payer: BCBS of TX PPO	$9.29
Rate for Payer: Cash Price	$15.79
Rate for Payer: Cigna Medicaid	$16.72
Rate for Payer: Molina CHIP/Medicaid	$16.72
Rate for Payer: Multiplan Auto	$15.09
Rate for Payer: Multiplan Commercial	$15.09
Rate for Payer: Multiplan Workers Comp	$15.09
Rate for Payer: Parkland Medicaid	$16.72
Rate for Payer: Scott and White EPO/PPO	$11.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.72
Rate for Payer: Superior Health Plan EPO	$3.16

CAUT PEN+TIP -- DHF

Facility

$23.22

Hospital Charge Code	81814402
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.79

CAUT TIP BAL/NED -- DHF

Facility

$326.37

Hospital Charge Code	81814501
Hospital Revenue Code	272
Rate for Payer: Cash Price	$221.93

CAUT TIP BAL/NED -- DHF

Facility

$326.37

Hospital Charge Code	81814501
Hospital Revenue Code	272
Min. Negotiated Rate	$29.37
Max. Negotiated Rate	$234.99
Rate for Payer: Amerigroup CHIP/Medicaid	$29.37
Rate for Payer: BCBS of TX Blue Advantage	$97.91
Rate for Payer: BCBS of TX Blue Essentials	$117.49
Rate for Payer: BCBS of TX PPO	$130.55
Rate for Payer: Cash Price	$221.93
Rate for Payer: Cigna Medicaid	$234.99
Rate for Payer: Molina CHIP/Medicaid	$234.99
Rate for Payer: Multiplan Auto	$212.14
Rate for Payer: Multiplan Commercial	$212.14
Rate for Payer: Multiplan Workers Comp	$212.14
Rate for Payer: Parkland Medicaid	$234.99
Rate for Payer: Scott and White EPO/PPO	$163.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$234.99
Rate for Payer: Superior Health Plan EPO	$44.39

CB12LT ENDPH XCEL INTEGRATED STABILITY

Facility

$136.47

Hospital Charge Code	992775
Hospital Revenue Code	272
Rate for Payer: Cash Price	$92.80

CB12LT ENDPH XCEL INTEGRATED STABILITY

Facility

$136.47

Hospital Charge Code	992775
Hospital Revenue Code	272
Min. Negotiated Rate	$12.28
Max. Negotiated Rate	$98.26
Rate for Payer: Amerigroup CHIP/Medicaid	$12.28
Rate for Payer: BCBS of TX Blue Advantage	$40.94
Rate for Payer: BCBS of TX Blue Essentials	$49.13
Rate for Payer: BCBS of TX PPO	$54.59
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cigna Medicaid	$98.26
Rate for Payer: Molina CHIP/Medicaid	$98.26
Rate for Payer: Multiplan Auto	$88.71
Rate for Payer: Multiplan Commercial	$88.71
Rate for Payer: Multiplan Workers Comp	$88.71
Rate for Payer: Parkland Medicaid	$98.26
Rate for Payer: Scott and White EPO/PPO	$68.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.26
Rate for Payer: Superior Health Plan EPO	$18.56

CB5LT ENDPH XCEL INTEGRATED STABILITY T

Facility

$121.63

Hospital Charge Code	992751
Hospital Revenue Code	272
Min. Negotiated Rate	$10.95
Max. Negotiated Rate	$87.57
Rate for Payer: Amerigroup CHIP/Medicaid	$10.95
Rate for Payer: BCBS of TX Blue Advantage	$36.49
Rate for Payer: BCBS of TX Blue Essentials	$43.79
Rate for Payer: BCBS of TX PPO	$48.65
Rate for Payer: Cash Price	$82.71
Rate for Payer: Cigna Medicaid	$87.57
Rate for Payer: Molina CHIP/Medicaid	$87.57
Rate for Payer: Multiplan Auto	$79.06
Rate for Payer: Multiplan Commercial	$79.06
Rate for Payer: Multiplan Workers Comp	$79.06
Rate for Payer: Parkland Medicaid	$87.57
Rate for Payer: Scott and White EPO/PPO	$60.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$87.57
Rate for Payer: Superior Health Plan EPO	$16.54

CB5LT ENDPH XCEL INTEGRATED STABILITY T

Facility

$121.63

Hospital Charge Code	992751
Hospital Revenue Code	272
Rate for Payer: Cash Price	$82.71

CCHD Screen Result, Initial -> Fail

Facility

$26.64

Service Code	HCPCS 94760
Hospital Charge Code	10108
Hospital Revenue Code	410
Rate for Payer: Cash Price	$18.12

Know your out-of-pocket cost for care.

All Charges