White Rock Medical Center

All Charges

Charge

Type

Setting

Price

INTRODUCER SHEATH

Facility

$908.00

Service Code	HCPCS C1894
Hospital Charge Code	8484503
Hospital Revenue Code	272
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$590.20
Rate for Payer: Aetna Commercial	$499.40
Rate for Payer: Amerigroup CHIP/Medicaid	$81.72
Rate for Payer: BCBS of TX Blue Advantage	$272.40
Rate for Payer: BCBS of TX Blue Essentials	$326.88
Rate for Payer: BCBS of TX PPO	$363.20
Rate for Payer: Cash Price	$799.04
Rate for Payer: Multiplan Auto	$590.20
Rate for Payer: Multiplan Commercial	$590.20
Rate for Payer: Multiplan Workers Comp	$590.20
Rate for Payer: Scott and White EPO/PPO	$454.00
Rate for Payer: Superior Health Plan EPO	$123.49

INTRODUCER SHEATH

Facility

$908.00

Service Code	HCPCS C1894
Hospital Charge Code	8484503
Hospital Revenue Code	272
Rate for Payer: Cash Price	$799.04

introducer sheath peelaway

Facility

$227.00

Hospital Charge Code	80732605
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.76

introducer sheath peelaway

Facility

$227.00

Hospital Charge Code	80732605
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$147.55
Rate for Payer: Aetna Commercial	$124.85
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	$199.76
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: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan EPO	$30.87

INTRO EP IC N-LSR N-GD 2 -- DHF

Facility

$367.22

Service Code	HCPCS C1894
Hospital Charge Code	82402298
Hospital Revenue Code	272
Min. Negotiated Rate	$33.05
Max. Negotiated Rate	$238.69
Rate for Payer: Aetna Commercial	$201.97
Rate for Payer: Amerigroup CHIP/Medicaid	$33.05
Rate for Payer: BCBS of TX Blue Advantage	$110.17
Rate for Payer: BCBS of TX Blue Essentials	$132.20
Rate for Payer: BCBS of TX PPO	$146.89
Rate for Payer: Cash Price	$323.15
Rate for Payer: Multiplan Auto	$238.69
Rate for Payer: Multiplan Commercial	$238.69
Rate for Payer: Multiplan Workers Comp	$238.69
Rate for Payer: Scott and White EPO/PPO	$183.61
Rate for Payer: Superior Health Plan EPO	$49.94

INTRO EP IC N-LSR N-GD 2 -- DHF

Facility

$367.22

Service Code	HCPCS C1894
Hospital Charge Code	82402298
Hospital Revenue Code	272
Rate for Payer: Cash Price	$323.15

INTRO NDL DIAL-CIRC BAL-PLASTY+S&I

Facility

$11,501.00

Service Code	CPT 36902
Hospital Charge Code	2351101
Hospital Revenue Code	360
Rate for Payer: Cash Price	$10,120.88

INTRO NDL DIAL-CIRC BAL-PLASTY+S&I

Facility

$11,501.00

Service Code	CPT 36902
Hospital Charge Code	2351101
Hospital Revenue Code	360
Min. Negotiated Rate	$115.30
Max. Negotiated Rate	$12,483.85
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$7,840.86
Rate for Payer: Amerigroup CHIP/Medicaid	$1,764.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Amerigroup Medicare	$5,227.24
Rate for Payer: BCBS of TX Blue Advantage	$8,273.03
Rate for Payer: BCBS of TX Blue Essentials	$9,907.82
Rate for Payer: BCBS of TX Medicare	$5,227.24
Rate for Payer: BCBS of TX PPO	$12,483.85
Rate for Payer: Cash Price	$10,120.88
Rate for Payer: Cash Price	$10,120.88
Rate for Payer: Cigna Commercial	$11,841.22
Rate for Payer: Cigna Medicaid	$1,764.89
Rate for Payer: Cigna Medicare	$5,227.24
Rate for Payer: Employer Direct Commercial	$5,227.24
Rate for Payer: Humana Medicare/TRICARE	$5,227.24
Rate for Payer: Molina CHIP/Medicaid	$1,764.89
Rate for Payer: Molina Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Molina Medicare	$5,227.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,764.89
Rate for Payer: Scott and White EPO/PPO	$115.30
Rate for Payer: Scott and White Medicare	$5,227.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,764.89
Rate for Payer: Superior Health Plan EPO	$5,227.24
Rate for Payer: Superior Health Plan Medicare	$5,227.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Universal American Medicare	$5,227.24
Rate for Payer: Wellcare Medicare	$5,227.24
Rate for Payer: Wellmed Medicare	$5,227.24

INTRO NDL DIAL-CIRC STNT+PLSTY+S&I

Facility

$15,356.00

Service Code	CPT 36903
Hospital Charge Code	2351102
Hospital Revenue Code	360
Min. Negotiated Rate	$221.91
Max. Negotiated Rate	$24,969.37
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$15,091.60
Rate for Payer: Amerigroup CHIP/Medicaid	$5,270.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Amerigroup Medicare	$10,061.07
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$10,061.07
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$13,513.28
Rate for Payer: Cash Price	$13,513.28
Rate for Payer: Cigna Commercial	$22,791.24
Rate for Payer: Cigna Medicaid	$5,270.09
Rate for Payer: Cigna Medicare	$10,061.07
Rate for Payer: Employer Direct Commercial	$10,061.07
Rate for Payer: Humana Medicare/TRICARE	$10,061.07
Rate for Payer: Molina CHIP/Medicaid	$5,270.09
Rate for Payer: Molina Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Molina Medicare	$10,061.07
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,270.09
Rate for Payer: Scott and White EPO/PPO	$221.91
Rate for Payer: Scott and White Medicare	$10,061.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,270.09
Rate for Payer: Superior Health Plan EPO	$10,061.07
Rate for Payer: Superior Health Plan Medicare	$10,061.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,061.07
Rate for Payer: Universal American Medicare	$10,061.07
Rate for Payer: Wellcare Medicare	$10,061.07
Rate for Payer: Wellmed Medicare	$10,061.07

INTRO NDL DIAL-CIRC STNT+PLSTY+S&I

Facility

$15,356.00

Service Code	CPT 36903
Hospital Charge Code	2351102
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,513.28

INTRO SHEATH GD LONG

Facility

$350.71

Service Code	HCPCS C1893
Hospital Charge Code	8470490
Hospital Revenue Code	272
Min. Negotiated Rate	$31.56
Max. Negotiated Rate	$227.96
Rate for Payer: Aetna Commercial	$192.89
Rate for Payer: Amerigroup CHIP/Medicaid	$31.56
Rate for Payer: BCBS of TX Blue Advantage	$105.21
Rate for Payer: BCBS of TX Blue Essentials	$126.26
Rate for Payer: BCBS of TX PPO	$140.28
Rate for Payer: Cash Price	$308.62
Rate for Payer: Multiplan Auto	$227.96
Rate for Payer: Multiplan Commercial	$227.96
Rate for Payer: Multiplan Workers Comp	$227.96
Rate for Payer: Scott and White EPO/PPO	$175.36
Rate for Payer: Superior Health Plan EPO	$47.70

INTRO SHEATH GD LONG

Facility

$350.71

Service Code	HCPCS C1893
Hospital Charge Code	8470490
Hospital Revenue Code	272
Rate for Payer: Cash Price	$308.62

INTR SHTH PERIPH PINNACL -- DHF

Facility

$49.00

Service Code	HCPCS C1894
Hospital Charge Code	82415068
Hospital Revenue Code	272
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$31.85
Rate for Payer: Aetna Commercial	$26.95
Rate for Payer: Amerigroup CHIP/Medicaid	$4.41
Rate for Payer: BCBS of TX Blue Advantage	$14.70
Rate for Payer: BCBS of TX Blue Essentials	$17.64
Rate for Payer: BCBS of TX PPO	$19.60
Rate for Payer: Cash Price	$43.12
Rate for Payer: Multiplan Auto	$31.85
Rate for Payer: Multiplan Commercial	$31.85
Rate for Payer: Multiplan Workers Comp	$31.85
Rate for Payer: Scott and White EPO/PPO	$24.50
Rate for Payer: Superior Health Plan EPO	$6.66

INTR SHTH PERIPH PINNACL -- DHF

Facility

$49.00

Service Code	HCPCS C1894
Hospital Charge Code	82415068
Hospital Revenue Code	272
Rate for Payer: Cash Price	$43.12

iodixanol 320 mg/mL Inj Soln 100 mL

Facility

$217.00

Service Code	HCPCS Q9967
Hospital Charge Code	77636834
Hospital Revenue Code	258
Rate for Payer: Cash Price	$147.56

iodixanol 320 mg/mL Inj Soln 100 mL

Facility

$217.00

Service Code	HCPCS Q9967
Hospital Charge Code	77636834
Hospital Revenue Code	258
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$141.05
Rate for Payer: Amerigroup CHIP/Medicaid	$19.53
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
Rate for Payer: Cash Price	$147.56
Rate for Payer: Cash Price	$147.56
Rate for Payer: Multiplan Auto	$141.05
Rate for Payer: Multiplan Commercial	$141.05
Rate for Payer: Multiplan Workers Comp	$141.05
Rate for Payer: Scott and White EPO/PPO	$108.50
Rate for Payer: Superior Health Plan EPO	$29.51

iohexol 300 mg/mL Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77637772
Hospital Revenue Code	255
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

iohexol 300 mg/mL Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77637772
Hospital Revenue Code	255
Rate for Payer: Cash Price	$87.04

iohexol 350 mg/mL Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77638244
Hospital Revenue Code	255
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

iohexol 350 mg/mL Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77638244
Hospital Revenue Code	255
Rate for Payer: Cash Price	$87.04

iopamidol 61% Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77639119
Hospital Revenue Code	255
Rate for Payer: Cash Price	$87.04

iopamidol 61% Inj Soln 100 mL

Facility

$128.00

Service Code	HCPCS Q9967
Hospital Charge Code	77639119
Hospital Revenue Code	255
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

IP Hemodialysis Treatment Complete

Facility

$4,750.00

Hospital Charge Code	800011
Hospital Revenue Code	801
Min. Negotiated Rate	$427.50
Max. Negotiated Rate	$3,087.50
Rate for Payer: Aetna Commercial	$2,612.50
Rate for Payer: Amerigroup CHIP/Medicaid	$427.50
Rate for Payer: BCBS of TX Blue Advantage	$1,425.00
Rate for Payer: BCBS of TX Blue Essentials	$1,710.00
Rate for Payer: BCBS of TX PPO	$1,900.00
Rate for Payer: Cash Price	$4,180.00
Rate for Payer: Multiplan Auto	$3,087.50
Rate for Payer: Multiplan Commercial	$3,087.50
Rate for Payer: Multiplan Workers Comp	$3,087.50
Rate for Payer: Scott and White EPO/PPO	$2,375.00
Rate for Payer: Superior Health Plan EPO	$646.00

ipratropium 500 mcg/2.5 mL Inh Soln 2.5 mL

Facility

$7.65

Service Code	HCPCS J7644
Hospital Charge Code	77643468
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.82

ipratropium 500 mcg/2.5 mL Inh Soln 2.5 mL

Facility

$7.65

Service Code	HCPCS J7644
Hospital Charge Code	77643468
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.74
Rate for Payer: BCBS of TX Blue Essentials	$0.89
Rate for Payer: BCBS of TX PPO	$0.98
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges