White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATHETER ASPIRATION 50CM CATD KIT

Facility

$16,084.34

Service Code	HCPCS C1887
Hospital Charge Code	8598514
Hospital Revenue Code	278
Min. Negotiated Rate	$4,021.08
Max. Negotiated Rate	$8,042.17
Rate for Payer: Aetna Commercial	$4,825.30
Rate for Payer: Cash Price	$14,154.22
Rate for Payer: Cigna Commercial	$4,021.08
Rate for Payer: Multiplan Auto	$8,042.17
Rate for Payer: Multiplan Commercial	$8,042.17
Rate for Payer: Multiplan Workers Comp	$8,042.17
Rate for Payer: Scott and White EPO/PPO	$8,042.17

CATHETER ASPIRATION LIGHTING CAT12

Facility

$40,783.13

Service Code	HCPCS C1887
Hospital Charge Code	8568958
Hospital Revenue Code	278
Min. Negotiated Rate	$10,195.78
Max. Negotiated Rate	$20,391.56
Rate for Payer: Aetna Commercial	$12,234.94
Rate for Payer: Cash Price	$35,889.15
Rate for Payer: Cigna Commercial	$10,195.78
Rate for Payer: Multiplan Auto	$20,391.56
Rate for Payer: Multiplan Commercial	$20,391.56
Rate for Payer: Multiplan Workers Comp	$20,391.56
Rate for Payer: Scott and White EPO/PPO	$20,391.56

CATHETER ASPIRATION LIGHTING CAT12

Facility

$40,783.13

Service Code	HCPCS C1887
Hospital Charge Code	8568958
Hospital Revenue Code	278
Min. Negotiated Rate	$3,670.48
Max. Negotiated Rate	$20,391.56
Rate for Payer: Aetna Commercial	$12,234.94
Rate for Payer: Amerigroup CHIP/Medicaid	$3,670.48
Rate for Payer: BCBS of TX Blue Advantage	$12,234.94
Rate for Payer: BCBS of TX Blue Essentials	$14,681.93
Rate for Payer: BCBS of TX PPO	$16,313.25
Rate for Payer: Cash Price	$35,889.15
Rate for Payer: Multiplan Auto	$20,391.56
Rate for Payer: Multiplan Commercial	$20,391.56
Rate for Payer: Multiplan Workers Comp	$20,391.56
Rate for Payer: Scott and White EPO/PPO	$20,391.56
Rate for Payer: Superior Health Plan EPO	$5,546.51

CATHETER ASPIRATION LIGHTNING CAT 7

Facility

$33,554.22

Service Code	HCPCS C1887
Hospital Charge Code	8598515
Hospital Revenue Code	278
Min. Negotiated Rate	$3,019.88
Max. Negotiated Rate	$16,777.11
Rate for Payer: Aetna Commercial	$10,066.27
Rate for Payer: Amerigroup CHIP/Medicaid	$3,019.88
Rate for Payer: BCBS of TX Blue Advantage	$10,066.27
Rate for Payer: BCBS of TX Blue Essentials	$12,079.52
Rate for Payer: BCBS of TX PPO	$13,421.69
Rate for Payer: Cash Price	$29,527.71
Rate for Payer: Multiplan Auto	$16,777.11
Rate for Payer: Multiplan Commercial	$16,777.11
Rate for Payer: Multiplan Workers Comp	$16,777.11
Rate for Payer: Scott and White EPO/PPO	$16,777.11
Rate for Payer: Superior Health Plan EPO	$4,563.37

CATHETER ASPIRATION LIGHTNING CAT 7

Facility

$33,554.22

Service Code	HCPCS C1887
Hospital Charge Code	8598515
Hospital Revenue Code	278
Min. Negotiated Rate	$8,388.56
Max. Negotiated Rate	$16,777.11
Rate for Payer: Aetna Commercial	$10,066.27
Rate for Payer: Cash Price	$29,527.71
Rate for Payer: Cigna Commercial	$8,388.56
Rate for Payer: Multiplan Auto	$16,777.11
Rate for Payer: Multiplan Commercial	$16,777.11
Rate for Payer: Multiplan Workers Comp	$16,777.11
Rate for Payer: Scott and White EPO/PPO	$16,777.11

CATHETER BALLOON RELIANT

Facility

$2,020.30

Service Code	HCPCS C1725
Hospital Charge Code	8484498
Hospital Revenue Code	272
Min. Negotiated Rate	$181.83
Max. Negotiated Rate	$1,313.20
Rate for Payer: Aetna Commercial	$1,111.16
Rate for Payer: Amerigroup CHIP/Medicaid	$181.83
Rate for Payer: BCBS of TX Blue Advantage	$606.09
Rate for Payer: BCBS of TX Blue Essentials	$727.31
Rate for Payer: BCBS of TX PPO	$808.12
Rate for Payer: Cash Price	$1,777.86
Rate for Payer: Multiplan Auto	$1,313.20
Rate for Payer: Multiplan Commercial	$1,313.20
Rate for Payer: Multiplan Workers Comp	$1,313.20
Rate for Payer: Scott and White EPO/PPO	$1,010.15
Rate for Payer: Superior Health Plan EPO	$274.76

CATHETER BALLOON RELIANT

Facility

$2,020.30

Service Code	HCPCS C1725
Hospital Charge Code	8484498
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,777.86

CATHETER BLN DIL CRE ENDOSCOPI 110CM 18-20MM

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145521
Hospital Revenue Code	278
Min. Negotiated Rate	$535.14
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Cigna Commercial	$535.14
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27

CATHETER BLN DIL CRE ENDOSCOPI 110CM 18-20MM

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145521
Hospital Revenue Code	278
Min. Negotiated Rate	$192.65
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Amerigroup CHIP/Medicaid	$192.65
Rate for Payer: BCBS of TX Blue Advantage	$642.16
Rate for Payer: BCBS of TX Blue Essentials	$770.59
Rate for Payer: BCBS of TX PPO	$856.22
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27
Rate for Payer: Superior Health Plan EPO	$291.11

CATHETER BLN DIL CRE ENDOSCOPIC 110CM 15-18MM

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145520
Hospital Revenue Code	278
Min. Negotiated Rate	$192.65
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Amerigroup CHIP/Medicaid	$192.65
Rate for Payer: BCBS of TX Blue Advantage	$642.16
Rate for Payer: BCBS of TX Blue Essentials	$770.59
Rate for Payer: BCBS of TX PPO	$856.22
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27
Rate for Payer: Superior Health Plan EPO	$291.11

CATHETER BLN DIL CRE ENDOSCOPIC 110CM 15-18MM

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145520
Hospital Revenue Code	278
Min. Negotiated Rate	$535.14
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Cigna Commercial	$535.14
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27

CATHETER BLN DIL CRE ENDOSCOPIC 110CM 8-10 X3

Facility

$2,140.55

Service Code	HCPCS C1726
Hospital Charge Code	145522
Hospital Revenue Code	278
Min. Negotiated Rate	$192.65
Max. Negotiated Rate	$1,070.28
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Amerigroup CHIP/Medicaid	$192.65
Rate for Payer: BCBS of TX Blue Advantage	$642.16
Rate for Payer: BCBS of TX Blue Essentials	$770.60
Rate for Payer: BCBS of TX PPO	$856.22
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Multiplan Auto	$1,070.28
Rate for Payer: Multiplan Commercial	$1,070.28
Rate for Payer: Multiplan Workers Comp	$1,070.28
Rate for Payer: Scott and White EPO/PPO	$1,070.28
Rate for Payer: Superior Health Plan EPO	$291.11

CATHETER BLN DIL CRE ENDOSCOPIC 110CM 8-10 X3

Facility

$2,140.55

Service Code	HCPCS C1726
Hospital Charge Code	145522
Hospital Revenue Code	278
Min. Negotiated Rate	$535.14
Max. Negotiated Rate	$1,070.28
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Cigna Commercial	$535.14
Rate for Payer: Multiplan Auto	$1,070.28
Rate for Payer: Multiplan Commercial	$1,070.28
Rate for Payer: Multiplan Workers Comp	$1,070.28
Rate for Payer: Scott and White EPO/PPO	$1,070.28

CATHETER BLN DIL CRE ENDOSCOPIC 110 CSM 12-15MM X3

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145524
Hospital Revenue Code	278
Min. Negotiated Rate	$535.14
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Cigna Commercial	$535.14
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27

CATHETER BLN DIL CRE ENDOSCOPIC 110 CSM 12-15MM X3

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145524
Hospital Revenue Code	278
Min. Negotiated Rate	$192.65
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Amerigroup CHIP/Medicaid	$192.65
Rate for Payer: BCBS of TX Blue Advantage	$642.16
Rate for Payer: BCBS of TX Blue Essentials	$770.59
Rate for Payer: BCBS of TX PPO	$856.22
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27
Rate for Payer: Superior Health Plan EPO	$291.11

CATHETER BLN DIL CRE ENDSCOPIC 110CM 12-15MM

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145519
Hospital Revenue Code	278
Min. Negotiated Rate	$192.65
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Amerigroup CHIP/Medicaid	$192.65
Rate for Payer: BCBS of TX Blue Advantage	$642.16
Rate for Payer: BCBS of TX Blue Essentials	$770.59
Rate for Payer: BCBS of TX PPO	$856.22
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27
Rate for Payer: Superior Health Plan EPO	$291.11

CATHETER BLN DIL CRE ENDSCOPIC 110CM 12-15MM

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145519
Hospital Revenue Code	278
Min. Negotiated Rate	$535.14
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Cigna Commercial	$535.14
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27

CATHETER BLN DIL CRE ENOSCOPIC 110CM 10-12 X3

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145523
Hospital Revenue Code	278
Min. Negotiated Rate	$535.14
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Cigna Commercial	$535.14
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27

CATHETER BLN DIL CRE ENOSCOPIC 110CM 10-12 X3

Facility

$2,140.54

Service Code	HCPCS C1726
Hospital Charge Code	145523
Hospital Revenue Code	278
Min. Negotiated Rate	$192.65
Max. Negotiated Rate	$1,070.27
Rate for Payer: Aetna Commercial	$642.16
Rate for Payer: Amerigroup CHIP/Medicaid	$192.65
Rate for Payer: BCBS of TX Blue Advantage	$642.16
Rate for Payer: BCBS of TX Blue Essentials	$770.59
Rate for Payer: BCBS of TX PPO	$856.22
Rate for Payer: Cash Price	$1,883.68
Rate for Payer: Multiplan Auto	$1,070.27
Rate for Payer: Multiplan Commercial	$1,070.27
Rate for Payer: Multiplan Workers Comp	$1,070.27
Rate for Payer: Scott and White EPO/PPO	$1,070.27
Rate for Payer: Superior Health Plan EPO	$291.11

CATHETER BLN PASEO 35 9X60X130

Facility

$431.30

Service Code	HCPCS C1725
Hospital Charge Code	145424
Hospital Revenue Code	272
Rate for Payer: Cash Price	$379.54

CATHETER BLN PASEO 35 9X60X130

Facility

$431.30

Service Code	HCPCS C1725
Hospital Charge Code	145424
Hospital Revenue Code	272
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$280.34
Rate for Payer: Aetna Commercial	$237.22
Rate for Payer: Amerigroup CHIP/Medicaid	$38.82
Rate for Payer: BCBS of TX Blue Advantage	$129.39
Rate for Payer: BCBS of TX Blue Essentials	$155.27
Rate for Payer: BCBS of TX PPO	$172.52
Rate for Payer: Cash Price	$379.54
Rate for Payer: Multiplan Auto	$280.34
Rate for Payer: Multiplan Commercial	$280.34
Rate for Payer: Multiplan Workers Comp	$280.34
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan EPO	$58.66

CATHETER BLN PASSEO-14 2.5X180X150

Facility

$544.80

Service Code	HCPCS C1726
Hospital Charge Code	145597
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$354.12
Rate for Payer: Aetna Commercial	$299.64
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$479.42
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan EPO	$74.09

CATHETER BLN PASSEO-14 2.5X180X150

Facility

$544.80

Service Code	HCPCS C1726
Hospital Charge Code	145597
Hospital Revenue Code	272
Rate for Payer: Cash Price	$479.42

CATHETER BLN PASSEO-14 2X220X150

Facility

$544.80

Service Code	HCPCS C1725
Hospital Charge Code	145491
Hospital Revenue Code	272
Rate for Payer: Cash Price	$479.42

CATHETER BLN PASSEO-14 2X220X150

Facility

$544.80

Service Code	HCPCS C1725
Hospital Charge Code	145491
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$354.12
Rate for Payer: Aetna Commercial	$299.64
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$479.42
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan EPO	$74.09

Know your out-of-pocket cost for care.

All Charges