White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATHETER BLN PASSEO-14 3X180X150

Facility

$544.80

Service Code	HCPCS C1726
Hospital Charge Code	145598
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 3X180X150

Facility

$544.80

Service Code	HCPCS C1726
Hospital Charge Code	145598
Hospital Revenue Code	272
Rate for Payer: Cash Price	$479.42

CATHETER BLN PASSEO-18 PTA- OTW

Facility

$499.40

Service Code	HCPCS C1726
Hospital Charge Code	145599
Hospital Revenue Code	272
Rate for Payer: Cash Price	$439.47

CATHETER BLN PASSEO-18 PTA- OTW

Facility

$499.40

Service Code	HCPCS C1726
Hospital Charge Code	145599
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$324.61
Rate for Payer: Aetna Commercial	$274.67
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$439.47
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan EPO	$67.92

CATHETER BLN PASSEO-35 5X120X130

Facility

$499.40

Hospital Charge Code	145468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$439.47

CATHETER BLN PASSEO-35 5X120X130

Facility

$499.40

Hospital Charge Code	145468
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$324.61
Rate for Payer: Aetna Commercial	$274.67
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$439.47
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan EPO	$67.92

CATHETER BLN PASSEO 35 8X100X30

Facility

$431.30

Service Code	HCPCS C1725
Hospital Charge Code	145425
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 35 8X100X30

Facility

$431.30

Service Code	HCPCS C1725
Hospital Charge Code	145425
Hospital Revenue Code	272
Rate for Payer: Cash Price	$379.54

CATHETER BLN PASSO-35 6X200X35

Facility

$431.30

Service Code	HCPCS C1713
Hospital Charge Code	145465
Hospital Revenue Code	278
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$215.65
Rate for Payer: Aetna Commercial	$129.39
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	$215.65
Rate for Payer: Multiplan Commercial	$215.65
Rate for Payer: Multiplan Workers Comp	$215.65
Rate for Payer: Scott and White EPO/PPO	$215.65
Rate for Payer: Superior Health Plan EPO	$58.66

CATHETER BLN PASSO-35 6X200X35

Facility

$431.30

Service Code	HCPCS C1713
Hospital Charge Code	145465
Hospital Revenue Code	278
Min. Negotiated Rate	$107.82
Max. Negotiated Rate	$215.65
Rate for Payer: Aetna Commercial	$129.39
Rate for Payer: Cash Price	$379.54
Rate for Payer: Cigna Commercial	$107.82
Rate for Payer: Multiplan Auto	$215.65
Rate for Payer: Multiplan Commercial	$215.65
Rate for Payer: Multiplan Workers Comp	$215.65
Rate for Payer: Scott and White EPO/PPO	$215.65

CATHETER CORONARY DIL SAPPHIRE -- DHF

Facility

$662.65

Service Code	HCPCS C1725
Hospital Charge Code	80599020
Hospital Revenue Code	278
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$331.32
Rate for Payer: Aetna Commercial	$198.80
Rate for Payer: Amerigroup CHIP/Medicaid	$59.64
Rate for Payer: BCBS of TX Blue Advantage	$198.80
Rate for Payer: BCBS of TX Blue Essentials	$238.55
Rate for Payer: BCBS of TX PPO	$265.06
Rate for Payer: Cash Price	$583.13
Rate for Payer: Multiplan Auto	$331.32
Rate for Payer: Multiplan Commercial	$331.32
Rate for Payer: Multiplan Workers Comp	$331.32
Rate for Payer: Scott and White EPO/PPO	$331.32
Rate for Payer: Superior Health Plan EPO	$90.12

CATHETER CORONARY DIL SAPPHIRE -- DHF

Facility

$662.65

Service Code	HCPCS C1725
Hospital Charge Code	80599020
Hospital Revenue Code	278
Min. Negotiated Rate	$165.66
Max. Negotiated Rate	$331.32
Rate for Payer: Aetna Commercial	$198.80
Rate for Payer: Cash Price	$583.13
Rate for Payer: Cigna Commercial	$165.66
Rate for Payer: Multiplan Auto	$331.32
Rate for Payer: Multiplan Commercial	$331.32
Rate for Payer: Multiplan Workers Comp	$331.32
Rate for Payer: Scott and White EPO/PPO	$331.32

catheter dilation bakri occlusion

Facility

$1,180.04

Service Code	HCPCS C2628
Hospital Charge Code	8690512
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,038.44

catheter dilation bakri occlusion

Facility

$1,180.04

Service Code	HCPCS C2628
Hospital Charge Code	8690512
Hospital Revenue Code	272
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$767.03
Rate for Payer: Aetna Commercial	$649.02
Rate for Payer: Amerigroup CHIP/Medicaid	$106.20
Rate for Payer: BCBS of TX Blue Advantage	$354.01
Rate for Payer: BCBS of TX Blue Essentials	$424.81
Rate for Payer: BCBS of TX PPO	$472.02
Rate for Payer: Cash Price	$1,038.44
Rate for Payer: Multiplan Auto	$767.03
Rate for Payer: Multiplan Commercial	$767.03
Rate for Payer: Multiplan Workers Comp	$767.03
Rate for Payer: Scott and White EPO/PPO	$590.02
Rate for Payer: Superior Health Plan EPO	$160.49

CATHETER DILATION SAPP II -- DHF

Facility

$662.65

Service Code	HCPCS C1725
Hospital Charge Code	80599038
Hospital Revenue Code	278
Min. Negotiated Rate	$165.66
Max. Negotiated Rate	$331.32
Rate for Payer: Aetna Commercial	$198.80
Rate for Payer: Cash Price	$583.13
Rate for Payer: Cigna Commercial	$165.66
Rate for Payer: Multiplan Auto	$331.32
Rate for Payer: Multiplan Commercial	$331.32
Rate for Payer: Multiplan Workers Comp	$331.32
Rate for Payer: Scott and White EPO/PPO	$331.32

CATHETER DILATION SAPP II -- DHF

Facility

$662.65

Service Code	HCPCS C1725
Hospital Charge Code	80599038
Hospital Revenue Code	278
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$331.32
Rate for Payer: Aetna Commercial	$198.80
Rate for Payer: Amerigroup CHIP/Medicaid	$59.64
Rate for Payer: BCBS of TX Blue Advantage	$198.80
Rate for Payer: BCBS of TX Blue Essentials	$238.55
Rate for Payer: BCBS of TX PPO	$265.06
Rate for Payer: Cash Price	$583.13
Rate for Payer: Multiplan Auto	$331.32
Rate for Payer: Multiplan Commercial	$331.32
Rate for Payer: Multiplan Workers Comp	$331.32
Rate for Payer: Scott and White EPO/PPO	$331.32
Rate for Payer: Superior Health Plan EPO	$90.12

CATHETER DORADO DR8074

Facility

$1,355.42

Service Code	HCPCS C1725
Hospital Charge Code	107844
Hospital Revenue Code	278
Min. Negotiated Rate	$338.86
Max. Negotiated Rate	$677.71
Rate for Payer: Aetna Commercial	$406.63
Rate for Payer: Cash Price	$1,192.77
Rate for Payer: Cigna Commercial	$338.86
Rate for Payer: Multiplan Auto	$677.71
Rate for Payer: Multiplan Commercial	$677.71
Rate for Payer: Multiplan Workers Comp	$677.71
Rate for Payer: Scott and White EPO/PPO	$677.71

CATHETER DORADO DR8074

Facility

$1,355.42

Service Code	HCPCS C1725
Hospital Charge Code	107844
Hospital Revenue Code	278
Min. Negotiated Rate	$121.99
Max. Negotiated Rate	$677.71
Rate for Payer: Aetna Commercial	$406.63
Rate for Payer: Amerigroup CHIP/Medicaid	$121.99
Rate for Payer: BCBS of TX Blue Advantage	$406.63
Rate for Payer: BCBS of TX Blue Essentials	$487.95
Rate for Payer: BCBS of TX PPO	$542.17
Rate for Payer: Cash Price	$1,192.77
Rate for Payer: Multiplan Auto	$677.71
Rate for Payer: Multiplan Commercial	$677.71
Rate for Payer: Multiplan Workers Comp	$677.71
Rate for Payer: Scott and White EPO/PPO	$677.71
Rate for Payer: Superior Health Plan EPO	$184.34

CATHETER DORADO DR8084

Facility

$1,355.42

Service Code	HCPCS C1725
Hospital Charge Code	108183
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,192.77

CATHETER DORADO DR8084

Facility

$1,355.42

Service Code	HCPCS C1725
Hospital Charge Code	108183
Hospital Revenue Code	272
Min. Negotiated Rate	$121.99
Max. Negotiated Rate	$881.02
Rate for Payer: Aetna Commercial	$745.48
Rate for Payer: Amerigroup CHIP/Medicaid	$121.99
Rate for Payer: BCBS of TX Blue Advantage	$406.63
Rate for Payer: BCBS of TX Blue Essentials	$487.95
Rate for Payer: BCBS of TX PPO	$542.17
Rate for Payer: Cash Price	$1,192.77
Rate for Payer: Multiplan Auto	$881.02
Rate for Payer: Multiplan Commercial	$881.02
Rate for Payer: Multiplan Workers Comp	$881.02
Rate for Payer: Scott and White EPO/PPO	$677.71
Rate for Payer: Superior Health Plan EPO	$184.34

CATHETER DORADO DR8094

Facility

$1,355.42

Service Code	HCPCS C1725
Hospital Charge Code	82401266
Hospital Revenue Code	278
Min. Negotiated Rate	$121.99
Max. Negotiated Rate	$677.71
Rate for Payer: Aetna Commercial	$406.63
Rate for Payer: Amerigroup CHIP/Medicaid	$121.99
Rate for Payer: BCBS of TX Blue Advantage	$406.63
Rate for Payer: BCBS of TX Blue Essentials	$487.95
Rate for Payer: BCBS of TX PPO	$542.17
Rate for Payer: Cash Price	$1,192.77
Rate for Payer: Multiplan Auto	$677.71
Rate for Payer: Multiplan Commercial	$677.71
Rate for Payer: Multiplan Workers Comp	$677.71
Rate for Payer: Scott and White EPO/PPO	$677.71
Rate for Payer: Superior Health Plan EPO	$184.34

CATHETER DORADO DR8094

Facility

$1,355.42

Service Code	HCPCS C1725
Hospital Charge Code	82401266
Hospital Revenue Code	278
Min. Negotiated Rate	$338.86
Max. Negotiated Rate	$677.71
Rate for Payer: Aetna Commercial	$406.63
Rate for Payer: Cash Price	$1,192.77
Rate for Payer: Cigna Commercial	$338.86
Rate for Payer: Multiplan Auto	$677.71
Rate for Payer: Multiplan Commercial	$677.71
Rate for Payer: Multiplan Workers Comp	$677.71
Rate for Payer: Scott and White EPO/PPO	$677.71

CATHETER, EMBOLECTOMY ARTERIAL GREEN 3FR 80CM L -- DHF

Facility

$365.30

Service Code	HCPCS C1757
Hospital Charge Code	80563182
Hospital Revenue Code	278
Min. Negotiated Rate	$91.32
Max. Negotiated Rate	$182.65
Rate for Payer: Aetna Commercial	$109.59
Rate for Payer: Cash Price	$321.46
Rate for Payer: Cigna Commercial	$91.32
Rate for Payer: Multiplan Auto	$182.65
Rate for Payer: Multiplan Commercial	$182.65
Rate for Payer: Multiplan Workers Comp	$182.65
Rate for Payer: Scott and White EPO/PPO	$182.65

CATHETER, EMBOLECTOMY ARTERIAL GREEN 3FR 80CM L -- DHF

Facility

$365.30

Service Code	HCPCS C1757
Hospital Charge Code	80563182
Hospital Revenue Code	278
Min. Negotiated Rate	$32.88
Max. Negotiated Rate	$182.65
Rate for Payer: Aetna Commercial	$109.59
Rate for Payer: Amerigroup CHIP/Medicaid	$32.88
Rate for Payer: BCBS of TX Blue Advantage	$109.59
Rate for Payer: BCBS of TX Blue Essentials	$131.51
Rate for Payer: BCBS of TX PPO	$146.12
Rate for Payer: Cash Price	$321.46
Rate for Payer: Multiplan Auto	$182.65
Rate for Payer: Multiplan Commercial	$182.65
Rate for Payer: Multiplan Workers Comp	$182.65
Rate for Payer: Scott and White EPO/PPO	$182.65
Rate for Payer: Superior Health Plan EPO	$49.68

CATHETER, EMBOLECTOMY ARTERIAL RED 4FR 40CM L -- DHF

Facility

$365.30

Service Code	HCPCS C1757
Hospital Charge Code	80563182
Hospital Revenue Code	278
Min. Negotiated Rate	$91.32
Max. Negotiated Rate	$182.65
Rate for Payer: Aetna Commercial	$109.59
Rate for Payer: Cash Price	$321.46
Rate for Payer: Cigna Commercial	$91.32
Rate for Payer: Multiplan Auto	$182.65
Rate for Payer: Multiplan Commercial	$182.65
Rate for Payer: Multiplan Workers Comp	$182.65
Rate for Payer: Scott and White EPO/PPO	$182.65

Know your out-of-pocket cost for care.

All Charges