White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

CATHETER, EMBOLECTOMY ARTERIAL RED 4FR 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 RED 4FR 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 WHITE 5FR 80CM L -- DHF

Facility

$17,373.49

Service Code	HCPCS C1757
Hospital Charge Code	80563182
Hospital Revenue Code	278
Min. Negotiated Rate	$1,563.61
Max. Negotiated Rate	$8,686.74
Rate for Payer: Aetna Commercial	$5,212.05
Rate for Payer: Amerigroup CHIP/Medicaid	$1,563.61
Rate for Payer: BCBS of TX Blue Advantage	$5,212.05
Rate for Payer: BCBS of TX Blue Essentials	$6,254.46
Rate for Payer: BCBS of TX PPO	$6,949.40
Rate for Payer: Cash Price	$15,288.67
Rate for Payer: Multiplan Auto	$8,686.74
Rate for Payer: Multiplan Commercial	$8,686.74
Rate for Payer: Multiplan Workers Comp	$8,686.74
Rate for Payer: Scott and White EPO/PPO	$8,686.74
Rate for Payer: Superior Health Plan EPO	$2,362.79

CATHETER, EMBOLECTOMY ARTERIAL WHITE 5FR 80CM L -- DHF

Facility

$17,373.49

Service Code	HCPCS C1757
Hospital Charge Code	80563182
Hospital Revenue Code	278
Min. Negotiated Rate	$4,343.37
Max. Negotiated Rate	$8,686.74
Rate for Payer: Aetna Commercial	$5,212.05
Rate for Payer: Cash Price	$15,288.67
Rate for Payer: Cigna Commercial	$4,343.37
Rate for Payer: Multiplan Auto	$8,686.74
Rate for Payer: Multiplan Commercial	$8,686.74
Rate for Payer: Multiplan Workers Comp	$8,686.74
Rate for Payer: Scott and White EPO/PPO	$8,686.74

CATHETER EP BIOSENSE DECAPOLAR 7F 2.3MM X 110CM

Facility

$5,833.90

Service Code	HCPCS C1730
Hospital Charge Code	8556477
Hospital Revenue Code	272
Min. Negotiated Rate	$525.05
Max. Negotiated Rate	$3,792.04
Rate for Payer: Aetna Commercial	$3,208.64
Rate for Payer: Amerigroup CHIP/Medicaid	$525.05
Rate for Payer: BCBS of TX Blue Advantage	$1,750.17
Rate for Payer: BCBS of TX Blue Essentials	$2,100.20
Rate for Payer: BCBS of TX PPO	$2,333.56
Rate for Payer: Cash Price	$5,133.83
Rate for Payer: Multiplan Auto	$3,792.04
Rate for Payer: Multiplan Commercial	$3,792.04
Rate for Payer: Multiplan Workers Comp	$3,792.04
Rate for Payer: Scott and White EPO/PPO	$2,916.95
Rate for Payer: Superior Health Plan EPO	$793.41

CATHETER EP BIOSENSE DECAPOLAR 7F 2.3MM X 110CM

Facility

$5,833.90

Service Code	HCPCS C1730
Hospital Charge Code	8556477
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,133.83

catheter extractor pro xl retrieval blln 9-12mm

Facility

$596.38

Service Code	HCPCS C1876
Hospital Charge Code	116306
Hospital Revenue Code	278
Min. Negotiated Rate	$149.10
Max. Negotiated Rate	$298.19
Rate for Payer: Aetna Commercial	$178.91
Rate for Payer: Cash Price	$524.81
Rate for Payer: Cigna Commercial	$149.10
Rate for Payer: Multiplan Auto	$298.19
Rate for Payer: Multiplan Commercial	$298.19
Rate for Payer: Multiplan Workers Comp	$298.19
Rate for Payer: Scott and White EPO/PPO	$298.19

catheter extractor pro xl retrieval blln 9-12mm

Facility

$596.38

Service Code	HCPCS C1876
Hospital Charge Code	116306
Hospital Revenue Code	278
Min. Negotiated Rate	$53.67
Max. Negotiated Rate	$298.19
Rate for Payer: Aetna Commercial	$178.91
Rate for Payer: Amerigroup CHIP/Medicaid	$53.67
Rate for Payer: BCBS of TX Blue Advantage	$178.91
Rate for Payer: BCBS of TX Blue Essentials	$214.70
Rate for Payer: BCBS of TX PPO	$238.55
Rate for Payer: Cash Price	$524.81
Rate for Payer: Multiplan Auto	$298.19
Rate for Payer: Multiplan Commercial	$298.19
Rate for Payer: Multiplan Workers Comp	$298.19
Rate for Payer: Scott and White EPO/PPO	$298.19
Rate for Payer: Superior Health Plan EPO	$81.11

CATHETER INFUSIONPIC DBL LMN W/ CUFF

Facility

$2,981.63

Service Code	HCPCS C1752
Hospital Charge Code	110664
Hospital Revenue Code	278
Min. Negotiated Rate	$268.35
Max. Negotiated Rate	$1,490.82
Rate for Payer: Aetna Commercial	$894.49
Rate for Payer: Amerigroup CHIP/Medicaid	$268.35
Rate for Payer: BCBS of TX Blue Advantage	$894.49
Rate for Payer: BCBS of TX Blue Essentials	$1,073.39
Rate for Payer: BCBS of TX PPO	$1,192.65
Rate for Payer: Cash Price	$2,623.83
Rate for Payer: Multiplan Auto	$1,490.82
Rate for Payer: Multiplan Commercial	$1,490.82
Rate for Payer: Multiplan Workers Comp	$1,490.82
Rate for Payer: Scott and White EPO/PPO	$1,490.82
Rate for Payer: Superior Health Plan EPO	$405.50

CATHETER INFUSIONPIC DBL LMN W/ CUFF

Facility

$2,981.63

Service Code	HCPCS C1752
Hospital Charge Code	110664
Hospital Revenue Code	278
Min. Negotiated Rate	$745.41
Max. Negotiated Rate	$1,490.82
Rate for Payer: Aetna Commercial	$894.49
Rate for Payer: Cash Price	$2,623.83
Rate for Payer: Cigna Commercial	$745.41
Rate for Payer: Multiplan Auto	$1,490.82
Rate for Payer: Multiplan Commercial	$1,490.82
Rate for Payer: Multiplan Workers Comp	$1,490.82
Rate for Payer: Scott and White EPO/PPO	$1,490.82

CATHETER, INTERMITTENT VINYL FEMALE LENGTH PVC -- DHF

Facility

$50.69

Hospital Charge Code	80412026
Hospital Revenue Code	272
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$32.95
Rate for Payer: Aetna Commercial	$27.88
Rate for Payer: Amerigroup CHIP/Medicaid	$4.56
Rate for Payer: BCBS of TX Blue Advantage	$15.21
Rate for Payer: BCBS of TX Blue Essentials	$18.25
Rate for Payer: BCBS of TX PPO	$20.28
Rate for Payer: Cash Price	$44.61
Rate for Payer: Multiplan Auto	$32.95
Rate for Payer: Multiplan Commercial	$32.95
Rate for Payer: Multiplan Workers Comp	$32.95
Rate for Payer: Scott and White EPO/PPO	$25.34
Rate for Payer: Superior Health Plan EPO	$6.89

CATHETER, INTERMITTENT VINYL FEMALE LENGTH PVC -- DHF

Facility

$50.69

Hospital Charge Code	80412026
Hospital Revenue Code	272
Rate for Payer: Cash Price	$44.61

CATHETER, INTRAUTERINE MANIP HNDL ARCH TIP 3.0CM--DHF

Facility

$477.51

Hospital Charge Code	80565252
Hospital Revenue Code	272
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$310.38
Rate for Payer: Aetna Commercial	$262.63
Rate for Payer: Amerigroup CHIP/Medicaid	$42.98
Rate for Payer: BCBS of TX Blue Advantage	$143.25
Rate for Payer: BCBS of TX Blue Essentials	$171.90
Rate for Payer: BCBS of TX PPO	$191.00
Rate for Payer: Cash Price	$420.21
Rate for Payer: Multiplan Auto	$310.38
Rate for Payer: Multiplan Commercial	$310.38
Rate for Payer: Multiplan Workers Comp	$310.38
Rate for Payer: Scott and White EPO/PPO	$238.76
Rate for Payer: Superior Health Plan EPO	$64.94

CATHETER, INTRAUTERINE MANIP HNDL ARCH TP 2.5CM -- DHF

Facility

$477.51

Hospital Charge Code	80565252
Hospital Revenue Code	272
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$310.38
Rate for Payer: Aetna Commercial	$262.63
Rate for Payer: Amerigroup CHIP/Medicaid	$42.98
Rate for Payer: BCBS of TX Blue Advantage	$143.25
Rate for Payer: BCBS of TX Blue Essentials	$171.90
Rate for Payer: BCBS of TX PPO	$191.00
Rate for Payer: Cash Price	$420.21
Rate for Payer: Multiplan Auto	$310.38
Rate for Payer: Multiplan Commercial	$310.38
Rate for Payer: Multiplan Workers Comp	$310.38
Rate for Payer: Scott and White EPO/PPO	$238.76
Rate for Payer: Superior Health Plan EPO	$64.94

CATHETER, INTRAUTERINE MANIP HNDL ARCH TP 3.5CM -- DHF

Facility

$477.51

Hospital Charge Code	80565252
Hospital Revenue Code	272
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$310.38
Rate for Payer: Aetna Commercial	$262.63
Rate for Payer: Amerigroup CHIP/Medicaid	$42.98
Rate for Payer: BCBS of TX Blue Advantage	$143.25
Rate for Payer: BCBS of TX Blue Essentials	$171.90
Rate for Payer: BCBS of TX PPO	$191.00
Rate for Payer: Cash Price	$420.21
Rate for Payer: Multiplan Auto	$310.38
Rate for Payer: Multiplan Commercial	$310.38
Rate for Payer: Multiplan Workers Comp	$310.38
Rate for Payer: Scott and White EPO/PPO	$238.76
Rate for Payer: Superior Health Plan EPO	$64.94

CATHETER, INTRAUTERINE MANIP HNDL ARCH TP 4.0CM -- DHF

Facility

$477.51

Hospital Charge Code	80565252
Hospital Revenue Code	272
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$310.38
Rate for Payer: Aetna Commercial	$262.63
Rate for Payer: Amerigroup CHIP/Medicaid	$42.98
Rate for Payer: BCBS of TX Blue Advantage	$143.25
Rate for Payer: BCBS of TX Blue Essentials	$171.90
Rate for Payer: BCBS of TX PPO	$191.00
Rate for Payer: Cash Price	$420.21
Rate for Payer: Multiplan Auto	$310.38
Rate for Payer: Multiplan Commercial	$310.38
Rate for Payer: Multiplan Workers Comp	$310.38
Rate for Payer: Scott and White EPO/PPO	$238.76
Rate for Payer: Superior Health Plan EPO	$64.94

CATHETER, INTRAUTERINE MANIP HNDL ARCH TP 4.0CM -- DHF

Facility

$477.51

Hospital Charge Code	80565252
Hospital Revenue Code	272
Rate for Payer: Cash Price	$420.21

CATHETER, IV INTROCAN SAFETY TFLN 14G X 2'''' STERILE -- DHF

Facility

$57.27

Hospital Charge Code	54201504
Hospital Revenue Code	270
Min. Negotiated Rate	$5.15
Max. Negotiated Rate	$37.23
Rate for Payer: Aetna Commercial	$31.50
Rate for Payer: Amerigroup CHIP/Medicaid	$5.15
Rate for Payer: BCBS of TX Blue Advantage	$17.18
Rate for Payer: BCBS of TX Blue Essentials	$20.62
Rate for Payer: BCBS of TX PPO	$22.91
Rate for Payer: Cash Price	$50.40
Rate for Payer: Multiplan Auto	$37.23
Rate for Payer: Multiplan Commercial	$37.23
Rate for Payer: Multiplan Workers Comp	$37.23
Rate for Payer: Scott and White EPO/PPO	$28.64
Rate for Payer: Superior Health Plan EPO	$7.79

CATHETER, IV INTROCAN SAFETY TFLN 14G X 2'''' STERILE -- DHF

Facility

$57.27

Hospital Charge Code	54201504
Hospital Revenue Code	270
Rate for Payer: Cash Price	$50.40

CATHETER IVUS -- DHF

Facility

$3,246.10

Service Code	HCPCS C1753
Hospital Charge Code	80565427
Hospital Revenue Code	272
Min. Negotiated Rate	$292.15
Max. Negotiated Rate	$2,109.96
Rate for Payer: Aetna Commercial	$1,785.36
Rate for Payer: Amerigroup CHIP/Medicaid	$292.15
Rate for Payer: BCBS of TX Blue Advantage	$973.83
Rate for Payer: BCBS of TX Blue Essentials	$1,168.60
Rate for Payer: BCBS of TX PPO	$1,298.44
Rate for Payer: Cash Price	$2,856.57
Rate for Payer: Multiplan Auto	$2,109.96
Rate for Payer: Multiplan Commercial	$2,109.96
Rate for Payer: Multiplan Workers Comp	$2,109.96
Rate for Payer: Scott and White EPO/PPO	$1,623.05
Rate for Payer: Superior Health Plan EPO	$441.47

CATHETER IVUS -- DHF

Facility

$3,246.10

Service Code	HCPCS C1753
Hospital Charge Code	80565427
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,856.57

CATHETER MOLDING & OCCLUSION MOB37

Facility

$2,528.78

Hospital Charge Code	141584
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,225.33

CATHETER MOLDING & OCCLUSION MOB37

Facility

$2,528.78

Hospital Charge Code	141584
Hospital Revenue Code	272
Min. Negotiated Rate	$227.59
Max. Negotiated Rate	$1,643.71
Rate for Payer: Aetna Commercial	$1,390.83
Rate for Payer: Amerigroup CHIP/Medicaid	$227.59
Rate for Payer: BCBS of TX Blue Advantage	$758.63
Rate for Payer: BCBS of TX Blue Essentials	$910.36
Rate for Payer: BCBS of TX PPO	$1,011.51
Rate for Payer: Cash Price	$2,225.33
Rate for Payer: Multiplan Auto	$1,643.71
Rate for Payer: Multiplan Commercial	$1,643.71
Rate for Payer: Multiplan Workers Comp	$1,643.71
Rate for Payer: Scott and White EPO/PPO	$1,264.39
Rate for Payer: Superior Health Plan EPO	$343.91

CATHETER, PALINDROME DUAL LUMEN 14.5X19

Facility

$1,387.33

Service Code	HCPCS C1752
Hospital Charge Code	8568496
Hospital Revenue Code	272
Min. Negotiated Rate	$124.86
Max. Negotiated Rate	$901.76
Rate for Payer: Aetna Commercial	$763.03
Rate for Payer: Amerigroup CHIP/Medicaid	$124.86
Rate for Payer: BCBS of TX Blue Advantage	$416.20
Rate for Payer: BCBS of TX Blue Essentials	$499.44
Rate for Payer: BCBS of TX PPO	$554.93
Rate for Payer: Cash Price	$1,220.85
Rate for Payer: Multiplan Auto	$901.76
Rate for Payer: Multiplan Commercial	$901.76
Rate for Payer: Multiplan Workers Comp	$901.76
Rate for Payer: Scott and White EPO/PPO	$693.66
Rate for Payer: Superior Health Plan EPO	$188.68

Know your out-of-pocket cost for care.

All Charges