White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATH GUIDING -- DHF

Facility

$1,306.27

Service Code	HCPCS C1887
Hospital Charge Code	82400961
Hospital Revenue Code	278
Min. Negotiated Rate	$117.56
Max. Negotiated Rate	$653.14
Rate for Payer: Aetna Commercial	$391.88
Rate for Payer: Amerigroup CHIP/Medicaid	$117.56
Rate for Payer: BCBS of TX Blue Advantage	$391.88
Rate for Payer: BCBS of TX Blue Essentials	$470.26
Rate for Payer: BCBS of TX PPO	$522.51
Rate for Payer: Cash Price	$1,149.52
Rate for Payer: Multiplan Auto	$653.14
Rate for Payer: Multiplan Commercial	$653.14
Rate for Payer: Multiplan Workers Comp	$653.14
Rate for Payer: Scott and White EPO/PPO	$653.14
Rate for Payer: Superior Health Plan EPO	$177.65

CATH HEMODIAL LONG TERM -- DHF

Facility

$2,071.51

Service Code	HCPCS C1750
Hospital Charge Code	82400987
Hospital Revenue Code	278
Min. Negotiated Rate	$186.44
Max. Negotiated Rate	$1,035.76
Rate for Payer: Aetna Commercial	$621.45
Rate for Payer: Amerigroup CHIP/Medicaid	$186.44
Rate for Payer: BCBS of TX Blue Advantage	$621.45
Rate for Payer: BCBS of TX Blue Essentials	$745.74
Rate for Payer: BCBS of TX PPO	$828.60
Rate for Payer: Cash Price	$1,822.93
Rate for Payer: Multiplan Auto	$1,035.76
Rate for Payer: Multiplan Commercial	$1,035.76
Rate for Payer: Multiplan Workers Comp	$1,035.76
Rate for Payer: Scott and White EPO/PPO	$1,035.76
Rate for Payer: Superior Health Plan EPO	$281.73

CATH HEMODIAL LONG TERM -- DHF

Facility

$2,071.51

Service Code	HCPCS C1750
Hospital Charge Code	82400987
Hospital Revenue Code	278
Min. Negotiated Rate	$517.88
Max. Negotiated Rate	$1,035.76
Rate for Payer: Aetna Commercial	$621.45
Rate for Payer: Cash Price	$1,822.93
Rate for Payer: Cigna Commercial	$517.88
Rate for Payer: Multiplan Auto	$1,035.76
Rate for Payer: Multiplan Commercial	$1,035.76
Rate for Payer: Multiplan Workers Comp	$1,035.76
Rate for Payer: Scott and White EPO/PPO	$1,035.76

CATH HICKMAN INT -- DHF

Facility

$1,467.23

Service Code	HCPCS C1751
Hospital Charge Code	80564859
Hospital Revenue Code	278
Min. Negotiated Rate	$132.05
Max. Negotiated Rate	$733.62
Rate for Payer: Aetna Commercial	$440.17
Rate for Payer: Amerigroup CHIP/Medicaid	$132.05
Rate for Payer: BCBS of TX Blue Advantage	$440.17
Rate for Payer: BCBS of TX Blue Essentials	$528.20
Rate for Payer: BCBS of TX PPO	$586.89
Rate for Payer: Cash Price	$1,291.16
Rate for Payer: Multiplan Auto	$733.62
Rate for Payer: Multiplan Commercial	$733.62
Rate for Payer: Multiplan Workers Comp	$733.62
Rate for Payer: Scott and White EPO/PPO	$733.62
Rate for Payer: Superior Health Plan EPO	$199.54

CATH HICKMAN INT -- DHF

Facility

$1,467.23

Service Code	HCPCS C1751
Hospital Charge Code	80564859
Hospital Revenue Code	278
Min. Negotiated Rate	$366.81
Max. Negotiated Rate	$733.62
Rate for Payer: Aetna Commercial	$440.17
Rate for Payer: Cash Price	$1,291.16
Rate for Payer: Cigna Commercial	$366.81
Rate for Payer: Multiplan Auto	$733.62
Rate for Payer: Multiplan Commercial	$733.62
Rate for Payer: Multiplan Workers Comp	$733.62
Rate for Payer: Scott and White EPO/PPO	$733.62

CATH INF PICC -- DHF

Facility

$768.01

Service Code	HCPCS C1751
Hospital Charge Code	82457557
Hospital Revenue Code	278
Min. Negotiated Rate	$69.12
Max. Negotiated Rate	$384.00
Rate for Payer: Aetna Commercial	$230.40
Rate for Payer: Amerigroup CHIP/Medicaid	$69.12
Rate for Payer: BCBS of TX Blue Advantage	$230.40
Rate for Payer: BCBS of TX Blue Essentials	$276.48
Rate for Payer: BCBS of TX PPO	$307.20
Rate for Payer: Cash Price	$675.85
Rate for Payer: Multiplan Auto	$384.00
Rate for Payer: Multiplan Commercial	$384.00
Rate for Payer: Multiplan Workers Comp	$384.00
Rate for Payer: Scott and White EPO/PPO	$384.00
Rate for Payer: Superior Health Plan EPO	$104.45

CATH INF PICC -- DHF

Facility

$768.01

Service Code	HCPCS C1751
Hospital Charge Code	82457557
Hospital Revenue Code	278
Min. Negotiated Rate	$192.00
Max. Negotiated Rate	$384.00
Rate for Payer: Aetna Commercial	$230.40
Rate for Payer: Cash Price	$675.85
Rate for Payer: Cigna Commercial	$192.00
Rate for Payer: Multiplan Auto	$384.00
Rate for Payer: Multiplan Commercial	$384.00
Rate for Payer: Multiplan Workers Comp	$384.00
Rate for Payer: Scott and White EPO/PPO	$384.00

CATH INF PICC DL PWR -- DHF

Facility

$741.52

Service Code	HCPCS C1751
Hospital Charge Code	82457532
Hospital Revenue Code	278
Min. Negotiated Rate	$66.74
Max. Negotiated Rate	$370.76
Rate for Payer: Aetna Commercial	$222.46
Rate for Payer: Amerigroup CHIP/Medicaid	$66.74
Rate for Payer: BCBS of TX Blue Advantage	$222.46
Rate for Payer: BCBS of TX Blue Essentials	$266.95
Rate for Payer: BCBS of TX PPO	$296.61
Rate for Payer: Cash Price	$652.54
Rate for Payer: Multiplan Auto	$370.76
Rate for Payer: Multiplan Commercial	$370.76
Rate for Payer: Multiplan Workers Comp	$370.76
Rate for Payer: Scott and White EPO/PPO	$370.76
Rate for Payer: Superior Health Plan EPO	$100.85

CATH INF PICC DL PWR -- DHF

Facility

$741.52

Service Code	HCPCS C1751
Hospital Charge Code	82457532
Hospital Revenue Code	278
Min. Negotiated Rate	$185.38
Max. Negotiated Rate	$370.76
Rate for Payer: Aetna Commercial	$222.46
Rate for Payer: Cash Price	$652.54
Rate for Payer: Cigna Commercial	$185.38
Rate for Payer: Multiplan Auto	$370.76
Rate for Payer: Multiplan Commercial	$370.76
Rate for Payer: Multiplan Workers Comp	$370.76
Rate for Payer: Scott and White EPO/PPO	$370.76

CATH IV 16X1-1/4 -- DHF

Facility

$72.12

Hospital Charge Code	54201447
Hospital Revenue Code	270
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$46.88
Rate for Payer: Aetna Commercial	$39.67
Rate for Payer: Amerigroup CHIP/Medicaid	$6.49
Rate for Payer: BCBS of TX Blue Advantage	$21.64
Rate for Payer: BCBS of TX Blue Essentials	$25.96
Rate for Payer: BCBS of TX PPO	$28.85
Rate for Payer: Cash Price	$63.47
Rate for Payer: Multiplan Auto	$46.88
Rate for Payer: Multiplan Commercial	$46.88
Rate for Payer: Multiplan Workers Comp	$46.88
Rate for Payer: Scott and White EPO/PPO	$36.06
Rate for Payer: Superior Health Plan EPO	$9.81

CATH IV 16X1-1/4 -- DHF

Facility

$72.12

Hospital Charge Code	54201447
Hospital Revenue Code	270
Rate for Payer: Cash Price	$63.47

CATH IV 18X1-1/4 -- DHF

Facility

$72.12

Hospital Charge Code	54201454
Hospital Revenue Code	270
Rate for Payer: Cash Price	$63.47

CATH IV 18X1-1/4 -- DHF

Facility

$72.12

Hospital Charge Code	54201454
Hospital Revenue Code	270
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$46.88
Rate for Payer: Aetna Commercial	$39.67
Rate for Payer: Amerigroup CHIP/Medicaid	$6.49
Rate for Payer: BCBS of TX Blue Advantage	$21.64
Rate for Payer: BCBS of TX Blue Essentials	$25.96
Rate for Payer: BCBS of TX PPO	$28.85
Rate for Payer: Cash Price	$63.47
Rate for Payer: Multiplan Auto	$46.88
Rate for Payer: Multiplan Commercial	$46.88
Rate for Payer: Multiplan Workers Comp	$46.88
Rate for Payer: Scott and White EPO/PPO	$36.06
Rate for Payer: Superior Health Plan EPO	$9.81

CATH IV 20X1-1/4 -- DHF

Facility

$57.27

Hospital Charge Code	54201496
Hospital Revenue Code	270
Rate for Payer: Cash Price	$50.40

CATH IV 20X1-1/4 -- DHF

Facility

$57.27

Hospital Charge Code	54201496
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

Cath iv inssyte-n 24gx.56

Facility

$10.03

Hospital Charge Code	8616505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.83

Cath iv inssyte-n 24gx.56

Facility

$10.03

Hospital Charge Code	8616505
Hospital Revenue Code	272
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$6.52
Rate for Payer: Aetna Commercial	$5.52
Rate for Payer: Amerigroup CHIP/Medicaid	$0.90
Rate for Payer: BCBS of TX Blue Advantage	$3.01
Rate for Payer: BCBS of TX Blue Essentials	$3.61
Rate for Payer: BCBS of TX PPO	$4.01
Rate for Payer: Cash Price	$8.83
Rate for Payer: Multiplan Auto	$6.52
Rate for Payer: Multiplan Commercial	$6.52
Rate for Payer: Multiplan Workers Comp	$6.52
Rate for Payer: Scott and White EPO/PPO	$5.02
Rate for Payer: Superior Health Plan EPO	$1.36

CATH IV PLCMNT -- DHF

Facility

$82.72

Hospital Charge Code	54201959
Hospital Revenue Code	270
Rate for Payer: Cash Price	$72.79

CATH IV PLCMNT -- DHF

Facility

$82.72

Hospital Charge Code	54201959
Hospital Revenue Code	270
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$53.77
Rate for Payer: Aetna Commercial	$45.50
Rate for Payer: Amerigroup CHIP/Medicaid	$7.44
Rate for Payer: BCBS of TX Blue Advantage	$24.82
Rate for Payer: BCBS of TX Blue Essentials	$29.78
Rate for Payer: BCBS of TX PPO	$33.09
Rate for Payer: Cash Price	$72.79
Rate for Payer: Multiplan Auto	$53.77
Rate for Payer: Multiplan Commercial	$53.77
Rate for Payer: Multiplan Workers Comp	$53.77
Rate for Payer: Scott and White EPO/PPO	$41.36
Rate for Payer: Superior Health Plan EPO	$11.25

CATH IVUS DIGITL PV.035 -- DHF

Facility

$4,313.00

Service Code	HCPCS C1753
Hospital Charge Code	80565435
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,795.44

CATH IVUS DIGITL PV.035 -- DHF

Facility

$4,313.00

Service Code	HCPCS C1753
Hospital Charge Code	80565435
Hospital Revenue Code	272
Min. Negotiated Rate	$388.17
Max. Negotiated Rate	$2,803.45
Rate for Payer: Aetna Commercial	$2,372.15
Rate for Payer: Amerigroup CHIP/Medicaid	$388.17
Rate for Payer: BCBS of TX Blue Advantage	$1,293.90
Rate for Payer: BCBS of TX Blue Essentials	$1,552.68
Rate for Payer: BCBS of TX PPO	$1,725.20
Rate for Payer: Cash Price	$3,795.44
Rate for Payer: Multiplan Auto	$2,803.45
Rate for Payer: Multiplan Commercial	$2,803.45
Rate for Payer: Multiplan Workers Comp	$2,803.45
Rate for Payer: Scott and White EPO/PPO	$2,156.50
Rate for Payer: Superior Health Plan EPO	$586.57

CATH IVUS IMAG PLATINUM -- DHF

Facility

$6,583.00

Service Code	HCPCS C1753
Hospital Charge Code	80565468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,793.04

CATH IVUS IMAG PLATINUM -- DHF

Facility

$6,583.00

Service Code	HCPCS C1753
Hospital Charge Code	80565468
Hospital Revenue Code	272
Min. Negotiated Rate	$592.47
Max. Negotiated Rate	$4,278.95
Rate for Payer: Aetna Commercial	$3,620.65
Rate for Payer: Amerigroup CHIP/Medicaid	$592.47
Rate for Payer: BCBS of TX Blue Advantage	$1,974.90
Rate for Payer: BCBS of TX Blue Essentials	$2,369.88
Rate for Payer: BCBS of TX PPO	$2,633.20
Rate for Payer: Cash Price	$5,793.04
Rate for Payer: Multiplan Auto	$4,278.95
Rate for Payer: Multiplan Commercial	$4,278.95
Rate for Payer: Multiplan Workers Comp	$4,278.95
Rate for Payer: Scott and White EPO/PPO	$3,291.50
Rate for Payer: Superior Health Plan EPO	$895.29

CATH KIT SURESTEP FOLEY

Facility

$94.97

Hospital Charge Code	8504483
Hospital Revenue Code	272
Rate for Payer: Cash Price	$83.57

CATH KIT SURESTEP FOLEY

Facility

$94.97

Hospital Charge Code	8504483
Hospital Revenue Code	272
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$61.73
Rate for Payer: Aetna Commercial	$52.23
Rate for Payer: Amerigroup CHIP/Medicaid	$8.55
Rate for Payer: BCBS of TX Blue Advantage	$28.49
Rate for Payer: BCBS of TX Blue Essentials	$34.19
Rate for Payer: BCBS of TX PPO	$37.99
Rate for Payer: Cash Price	$83.57
Rate for Payer: Multiplan Auto	$61.73
Rate for Payer: Multiplan Commercial	$61.73
Rate for Payer: Multiplan Workers Comp	$61.73
Rate for Payer: Scott and White EPO/PPO	$47.48
Rate for Payer: Superior Health Plan EPO	$12.92

Know your out-of-pocket cost for care.

All Charges