White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CATH R&L HRT ART/VENT

Facility

$25,230.00

Service Code	CPT 93460
Hospital Charge Code	2320529
Hospital Revenue Code	481
Min. Negotiated Rate	$53.30
Max. Negotiated Rate	$16,399.50
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$4,470.16
Rate for Payer: Amerigroup CHIP/Medicaid	$2,270.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,980.11
Rate for Payer: Amerigroup Medicare	$2,980.11
Rate for Payer: BCBS of TX Blue Advantage	$4,759.42
Rate for Payer: BCBS of TX Blue Essentials	$5,699.90
Rate for Payer: BCBS of TX Medicare	$2,980.11
Rate for Payer: BCBS of TX PPO	$7,181.87
Rate for Payer: Cash Price	$22,202.40
Rate for Payer: Cash Price	$22,202.40
Rate for Payer: Cash Price	$22,202.40
Rate for Payer: Cigna Commercial	$6,750.80
Rate for Payer: Cigna Medicare	$2,980.11
Rate for Payer: Employer Direct Commercial	$2,980.11
Rate for Payer: Humana Medicare/TRICARE	$2,980.11
Rate for Payer: Molina Dual Medicare/Medicaid	$2,980.11
Rate for Payer: Molina Medicare	$2,980.11
Rate for Payer: Multiplan Auto	$16,399.50
Rate for Payer: Multiplan Commercial	$16,399.50
Rate for Payer: Multiplan Workers Comp	$16,399.50
Rate for Payer: Scott and White EPO/PPO	$53.30
Rate for Payer: Scott and White Medicare	$2,980.11
Rate for Payer: Superior Health Plan EPO	$2,980.11
Rate for Payer: Superior Health Plan Medicare	$2,980.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,980.11
Rate for Payer: Universal American Medicare	$2,980.11
Rate for Payer: Wellcare Medicare	$2,980.11
Rate for Payer: Wellmed Medicare	$2,980.11

CATH R&L HRT AR/VNT BPGF

Facility

$26,826.07

Service Code	CPT 93461
Hospital Charge Code	2320530
Hospital Revenue Code	481
Rate for Payer: Cash Price	$23,606.94

CATH R&L HRT AR/VNT BPGF

Facility

$26,826.07

Service Code	CPT 93461
Hospital Charge Code	2320530
Hospital Revenue Code	481
Min. Negotiated Rate	$53.30
Max. Negotiated Rate	$17,436.95
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$4,470.16
Rate for Payer: Amerigroup CHIP/Medicaid	$2,414.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,980.11
Rate for Payer: Amerigroup Medicare	$2,980.11
Rate for Payer: BCBS of TX Blue Advantage	$4,759.42
Rate for Payer: BCBS of TX Blue Essentials	$5,699.90
Rate for Payer: BCBS of TX Medicare	$2,980.11
Rate for Payer: BCBS of TX PPO	$7,181.87
Rate for Payer: Cash Price	$23,606.94
Rate for Payer: Cash Price	$23,606.94
Rate for Payer: Cash Price	$23,606.94
Rate for Payer: Cigna Commercial	$6,750.80
Rate for Payer: Cigna Medicare	$2,980.11
Rate for Payer: Employer Direct Commercial	$2,980.11
Rate for Payer: Humana Medicare/TRICARE	$2,980.11
Rate for Payer: Molina Dual Medicare/Medicaid	$2,980.11
Rate for Payer: Molina Medicare	$2,980.11
Rate for Payer: Multiplan Auto	$17,436.95
Rate for Payer: Multiplan Commercial	$17,436.95
Rate for Payer: Multiplan Workers Comp	$17,436.95
Rate for Payer: Scott and White EPO/PPO	$53.30
Rate for Payer: Scott and White Medicare	$2,980.11
Rate for Payer: Superior Health Plan EPO	$2,980.11
Rate for Payer: Superior Health Plan Medicare	$2,980.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,980.11
Rate for Payer: Universal American Medicare	$2,980.11
Rate for Payer: Wellcare Medicare	$2,980.11
Rate for Payer: Wellmed Medicare	$2,980.11

CATH SET COOKWAYNE PNEUMO

Facility

$911.36

Service Code	HCPCS C1729
Hospital Charge Code	145580
Hospital Revenue Code	272
Rate for Payer: Cash Price	$802.00

CATH SET COOKWAYNE PNEUMO

Facility

$911.36

Service Code	HCPCS C1729
Hospital Charge Code	145580
Hospital Revenue Code	272
Min. Negotiated Rate	$82.02
Max. Negotiated Rate	$592.38
Rate for Payer: Aetna Commercial	$501.25
Rate for Payer: Amerigroup CHIP/Medicaid	$82.02
Rate for Payer: BCBS of TX Blue Advantage	$273.41
Rate for Payer: BCBS of TX Blue Essentials	$328.09
Rate for Payer: BCBS of TX PPO	$364.54
Rate for Payer: Cash Price	$802.00
Rate for Payer: Multiplan Auto	$592.38
Rate for Payer: Multiplan Commercial	$592.38
Rate for Payer: Multiplan Workers Comp	$592.38
Rate for Payer: Scott and White EPO/PPO	$455.68
Rate for Payer: Superior Health Plan EPO	$123.94

CATH SPEC -- DHF

Facility

$364.30

Hospital Charge Code	80567050
Hospital Revenue Code	272
Rate for Payer: Cash Price	$320.58

CATH SPEC -- DHF

Facility

$364.30

Hospital Charge Code	80567050
Hospital Revenue Code	272
Min. Negotiated Rate	$32.79
Max. Negotiated Rate	$236.80
Rate for Payer: Aetna Commercial	$200.36
Rate for Payer: Amerigroup CHIP/Medicaid	$32.79
Rate for Payer: BCBS of TX Blue Advantage	$109.29
Rate for Payer: BCBS of TX Blue Essentials	$131.15
Rate for Payer: BCBS of TX PPO	$145.72
Rate for Payer: Cash Price	$320.58
Rate for Payer: Multiplan Auto	$236.80
Rate for Payer: Multiplan Commercial	$236.80
Rate for Payer: Multiplan Workers Comp	$236.80
Rate for Payer: Scott and White EPO/PPO	$182.15
Rate for Payer: Superior Health Plan EPO	$49.54

CATH SUCT A/S -- DHF

Facility

$45.82

Hospital Charge Code	80316300
Hospital Revenue Code	272
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

CATH SUCT A/S -- DHF

Facility

$45.82

Hospital Charge Code	80316300
Hospital Revenue Code	272
Rate for Payer: Cash Price	$40.32

CATH SW-GZ MNTR -- DHF

Facility

$3,404.88

Hospital Charge Code	80567555
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,996.29

CATH SW-GZ MNTR -- DHF

Facility

$3,404.88

Hospital Charge Code	80567555
Hospital Revenue Code	272
Min. Negotiated Rate	$306.44
Max. Negotiated Rate	$2,213.17
Rate for Payer: Aetna Commercial	$1,872.68
Rate for Payer: Amerigroup CHIP/Medicaid	$306.44
Rate for Payer: BCBS of TX Blue Advantage	$1,021.46
Rate for Payer: BCBS of TX Blue Essentials	$1,225.76
Rate for Payer: BCBS of TX PPO	$1,361.95
Rate for Payer: Cash Price	$2,996.29
Rate for Payer: Multiplan Auto	$2,213.17
Rate for Payer: Multiplan Commercial	$2,213.17
Rate for Payer: Multiplan Workers Comp	$2,213.17
Rate for Payer: Scott and White EPO/PPO	$1,702.44
Rate for Payer: Superior Health Plan EPO	$463.06

CATH SW-GZ THERM -- DHF

Facility

$317.80

Hospital Charge Code	80567654
Hospital Revenue Code	272
Rate for Payer: Cash Price	$279.66

CATH SW-GZ THERM -- DHF

Facility

$317.80

Hospital Charge Code	80567654
Hospital Revenue Code	272
Min. Negotiated Rate	$28.60
Max. Negotiated Rate	$206.57
Rate for Payer: Aetna Commercial	$174.79
Rate for Payer: Amerigroup CHIP/Medicaid	$28.60
Rate for Payer: BCBS of TX Blue Advantage	$95.34
Rate for Payer: BCBS of TX Blue Essentials	$114.41
Rate for Payer: BCBS of TX PPO	$127.12
Rate for Payer: Cash Price	$279.66
Rate for Payer: Multiplan Auto	$206.57
Rate for Payer: Multiplan Commercial	$206.57
Rate for Payer: Multiplan Workers Comp	$206.57
Rate for Payer: Scott and White EPO/PPO	$158.90
Rate for Payer: Superior Health Plan EPO	$43.22

CATHTER ANGION SOFT-VU 5FRX65CM .035

Facility

$119.86

Hospital Charge Code	106577
Hospital Revenue Code	272
Rate for Payer: Cash Price	$105.48

CATHTER ANGION SOFT-VU 5FRX65CM .035

Facility

$119.86

Hospital Charge Code	106577
Hospital Revenue Code	272
Min. Negotiated Rate	$10.79
Max. Negotiated Rate	$77.91
Rate for Payer: Aetna Commercial	$65.92
Rate for Payer: Amerigroup CHIP/Medicaid	$10.79
Rate for Payer: BCBS of TX Blue Advantage	$35.96
Rate for Payer: BCBS of TX Blue Essentials	$43.15
Rate for Payer: BCBS of TX PPO	$47.94
Rate for Payer: Cash Price	$105.48
Rate for Payer: Multiplan Auto	$77.91
Rate for Payer: Multiplan Commercial	$77.91
Rate for Payer: Multiplan Workers Comp	$77.91
Rate for Payer: Scott and White EPO/PPO	$59.93
Rate for Payer: Superior Health Plan EPO	$16.30

cathter extractor pro xl retrieval bln 15-18mm

Facility

$2,707.59

Service Code	HCPCS C1876
Hospital Charge Code	116308
Hospital Revenue Code	278
Min. Negotiated Rate	$676.90
Max. Negotiated Rate	$1,353.80
Rate for Payer: Aetna Commercial	$812.28
Rate for Payer: Cash Price	$2,382.68
Rate for Payer: Cigna Commercial	$676.90
Rate for Payer: Multiplan Auto	$1,353.80
Rate for Payer: Multiplan Commercial	$1,353.80
Rate for Payer: Multiplan Workers Comp	$1,353.80
Rate for Payer: Scott and White EPO/PPO	$1,353.80

cathter extractor pro xl retrieval bln 15-18mm

Facility

$2,707.59

Service Code	HCPCS C1876
Hospital Charge Code	116308
Hospital Revenue Code	278
Min. Negotiated Rate	$243.68
Max. Negotiated Rate	$1,353.80
Rate for Payer: Aetna Commercial	$812.28
Rate for Payer: Amerigroup CHIP/Medicaid	$243.68
Rate for Payer: BCBS of TX Blue Advantage	$812.28
Rate for Payer: BCBS of TX Blue Essentials	$974.73
Rate for Payer: BCBS of TX PPO	$1,083.04
Rate for Payer: Cash Price	$2,382.68
Rate for Payer: Multiplan Auto	$1,353.80
Rate for Payer: Multiplan Commercial	$1,353.80
Rate for Payer: Multiplan Workers Comp	$1,353.80
Rate for Payer: Scott and White EPO/PPO	$1,353.80
Rate for Payer: Superior Health Plan EPO	$368.23

CATH THORACIC -- DHF

Facility

$380.00

Service Code	HCPCS C1729
Hospital Charge Code	80567803
Hospital Revenue Code	278
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$190.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Cash Price	$334.40
Rate for Payer: Cigna Commercial	$95.00
Rate for Payer: Multiplan Auto	$190.00
Rate for Payer: Multiplan Commercial	$190.00
Rate for Payer: Multiplan Workers Comp	$190.00
Rate for Payer: Scott and White EPO/PPO	$190.00

CATH THORACIC -- DHF

Facility

$380.00

Service Code	HCPCS C1729
Hospital Charge Code	80567803
Hospital Revenue Code	278
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$190.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Amerigroup CHIP/Medicaid	$34.20
Rate for Payer: BCBS of TX Blue Advantage	$114.00
Rate for Payer: BCBS of TX Blue Essentials	$136.80
Rate for Payer: BCBS of TX PPO	$152.00
Rate for Payer: Cash Price	$334.40
Rate for Payer: Multiplan Auto	$190.00
Rate for Payer: Multiplan Commercial	$190.00
Rate for Payer: Multiplan Workers Comp	$190.00
Rate for Payer: Scott and White EPO/PPO	$190.00
Rate for Payer: Superior Health Plan EPO	$51.68

CATH TRIPLE LUM PWR

Facility

$1,453.13

Service Code	HCPCS C1752
Hospital Charge Code	8514466
Hospital Revenue Code	278
Min. Negotiated Rate	$130.78
Max. Negotiated Rate	$726.56
Rate for Payer: Aetna Commercial	$435.94
Rate for Payer: Amerigroup CHIP/Medicaid	$130.78
Rate for Payer: BCBS of TX Blue Advantage	$435.94
Rate for Payer: BCBS of TX Blue Essentials	$523.13
Rate for Payer: BCBS of TX PPO	$581.25
Rate for Payer: Cash Price	$1,278.75
Rate for Payer: Multiplan Auto	$726.56
Rate for Payer: Multiplan Commercial	$726.56
Rate for Payer: Multiplan Workers Comp	$726.56
Rate for Payer: Scott and White EPO/PPO	$726.56
Rate for Payer: Superior Health Plan EPO	$197.63

CATH TRIPLE LUM PWR

Facility

$1,453.13

Service Code	HCPCS C1752
Hospital Charge Code	8514466
Hospital Revenue Code	278
Min. Negotiated Rate	$363.28
Max. Negotiated Rate	$726.56
Rate for Payer: Aetna Commercial	$435.94
Rate for Payer: Cash Price	$1,278.75
Rate for Payer: Cigna Commercial	$363.28
Rate for Payer: Multiplan Auto	$726.56
Rate for Payer: Multiplan Commercial	$726.56
Rate for Payer: Multiplan Workers Comp	$726.56
Rate for Payer: Scott and White EPO/PPO	$726.56

CATH URETERAL -- DHF

Facility

$445.91

Service Code	HCPCS C1758
Hospital Charge Code	80412513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$392.40

CATH URETERAL -- DHF

Facility

$445.91

Service Code	HCPCS C1758
Hospital Charge Code	80412513
Hospital Revenue Code	272
Min. Negotiated Rate	$40.13
Max. Negotiated Rate	$289.84
Rate for Payer: Aetna Commercial	$245.25
Rate for Payer: Amerigroup CHIP/Medicaid	$40.13
Rate for Payer: BCBS of TX Blue Advantage	$133.77
Rate for Payer: BCBS of TX Blue Essentials	$160.53
Rate for Payer: BCBS of TX PPO	$178.36
Rate for Payer: Cash Price	$392.40
Rate for Payer: Multiplan Auto	$289.84
Rate for Payer: Multiplan Commercial	$289.84
Rate for Payer: Multiplan Workers Comp	$289.84
Rate for Payer: Scott and White EPO/PPO	$222.96
Rate for Payer: Superior Health Plan EPO	$60.64

CATH VESL UMBLCL -- DHF

Facility

$636.00

Hospital Charge Code	80568256
Hospital Revenue Code	272
Min. Negotiated Rate	$57.24
Max. Negotiated Rate	$413.40
Rate for Payer: Aetna Commercial	$349.80
Rate for Payer: Amerigroup CHIP/Medicaid	$57.24
Rate for Payer: BCBS of TX Blue Advantage	$190.80
Rate for Payer: BCBS of TX Blue Essentials	$228.96
Rate for Payer: BCBS of TX PPO	$254.40
Rate for Payer: Cash Price	$559.68
Rate for Payer: Multiplan Auto	$413.40
Rate for Payer: Multiplan Commercial	$413.40
Rate for Payer: Multiplan Workers Comp	$413.40
Rate for Payer: Scott and White EPO/PPO	$318.00
Rate for Payer: Superior Health Plan EPO	$86.50

CATH VESL UMBLCL -- DHF

Facility

$636.00

Hospital Charge Code	80568256
Hospital Revenue Code	272
Rate for Payer: Cash Price	$559.68

Know your out-of-pocket cost for care.

All Charges