White Rock Medical Center

All Charges

Charge

Type

Setting

Price

graft kerecis micro omega 3 38cm ea

Facility

$288.49

Service Code	HCPCS Q4158
Hospital Charge Code	8738541
Hospital Revenue Code	278
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$144.24
Rate for Payer: Aetna Commercial	$86.55
Rate for Payer: Amerigroup CHIP/Medicaid	$25.96
Rate for Payer: BCBS of TX Blue Advantage	$86.55
Rate for Payer: BCBS of TX Blue Essentials	$103.86
Rate for Payer: BCBS of TX PPO	$115.40
Rate for Payer: Cash Price	$253.87
Rate for Payer: Multiplan Auto	$144.24
Rate for Payer: Multiplan Commercial	$144.24
Rate for Payer: Multiplan Workers Comp	$144.24
Rate for Payer: Scott and White EPO/PPO	$144.24
Rate for Payer: Superior Health Plan EPO	$39.23

graft kerecis micro omega 3 38cm ea

Facility

$288.49

Service Code	HCPCS Q4158
Hospital Charge Code	8738541
Hospital Revenue Code	278
Min. Negotiated Rate	$72.12
Max. Negotiated Rate	$144.24
Rate for Payer: Aetna Commercial	$86.55
Rate for Payer: Cash Price	$253.87
Rate for Payer: Cigna Commercial	$72.12
Rate for Payer: Multiplan Auto	$144.24
Rate for Payer: Multiplan Commercial	$144.24
Rate for Payer: Multiplan Workers Comp	$144.24
Rate for Payer: Scott and White EPO/PPO	$144.24

graft nushield membrane mnts 4x6cm

Facility

$439.28

Service Code	HCPCS Q4160
Hospital Charge Code	8672534
Hospital Revenue Code	278
Min. Negotiated Rate	$109.82
Max. Negotiated Rate	$219.64
Rate for Payer: Aetna Commercial	$131.78
Rate for Payer: Cash Price	$386.57
Rate for Payer: Cigna Commercial	$109.82
Rate for Payer: Multiplan Auto	$219.64
Rate for Payer: Multiplan Commercial	$219.64
Rate for Payer: Multiplan Workers Comp	$219.64
Rate for Payer: Scott and White EPO/PPO	$219.64

graft nushield membrane mnts 4x6cm

Facility

$439.28

Service Code	HCPCS Q4160
Hospital Charge Code	8672534
Hospital Revenue Code	278
Min. Negotiated Rate	$39.54
Max. Negotiated Rate	$219.64
Rate for Payer: Aetna Commercial	$131.78
Rate for Payer: Amerigroup CHIP/Medicaid	$39.54
Rate for Payer: BCBS of TX Blue Advantage	$131.78
Rate for Payer: BCBS of TX Blue Essentials	$158.14
Rate for Payer: BCBS of TX PPO	$175.71
Rate for Payer: Cash Price	$386.57
Rate for Payer: Multiplan Auto	$219.64
Rate for Payer: Multiplan Commercial	$219.64
Rate for Payer: Multiplan Workers Comp	$219.64
Rate for Payer: Scott and White EPO/PPO	$219.64
Rate for Payer: Superior Health Plan EPO	$59.74

Graft rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

Facility

$12,223.34

Service Code	CPT 21230
Hospital Charge Code	36021230
Hospital Revenue Code	360
Min. Negotiated Rate	$118.13
Max. Negotiated Rate	$12,223.34
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$8,033.61
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Amerigroup Medicare	$5,355.74
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,355.74
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,132.30
Rate for Payer: Cigna Medicaid	$1,954.22
Rate for Payer: Cigna Medicare	$5,355.74
Rate for Payer: Employer Direct Commercial	$5,355.74
Rate for Payer: Humana Medicare/TRICARE	$5,355.74
Rate for Payer: Molina CHIP/Medicaid	$1,954.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Molina Medicare	$5,355.74
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,954.22
Rate for Payer: Scott and White EPO/PPO	$118.13
Rate for Payer: Scott and White Medicare	$5,355.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.22
Rate for Payer: Superior Health Plan EPO	$5,355.74
Rate for Payer: Superior Health Plan Medicare	$5,355.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,355.74
Rate for Payer: Universal American Medicare	$5,355.74
Rate for Payer: Wellcare Medicare	$5,355.74
Rate for Payer: Wellmed Medicare	$5,355.74

GRAFT STRATTICE 2025002 PER SQ CM

Facility

$175.24

Service Code	HCPCS Q4130
Hospital Charge Code	118460
Hospital Revenue Code	278
Min. Negotiated Rate	$43.81
Max. Negotiated Rate	$87.62
Rate for Payer: Aetna Commercial	$52.57
Rate for Payer: Cash Price	$154.21
Rate for Payer: Cigna Commercial	$43.81
Rate for Payer: Multiplan Auto	$87.62
Rate for Payer: Multiplan Commercial	$87.62
Rate for Payer: Multiplan Workers Comp	$87.62
Rate for Payer: Scott and White EPO/PPO	$87.62

GRAFT STRATTICE 2025002 PER SQ CM

Facility

$175.24

Service Code	HCPCS Q4130
Hospital Charge Code	118460
Hospital Revenue Code	278
Min. Negotiated Rate	$15.77
Max. Negotiated Rate	$87.62
Rate for Payer: Aetna Commercial	$52.57
Rate for Payer: Amerigroup CHIP/Medicaid	$15.77
Rate for Payer: BCBS of TX Blue Advantage	$52.57
Rate for Payer: BCBS of TX Blue Essentials	$63.09
Rate for Payer: BCBS of TX PPO	$70.10
Rate for Payer: Cash Price	$154.21
Rate for Payer: Multiplan Auto	$87.62
Rate for Payer: Multiplan Commercial	$87.62
Rate for Payer: Multiplan Workers Comp	$87.62
Rate for Payer: Scott and White EPO/PPO	$87.62
Rate for Payer: Superior Health Plan EPO	$23.83

GRAFT TIBIALIS TENDON ANT/FRZ 20-25.9CML

Facility

$10,843.37

Service Code	HCPCS C1713
Hospital Charge Code	145369
Hospital Revenue Code	278
Min. Negotiated Rate	$2,710.84
Max. Negotiated Rate	$5,421.68
Rate for Payer: Aetna Commercial	$3,253.01
Rate for Payer: Cash Price	$9,542.17
Rate for Payer: Cigna Commercial	$2,710.84
Rate for Payer: Multiplan Auto	$5,421.68
Rate for Payer: Multiplan Commercial	$5,421.68
Rate for Payer: Multiplan Workers Comp	$5,421.68
Rate for Payer: Scott and White EPO/PPO	$5,421.68

GRAFT TIBIALIS TENDON ANT/FRZ 20-25.9CML

Facility

$10,843.37

Service Code	HCPCS C1713
Hospital Charge Code	145369
Hospital Revenue Code	278
Min. Negotiated Rate	$975.90
Max. Negotiated Rate	$5,421.68
Rate for Payer: Aetna Commercial	$3,253.01
Rate for Payer: Amerigroup CHIP/Medicaid	$975.90
Rate for Payer: BCBS of TX Blue Advantage	$3,253.01
Rate for Payer: BCBS of TX Blue Essentials	$3,903.61
Rate for Payer: BCBS of TX PPO	$4,337.35
Rate for Payer: Cash Price	$9,542.17
Rate for Payer: Multiplan Auto	$5,421.68
Rate for Payer: Multiplan Commercial	$5,421.68
Rate for Payer: Multiplan Workers Comp	$5,421.68
Rate for Payer: Scott and White EPO/PPO	$5,421.68
Rate for Payer: Superior Health Plan EPO	$1,474.70

GRAFT VASC ARTEGRAFT -- DHF

Facility

$16,319.28

Service Code	HCPCS C1768
Hospital Charge Code	81421364
Hospital Revenue Code	278
Min. Negotiated Rate	$1,468.74
Max. Negotiated Rate	$8,159.64
Rate for Payer: Aetna Commercial	$4,895.78
Rate for Payer: Amerigroup CHIP/Medicaid	$1,468.74
Rate for Payer: BCBS of TX Blue Advantage	$4,895.78
Rate for Payer: BCBS of TX Blue Essentials	$5,874.94
Rate for Payer: BCBS of TX PPO	$6,527.71
Rate for Payer: Cash Price	$14,360.97
Rate for Payer: Multiplan Auto	$8,159.64
Rate for Payer: Multiplan Commercial	$8,159.64
Rate for Payer: Multiplan Workers Comp	$8,159.64
Rate for Payer: Scott and White EPO/PPO	$8,159.64
Rate for Payer: Superior Health Plan EPO	$2,219.42

GRAFT VASC ARTEGRAFT -- DHF

Facility

$16,319.28

Service Code	HCPCS C1768
Hospital Charge Code	81421364
Hospital Revenue Code	278
Min. Negotiated Rate	$4,079.82
Max. Negotiated Rate	$8,159.64
Rate for Payer: Aetna Commercial	$4,895.78
Rate for Payer: Cash Price	$14,360.97
Rate for Payer: Cigna Commercial	$4,079.82
Rate for Payer: Multiplan Auto	$8,159.64
Rate for Payer: Multiplan Commercial	$8,159.64
Rate for Payer: Multiplan Workers Comp	$8,159.64
Rate for Payer: Scott and White EPO/PPO	$8,159.64

GRAFT VASCULAR THNWL PTFE

Facility

$17,373.49

Service Code	HCPCS C1768
Hospital Charge Code	8490531
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

GRAFT VASCULAR THNWL PTFE

Facility

$17,373.49

Service Code	HCPCS C1768
Hospital Charge Code	8490531
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

GRAFT VIAGRAFT 5.0CC

Facility

$13,554.21

Service Code	HCPCS Q4100
Hospital Charge Code	8504495
Hospital Revenue Code	278
Min. Negotiated Rate	$1,219.88
Max. Negotiated Rate	$6,777.10
Rate for Payer: Aetna Commercial	$4,066.26
Rate for Payer: Amerigroup CHIP/Medicaid	$1,219.88
Rate for Payer: BCBS of TX Blue Advantage	$4,066.26
Rate for Payer: BCBS of TX Blue Essentials	$4,879.52
Rate for Payer: BCBS of TX PPO	$5,421.68
Rate for Payer: Cash Price	$11,927.70
Rate for Payer: Multiplan Auto	$6,777.10
Rate for Payer: Multiplan Commercial	$6,777.10
Rate for Payer: Multiplan Workers Comp	$6,777.10
Rate for Payer: Scott and White EPO/PPO	$6,777.10
Rate for Payer: Superior Health Plan EPO	$1,843.37

GRAFT VIAGRAFT 5.0CC

Facility

$13,554.21

Service Code	HCPCS Q4100
Hospital Charge Code	8504495
Hospital Revenue Code	278
Min. Negotiated Rate	$3,388.55
Max. Negotiated Rate	$6,777.10
Rate for Payer: Aetna Commercial	$4,066.26
Rate for Payer: Cash Price	$11,927.70
Rate for Payer: Cigna Commercial	$3,388.55
Rate for Payer: Multiplan Auto	$6,777.10
Rate for Payer: Multiplan Commercial	$6,777.10
Rate for Payer: Multiplan Workers Comp	$6,777.10
Rate for Payer: Scott and White EPO/PPO	$6,777.10

Gram negative identification (Vitek)

Facility

$238.00

Service Code	CPT 87077
Hospital Charge Code	4108707
Hospital Revenue Code	306
Rate for Payer: Cash Price	$209.44

Gram negative identification (Vitek)

Facility

$238.00

Service Code	CPT 87077
Hospital Charge Code	4108707
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$154.70
Rate for Payer: Aetna Commercial	$8.49
Rate for Payer: Aetna Medicare	$12.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.08
Rate for Payer: Amerigroup Medicare	$8.08
Rate for Payer: BCBS of TX Blue Advantage	$13.33
Rate for Payer: BCBS of TX Blue Essentials	$16.00
Rate for Payer: BCBS of TX Medicare	$8.08
Rate for Payer: BCBS of TX PPO	$17.86
Rate for Payer: Cash Price	$209.44
Rate for Payer: Cash Price	$209.44
Rate for Payer: Cigna Medicaid	$8.08
Rate for Payer: Cigna Medicare	$8.08
Rate for Payer: Employer Direct Commercial	$8.08
Rate for Payer: Humana Medicare/TRICARE	$8.08
Rate for Payer: Molina CHIP/Medicaid	$8.08
Rate for Payer: Molina Dual Medicare/Medicaid	$8.08
Rate for Payer: Molina Medicare	$8.08
Rate for Payer: Multiplan Auto	$154.70
Rate for Payer: Multiplan Commercial	$154.70
Rate for Payer: Multiplan Workers Comp	$154.70
Rate for Payer: Parkland Medicaid	$8.08
Rate for Payer: Scott and White EPO/PPO	$10.10
Rate for Payer: Scott and White Medicare	$8.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.08
Rate for Payer: Superior Health Plan EPO	$8.08
Rate for Payer: Superior Health Plan Medicare	$8.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.08
Rate for Payer: Universal American Medicare	$8.08
Rate for Payer: Wellcare Medicare	$8.08
Rate for Payer: Wellmed Medicare	$8.08

Gram Stain

Facility

$138.00

Service Code	CPT 87205
Hospital Charge Code	4107205
Hospital Revenue Code	306
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$89.70
Rate for Payer: Aetna Commercial	$4.48
Rate for Payer: Aetna Medicare	$6.40
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$7.05
Rate for Payer: BCBS of TX Blue Essentials	$8.45
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$9.44
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cigna Medicaid	$4.27
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$4.27
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$89.70
Rate for Payer: Multiplan Commercial	$89.70
Rate for Payer: Multiplan Workers Comp	$89.70
Rate for Payer: Parkland Medicaid	$4.27
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.27
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

Gram Stain

Facility

$138.00

Service Code	CPT 87205
Hospital Charge Code	4107205
Hospital Revenue Code	306
Rate for Payer: Cash Price	$121.44

Gram Stain Body Fluid

Facility

$138.00

Service Code	CPT 87205
Hospital Charge Code	1604206
Hospital Revenue Code	306
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$89.70
Rate for Payer: Aetna Commercial	$4.48
Rate for Payer: Aetna Medicare	$6.40
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$7.05
Rate for Payer: BCBS of TX Blue Essentials	$8.45
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$9.44
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cash Price	$121.44
Rate for Payer: Cigna Medicaid	$4.27
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$4.27
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$89.70
Rate for Payer: Multiplan Commercial	$89.70
Rate for Payer: Multiplan Workers Comp	$89.70
Rate for Payer: Parkland Medicaid	$4.27
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.27
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

Gram Stain Body Fluid

Facility

$138.00

Service Code	CPT 87205
Hospital Charge Code	1604206
Hospital Revenue Code	306
Rate for Payer: Cash Price	$121.44

GRASPER ENDO 4 PRONG

Facility

$631.06

Hospital Charge Code	135111
Hospital Revenue Code	272
Rate for Payer: Cash Price	$555.33

GRASPER ENDO 4 PRONG

Facility

$631.06

Hospital Charge Code	135111
Hospital Revenue Code	272
Min. Negotiated Rate	$56.80
Max. Negotiated Rate	$410.19
Rate for Payer: Aetna Commercial	$347.08
Rate for Payer: Amerigroup CHIP/Medicaid	$56.80
Rate for Payer: BCBS of TX Blue Advantage	$189.32
Rate for Payer: BCBS of TX Blue Essentials	$227.18
Rate for Payer: BCBS of TX PPO	$252.42
Rate for Payer: Cash Price	$555.33
Rate for Payer: Multiplan Auto	$410.19
Rate for Payer: Multiplan Commercial	$410.19
Rate for Payer: Multiplan Workers Comp	$410.19
Rate for Payer: Scott and White EPO/PPO	$315.53
Rate for Payer: Superior Health Plan EPO	$85.82

grasper poly grab disp tip

Facility

$279.98

Hospital Charge Code	144836
Hospital Revenue Code	272
Rate for Payer: Cash Price	$246.38

grasper poly grab disp tip

Facility

$279.98

Hospital Charge Code	144836
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$181.99
Rate for Payer: Aetna Commercial	$153.99
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: BCBS of TX Blue Advantage	$83.99
Rate for Payer: BCBS of TX Blue Essentials	$100.79
Rate for Payer: BCBS of TX PPO	$111.99
Rate for Payer: Cash Price	$246.38
Rate for Payer: Multiplan Auto	$181.99
Rate for Payer: Multiplan Commercial	$181.99
Rate for Payer: Multiplan Workers Comp	$181.99
Rate for Payer: Scott and White EPO/PPO	$139.99
Rate for Payer: Superior Health Plan EPO	$38.08

Know your out-of-pocket cost for care.

All Charges