White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GRASPER RAPTOR FOREIGN BODY RETVL 2.4X230CM

Facility

$599.28

Hospital Charge Code	135744
Hospital Revenue Code	272
Min. Negotiated Rate	$53.94
Max. Negotiated Rate	$389.53
Rate for Payer: Aetna Commercial	$329.60
Rate for Payer: Amerigroup CHIP/Medicaid	$53.94
Rate for Payer: BCBS of TX Blue Advantage	$179.78
Rate for Payer: BCBS of TX Blue Essentials	$215.74
Rate for Payer: BCBS of TX PPO	$239.71
Rate for Payer: Cash Price	$527.37
Rate for Payer: Multiplan Auto	$389.53
Rate for Payer: Multiplan Commercial	$389.53
Rate for Payer: Multiplan Workers Comp	$389.53
Rate for Payer: Scott and White EPO/PPO	$299.64
Rate for Payer: Superior Health Plan EPO	$81.50

GRASPER RAPTOR FOREIGN BODY RETVL 2.4X230CM

Facility

$599.28

Hospital Charge Code	135744
Hospital Revenue Code	272
Rate for Payer: Cash Price	$527.37

GRFT MESH MARLX -- DHF

Facility

$2,705.90

Service Code	HCPCS C1781
Hospital Charge Code	81420804
Hospital Revenue Code	278
Min. Negotiated Rate	$676.48
Max. Negotiated Rate	$1,352.95
Rate for Payer: Aetna Commercial	$811.77
Rate for Payer: Cash Price	$2,381.19
Rate for Payer: Cigna Commercial	$676.48
Rate for Payer: Multiplan Auto	$1,352.95
Rate for Payer: Multiplan Commercial	$1,352.95
Rate for Payer: Multiplan Workers Comp	$1,352.95
Rate for Payer: Scott and White EPO/PPO	$1,352.95

GRFT MESH MARLX -- DHF

Facility

$2,705.90

Service Code	HCPCS C1781
Hospital Charge Code	81420804
Hospital Revenue Code	278
Min. Negotiated Rate	$243.53
Max. Negotiated Rate	$1,352.95
Rate for Payer: Aetna Commercial	$811.77
Rate for Payer: Amerigroup CHIP/Medicaid	$243.53
Rate for Payer: BCBS of TX Blue Advantage	$811.77
Rate for Payer: BCBS of TX Blue Essentials	$974.12
Rate for Payer: BCBS of TX PPO	$1,082.36
Rate for Payer: Cash Price	$2,381.19
Rate for Payer: Multiplan Auto	$1,352.95
Rate for Payer: Multiplan Commercial	$1,352.95
Rate for Payer: Multiplan Workers Comp	$1,352.95
Rate for Payer: Scott and White EPO/PPO	$1,352.95
Rate for Payer: Superior Health Plan EPO	$368.00

GRFT VASC STR B -- DHF

Facility

$10,623.13

Service Code	HCPCS C1768
Hospital Charge Code	81422008
Hospital Revenue Code	278
Min. Negotiated Rate	$2,655.78
Max. Negotiated Rate	$5,311.56
Rate for Payer: Aetna Commercial	$3,186.94
Rate for Payer: Cash Price	$9,348.35
Rate for Payer: Cigna Commercial	$2,655.78
Rate for Payer: Multiplan Auto	$5,311.56
Rate for Payer: Multiplan Commercial	$5,311.56
Rate for Payer: Multiplan Workers Comp	$5,311.56
Rate for Payer: Scott and White EPO/PPO	$5,311.56

GRFT VASC STR B -- DHF

Facility

$10,623.13

Service Code	HCPCS C1768
Hospital Charge Code	81422008
Hospital Revenue Code	278
Min. Negotiated Rate	$956.08
Max. Negotiated Rate	$5,311.56
Rate for Payer: Aetna Commercial	$3,186.94
Rate for Payer: Amerigroup CHIP/Medicaid	$956.08
Rate for Payer: BCBS of TX Blue Advantage	$3,186.94
Rate for Payer: BCBS of TX Blue Essentials	$3,824.33
Rate for Payer: BCBS of TX PPO	$4,249.25
Rate for Payer: Cash Price	$9,348.35
Rate for Payer: Multiplan Auto	$5,311.56
Rate for Payer: Multiplan Commercial	$5,311.56
Rate for Payer: Multiplan Workers Comp	$5,311.56
Rate for Payer: Scott and White EPO/PPO	$5,311.56
Rate for Payer: Superior Health Plan EPO	$1,444.75

GRFT VASC STR S -- DHF

Facility

$6,338.83

Service Code	HCPCS C1768
Hospital Charge Code	81422701
Hospital Revenue Code	278
Min. Negotiated Rate	$570.49
Max. Negotiated Rate	$3,169.42
Rate for Payer: Aetna Commercial	$1,901.65
Rate for Payer: Amerigroup CHIP/Medicaid	$570.49
Rate for Payer: BCBS of TX Blue Advantage	$1,901.65
Rate for Payer: BCBS of TX Blue Essentials	$2,281.98
Rate for Payer: BCBS of TX PPO	$2,535.53
Rate for Payer: Cash Price	$5,578.17
Rate for Payer: Multiplan Auto	$3,169.42
Rate for Payer: Multiplan Commercial	$3,169.42
Rate for Payer: Multiplan Workers Comp	$3,169.42
Rate for Payer: Scott and White EPO/PPO	$3,169.42
Rate for Payer: Superior Health Plan EPO	$862.08

GRFT VASC STR S -- DHF

Facility

$6,338.83

Service Code	HCPCS C1768
Hospital Charge Code	81422701
Hospital Revenue Code	278
Min. Negotiated Rate	$1,584.71
Max. Negotiated Rate	$3,169.42
Rate for Payer: Aetna Commercial	$1,901.65
Rate for Payer: Cash Price	$5,578.17
Rate for Payer: Cigna Commercial	$1,584.71
Rate for Payer: Multiplan Auto	$3,169.42
Rate for Payer: Multiplan Commercial	$3,169.42
Rate for Payer: Multiplan Workers Comp	$3,169.42
Rate for Payer: Scott and White EPO/PPO	$3,169.42

Group A Strep Culture

Facility

$229.00

Service Code	CPT 87081
Hospital Charge Code	4107081
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$148.85
Rate for Payer: Aetna Commercial	$6.96
Rate for Payer: Aetna Medicare	$9.94
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.63
Rate for Payer: Amerigroup Medicare	$6.63
Rate for Payer: BCBS of TX Blue Advantage	$10.94
Rate for Payer: BCBS of TX Blue Essentials	$13.13
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$14.65
Rate for Payer: Cash Price	$201.52
Rate for Payer: Cash Price	$201.52
Rate for Payer: Cigna Medicaid	$6.63
Rate for Payer: Cigna Medicare	$6.63
Rate for Payer: Employer Direct Commercial	$6.63
Rate for Payer: Humana Medicare/TRICARE	$6.63
Rate for Payer: Molina CHIP/Medicaid	$6.63
Rate for Payer: Molina Dual Medicare/Medicaid	$6.63
Rate for Payer: Molina Medicare	$6.63
Rate for Payer: Multiplan Auto	$148.85
Rate for Payer: Multiplan Commercial	$148.85
Rate for Payer: Multiplan Workers Comp	$148.85
Rate for Payer: Parkland Medicaid	$6.63
Rate for Payer: Scott and White EPO/PPO	$8.29
Rate for Payer: Scott and White Medicare	$6.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.63
Rate for Payer: Superior Health Plan EPO	$6.63
Rate for Payer: Superior Health Plan Medicare	$6.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.63
Rate for Payer: Universal American Medicare	$6.63
Rate for Payer: Wellcare Medicare	$6.63
Rate for Payer: Wellmed Medicare	$6.63

Group A Strep Culture

Facility

$229.00

Service Code	CPT 87081
Hospital Charge Code	4107081
Hospital Revenue Code	306
Rate for Payer: Cash Price	$201.52

Group B Strep Culture

Facility

$229.00

Service Code	CPT 87081
Hospital Charge Code	4107044
Hospital Revenue Code	306
Rate for Payer: Cash Price	$201.52

Group B Strep Culture

Facility

$229.00

Service Code	CPT 87081
Hospital Charge Code	4107044
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$148.85
Rate for Payer: Aetna Commercial	$6.96
Rate for Payer: Aetna Medicare	$9.94
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.63
Rate for Payer: Amerigroup Medicare	$6.63
Rate for Payer: BCBS of TX Blue Advantage	$10.94
Rate for Payer: BCBS of TX Blue Essentials	$13.13
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$14.65
Rate for Payer: Cash Price	$201.52
Rate for Payer: Cash Price	$201.52
Rate for Payer: Cigna Medicaid	$6.63
Rate for Payer: Cigna Medicare	$6.63
Rate for Payer: Employer Direct Commercial	$6.63
Rate for Payer: Humana Medicare/TRICARE	$6.63
Rate for Payer: Molina CHIP/Medicaid	$6.63
Rate for Payer: Molina Dual Medicare/Medicaid	$6.63
Rate for Payer: Molina Medicare	$6.63
Rate for Payer: Multiplan Auto	$148.85
Rate for Payer: Multiplan Commercial	$148.85
Rate for Payer: Multiplan Workers Comp	$148.85
Rate for Payer: Parkland Medicaid	$6.63
Rate for Payer: Scott and White EPO/PPO	$8.29
Rate for Payer: Scott and White Medicare	$6.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.63
Rate for Payer: Superior Health Plan EPO	$6.63
Rate for Payer: Superior Health Plan Medicare	$6.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.63
Rate for Payer: Universal American Medicare	$6.63
Rate for Payer: Wellcare Medicare	$6.63
Rate for Payer: Wellmed Medicare	$6.63

Growth Hormone, Serum SO

Facility

$88.00

Service Code	CPT 83003
Hospital Charge Code	1701382
Hospital Revenue Code	301
Rate for Payer: Cash Price	$77.44

Growth Hormone, Serum SO

Facility

$88.00

Service Code	CPT 83003
Hospital Charge Code	1701382
Hospital Revenue Code	301
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$57.20
Rate for Payer: Aetna Commercial	$17.50
Rate for Payer: Aetna Medicare	$25.00
Rate for Payer: Amerigroup CHIP/Medicaid	$6.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.67
Rate for Payer: Amerigroup Medicare	$16.67
Rate for Payer: BCBS of TX Blue Advantage	$27.51
Rate for Payer: BCBS of TX Blue Essentials	$33.01
Rate for Payer: BCBS of TX Medicare	$16.67
Rate for Payer: BCBS of TX PPO	$36.84
Rate for Payer: Cash Price	$77.44
Rate for Payer: Cash Price	$77.44
Rate for Payer: Cigna Medicaid	$16.67
Rate for Payer: Cigna Medicare	$16.67
Rate for Payer: Employer Direct Commercial	$16.67
Rate for Payer: Humana Medicare/TRICARE	$16.67
Rate for Payer: Molina CHIP/Medicaid	$16.67
Rate for Payer: Molina Dual Medicare/Medicaid	$16.67
Rate for Payer: Molina Medicare	$16.67
Rate for Payer: Multiplan Auto	$57.20
Rate for Payer: Multiplan Commercial	$57.20
Rate for Payer: Multiplan Workers Comp	$57.20
Rate for Payer: Parkland Medicaid	$16.67
Rate for Payer: Scott and White EPO/PPO	$20.84
Rate for Payer: Scott and White Medicare	$16.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.67
Rate for Payer: Superior Health Plan EPO	$16.67
Rate for Payer: Superior Health Plan Medicare	$16.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.67
Rate for Payer: Universal American Medicare	$16.67
Rate for Payer: Wellcare Medicare	$16.67
Rate for Payer: Wellmed Medicare	$16.67

guaiFENesin 100 mg/5 mL Oral Liquid 10 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77597175
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

guaiFENesin 100 mg/5 mL Oral Liquid 10 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77597175
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

guaiFENesin 600 mg ER Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77598021
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

guaiFENesin 600 mg ER Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77598021
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

GUIDE EXTENSION MEDTRONIC TELESCOPE 6FR

Facility

$1,816.00

Service Code	HCPCS C1887
Hospital Charge Code	145096
Hospital Revenue Code	278
Min. Negotiated Rate	$163.44
Max. Negotiated Rate	$908.00
Rate for Payer: Aetna Commercial	$544.80
Rate for Payer: Amerigroup CHIP/Medicaid	$163.44
Rate for Payer: BCBS of TX Blue Advantage	$544.80
Rate for Payer: BCBS of TX Blue Essentials	$653.76
Rate for Payer: BCBS of TX PPO	$726.40
Rate for Payer: Cash Price	$1,598.08
Rate for Payer: Multiplan Auto	$908.00
Rate for Payer: Multiplan Commercial	$908.00
Rate for Payer: Multiplan Workers Comp	$908.00
Rate for Payer: Scott and White EPO/PPO	$908.00
Rate for Payer: Superior Health Plan EPO	$246.98

GUIDE EXTENSION MEDTRONIC TELESCOPE 6FR

Facility

$1,816.00

Service Code	HCPCS C1887
Hospital Charge Code	145096
Hospital Revenue Code	278
Min. Negotiated Rate	$454.00
Max. Negotiated Rate	$908.00
Rate for Payer: Aetna Commercial	$544.80
Rate for Payer: Cash Price	$1,598.08
Rate for Payer: Cigna Commercial	$454.00
Rate for Payer: Multiplan Auto	$908.00
Rate for Payer: Multiplan Commercial	$908.00
Rate for Payer: Multiplan Workers Comp	$908.00
Rate for Payer: Scott and White EPO/PPO	$908.00

GUIDE PIN FLEX XACTPIN

Facility

$903.46

Hospital Charge Code	8398513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$795.04

GUIDE PIN FLEX XACTPIN

Facility

$903.46

Hospital Charge Code	8398513
Hospital Revenue Code	272
Min. Negotiated Rate	$81.31
Max. Negotiated Rate	$587.25
Rate for Payer: Aetna Commercial	$496.90
Rate for Payer: Amerigroup CHIP/Medicaid	$81.31
Rate for Payer: BCBS of TX Blue Advantage	$271.04
Rate for Payer: BCBS of TX Blue Essentials	$325.25
Rate for Payer: BCBS of TX PPO	$361.38
Rate for Payer: Cash Price	$795.04
Rate for Payer: Multiplan Auto	$587.25
Rate for Payer: Multiplan Commercial	$587.25
Rate for Payer: Multiplan Workers Comp	$587.25
Rate for Payer: Scott and White EPO/PPO	$451.73
Rate for Payer: Superior Health Plan EPO	$122.87

GUIDEWIRE .035X180CM DYNJGWIRE03

Facility

$37.09

Service Code	HCPCS C1769
Hospital Charge Code	145200
Hospital Revenue Code	272
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$24.11
Rate for Payer: Aetna Commercial	$20.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3.34
Rate for Payer: BCBS of TX Blue Advantage	$11.13
Rate for Payer: BCBS of TX Blue Essentials	$13.35
Rate for Payer: BCBS of TX PPO	$14.84
Rate for Payer: Cash Price	$32.64
Rate for Payer: Multiplan Auto	$24.11
Rate for Payer: Multiplan Commercial	$24.11
Rate for Payer: Multiplan Workers Comp	$24.11
Rate for Payer: Scott and White EPO/PPO	$18.54
Rate for Payer: Superior Health Plan EPO	$5.04

GUIDEWIRE .035X180CM DYNJGWIRE03

Facility

$37.09

Service Code	HCPCS C1769
Hospital Charge Code	145200
Hospital Revenue Code	272
Rate for Payer: Cash Price	$32.64

GUIDEWIRE .035X260 DYNJGWIRE20

Facility

$47.67

Service Code	HCPCS C1769
Hospital Charge Code	145201
Hospital Revenue Code	272
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$30.99
Rate for Payer: Aetna Commercial	$26.22
Rate for Payer: Amerigroup CHIP/Medicaid	$4.29
Rate for Payer: BCBS of TX Blue Advantage	$14.30
Rate for Payer: BCBS of TX Blue Essentials	$17.16
Rate for Payer: BCBS of TX PPO	$19.07
Rate for Payer: Cash Price	$41.95
Rate for Payer: Multiplan Auto	$30.99
Rate for Payer: Multiplan Commercial	$30.99
Rate for Payer: Multiplan Workers Comp	$30.99
Rate for Payer: Scott and White EPO/PPO	$23.84
Rate for Payer: Superior Health Plan EPO	$6.48

Know your out-of-pocket cost for care.

All Charges