White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GUIDEWIRE .035X260 DYNJGWIRE20

Facility

$47.67

Service Code	HCPCS C1769
Hospital Charge Code	145201
Hospital Revenue Code	272
Rate for Payer: Cash Price	$41.95

GUIDE WIRE 3.2MM

Facility

$299.64

Service Code	HCPCS C1769
Hospital Charge Code	122965
Hospital Revenue Code	272
Min. Negotiated Rate	$26.97
Max. Negotiated Rate	$194.77
Rate for Payer: Aetna Commercial	$164.80
Rate for Payer: Amerigroup CHIP/Medicaid	$26.97
Rate for Payer: BCBS of TX Blue Advantage	$89.89
Rate for Payer: BCBS of TX Blue Essentials	$107.87
Rate for Payer: BCBS of TX PPO	$119.86
Rate for Payer: Cash Price	$263.68
Rate for Payer: Multiplan Auto	$194.77
Rate for Payer: Multiplan Commercial	$194.77
Rate for Payer: Multiplan Workers Comp	$194.77
Rate for Payer: Scott and White EPO/PPO	$149.82
Rate for Payer: Superior Health Plan EPO	$40.75

GUIDE WIRE 3.2MM

Facility

$299.64

Service Code	HCPCS C1769
Hospital Charge Code	122965
Hospital Revenue Code	272
Rate for Payer: Cash Price	$263.68

GUIDEWIRE 3.2 X 300 702627S

Facility

$613.81

Service Code	HCPCS C1769
Hospital Charge Code	8720618
Hospital Revenue Code	272
Min. Negotiated Rate	$55.24
Max. Negotiated Rate	$398.98
Rate for Payer: Aetna Commercial	$337.60
Rate for Payer: Amerigroup CHIP/Medicaid	$55.24
Rate for Payer: BCBS of TX Blue Advantage	$184.14
Rate for Payer: BCBS of TX Blue Essentials	$220.97
Rate for Payer: BCBS of TX PPO	$245.52
Rate for Payer: Cash Price	$540.15
Rate for Payer: Multiplan Auto	$398.98
Rate for Payer: Multiplan Commercial	$398.98
Rate for Payer: Multiplan Workers Comp	$398.98
Rate for Payer: Scott and White EPO/PPO	$306.90
Rate for Payer: Superior Health Plan EPO	$83.48

GUIDEWIRE 3.2 X 300 702627S

Facility

$613.81

Service Code	HCPCS C1769
Hospital Charge Code	8720618
Hospital Revenue Code	272
Rate for Payer: Cash Price	$540.15

GUIDEWIRE ADVANTAGE NTNL .035 X 260CM

Facility

$208.84

Service Code	HCPCS C1769
Hospital Charge Code	107731
Hospital Revenue Code	272
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$135.75
Rate for Payer: Aetna Commercial	$114.86
Rate for Payer: Amerigroup CHIP/Medicaid	$18.80
Rate for Payer: BCBS of TX Blue Advantage	$62.65
Rate for Payer: BCBS of TX Blue Essentials	$75.18
Rate for Payer: BCBS of TX PPO	$83.54
Rate for Payer: Cash Price	$183.78
Rate for Payer: Multiplan Auto	$135.75
Rate for Payer: Multiplan Commercial	$135.75
Rate for Payer: Multiplan Workers Comp	$135.75
Rate for Payer: Scott and White EPO/PPO	$104.42
Rate for Payer: Superior Health Plan EPO	$28.40

GUIDEWIRE ADVANTAGE NTNL .035 X 260CM

Facility

$208.84

Service Code	HCPCS C1769
Hospital Charge Code	107731
Hospital Revenue Code	272
Rate for Payer: Cash Price	$183.78

GUIDEWIRE ADVANTAGE STIFF .035 X260CM

Facility

$234.49

Service Code	HCPCS C1769
Hospital Charge Code	80732308
Hospital Revenue Code	272
Min. Negotiated Rate	$21.10
Max. Negotiated Rate	$152.42
Rate for Payer: Aetna Commercial	$128.97
Rate for Payer: Amerigroup CHIP/Medicaid	$21.10
Rate for Payer: BCBS of TX Blue Advantage	$70.35
Rate for Payer: BCBS of TX Blue Essentials	$84.42
Rate for Payer: BCBS of TX PPO	$93.80
Rate for Payer: Cash Price	$206.35
Rate for Payer: Multiplan Auto	$152.42
Rate for Payer: Multiplan Commercial	$152.42
Rate for Payer: Multiplan Workers Comp	$152.42
Rate for Payer: Scott and White EPO/PPO	$117.24
Rate for Payer: Superior Health Plan EPO	$31.89

GUIDEWIRE ADVANTAGE STIFF .035 X260CM

Facility

$234.49

Service Code	HCPCS C1769
Hospital Charge Code	80732308
Hospital Revenue Code	272
Rate for Payer: Cash Price	$206.35

GUIDEWIRE AMPLATZ SS .035X180 M00146525

Facility

$173.11

Service Code	HCPCS C1769
Hospital Charge Code	8550489
Hospital Revenue Code	272
Min. Negotiated Rate	$15.58
Max. Negotiated Rate	$112.52
Rate for Payer: Aetna Commercial	$95.21
Rate for Payer: Amerigroup CHIP/Medicaid	$15.58
Rate for Payer: BCBS of TX Blue Advantage	$51.93
Rate for Payer: BCBS of TX Blue Essentials	$62.32
Rate for Payer: BCBS of TX PPO	$69.24
Rate for Payer: Cash Price	$152.34
Rate for Payer: Multiplan Auto	$112.52
Rate for Payer: Multiplan Commercial	$112.52
Rate for Payer: Multiplan Workers Comp	$112.52
Rate for Payer: Scott and White EPO/PPO	$86.56
Rate for Payer: Superior Health Plan EPO	$23.54

GUIDEWIRE AMPLATZ SS .035X180 M00146525

Facility

$173.11

Service Code	HCPCS C1769
Hospital Charge Code	8550489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$152.34

GUIDEWIRE AMPLATZ SS .05X260 M001465261

Facility

$179.64

Service Code	HCPCS C1769
Hospital Charge Code	8550490
Hospital Revenue Code	272
Min. Negotiated Rate	$16.17
Max. Negotiated Rate	$116.77
Rate for Payer: Aetna Commercial	$98.80
Rate for Payer: Amerigroup CHIP/Medicaid	$16.17
Rate for Payer: BCBS of TX Blue Advantage	$53.89
Rate for Payer: BCBS of TX Blue Essentials	$64.67
Rate for Payer: BCBS of TX PPO	$71.86
Rate for Payer: Cash Price	$158.08
Rate for Payer: Multiplan Auto	$116.77
Rate for Payer: Multiplan Commercial	$116.77
Rate for Payer: Multiplan Workers Comp	$116.77
Rate for Payer: Scott and White EPO/PPO	$89.82
Rate for Payer: Superior Health Plan EPO	$24.43

GUIDEWIRE AMPLATZ SS .05X260 M001465261

Facility

$179.64

Service Code	HCPCS C1769
Hospital Charge Code	8550490
Hospital Revenue Code	272
Rate for Payer: Cash Price	$158.08

GUIDEWIRE BALL NOSE

Facility

$2,111.10

Service Code	HCPCS C1769
Hospital Charge Code	8428491
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,857.77

GUIDEWIRE BALL NOSE

Facility

$2,111.10

Service Code	HCPCS C1769
Hospital Charge Code	8428491
Hospital Revenue Code	272
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$1,372.22
Rate for Payer: Aetna Commercial	$1,161.10
Rate for Payer: Amerigroup CHIP/Medicaid	$190.00
Rate for Payer: BCBS of TX Blue Advantage	$633.33
Rate for Payer: BCBS of TX Blue Essentials	$760.00
Rate for Payer: BCBS of TX PPO	$844.44
Rate for Payer: Cash Price	$1,857.77
Rate for Payer: Multiplan Auto	$1,372.22
Rate for Payer: Multiplan Commercial	$1,372.22
Rate for Payer: Multiplan Workers Comp	$1,372.22
Rate for Payer: Scott and White EPO/PPO	$1,055.55
Rate for Payer: Superior Health Plan EPO	$287.11

GUIDEWIRE BALL TIP 3X800

Facility

$1,144.62

Service Code	HCPCS C1769
Hospital Charge Code	122959
Hospital Revenue Code	272
Min. Negotiated Rate	$103.02
Max. Negotiated Rate	$744.00
Rate for Payer: Aetna Commercial	$629.54
Rate for Payer: Amerigroup CHIP/Medicaid	$103.02
Rate for Payer: BCBS of TX Blue Advantage	$343.39
Rate for Payer: BCBS of TX Blue Essentials	$412.06
Rate for Payer: BCBS of TX PPO	$457.85
Rate for Payer: Cash Price	$1,007.27
Rate for Payer: Multiplan Auto	$744.00
Rate for Payer: Multiplan Commercial	$744.00
Rate for Payer: Multiplan Workers Comp	$744.00
Rate for Payer: Scott and White EPO/PPO	$572.31
Rate for Payer: Superior Health Plan EPO	$155.67

GUIDEWIRE BALL TIP 3X800

Facility

$1,144.62

Service Code	HCPCS C1769
Hospital Charge Code	122959
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,007.27

GUIDEWIRE BALL TIP ROD

Facility

$567.50

Service Code	HCPCS C1769
Hospital Charge Code	145469
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$368.88
Rate for Payer: Aetna Commercial	$312.12
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$499.40
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan EPO	$77.18

GUIDEWIRE BALL TIP ROD

Facility

$567.50

Service Code	HCPCS C1769
Hospital Charge Code	145469
Hospital Revenue Code	272
Rate for Payer: Cash Price	$499.40

GUIDEWIRE BALL TIP SHEATH

Facility

$862.60

Service Code	HCPCS C1769
Hospital Charge Code	145157
Hospital Revenue Code	272
Min. Negotiated Rate	$77.63
Max. Negotiated Rate	$560.69
Rate for Payer: Aetna Commercial	$474.43
Rate for Payer: Amerigroup CHIP/Medicaid	$77.63
Rate for Payer: BCBS of TX Blue Advantage	$258.78
Rate for Payer: BCBS of TX Blue Essentials	$310.54
Rate for Payer: BCBS of TX PPO	$345.04
Rate for Payer: Cash Price	$759.09
Rate for Payer: Multiplan Auto	$560.69
Rate for Payer: Multiplan Commercial	$560.69
Rate for Payer: Multiplan Workers Comp	$560.69
Rate for Payer: Scott and White EPO/PPO	$431.30
Rate for Payer: Superior Health Plan EPO	$117.31

GUIDEWIRE BALL TIP SHEATH

Facility

$862.60

Service Code	HCPCS C1769
Hospital Charge Code	145157
Hospital Revenue Code	272
Rate for Payer: Cash Price	$759.09

guidewire ball tip t2 3x1000mm

Facility

$668.29

Service Code	HCPCS C1769
Hospital Charge Code	8688546
Hospital Revenue Code	272
Min. Negotiated Rate	$60.15
Max. Negotiated Rate	$434.39
Rate for Payer: Aetna Commercial	$367.56
Rate for Payer: Amerigroup CHIP/Medicaid	$60.15
Rate for Payer: BCBS of TX Blue Advantage	$200.49
Rate for Payer: BCBS of TX Blue Essentials	$240.58
Rate for Payer: BCBS of TX PPO	$267.32
Rate for Payer: Cash Price	$588.10
Rate for Payer: Multiplan Auto	$434.39
Rate for Payer: Multiplan Commercial	$434.39
Rate for Payer: Multiplan Workers Comp	$434.39
Rate for Payer: Scott and White EPO/PPO	$334.14
Rate for Payer: Superior Health Plan EPO	$90.89

guidewire ball tip t2 3x1000mm

Facility

$668.29

Service Code	HCPCS C1769
Hospital Charge Code	8688546
Hospital Revenue Code	272
Rate for Payer: Cash Price	$588.10

GUIDE WIRE CHOICE PT 182CM

Facility

$374.10

Service Code	HCPCS C1769
Hospital Charge Code	107677
Hospital Revenue Code	272
Min. Negotiated Rate	$33.67
Max. Negotiated Rate	$243.16
Rate for Payer: Aetna Commercial	$205.76
Rate for Payer: Amerigroup CHIP/Medicaid	$33.67
Rate for Payer: BCBS of TX Blue Advantage	$112.23
Rate for Payer: BCBS of TX Blue Essentials	$134.68
Rate for Payer: BCBS of TX PPO	$149.64
Rate for Payer: Cash Price	$329.21
Rate for Payer: Multiplan Auto	$243.16
Rate for Payer: Multiplan Commercial	$243.16
Rate for Payer: Multiplan Workers Comp	$243.16
Rate for Payer: Scott and White EPO/PPO	$187.05
Rate for Payer: Superior Health Plan EPO	$50.88

GUIDE WIRE CHOICE PT 182CM

Facility

$374.10

Service Code	HCPCS C1769
Hospital Charge Code	107677
Hospital Revenue Code	272
Rate for Payer: Cash Price	$329.21

Know your out-of-pocket cost for care.

All Charges