White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GUIDEWIRE -- DHF

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	82401795
Hospital Revenue Code	272
Rate for Payer: Cash Price	$439.47

GUIDEWIRE -- DHF

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	82401795
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$324.61
Rate for Payer: Aetna Commercial	$274.67
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$439.47
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan EPO	$67.92

GUIDEWIRE ENDOVAS HI-TORQUE COMMAND

Facility

$749.10

Service Code	HCPCS C1769
Hospital Charge Code	82401670
Hospital Revenue Code	272
Min. Negotiated Rate	$67.42
Max. Negotiated Rate	$486.92
Rate for Payer: Aetna Commercial	$412.00
Rate for Payer: Amerigroup CHIP/Medicaid	$67.42
Rate for Payer: BCBS of TX Blue Advantage	$224.73
Rate for Payer: BCBS of TX Blue Essentials	$269.68
Rate for Payer: BCBS of TX PPO	$299.64
Rate for Payer: Cash Price	$659.21
Rate for Payer: Multiplan Auto	$486.92
Rate for Payer: Multiplan Commercial	$486.92
Rate for Payer: Multiplan Workers Comp	$486.92
Rate for Payer: Scott and White EPO/PPO	$374.55
Rate for Payer: Superior Health Plan EPO	$101.88

GUIDEWIRE ENDOVAS HI-TORQUE COMMAND

Facility

$749.10

Service Code	HCPCS C1769
Hospital Charge Code	82401670
Hospital Revenue Code	272
Rate for Payer: Cash Price	$659.21

GUIDEWIRE EXCHANGE TUBE

Facility

$559.33

Service Code	HCPCS C1769
Hospital Charge Code	145340
Hospital Revenue Code	272
Min. Negotiated Rate	$50.34
Max. Negotiated Rate	$363.56
Rate for Payer: Aetna Commercial	$307.63
Rate for Payer: Amerigroup CHIP/Medicaid	$50.34
Rate for Payer: BCBS of TX Blue Advantage	$167.80
Rate for Payer: BCBS of TX Blue Essentials	$201.36
Rate for Payer: BCBS of TX PPO	$223.73
Rate for Payer: Cash Price	$492.21
Rate for Payer: Multiplan Auto	$363.56
Rate for Payer: Multiplan Commercial	$363.56
Rate for Payer: Multiplan Workers Comp	$363.56
Rate for Payer: Scott and White EPO/PPO	$279.66
Rate for Payer: Superior Health Plan EPO	$76.07

GUIDEWIRE EXCHANGE TUBE

Facility

$559.33

Service Code	HCPCS C1769
Hospital Charge Code	145340
Hospital Revenue Code	272
Rate for Payer: Cash Price	$492.21

GUIDEWIRE HYD/JAGWIRE .035X260 M00556021

Facility

$895.47

Service Code	HCPCS C1769
Hospital Charge Code	145324
Hospital Revenue Code	272
Rate for Payer: Cash Price	$788.01

GUIDEWIRE HYD/JAGWIRE .035X260 M00556021

Facility

$895.47

Service Code	HCPCS C1769
Hospital Charge Code	145324
Hospital Revenue Code	272
Min. Negotiated Rate	$80.59
Max. Negotiated Rate	$582.06
Rate for Payer: Aetna Commercial	$492.51
Rate for Payer: Amerigroup CHIP/Medicaid	$80.59
Rate for Payer: BCBS of TX Blue Advantage	$268.64
Rate for Payer: BCBS of TX Blue Essentials	$322.37
Rate for Payer: BCBS of TX PPO	$358.19
Rate for Payer: Cash Price	$788.01
Rate for Payer: Multiplan Auto	$582.06
Rate for Payer: Multiplan Commercial	$582.06
Rate for Payer: Multiplan Workers Comp	$582.06
Rate for Payer: Scott and White EPO/PPO	$447.74
Rate for Payer: Superior Health Plan EPO	$121.78

GUIDEWIRE LONG SPECIAL

Facility

$567.50

Service Code	HCPCS C1769
Hospital Charge Code	145475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$499.40

GUIDEWIRE LONG SPECIAL

Facility

$567.50

Service Code	HCPCS C1769
Hospital Charge Code	145475
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 NITINOL RD TIP 02.4X950

Facility

$559.33

Service Code	HCPCS C1769
Hospital Charge Code	145341
Hospital Revenue Code	272
Min. Negotiated Rate	$50.34
Max. Negotiated Rate	$363.56
Rate for Payer: Aetna Commercial	$307.63
Rate for Payer: Amerigroup CHIP/Medicaid	$50.34
Rate for Payer: BCBS of TX Blue Advantage	$167.80
Rate for Payer: BCBS of TX Blue Essentials	$201.36
Rate for Payer: BCBS of TX PPO	$223.73
Rate for Payer: Cash Price	$492.21
Rate for Payer: Multiplan Auto	$363.56
Rate for Payer: Multiplan Commercial	$363.56
Rate for Payer: Multiplan Workers Comp	$363.56
Rate for Payer: Scott and White EPO/PPO	$279.66
Rate for Payer: Superior Health Plan EPO	$76.07

GUIDEWIRE NITINOL RD TIP 02.4X950

Facility

$559.33

Service Code	HCPCS C1769
Hospital Charge Code	145341
Hospital Revenue Code	272
Rate for Payer: Cash Price	$492.21

GUIDEWIRE PRELOAD CATHETER PROGREAT COAX

Facility

$2,542.40

Service Code	HCPCS C1769
Hospital Charge Code	8470499
Hospital Revenue Code	272
Min. Negotiated Rate	$228.82
Max. Negotiated Rate	$1,652.56
Rate for Payer: Aetna Commercial	$1,398.32
Rate for Payer: Amerigroup CHIP/Medicaid	$228.82
Rate for Payer: BCBS of TX Blue Advantage	$762.72
Rate for Payer: BCBS of TX Blue Essentials	$915.26
Rate for Payer: BCBS of TX PPO	$1,016.96
Rate for Payer: Cash Price	$2,237.31
Rate for Payer: Multiplan Auto	$1,652.56
Rate for Payer: Multiplan Commercial	$1,652.56
Rate for Payer: Multiplan Workers Comp	$1,652.56
Rate for Payer: Scott and White EPO/PPO	$1,271.20
Rate for Payer: Superior Health Plan EPO	$345.77

GUIDEWIRE PRELOAD CATHETER PROGREAT COAX

Facility

$2,542.40

Service Code	HCPCS C1769
Hospital Charge Code	8470499
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,237.31

GUIDEWIRE SHORT

Facility

$454.00

Service Code	HCPCS C1769
Hospital Charge Code	145470
Hospital Revenue Code	272
Rate for Payer: Cash Price	$399.52

GUIDEWIRE SHORT

Facility

$454.00

Service Code	HCPCS C1769
Hospital Charge Code	145470
Hospital Revenue Code	272
Min. Negotiated Rate	$40.86
Max. Negotiated Rate	$295.10
Rate for Payer: Aetna Commercial	$249.70
Rate for Payer: Amerigroup CHIP/Medicaid	$40.86
Rate for Payer: BCBS of TX Blue Advantage	$136.20
Rate for Payer: BCBS of TX Blue Essentials	$163.44
Rate for Payer: BCBS of TX PPO	$181.60
Rate for Payer: Cash Price	$399.52
Rate for Payer: Multiplan Auto	$295.10
Rate for Payer: Multiplan Commercial	$295.10
Rate for Payer: Multiplan Workers Comp	$295.10
Rate for Payer: Scott and White EPO/PPO	$227.00
Rate for Payer: Superior Health Plan EPO	$61.74

GUIDEWIRE SMOOTH TIP 3X800

Facility

$1,123.65

Service Code	HCPCS C1769
Hospital Charge Code	145505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$988.81

GUIDEWIRE SMOOTH TIP 3X800

Facility

$1,123.65

Service Code	HCPCS C1769
Hospital Charge Code	145505
Hospital Revenue Code	272
Min. Negotiated Rate	$101.13
Max. Negotiated Rate	$730.37
Rate for Payer: Aetna Commercial	$618.01
Rate for Payer: Amerigroup CHIP/Medicaid	$101.13
Rate for Payer: BCBS of TX Blue Advantage	$337.10
Rate for Payer: BCBS of TX Blue Essentials	$404.51
Rate for Payer: BCBS of TX PPO	$449.46
Rate for Payer: Cash Price	$988.81
Rate for Payer: Multiplan Auto	$730.37
Rate for Payer: Multiplan Commercial	$730.37
Rate for Payer: Multiplan Workers Comp	$730.37
Rate for Payer: Scott and White EPO/PPO	$561.82
Rate for Payer: Superior Health Plan EPO	$152.82

GUIDEWIRE TROCAR TIP

Facility

$862.60

Service Code	HCPCS C1769
Hospital Charge Code	145156
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 TROCAR TIP

Facility

$862.60

Service Code	HCPCS C1769
Hospital Charge Code	145156
Hospital Revenue Code	272
Rate for Payer: Cash Price	$759.09

GUIDEWIRE VASC .016-180CM FATHOM

Facility

$1,574.47

Service Code	HCPCS C1769
Hospital Charge Code	107628
Hospital Revenue Code	272
Min. Negotiated Rate	$141.70
Max. Negotiated Rate	$1,023.41
Rate for Payer: Aetna Commercial	$865.96
Rate for Payer: Amerigroup CHIP/Medicaid	$141.70
Rate for Payer: BCBS of TX Blue Advantage	$472.34
Rate for Payer: BCBS of TX Blue Essentials	$566.81
Rate for Payer: BCBS of TX PPO	$629.79
Rate for Payer: Cash Price	$1,385.53
Rate for Payer: Multiplan Auto	$1,023.41
Rate for Payer: Multiplan Commercial	$1,023.41
Rate for Payer: Multiplan Workers Comp	$1,023.41
Rate for Payer: Scott and White EPO/PPO	$787.24
Rate for Payer: Superior Health Plan EPO	$214.13

GUIDEWIRE VASC .016-180CM FATHOM

Facility

$1,574.47

Service Code	HCPCS C1769
Hospital Charge Code	107628
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,385.53

GUIDEWIRE VASC HI-TORQ WINN

Facility

$681.00

Service Code	HCPCS C1769
Hospital Charge Code	107812
Hospital Revenue Code	272
Rate for Payer: Cash Price	$599.28

GUIDEWIRE VASC HI-TORQ WINN

Facility

$681.00

Service Code	HCPCS C1769
Hospital Charge Code	107812
Hospital Revenue Code	272
Min. Negotiated Rate	$61.29
Max. Negotiated Rate	$442.65
Rate for Payer: Aetna Commercial	$374.55
Rate for Payer: Amerigroup CHIP/Medicaid	$61.29
Rate for Payer: BCBS of TX Blue Advantage	$204.30
Rate for Payer: BCBS of TX Blue Essentials	$245.16
Rate for Payer: BCBS of TX PPO	$272.40
Rate for Payer: Cash Price	$599.28
Rate for Payer: Multiplan Auto	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan EPO	$92.62

GUIDE WIRE VERSACORE 145CM

Facility

$340.50

Service Code	HCPCS C1769
Hospital Charge Code	107612
Hospital Revenue Code	272
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$221.32
Rate for Payer: Aetna Commercial	$187.28
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$299.64
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan EPO	$46.31

Know your out-of-pocket cost for care.

All Charges