White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

GUIDE WIRE VERSACORE 260CM

Facility

$408.60

Service Code	HCPCS C1769
Hospital Charge Code	131685
Hospital Revenue Code	272
Min. Negotiated Rate	$36.77
Max. Negotiated Rate	$265.59
Rate for Payer: Aetna Commercial	$224.73
Rate for Payer: Amerigroup CHIP/Medicaid	$36.77
Rate for Payer: BCBS of TX Blue Advantage	$122.58
Rate for Payer: BCBS of TX Blue Essentials	$147.10
Rate for Payer: BCBS of TX PPO	$163.44
Rate for Payer: Cash Price	$359.57
Rate for Payer: Multiplan Auto	$265.59
Rate for Payer: Multiplan Commercial	$265.59
Rate for Payer: Multiplan Workers Comp	$265.59
Rate for Payer: Scott and White EPO/PPO	$204.30
Rate for Payer: Superior Health Plan EPO	$55.57

GUIDE WIRE VERSACORE 260CM

Facility

$408.60

Service Code	HCPCS C1769
Hospital Charge Code	131685
Hospital Revenue Code	272
Rate for Payer: Cash Price	$359.57

GW 80730559 -- DHF

Facility

$487.79

Service Code	HCPCS C1769
Hospital Charge Code	80730559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$429.26

GW 80730559 -- DHF

Facility

$487.79

Service Code	HCPCS C1769
Hospital Charge Code	80730559
Hospital Revenue Code	272
Min. Negotiated Rate	$43.90
Max. Negotiated Rate	$317.06
Rate for Payer: Aetna Commercial	$268.28
Rate for Payer: Amerigroup CHIP/Medicaid	$43.90
Rate for Payer: BCBS of TX Blue Advantage	$146.34
Rate for Payer: BCBS of TX Blue Essentials	$175.60
Rate for Payer: BCBS of TX PPO	$195.12
Rate for Payer: Cash Price	$429.26
Rate for Payer: Multiplan Auto	$317.06
Rate for Payer: Multiplan Commercial	$317.06
Rate for Payer: Multiplan Workers Comp	$317.06
Rate for Payer: Scott and White EPO/PPO	$243.90
Rate for Payer: Superior Health Plan EPO	$66.34

GW 80730609 -- DHF

Facility

$161.55

Service Code	HCPCS C1769
Hospital Charge Code	80730609
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.16

GW 80730609 -- DHF

Facility

$161.55

Service Code	HCPCS C1769
Hospital Charge Code	80730609
Hospital Revenue Code	272
Min. Negotiated Rate	$14.54
Max. Negotiated Rate	$105.01
Rate for Payer: Aetna Commercial	$88.85
Rate for Payer: Amerigroup CHIP/Medicaid	$14.54
Rate for Payer: BCBS of TX Blue Advantage	$48.46
Rate for Payer: BCBS of TX Blue Essentials	$58.16
Rate for Payer: BCBS of TX PPO	$64.62
Rate for Payer: Cash Price	$142.16
Rate for Payer: Multiplan Auto	$105.01
Rate for Payer: Multiplan Commercial	$105.01
Rate for Payer: Multiplan Workers Comp	$105.01
Rate for Payer: Scott and White EPO/PPO	$80.78
Rate for Payer: Superior Health Plan EPO	$21.97

GW 80730757 -- DHF

Facility

$225.38

Service Code	HCPCS C1769
Hospital Charge Code	80730757
Hospital Revenue Code	272
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$146.50
Rate for Payer: Aetna Commercial	$123.96
Rate for Payer: Amerigroup CHIP/Medicaid	$20.28
Rate for Payer: BCBS of TX Blue Advantage	$67.61
Rate for Payer: BCBS of TX Blue Essentials	$81.14
Rate for Payer: BCBS of TX PPO	$90.15
Rate for Payer: Cash Price	$198.33
Rate for Payer: Multiplan Auto	$146.50
Rate for Payer: Multiplan Commercial	$146.50
Rate for Payer: Multiplan Workers Comp	$146.50
Rate for Payer: Scott and White EPO/PPO	$112.69
Rate for Payer: Superior Health Plan EPO	$30.65

GW 80730757 -- DHF

Facility

$225.38

Service Code	HCPCS C1769
Hospital Charge Code	80730757
Hospital Revenue Code	272
Rate for Payer: Cash Price	$198.33

GW 80730856 -- DHF

Facility

$759.06

Service Code	HCPCS C1769
Hospital Charge Code	80730856
Hospital Revenue Code	272
Min. Negotiated Rate	$68.32
Max. Negotiated Rate	$493.39
Rate for Payer: Aetna Commercial	$417.48
Rate for Payer: Amerigroup CHIP/Medicaid	$68.32
Rate for Payer: BCBS of TX Blue Advantage	$227.72
Rate for Payer: BCBS of TX Blue Essentials	$273.26
Rate for Payer: BCBS of TX PPO	$303.62
Rate for Payer: Cash Price	$667.97
Rate for Payer: Multiplan Auto	$493.39
Rate for Payer: Multiplan Commercial	$493.39
Rate for Payer: Multiplan Workers Comp	$493.39
Rate for Payer: Scott and White EPO/PPO	$379.53
Rate for Payer: Superior Health Plan EPO	$103.23

GW 80730856 -- DHF

Facility

$759.06

Service Code	HCPCS C1769
Hospital Charge Code	80730856
Hospital Revenue Code	272
Rate for Payer: Cash Price	$667.97

GW 80730864 -- DHF

Facility

$267.72

Service Code	HCPCS C1769
Hospital Charge Code	80730864
Hospital Revenue Code	272
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$174.02
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Amerigroup CHIP/Medicaid	$24.09
Rate for Payer: BCBS of TX Blue Advantage	$80.32
Rate for Payer: BCBS of TX Blue Essentials	$96.38
Rate for Payer: BCBS of TX PPO	$107.09
Rate for Payer: Cash Price	$235.59
Rate for Payer: Multiplan Auto	$174.02
Rate for Payer: Multiplan Commercial	$174.02
Rate for Payer: Multiplan Workers Comp	$174.02
Rate for Payer: Scott and White EPO/PPO	$133.86
Rate for Payer: Superior Health Plan EPO	$36.41

GW 80730864 -- DHF

Facility

$267.72

Service Code	HCPCS C1769
Hospital Charge Code	80730864
Hospital Revenue Code	272
Rate for Payer: Cash Price	$235.59

GW DRILL TIP -- DHF

Facility

$53.01

Service Code	HCPCS C1769
Hospital Charge Code	80731441
Hospital Revenue Code	272
Rate for Payer: Cash Price	$46.65

GW DRILL TIP -- DHF

Facility

$53.01

Service Code	HCPCS C1769
Hospital Charge Code	80731441
Hospital Revenue Code	272
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$34.46
Rate for Payer: Aetna Commercial	$29.16
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: BCBS of TX Blue Advantage	$15.90
Rate for Payer: BCBS of TX Blue Essentials	$19.08
Rate for Payer: BCBS of TX PPO	$21.20
Rate for Payer: Cash Price	$46.65
Rate for Payer: Multiplan Auto	$34.46
Rate for Payer: Multiplan Commercial	$34.46
Rate for Payer: Multiplan Workers Comp	$34.46
Rate for Payer: Scott and White EPO/PPO	$26.50
Rate for Payer: Superior Health Plan EPO	$7.21

GW EMBOSHIELD

Facility

$544.80

Service Code	HCPCS C1769
Hospital Charge Code	8452478
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$354.12
Rate for Payer: Aetna Commercial	$299.64
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$479.42
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan EPO	$74.09

GW EMBOSHIELD

Facility

$544.80

Service Code	HCPCS C1769
Hospital Charge Code	8452478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$479.42

GW GLIDEWIRE GOLD -- DHF

Facility

$567.50

Service Code	HCPCS C1769
Hospital Charge Code	82466657
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

GW GLIDEWIRE GOLD -- DHF

Facility

$567.50

Service Code	HCPCS C1769
Hospital Charge Code	82466657
Hospital Revenue Code	272
Rate for Payer: Cash Price	$499.40

GW HI-TORQ BALANCE MW -- DHF

Facility

$354.12

Service Code	HCPCS C1769
Hospital Charge Code	82412545
Hospital Revenue Code	272
Rate for Payer: Cash Price	$311.63

GW HI-TORQ BALANCE MW -- DHF

Facility

$354.12

Service Code	HCPCS C1769
Hospital Charge Code	82412545
Hospital Revenue Code	272
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$230.18
Rate for Payer: Aetna Commercial	$194.77
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.24
Rate for Payer: BCBS of TX Blue Essentials	$127.48
Rate for Payer: BCBS of TX PPO	$141.65
Rate for Payer: Cash Price	$311.63
Rate for Payer: Multiplan Auto	$230.18
Rate for Payer: Multiplan Commercial	$230.18
Rate for Payer: Multiplan Workers Comp	$230.18
Rate for Payer: Scott and White EPO/PPO	$177.06
Rate for Payer: Superior Health Plan EPO	$48.16

GW HI-TORQ IRONMAN -- DHF

Facility

$354.12

Service Code	HCPCS C1769
Hospital Charge Code	82412701
Hospital Revenue Code	272
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$230.18
Rate for Payer: Aetna Commercial	$194.77
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.24
Rate for Payer: BCBS of TX Blue Essentials	$127.48
Rate for Payer: BCBS of TX PPO	$141.65
Rate for Payer: Cash Price	$311.63
Rate for Payer: Multiplan Auto	$230.18
Rate for Payer: Multiplan Commercial	$230.18
Rate for Payer: Multiplan Workers Comp	$230.18
Rate for Payer: Scott and White EPO/PPO	$177.06
Rate for Payer: Superior Health Plan EPO	$48.16

GW HI-TORQ IRONMAN -- DHF

Facility

$354.12

Service Code	HCPCS C1769
Hospital Charge Code	82412701
Hospital Revenue Code	272
Rate for Payer: Cash Price	$311.63

GW HITORQ WHOLY J SYS260 -- DHF

Facility

$678.94

Service Code	HCPCS C1769
Hospital Charge Code	82466947
Hospital Revenue Code	272
Min. Negotiated Rate	$61.10
Max. Negotiated Rate	$441.31
Rate for Payer: Aetna Commercial	$373.42
Rate for Payer: Amerigroup CHIP/Medicaid	$61.10
Rate for Payer: BCBS of TX Blue Advantage	$203.68
Rate for Payer: BCBS of TX Blue Essentials	$244.42
Rate for Payer: BCBS of TX PPO	$271.58
Rate for Payer: Cash Price	$597.47
Rate for Payer: Multiplan Auto	$441.31
Rate for Payer: Multiplan Commercial	$441.31
Rate for Payer: Multiplan Workers Comp	$441.31
Rate for Payer: Scott and White EPO/PPO	$339.47
Rate for Payer: Superior Health Plan EPO	$92.34

GW HITORQ WHOLY J SYS260 -- DHF

Facility

$678.94

Service Code	HCPCS C1769
Hospital Charge Code	82466947
Hospital Revenue Code	272
Rate for Payer: Cash Price	$597.47

Know your out-of-pocket cost for care.

All Charges