White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GI cocktail 30 mL

Facility

$97.60

Service Code	HCPCS J3490
Hospital Charge Code	78921429
Hospital Revenue Code	250
Rate for Payer: Cash Price	$66.37

GI cocktail 30 mL

Facility

$97.60

Service Code	HCPCS J3490
Hospital Charge Code	78921429
Hospital Revenue Code	250
Min. Negotiated Rate	$8.78
Max. Negotiated Rate	$70.27
Rate for Payer: Amerigroup CHIP/Medicaid	$8.78
Rate for Payer: BCBS of TX Blue Advantage	$29.28
Rate for Payer: BCBS of TX Blue Essentials	$35.14
Rate for Payer: BCBS of TX PPO	$39.04
Rate for Payer: Cash Price	$66.37
Rate for Payer: Cigna Medicaid	$70.27
Rate for Payer: Molina CHIP/Medicaid	$70.27
Rate for Payer: Multiplan Auto	$63.44
Rate for Payer: Multiplan Commercial	$63.44
Rate for Payer: Multiplan Workers Comp	$63.44
Rate for Payer: Parkland Medicaid	$70.27
Rate for Payer: Scott and White EPO/PPO	$48.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.27
Rate for Payer: Superior Health Plan EPO	$13.27

G.I. HEMORRHAGE W CC

Facility

$18,715.00

Service Code	MSDRG 378
Min. Negotiated Rate	$8,516.58
Max. Negotiated Rate	$18,715.00
Rate for Payer: BCBS of TX Blue Advantage	$8,516.58
Rate for Payer: BCBS of TX Blue Essentials	$10,218.91
Rate for Payer: BCBS of TX PPO	$11,354.78

G.I. HEMORRHAGE W MCC

Facility

$33,782.00

Service Code	MSDRG 377
Min. Negotiated Rate	$15,383.68
Max. Negotiated Rate	$33,782.00
Rate for Payer: BCBS of TX Blue Advantage	$15,383.68
Rate for Payer: BCBS of TX Blue Essentials	$18,458.63
Rate for Payer: BCBS of TX PPO	$20,510.38

G.I. HEMORRHAGE W/O CC/MCC

Facility

$12,042.20

Service Code	MSDRG 379
Min. Negotiated Rate	$5,545.75
Max. Negotiated Rate	$12,042.20
Rate for Payer: BCBS of TX Blue Advantage	$5,617.52
Rate for Payer: BCBS of TX Blue Essentials	$6,740.37
Rate for Payer: BCBS of TX PPO	$7,489.59

GINTRO RAMP -- DHF

Facility

$900.24

Hospital Charge Code	82411604
Hospital Revenue Code	272
Min. Negotiated Rate	$81.02
Max. Negotiated Rate	$648.17
Rate for Payer: Amerigroup CHIP/Medicaid	$81.02
Rate for Payer: BCBS of TX Blue Advantage	$270.07
Rate for Payer: BCBS of TX Blue Essentials	$324.09
Rate for Payer: BCBS of TX PPO	$360.10
Rate for Payer: Cash Price	$612.16
Rate for Payer: Cigna Medicaid	$648.17
Rate for Payer: Molina CHIP/Medicaid	$648.17
Rate for Payer: Multiplan Auto	$585.16
Rate for Payer: Multiplan Commercial	$585.16
Rate for Payer: Multiplan Workers Comp	$585.16
Rate for Payer: Parkland Medicaid	$648.17
Rate for Payer: Scott and White EPO/PPO	$450.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$648.17
Rate for Payer: Superior Health Plan EPO	$122.43

GINTRO RAMP -- DHF

Facility

$900.24

Hospital Charge Code	82411604
Hospital Revenue Code	272
Rate for Payer: Cash Price	$612.16

G.I. OBSTRUCTION W CC

Facility

$15,334.90

Service Code	MSDRG 389
Min. Negotiated Rate	$7,062.12
Max. Negotiated Rate	$15,334.90
Rate for Payer: BCBS of TX Blue Advantage	$7,251.52
Rate for Payer: BCBS of TX Blue Essentials	$8,700.98
Rate for Payer: BCBS of TX PPO	$9,668.13

G.I. OBSTRUCTION W MCC

Facility

$27,880.60

Service Code	MSDRG 388
Min. Negotiated Rate	$12,839.75
Max. Negotiated Rate	$27,880.60
Rate for Payer: BCBS of TX Blue Advantage	$13,164.02
Rate for Payer: BCBS of TX Blue Essentials	$15,795.29
Rate for Payer: BCBS of TX PPO	$17,551.01

G.I. OBSTRUCTION W/O CC/MCC

Facility

$10,744.50

Service Code	MSDRG 390
Min. Negotiated Rate	$4,948.12
Max. Negotiated Rate	$10,744.50
Rate for Payer: BCBS of TX Blue Advantage	$5,082.60
Rate for Payer: BCBS of TX Blue Essentials	$6,098.53
Rate for Payer: BCBS of TX PPO	$6,776.41

glass tubes

Facility

$0.16

Hospital Charge Code	993279
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.11

glass tubes

Facility

$0.16

Hospital Charge Code	993279
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.01
Rate for Payer: BCBS of TX Blue Advantage	$0.05
Rate for Payer: BCBS of TX Blue Essentials	$0.06
Rate for Payer: BCBS of TX PPO	$0.06
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna Medicaid	$0.12
Rate for Payer: Molina CHIP/Medicaid	$0.12
Rate for Payer: Multiplan Auto	$0.10
Rate for Payer: Multiplan Commercial	$0.10
Rate for Payer: Multiplan Workers Comp	$0.10
Rate for Payer: Parkland Medicaid	$0.12
Rate for Payer: Scott and White EPO/PPO	$0.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.12
Rate for Payer: Superior Health Plan EPO	$0.02

GLIDE/BRONCHOSCOPE BFLEX 5.8 0570-0397

Facility

$1,420.11

Hospital Charge Code	144213
Hospital Revenue Code	272
Min. Negotiated Rate	$127.81
Max. Negotiated Rate	$1,022.48
Rate for Payer: Amerigroup CHIP/Medicaid	$127.81
Rate for Payer: BCBS of TX Blue Advantage	$426.03
Rate for Payer: BCBS of TX Blue Essentials	$511.24
Rate for Payer: BCBS of TX PPO	$568.04
Rate for Payer: Cash Price	$965.67
Rate for Payer: Cigna Medicaid	$1,022.48
Rate for Payer: Molina CHIP/Medicaid	$1,022.48
Rate for Payer: Multiplan Auto	$923.07
Rate for Payer: Multiplan Commercial	$923.07
Rate for Payer: Multiplan Workers Comp	$923.07
Rate for Payer: Parkland Medicaid	$1,022.48
Rate for Payer: Scott and White EPO/PPO	$710.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,022.48
Rate for Payer: Superior Health Plan EPO	$193.13

GLIDE/BRONCHOSCOPE BFLEX 5.8 0570-0397

Facility

$1,420.11

Hospital Charge Code	144213
Hospital Revenue Code	272
Rate for Payer: Cash Price	$965.67

GLIDE/BRONCHOSCOPE BLEX 5.0 0570-0375

Facility

$1,221.26

Hospital Charge Code	144279
Hospital Revenue Code	272
Min. Negotiated Rate	$109.91
Max. Negotiated Rate	$879.31
Rate for Payer: Amerigroup CHIP/Medicaid	$109.91
Rate for Payer: BCBS of TX Blue Advantage	$366.38
Rate for Payer: BCBS of TX Blue Essentials	$439.65
Rate for Payer: BCBS of TX PPO	$488.50
Rate for Payer: Cash Price	$830.46
Rate for Payer: Cigna Medicaid	$879.31
Rate for Payer: Molina CHIP/Medicaid	$879.31
Rate for Payer: Multiplan Auto	$793.82
Rate for Payer: Multiplan Commercial	$793.82
Rate for Payer: Multiplan Workers Comp	$793.82
Rate for Payer: Parkland Medicaid	$879.31
Rate for Payer: Scott and White EPO/PPO	$610.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$879.31
Rate for Payer: Superior Health Plan EPO	$166.09

GLIDE/BRONCHOSCOPE BLEX 5.0 0570-0375

Facility

$1,221.26

Hospital Charge Code	144279
Hospital Revenue Code	272
Rate for Payer: Cash Price	$830.46

GLIDECATH 5FR 100CM ANGLED

Facility

$205.71

Service Code	HCPCS C1769
Hospital Charge Code	993875
Hospital Revenue Code	272
Min. Negotiated Rate	$18.51
Max. Negotiated Rate	$148.11
Rate for Payer: Amerigroup CHIP/Medicaid	$18.51
Rate for Payer: BCBS of TX Blue Advantage	$61.71
Rate for Payer: BCBS of TX Blue Essentials	$74.06
Rate for Payer: BCBS of TX PPO	$82.28
Rate for Payer: Cash Price	$139.88
Rate for Payer: Cigna Medicaid	$148.11
Rate for Payer: Molina CHIP/Medicaid	$148.11
Rate for Payer: Multiplan Auto	$133.71
Rate for Payer: Multiplan Commercial	$133.71
Rate for Payer: Multiplan Workers Comp	$133.71
Rate for Payer: Parkland Medicaid	$148.11
Rate for Payer: Scott and White EPO/PPO	$102.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$148.11
Rate for Payer: Superior Health Plan EPO	$27.98

GLIDECATH 5FR 100CM ANGLED

Facility

$205.71

Service Code	HCPCS C1769
Hospital Charge Code	993875
Hospital Revenue Code	272
Rate for Payer: Cash Price	$139.88

GlideScope AVL GVL 4 Stat

Facility

$429.05

Hospital Charge Code	82067597
Hospital Revenue Code	272
Rate for Payer: Cash Price	$291.75

GlideScope AVL GVL 4 Stat

Facility

$429.05

Hospital Charge Code	82067597
Hospital Revenue Code	272
Min. Negotiated Rate	$38.61
Max. Negotiated Rate	$308.92
Rate for Payer: Amerigroup CHIP/Medicaid	$38.61
Rate for Payer: BCBS of TX Blue Advantage	$128.72
Rate for Payer: BCBS of TX Blue Essentials	$154.46
Rate for Payer: BCBS of TX PPO	$171.62
Rate for Payer: Cash Price	$291.75
Rate for Payer: Cigna Medicaid	$308.92
Rate for Payer: Molina CHIP/Medicaid	$308.92
Rate for Payer: Multiplan Auto	$278.88
Rate for Payer: Multiplan Commercial	$278.88
Rate for Payer: Multiplan Workers Comp	$278.88
Rate for Payer: Parkland Medicaid	$308.92
Rate for Payer: Scott and White EPO/PPO	$214.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$308.92
Rate for Payer: Superior Health Plan EPO	$58.35

GLIDESCOPE INTUBATOR 3 STAT

Facility

$429.05

Hospital Charge Code	82067596
Hospital Revenue Code	272
Rate for Payer: Cash Price	$291.75

GLIDESCOPE INTUBATOR 3 STAT

Facility

$429.05

Hospital Charge Code	82067596
Hospital Revenue Code	272
Min. Negotiated Rate	$38.61
Max. Negotiated Rate	$308.92
Rate for Payer: Amerigroup CHIP/Medicaid	$38.61
Rate for Payer: BCBS of TX Blue Advantage	$128.72
Rate for Payer: BCBS of TX Blue Essentials	$154.46
Rate for Payer: BCBS of TX PPO	$171.62
Rate for Payer: Cash Price	$291.75
Rate for Payer: Cigna Medicaid	$308.92
Rate for Payer: Molina CHIP/Medicaid	$308.92
Rate for Payer: Multiplan Auto	$278.88
Rate for Payer: Multiplan Commercial	$278.88
Rate for Payer: Multiplan Workers Comp	$278.88
Rate for Payer: Parkland Medicaid	$308.92
Rate for Payer: Scott and White EPO/PPO	$214.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$308.92
Rate for Payer: Superior Health Plan EPO	$58.35

glidescope size 3

Facility

$67.56

Hospital Charge Code	993031
Hospital Revenue Code	270
Rate for Payer: Cash Price	$45.94

glidescope size 3

Facility

$67.56

Hospital Charge Code	993031
Hospital Revenue Code	270
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$48.64
Rate for Payer: Amerigroup CHIP/Medicaid	$6.08
Rate for Payer: BCBS of TX Blue Advantage	$20.27
Rate for Payer: BCBS of TX Blue Essentials	$24.32
Rate for Payer: BCBS of TX PPO	$27.02
Rate for Payer: Cash Price	$45.94
Rate for Payer: Cigna Medicaid	$48.64
Rate for Payer: Molina CHIP/Medicaid	$48.64
Rate for Payer: Multiplan Auto	$43.91
Rate for Payer: Multiplan Commercial	$43.91
Rate for Payer: Multiplan Workers Comp	$43.91
Rate for Payer: Parkland Medicaid	$48.64
Rate for Payer: Scott and White EPO/PPO	$33.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.64
Rate for Payer: Superior Health Plan EPO	$9.19

GLIDEWIRE ADV 0.035 180CM 3CM TPR ANG

Facility

$407.96

Service Code	HCPCS C1769
Hospital Charge Code	993707
Hospital Revenue Code	272
Min. Negotiated Rate	$36.72
Max. Negotiated Rate	$293.73
Rate for Payer: Amerigroup CHIP/Medicaid	$36.72
Rate for Payer: BCBS of TX Blue Advantage	$122.39
Rate for Payer: BCBS of TX Blue Essentials	$146.87
Rate for Payer: BCBS of TX PPO	$163.18
Rate for Payer: Cash Price	$277.41
Rate for Payer: Cigna Medicaid	$293.73
Rate for Payer: Molina CHIP/Medicaid	$293.73
Rate for Payer: Multiplan Auto	$265.17
Rate for Payer: Multiplan Commercial	$265.17
Rate for Payer: Multiplan Workers Comp	$265.17
Rate for Payer: Parkland Medicaid	$293.73
Rate for Payer: Scott and White EPO/PPO	$203.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$293.73
Rate for Payer: Superior Health Plan EPO	$55.48

Know your out-of-pocket cost for care.

All Charges