White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Gonorrhea PCR

Facility

$245.00

Service Code	HCPCS 87591
Hospital Charge Code	4107592
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$176.40
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$73.50
Rate for Payer: BCBS of TX Blue Essentials	$88.20
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$98.00
Rate for Payer: Cash Price	$166.60
Rate for Payer: Cash Price	$166.60
Rate for Payer: Cigna Medicaid	$176.40
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$176.40
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$159.25
Rate for Payer: Multiplan Commercial	$159.25
Rate for Payer: Multiplan Workers Comp	$159.25
Rate for Payer: Parkland Medicaid	$176.40
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$176.40
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

Gonorrhea PCR

Facility

$245.00

Service Code	HCPCS 87591
Hospital Charge Code	4107592
Hospital Revenue Code	306
Rate for Payer: Cash Price	$166.60

GONTAINER, SPEC, PORT ACCESS, STRL PATH, 40Z

Facility

$3.75

Hospital Charge Code	993342
Hospital Revenue Code	270
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$2.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.34
Rate for Payer: BCBS of TX Blue Advantage	$1.12
Rate for Payer: BCBS of TX Blue Essentials	$1.35
Rate for Payer: BCBS of TX PPO	$1.50
Rate for Payer: Cash Price	$2.55
Rate for Payer: Cigna Medicaid	$2.70
Rate for Payer: Molina CHIP/Medicaid	$2.70
Rate for Payer: Multiplan Auto	$2.44
Rate for Payer: Multiplan Commercial	$2.44
Rate for Payer: Multiplan Workers Comp	$2.44
Rate for Payer: Parkland Medicaid	$2.70
Rate for Payer: Scott and White EPO/PPO	$1.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.70
Rate for Payer: Superior Health Plan EPO	$0.51

GONTAINER, SPEC, PORT ACCESS, STRL PATH, 40Z

Facility

$3.75

Hospital Charge Code	993342
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.55

GORE EXCLUDER AAA ENDOPOSTHEISI 14.5 X 12

Facility

$31,205.00

Service Code	HCPCS C1874
Hospital Charge Code	145407
Hospital Revenue Code	278
Min. Negotiated Rate	$7,801.25
Max. Negotiated Rate	$15,602.50
Rate for Payer: Cash Price	$21,219.40
Rate for Payer: Cigna Commercial	$7,801.25
Rate for Payer: Multiplan Auto	$15,602.50
Rate for Payer: Multiplan Commercial	$15,602.50
Rate for Payer: Multiplan Workers Comp	$15,602.50
Rate for Payer: Scott and White EPO/PPO	$15,602.50

GORE EXCLUDER AAA ENDOPOSTHEISI 14.5 X 12

Facility

$31,205.00

Service Code	HCPCS C1874
Hospital Charge Code	145407
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.45
Max. Negotiated Rate	$22,467.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,808.45
Rate for Payer: BCBS of TX Blue Advantage	$9,361.50
Rate for Payer: BCBS of TX Blue Essentials	$11,233.80
Rate for Payer: BCBS of TX PPO	$12,482.00
Rate for Payer: Cash Price	$21,219.40
Rate for Payer: Cigna Medicaid	$22,467.60
Rate for Payer: Molina CHIP/Medicaid	$22,467.60
Rate for Payer: Multiplan Auto	$15,602.50
Rate for Payer: Multiplan Commercial	$15,602.50
Rate for Payer: Multiplan Workers Comp	$15,602.50
Rate for Payer: Parkland Medicaid	$22,467.60
Rate for Payer: Scott and White EPO/PPO	$15,602.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,467.60
Rate for Payer: Superior Health Plan EPO	$4,243.88

GORE EXCLUDER AAA ENDOPROSTHESIS 14.5X14

Facility

$31,205.00

Service Code	HCPCS C1874
Hospital Charge Code	119871
Hospital Revenue Code	278
Min. Negotiated Rate	$7,801.25
Max. Negotiated Rate	$15,602.50
Rate for Payer: Cash Price	$21,219.40
Rate for Payer: Cigna Commercial	$7,801.25
Rate for Payer: Multiplan Auto	$15,602.50
Rate for Payer: Multiplan Commercial	$15,602.50
Rate for Payer: Multiplan Workers Comp	$15,602.50
Rate for Payer: Scott and White EPO/PPO	$15,602.50

GORE EXCLUDER AAA ENDOPROSTHESIS 14.5X14

Facility

$31,205.00

Service Code	HCPCS C1874
Hospital Charge Code	119871
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.45
Max. Negotiated Rate	$22,467.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,808.45
Rate for Payer: BCBS of TX Blue Advantage	$9,361.50
Rate for Payer: BCBS of TX Blue Essentials	$11,233.80
Rate for Payer: BCBS of TX PPO	$12,482.00
Rate for Payer: Cash Price	$21,219.40
Rate for Payer: Cigna Medicaid	$22,467.60
Rate for Payer: Molina CHIP/Medicaid	$22,467.60
Rate for Payer: Multiplan Auto	$15,602.50
Rate for Payer: Multiplan Commercial	$15,602.50
Rate for Payer: Multiplan Workers Comp	$15,602.50
Rate for Payer: Parkland Medicaid	$22,467.60
Rate for Payer: Scott and White EPO/PPO	$15,602.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,467.60
Rate for Payer: Superior Health Plan EPO	$4,243.88

GORE EXCLUDER AAA ENDOPROSTHESIS 16X12

Facility

$30,590.00

Service Code	HCPCS C1874
Hospital Charge Code	8528498
Hospital Revenue Code	278
Min. Negotiated Rate	$2,753.10
Max. Negotiated Rate	$22,024.80
Rate for Payer: Amerigroup CHIP/Medicaid	$2,753.10
Rate for Payer: BCBS of TX Blue Advantage	$9,177.00
Rate for Payer: BCBS of TX Blue Essentials	$11,012.40
Rate for Payer: BCBS of TX PPO	$12,236.00
Rate for Payer: Cash Price	$20,801.20
Rate for Payer: Cigna Medicaid	$22,024.80
Rate for Payer: Molina CHIP/Medicaid	$22,024.80
Rate for Payer: Multiplan Auto	$15,295.00
Rate for Payer: Multiplan Commercial	$15,295.00
Rate for Payer: Multiplan Workers Comp	$15,295.00
Rate for Payer: Parkland Medicaid	$22,024.80
Rate for Payer: Scott and White EPO/PPO	$15,295.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,024.80
Rate for Payer: Superior Health Plan EPO	$4,160.24

GORE EXCLUDER AAA ENDOPROSTHESIS 16X12

Facility

$30,590.00

Service Code	HCPCS C1874
Hospital Charge Code	8528498
Hospital Revenue Code	278
Min. Negotiated Rate	$7,647.50
Max. Negotiated Rate	$15,295.00
Rate for Payer: Cash Price	$20,801.20
Rate for Payer: Cigna Commercial	$7,647.50
Rate for Payer: Multiplan Auto	$15,295.00
Rate for Payer: Multiplan Commercial	$15,295.00
Rate for Payer: Multiplan Workers Comp	$15,295.00
Rate for Payer: Scott and White EPO/PPO	$15,295.00

GORE EXCLUDER AAA ENDOPROTHESIS 16x11.15

Facility

$29,988.00

Service Code	HCPCS C1874
Hospital Charge Code	8392454
Hospital Revenue Code	278
Min. Negotiated Rate	$7,497.00
Max. Negotiated Rate	$14,994.00
Rate for Payer: Cash Price	$20,391.84
Rate for Payer: Cigna Commercial	$7,497.00
Rate for Payer: Multiplan Auto	$14,994.00
Rate for Payer: Multiplan Commercial	$14,994.00
Rate for Payer: Multiplan Workers Comp	$14,994.00
Rate for Payer: Scott and White EPO/PPO	$14,994.00

GORE EXCLUDER AAA ENDOPROTHESIS 16x11.15

Facility

$29,988.00

Service Code	HCPCS C1874
Hospital Charge Code	8392454
Hospital Revenue Code	278
Min. Negotiated Rate	$2,698.92
Max. Negotiated Rate	$21,591.36
Rate for Payer: Amerigroup CHIP/Medicaid	$2,698.92
Rate for Payer: BCBS of TX Blue Advantage	$8,996.40
Rate for Payer: BCBS of TX Blue Essentials	$10,795.68
Rate for Payer: BCBS of TX PPO	$11,995.20
Rate for Payer: Cash Price	$20,391.84
Rate for Payer: Cigna Medicaid	$21,591.36
Rate for Payer: Molina CHIP/Medicaid	$21,591.36
Rate for Payer: Multiplan Auto	$14,994.00
Rate for Payer: Multiplan Commercial	$14,994.00
Rate for Payer: Multiplan Workers Comp	$14,994.00
Rate for Payer: Parkland Medicaid	$21,591.36
Rate for Payer: Scott and White EPO/PPO	$14,994.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,591.36
Rate for Payer: Superior Health Plan EPO	$4,078.37

GORE EXCLUDER AAA ENDOPROTHESIS 16x95

Facility

$29,988.00

Service Code	HCPCS C1874
Hospital Charge Code	8392453
Hospital Revenue Code	278
Min. Negotiated Rate	$7,497.00
Max. Negotiated Rate	$14,994.00
Rate for Payer: Cash Price	$20,391.84
Rate for Payer: Cigna Commercial	$7,497.00
Rate for Payer: Multiplan Auto	$14,994.00
Rate for Payer: Multiplan Commercial	$14,994.00
Rate for Payer: Multiplan Workers Comp	$14,994.00
Rate for Payer: Scott and White EPO/PPO	$14,994.00

GORE EXCLUDER AAA ENDOPROTHESIS 16x95

Facility

$29,988.00

Service Code	HCPCS C1874
Hospital Charge Code	8392453
Hospital Revenue Code	278
Min. Negotiated Rate	$2,698.92
Max. Negotiated Rate	$21,591.36
Rate for Payer: Amerigroup CHIP/Medicaid	$2,698.92
Rate for Payer: BCBS of TX Blue Advantage	$8,996.40
Rate for Payer: BCBS of TX Blue Essentials	$10,795.68
Rate for Payer: BCBS of TX PPO	$11,995.20
Rate for Payer: Cash Price	$20,391.84
Rate for Payer: Cigna Medicaid	$21,591.36
Rate for Payer: Molina CHIP/Medicaid	$21,591.36
Rate for Payer: Multiplan Auto	$14,994.00
Rate for Payer: Multiplan Commercial	$14,994.00
Rate for Payer: Multiplan Workers Comp	$14,994.00
Rate for Payer: Parkland Medicaid	$21,591.36
Rate for Payer: Scott and White EPO/PPO	$14,994.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21,591.36
Rate for Payer: Superior Health Plan EPO	$4,078.37

GORE EXCLUDER AAA ENDOPROTHESIS 23x12x12

Facility

$73,145.00

Service Code	HCPCS C1874
Hospital Charge Code	8392455
Hospital Revenue Code	278
Min. Negotiated Rate	$6,583.05
Max. Negotiated Rate	$52,664.40
Rate for Payer: Amerigroup CHIP/Medicaid	$6,583.05
Rate for Payer: BCBS of TX Blue Advantage	$21,943.50
Rate for Payer: BCBS of TX Blue Essentials	$26,332.20
Rate for Payer: BCBS of TX PPO	$29,258.00
Rate for Payer: Cash Price	$49,738.60
Rate for Payer: Cigna Medicaid	$52,664.40
Rate for Payer: Molina CHIP/Medicaid	$52,664.40
Rate for Payer: Multiplan Auto	$36,572.50
Rate for Payer: Multiplan Commercial	$36,572.50
Rate for Payer: Multiplan Workers Comp	$36,572.50
Rate for Payer: Parkland Medicaid	$52,664.40
Rate for Payer: Scott and White EPO/PPO	$36,572.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52,664.40
Rate for Payer: Superior Health Plan EPO	$9,947.72

GORE EXCLUDER AAA ENDOPROTHESIS 23x12x12

Facility

$73,145.00

Service Code	HCPCS C1874
Hospital Charge Code	8392455
Hospital Revenue Code	278
Min. Negotiated Rate	$18,286.25
Max. Negotiated Rate	$36,572.50
Rate for Payer: Cash Price	$49,738.60
Rate for Payer: Cigna Commercial	$18,286.25
Rate for Payer: Multiplan Auto	$36,572.50
Rate for Payer: Multiplan Commercial	$36,572.50
Rate for Payer: Multiplan Workers Comp	$36,572.50
Rate for Payer: Scott and White EPO/PPO	$36,572.50

GORE EXCLUDER ENDOPROSTHESIS CXT261412

Facility

$87,855.00

Service Code	HCPCS C1874
Hospital Charge Code	145406
Hospital Revenue Code	278
Min. Negotiated Rate	$21,963.75
Max. Negotiated Rate	$43,927.50
Rate for Payer: Cash Price	$59,741.40
Rate for Payer: Cigna Commercial	$21,963.75
Rate for Payer: Multiplan Auto	$43,927.50
Rate for Payer: Multiplan Commercial	$43,927.50
Rate for Payer: Multiplan Workers Comp	$43,927.50
Rate for Payer: Scott and White EPO/PPO	$43,927.50

GORE EXCLUDER ENDOPROSTHESIS CXT261412

Facility

$87,855.00

Service Code	HCPCS C1874
Hospital Charge Code	145406
Hospital Revenue Code	278
Min. Negotiated Rate	$7,906.95
Max. Negotiated Rate	$63,255.60
Rate for Payer: Amerigroup CHIP/Medicaid	$7,906.95
Rate for Payer: BCBS of TX Blue Advantage	$26,356.50
Rate for Payer: BCBS of TX Blue Essentials	$31,627.80
Rate for Payer: BCBS of TX PPO	$35,142.00
Rate for Payer: Cash Price	$59,741.40
Rate for Payer: Cigna Medicaid	$63,255.60
Rate for Payer: Molina CHIP/Medicaid	$63,255.60
Rate for Payer: Multiplan Auto	$43,927.50
Rate for Payer: Multiplan Commercial	$43,927.50
Rate for Payer: Multiplan Workers Comp	$43,927.50
Rate for Payer: Parkland Medicaid	$63,255.60
Rate for Payer: Scott and White EPO/PPO	$43,927.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63,255.60
Rate for Payer: Superior Health Plan EPO	$11,948.28

GORE EXDLUDER AAA ENDOPROSTHESIS 35X14.5

Facility

$54,383.00

Service Code	HCPCS C1874
Hospital Charge Code	8532467
Hospital Revenue Code	278
Min. Negotiated Rate	$4,894.47
Max. Negotiated Rate	$39,155.76
Rate for Payer: Amerigroup CHIP/Medicaid	$4,894.47
Rate for Payer: BCBS of TX Blue Advantage	$16,314.90
Rate for Payer: BCBS of TX Blue Essentials	$19,577.88
Rate for Payer: BCBS of TX PPO	$21,753.20
Rate for Payer: Cash Price	$36,980.44
Rate for Payer: Cigna Medicaid	$39,155.76
Rate for Payer: Molina CHIP/Medicaid	$39,155.76
Rate for Payer: Multiplan Auto	$27,191.50
Rate for Payer: Multiplan Commercial	$27,191.50
Rate for Payer: Multiplan Workers Comp	$27,191.50
Rate for Payer: Parkland Medicaid	$39,155.76
Rate for Payer: Scott and White EPO/PPO	$27,191.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39,155.76
Rate for Payer: Superior Health Plan EPO	$7,396.09

GORE EXDLUDER AAA ENDOPROSTHESIS 35X14.5

Facility

$54,383.00

Service Code	HCPCS C1874
Hospital Charge Code	8532467
Hospital Revenue Code	278
Min. Negotiated Rate	$13,595.75
Max. Negotiated Rate	$27,191.50
Rate for Payer: Cash Price	$36,980.44
Rate for Payer: Cigna Commercial	$13,595.75
Rate for Payer: Multiplan Auto	$27,191.50
Rate for Payer: Multiplan Commercial	$27,191.50
Rate for Payer: Multiplan Workers Comp	$27,191.50
Rate for Payer: Scott and White EPO/PPO	$27,191.50

GORE EXLUDER AAA ENDOPROTHESIS 20X10

Facility

$30,590.36

Hospital Charge Code	8532468
Hospital Revenue Code	272
Min. Negotiated Rate	$2,753.13
Max. Negotiated Rate	$22,025.06
Rate for Payer: Amerigroup CHIP/Medicaid	$2,753.13
Rate for Payer: BCBS of TX Blue Advantage	$9,177.11
Rate for Payer: BCBS of TX Blue Essentials	$11,012.53
Rate for Payer: BCBS of TX PPO	$12,236.14
Rate for Payer: Cash Price	$20,801.44
Rate for Payer: Cigna Medicaid	$22,025.06
Rate for Payer: Molina CHIP/Medicaid	$22,025.06
Rate for Payer: Multiplan Auto	$19,883.73
Rate for Payer: Multiplan Commercial	$19,883.73
Rate for Payer: Multiplan Workers Comp	$19,883.73
Rate for Payer: Parkland Medicaid	$22,025.06
Rate for Payer: Scott and White EPO/PPO	$15,295.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,025.06
Rate for Payer: Superior Health Plan EPO	$4,160.29

GORE EXLUDER AAA ENDOPROTHESIS 20X10

Facility

$30,590.36

Hospital Charge Code	8532468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$20,801.44

Gore Propaten Thin Wall Removable Ringed Vascular Graft, 6 m

Facility

$5,876.12

Service Code	HCPCS C1760
Hospital Charge Code	105553
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,995.76

Gore Propaten Thin Wall Removable Ringed Vascular Graft, 6 m

Facility

$5,876.12

Service Code	HCPCS C1760
Hospital Charge Code	105553
Hospital Revenue Code	272
Min. Negotiated Rate	$528.85
Max. Negotiated Rate	$4,230.81
Rate for Payer: Amerigroup CHIP/Medicaid	$528.85
Rate for Payer: BCBS of TX Blue Advantage	$1,762.84
Rate for Payer: BCBS of TX Blue Essentials	$2,115.40
Rate for Payer: BCBS of TX PPO	$2,350.45
Rate for Payer: Cash Price	$3,995.76
Rate for Payer: Cigna Medicaid	$4,230.81
Rate for Payer: Molina CHIP/Medicaid	$4,230.81
Rate for Payer: Multiplan Auto	$3,819.48
Rate for Payer: Multiplan Commercial	$3,819.48
Rate for Payer: Multiplan Workers Comp	$3,819.48
Rate for Payer: Parkland Medicaid	$4,230.81
Rate for Payer: Scott and White EPO/PPO	$2,938.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,230.81
Rate for Payer: Superior Health Plan EPO	$799.15

Gore Propaten Thin Wall Removable Ringed Vascular Graft, 6 m

Facility

$5,876.12

Service Code	HCPCS C1760
Hospital Charge Code	82401332
Hospital Revenue Code	272
Min. Negotiated Rate	$528.85
Max. Negotiated Rate	$4,230.81
Rate for Payer: Amerigroup CHIP/Medicaid	$528.85
Rate for Payer: BCBS of TX Blue Advantage	$1,762.84
Rate for Payer: BCBS of TX Blue Essentials	$2,115.40
Rate for Payer: BCBS of TX PPO	$2,350.45
Rate for Payer: Cash Price	$3,995.76
Rate for Payer: Cigna Medicaid	$4,230.81
Rate for Payer: Molina CHIP/Medicaid	$4,230.81
Rate for Payer: Multiplan Auto	$3,819.48
Rate for Payer: Multiplan Commercial	$3,819.48
Rate for Payer: Multiplan Workers Comp	$3,819.48
Rate for Payer: Parkland Medicaid	$4,230.81
Rate for Payer: Scott and White EPO/PPO	$2,938.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,230.81
Rate for Payer: Superior Health Plan EPO	$799.15

Know your out-of-pocket cost for care.

All Charges