White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Gram Stain Report

Facility

$138.00

Service Code	HCPCS 87205
Hospital Charge Code	4107205
Hospital Revenue Code	306
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$99.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$41.40
Rate for Payer: BCBS of TX Blue Essentials	$49.68
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$55.20
Rate for Payer: Cash Price	$93.84
Rate for Payer: Cash Price	$93.84
Rate for Payer: Cigna Medicaid	$99.36
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$99.36
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$89.70
Rate for Payer: Multiplan Commercial	$89.70
Rate for Payer: Multiplan Workers Comp	$89.70
Rate for Payer: Parkland Medicaid	$99.36
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.36
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

Gram Stain Report

Facility

$138.00

Service Code	HCPCS 87205
Hospital Charge Code	4107205
Hospital Revenue Code	306
Rate for Payer: Cash Price	$93.84

GRASPER, ENDO 4-PR

Facility

$631.06

Hospital Charge Code	135111
Hospital Revenue Code	272
Min. Negotiated Rate	$56.80
Max. Negotiated Rate	$454.36
Rate for Payer: Amerigroup CHIP/Medicaid	$56.80
Rate for Payer: BCBS of TX Blue Advantage	$189.32
Rate for Payer: BCBS of TX Blue Essentials	$227.18
Rate for Payer: BCBS of TX PPO	$252.42
Rate for Payer: Cash Price	$429.12
Rate for Payer: Cigna Medicaid	$454.36
Rate for Payer: Molina CHIP/Medicaid	$454.36
Rate for Payer: Multiplan Auto	$410.19
Rate for Payer: Multiplan Commercial	$410.19
Rate for Payer: Multiplan Workers Comp	$410.19
Rate for Payer: Parkland Medicaid	$454.36
Rate for Payer: Scott and White EPO/PPO	$315.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$454.36
Rate for Payer: Superior Health Plan EPO	$85.82

GRASPER, ENDO 4-PR

Facility

$631.06

Hospital Charge Code	135111
Hospital Revenue Code	272
Rate for Payer: Cash Price	$429.12

grasper poly grab disp tip

Facility

$279.98

Hospital Charge Code	144836
Hospital Revenue Code	272
Rate for Payer: Cash Price	$190.39

grasper poly grab disp tip

Facility

$279.98

Hospital Charge Code	144836
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$201.59
Rate for Payer: Amerigroup CHIP/Medicaid	$25.20
Rate for Payer: BCBS of TX Blue Advantage	$83.99
Rate for Payer: BCBS of TX Blue Essentials	$100.79
Rate for Payer: BCBS of TX PPO	$111.99
Rate for Payer: Cash Price	$190.39
Rate for Payer: Cigna Medicaid	$201.59
Rate for Payer: Molina CHIP/Medicaid	$201.59
Rate for Payer: Multiplan Auto	$181.99
Rate for Payer: Multiplan Commercial	$181.99
Rate for Payer: Multiplan Workers Comp	$181.99
Rate for Payer: Parkland Medicaid	$201.59
Rate for Payer: Scott and White EPO/PPO	$139.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$201.59
Rate for Payer: Superior Health Plan EPO	$38.08

GRASPER, RAPTOR FOREIGN BODY RETRIEVAL 2.4MMX230CM

Facility

$599.28

Hospital Charge Code	135744
Hospital Revenue Code	272
Min. Negotiated Rate	$53.94
Max. Negotiated Rate	$431.48
Rate for Payer: Amerigroup CHIP/Medicaid	$53.94
Rate for Payer: BCBS of TX Blue Advantage	$179.78
Rate for Payer: BCBS of TX Blue Essentials	$215.74
Rate for Payer: BCBS of TX PPO	$239.71
Rate for Payer: Cash Price	$407.51
Rate for Payer: Cigna Medicaid	$431.48
Rate for Payer: Molina CHIP/Medicaid	$431.48
Rate for Payer: Multiplan Auto	$389.53
Rate for Payer: Multiplan Commercial	$389.53
Rate for Payer: Multiplan Workers Comp	$389.53
Rate for Payer: Parkland Medicaid	$431.48
Rate for Payer: Scott and White EPO/PPO	$299.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$431.48
Rate for Payer: Superior Health Plan EPO	$81.50

GRASPER, RAPTOR FOREIGN BODY RETRIEVAL 2.4MMX230CM

Facility

$599.28

Hospital Charge Code	135744
Hospital Revenue Code	272
Rate for Payer: Cash Price	$407.51

GRASPER, SUTURE

Facility

$128.97

Hospital Charge Code	992897
Hospital Revenue Code	272
Rate for Payer: Cash Price	$87.70

GRASPER, SUTURE

Facility

$128.97

Hospital Charge Code	992897
Hospital Revenue Code	272
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$92.86
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$38.69
Rate for Payer: BCBS of TX Blue Essentials	$46.43
Rate for Payer: BCBS of TX PPO	$51.59
Rate for Payer: Cash Price	$87.70
Rate for Payer: Cigna Medicaid	$92.86
Rate for Payer: Molina CHIP/Medicaid	$92.86
Rate for Payer: Multiplan Auto	$83.83
Rate for Payer: Multiplan Commercial	$83.83
Rate for Payer: Multiplan Workers Comp	$83.83
Rate for Payer: Parkland Medicaid	$92.86
Rate for Payer: Scott and White EPO/PPO	$64.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.86
Rate for Payer: Superior Health Plan EPO	$17.54

GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE

Facility

$6,378.70

Hospital Charge Code	993448
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,337.52

GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE

Facility

$6,378.70

Hospital Charge Code	993448
Hospital Revenue Code	272
Min. Negotiated Rate	$574.08
Max. Negotiated Rate	$4,592.66
Rate for Payer: Amerigroup CHIP/Medicaid	$574.08
Rate for Payer: BCBS of TX Blue Advantage	$1,913.61
Rate for Payer: BCBS of TX Blue Essentials	$2,296.33
Rate for Payer: BCBS of TX PPO	$2,551.48
Rate for Payer: Cash Price	$4,337.52
Rate for Payer: Cigna Medicaid	$4,592.66
Rate for Payer: Molina CHIP/Medicaid	$4,592.66
Rate for Payer: Multiplan Auto	$4,146.15
Rate for Payer: Multiplan Commercial	$4,146.15
Rate for Payer: Multiplan Workers Comp	$4,146.15
Rate for Payer: Parkland Medicaid	$4,592.66
Rate for Payer: Scott and White EPO/PPO	$3,189.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,592.66
Rate for Payer: Superior Health Plan EPO	$867.50

GREAT WHITE 4.2MM 15 DEGREE

Facility

$231.72

Hospital Charge Code	145980
Hospital Revenue Code	272
Rate for Payer: Cash Price	$157.57

GREAT WHITE 4.2MM 15 DEGREE

Facility

$231.72

Hospital Charge Code	145980
Hospital Revenue Code	272
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$166.84
Rate for Payer: Amerigroup CHIP/Medicaid	$20.85
Rate for Payer: BCBS of TX Blue Advantage	$69.52
Rate for Payer: BCBS of TX Blue Essentials	$83.42
Rate for Payer: BCBS of TX PPO	$92.69
Rate for Payer: Cash Price	$157.57
Rate for Payer: Cigna Medicaid	$166.84
Rate for Payer: Molina CHIP/Medicaid	$166.84
Rate for Payer: Multiplan Auto	$150.62
Rate for Payer: Multiplan Commercial	$150.62
Rate for Payer: Multiplan Workers Comp	$150.62
Rate for Payer: Parkland Medicaid	$166.84
Rate for Payer: Scott and White EPO/PPO	$115.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$166.84
Rate for Payer: Superior Health Plan EPO	$31.51

GRFT VASC STR B -- DHF

Facility

$10,623.00

Service Code	HCPCS C1768
Hospital Charge Code	81422008
Hospital Revenue Code	278
Min. Negotiated Rate	$956.07
Max. Negotiated Rate	$7,648.56
Rate for Payer: Amerigroup CHIP/Medicaid	$956.07
Rate for Payer: BCBS of TX Blue Advantage	$3,186.90
Rate for Payer: BCBS of TX Blue Essentials	$3,824.28
Rate for Payer: BCBS of TX PPO	$4,249.20
Rate for Payer: Cash Price	$7,223.64
Rate for Payer: Cigna Medicaid	$7,648.56
Rate for Payer: Molina CHIP/Medicaid	$7,648.56
Rate for Payer: Multiplan Auto	$5,311.50
Rate for Payer: Multiplan Commercial	$5,311.50
Rate for Payer: Multiplan Workers Comp	$5,311.50
Rate for Payer: Parkland Medicaid	$7,648.56
Rate for Payer: Scott and White EPO/PPO	$5,311.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,648.56
Rate for Payer: Superior Health Plan EPO	$1,444.73

GRFT VASC STR B -- DHF

Facility

$10,623.00

Service Code	HCPCS C1768
Hospital Charge Code	81422008
Hospital Revenue Code	278
Min. Negotiated Rate	$2,655.75
Max. Negotiated Rate	$5,311.50
Rate for Payer: Cash Price	$7,223.64
Rate for Payer: Cigna Commercial	$2,655.75
Rate for Payer: Multiplan Auto	$5,311.50
Rate for Payer: Multiplan Commercial	$5,311.50
Rate for Payer: Multiplan Workers Comp	$5,311.50
Rate for Payer: Scott and White EPO/PPO	$5,311.50

GRFT VASC STR S -- DHF

Facility

$6,339.00

Service Code	HCPCS C1768
Hospital Charge Code	81422701
Hospital Revenue Code	278
Min. Negotiated Rate	$570.51
Max. Negotiated Rate	$4,564.08
Rate for Payer: Amerigroup CHIP/Medicaid	$570.51
Rate for Payer: BCBS of TX Blue Advantage	$1,901.70
Rate for Payer: BCBS of TX Blue Essentials	$2,282.04
Rate for Payer: BCBS of TX PPO	$2,535.60
Rate for Payer: Cash Price	$4,310.52
Rate for Payer: Cigna Medicaid	$4,564.08
Rate for Payer: Molina CHIP/Medicaid	$4,564.08
Rate for Payer: Multiplan Auto	$3,169.50
Rate for Payer: Multiplan Commercial	$3,169.50
Rate for Payer: Multiplan Workers Comp	$3,169.50
Rate for Payer: Parkland Medicaid	$4,564.08
Rate for Payer: Scott and White EPO/PPO	$3,169.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,564.08
Rate for Payer: Superior Health Plan EPO	$862.10

GRFT VASC STR S -- DHF

Facility

$6,339.00

Service Code	HCPCS C1768
Hospital Charge Code	81422701
Hospital Revenue Code	278
Min. Negotiated Rate	$1,584.75
Max. Negotiated Rate	$3,169.50
Rate for Payer: Cash Price	$4,310.52
Rate for Payer: Cigna Commercial	$1,584.75
Rate for Payer: Multiplan Auto	$3,169.50
Rate for Payer: Multiplan Commercial	$3,169.50
Rate for Payer: Multiplan Workers Comp	$3,169.50
Rate for Payer: Scott and White EPO/PPO	$3,169.50

Group A Strep Culture

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4107081
Hospital Revenue Code	306
Rate for Payer: Cash Price	$155.72

Group A Strep Culture

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4107081
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$164.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.63
Rate for Payer: Amerigroup Medicare	$6.63
Rate for Payer: BCBS of TX Blue Advantage	$68.70
Rate for Payer: BCBS of TX Blue Essentials	$82.44
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$91.60
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cigna Medicaid	$164.88
Rate for Payer: Cigna Medicare	$6.63
Rate for Payer: Employer Direct Commercial	$6.63
Rate for Payer: Humana Medicare/TRICARE	$6.63
Rate for Payer: Molina CHIP/Medicaid	$164.88
Rate for Payer: Molina Dual Medicare/Medicaid	$6.63
Rate for Payer: Molina Medicare	$6.63
Rate for Payer: Multiplan Auto	$148.85
Rate for Payer: Multiplan Commercial	$148.85
Rate for Payer: Multiplan Workers Comp	$148.85
Rate for Payer: Parkland Medicaid	$164.88
Rate for Payer: Scott and White EPO/PPO	$8.29
Rate for Payer: Scott and White Medicare	$6.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164.88
Rate for Payer: Superior Health Plan EPO	$6.63
Rate for Payer: Superior Health Plan Medicare	$6.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.63
Rate for Payer: Universal American Medicare	$6.63
Rate for Payer: Wellcare Medicare	$6.63
Rate for Payer: Wellmed Medicare	$6.63

Group B Strep Culture

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4107044
Hospital Revenue Code	306
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$164.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.63
Rate for Payer: Amerigroup Medicare	$6.63
Rate for Payer: BCBS of TX Blue Advantage	$68.70
Rate for Payer: BCBS of TX Blue Essentials	$82.44
Rate for Payer: BCBS of TX Medicare	$6.63
Rate for Payer: BCBS of TX PPO	$91.60
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cash Price	$155.72
Rate for Payer: Cigna Medicaid	$164.88
Rate for Payer: Cigna Medicare	$6.63
Rate for Payer: Employer Direct Commercial	$6.63
Rate for Payer: Humana Medicare/TRICARE	$6.63
Rate for Payer: Molina CHIP/Medicaid	$164.88
Rate for Payer: Molina Dual Medicare/Medicaid	$6.63
Rate for Payer: Molina Medicare	$6.63
Rate for Payer: Multiplan Auto	$148.85
Rate for Payer: Multiplan Commercial	$148.85
Rate for Payer: Multiplan Workers Comp	$148.85
Rate for Payer: Parkland Medicaid	$164.88
Rate for Payer: Scott and White EPO/PPO	$8.29
Rate for Payer: Scott and White Medicare	$6.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$164.88
Rate for Payer: Superior Health Plan EPO	$6.63
Rate for Payer: Superior Health Plan Medicare	$6.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.63
Rate for Payer: Universal American Medicare	$6.63
Rate for Payer: Wellcare Medicare	$6.63
Rate for Payer: Wellmed Medicare	$6.63

Group B Strep Culture

Facility

$229.00

Service Code	HCPCS 87081
Hospital Charge Code	4107044
Hospital Revenue Code	306
Rate for Payer: Cash Price	$155.72

Growth Hormone, Serum SO

Facility

$88.00

Service Code	HCPCS 83003
Hospital Charge Code	1701382
Hospital Revenue Code	301
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$63.36
Rate for Payer: Amerigroup CHIP/Medicaid	$6.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.67
Rate for Payer: Amerigroup Medicare	$16.67
Rate for Payer: BCBS of TX Blue Advantage	$26.40
Rate for Payer: BCBS of TX Blue Essentials	$31.68
Rate for Payer: BCBS of TX Medicare	$16.67
Rate for Payer: BCBS of TX PPO	$35.20
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cigna Medicaid	$63.36
Rate for Payer: Cigna Medicare	$16.67
Rate for Payer: Employer Direct Commercial	$16.67
Rate for Payer: Humana Medicare/TRICARE	$16.67
Rate for Payer: Molina CHIP/Medicaid	$63.36
Rate for Payer: Molina Dual Medicare/Medicaid	$16.67
Rate for Payer: Molina Medicare	$16.67
Rate for Payer: Multiplan Auto	$57.20
Rate for Payer: Multiplan Commercial	$57.20
Rate for Payer: Multiplan Workers Comp	$57.20
Rate for Payer: Parkland Medicaid	$63.36
Rate for Payer: Scott and White EPO/PPO	$20.84
Rate for Payer: Scott and White Medicare	$16.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.36
Rate for Payer: Superior Health Plan EPO	$16.67
Rate for Payer: Superior Health Plan Medicare	$16.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.67
Rate for Payer: Universal American Medicare	$16.67
Rate for Payer: Wellcare Medicare	$16.67
Rate for Payer: Wellmed Medicare	$16.67

Growth Hormone, Serum SO

Facility

$88.00

Service Code	HCPCS 83003
Hospital Charge Code	1701382
Hospital Revenue Code	301
Rate for Payer: Cash Price	$59.84

Gryphon Peek v / Proknot

Facility

$3,349.40

Service Code	HCPCS C1713
Hospital Charge Code	992195
Hospital Revenue Code	278
Min. Negotiated Rate	$837.35
Max. Negotiated Rate	$1,674.70
Rate for Payer: Cash Price	$2,277.59
Rate for Payer: Cigna Commercial	$837.35
Rate for Payer: Multiplan Auto	$1,674.70
Rate for Payer: Multiplan Commercial	$1,674.70
Rate for Payer: Multiplan Workers Comp	$1,674.70
Rate for Payer: Scott and White EPO/PPO	$1,674.70

Know your out-of-pocket cost for care.

All Charges