White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Gryphon Peek v / Proknot

Facility

$3,349.40

Service Code	HCPCS C1713
Hospital Charge Code	992195
Hospital Revenue Code	278
Min. Negotiated Rate	$301.45
Max. Negotiated Rate	$2,411.57
Rate for Payer: Amerigroup CHIP/Medicaid	$301.45
Rate for Payer: BCBS of TX Blue Advantage	$1,004.82
Rate for Payer: BCBS of TX Blue Essentials	$1,205.78
Rate for Payer: BCBS of TX PPO	$1,339.76
Rate for Payer: Cash Price	$2,277.59
Rate for Payer: Cigna Medicaid	$2,411.57
Rate for Payer: Molina CHIP/Medicaid	$2,411.57
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: Parkland Medicaid	$2,411.57
Rate for Payer: Scott and White EPO/PPO	$1,674.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,411.57
Rate for Payer: Superior Health Plan EPO	$455.52

GTR CANCELLOUS CRUSH 15CC

Facility

$784.00

Service Code	HCPCS C1713
Hospital Charge Code	146445
Hospital Revenue Code	278
Min. Negotiated Rate	$196.00
Max. Negotiated Rate	$392.00
Rate for Payer: Cash Price	$533.12
Rate for Payer: Cigna Commercial	$196.00
Rate for Payer: Multiplan Auto	$392.00
Rate for Payer: Multiplan Commercial	$392.00
Rate for Payer: Multiplan Workers Comp	$392.00
Rate for Payer: Scott and White EPO/PPO	$392.00

GTR CANCELLOUS CRUSH 15CC

Facility

$784.00

Service Code	HCPCS C1713
Hospital Charge Code	146445
Hospital Revenue Code	278
Min. Negotiated Rate	$70.56
Max. Negotiated Rate	$564.48
Rate for Payer: Amerigroup CHIP/Medicaid	$70.56
Rate for Payer: BCBS of TX Blue Advantage	$235.20
Rate for Payer: BCBS of TX Blue Essentials	$282.24
Rate for Payer: BCBS of TX PPO	$313.60
Rate for Payer: Cash Price	$533.12
Rate for Payer: Cigna Medicaid	$564.48
Rate for Payer: Molina CHIP/Medicaid	$564.48
Rate for Payer: Multiplan Auto	$392.00
Rate for Payer: Multiplan Commercial	$392.00
Rate for Payer: Multiplan Workers Comp	$392.00
Rate for Payer: Parkland Medicaid	$564.48
Rate for Payer: Scott and White EPO/PPO	$392.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.48
Rate for Payer: Superior Health Plan EPO	$106.62

G-tube, standard,M00509050

Facility

$552.48

Service Code	HCPCS B4087
Hospital Charge Code	994096
Hospital Revenue Code	272
Min. Negotiated Rate	$49.72
Max. Negotiated Rate	$397.79
Rate for Payer: Amerigroup CHIP/Medicaid	$49.72
Rate for Payer: BCBS of TX Blue Advantage	$165.74
Rate for Payer: BCBS of TX Blue Essentials	$198.89
Rate for Payer: BCBS of TX PPO	$220.99
Rate for Payer: Cash Price	$375.69
Rate for Payer: Cigna Medicaid	$397.79
Rate for Payer: Molina CHIP/Medicaid	$397.79
Rate for Payer: Multiplan Auto	$359.11
Rate for Payer: Multiplan Commercial	$359.11
Rate for Payer: Multiplan Workers Comp	$359.11
Rate for Payer: Parkland Medicaid	$397.79
Rate for Payer: Scott and White EPO/PPO	$276.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$397.79
Rate for Payer: Superior Health Plan EPO	$75.14

G-tube, standard,M00509050

Facility

$552.48

Service Code	HCPCS B4087
Hospital Charge Code	994096
Hospital Revenue Code	272
Rate for Payer: Cash Price	$375.69

guaiFENesin 100 mg/5 mL Oral Liquid 10 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77597175
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

guaiFENesin 100 mg/5 mL Oral Liquid 10 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77597175
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

guaiFENesin 100 mg/5 mL Oral Liquid 5 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77597603
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

guaiFENesin 100 mg/5 mL Oral Liquid 5 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77597603
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

guaiFENesin 600 mg ER Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77598021
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

guaiFENesin 600 mg ER Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77598021
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

Guardian Suction Canister with Locking Lid, 1200 cc

Facility

$7.85

Hospital Charge Code	993869
Hospital Revenue Code	271
Rate for Payer: Cash Price	$5.34

Guardian Suction Canister with Locking Lid, 1200 cc

Facility

$7.85

Hospital Charge Code	993869
Hospital Revenue Code	271
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$5.65
Rate for Payer: Amerigroup CHIP/Medicaid	$0.71
Rate for Payer: BCBS of TX Blue Advantage	$2.35
Rate for Payer: BCBS of TX Blue Essentials	$2.83
Rate for Payer: BCBS of TX PPO	$3.14
Rate for Payer: Cash Price	$5.34
Rate for Payer: Cigna Medicaid	$5.65
Rate for Payer: Molina CHIP/Medicaid	$5.65
Rate for Payer: Multiplan Auto	$5.10
Rate for Payer: Multiplan Commercial	$5.10
Rate for Payer: Multiplan Workers Comp	$5.10
Rate for Payer: Parkland Medicaid	$5.65
Rate for Payer: Scott and White EPO/PPO	$3.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.65
Rate for Payer: Superior Health Plan EPO	$1.07

GUIDE PIN FLEX XACTPIN

Facility

$903.46

Hospital Charge Code	8398513
Hospital Revenue Code	272
Rate for Payer: Cash Price	$614.35

GUIDE PIN FLEX XACTPIN

Facility

$903.46

Hospital Charge Code	8398513
Hospital Revenue Code	272
Min. Negotiated Rate	$81.31
Max. Negotiated Rate	$650.49
Rate for Payer: Amerigroup CHIP/Medicaid	$81.31
Rate for Payer: BCBS of TX Blue Advantage	$271.04
Rate for Payer: BCBS of TX Blue Essentials	$325.25
Rate for Payer: BCBS of TX PPO	$361.38
Rate for Payer: Cash Price	$614.35
Rate for Payer: Cigna Medicaid	$650.49
Rate for Payer: Molina CHIP/Medicaid	$650.49
Rate for Payer: Multiplan Auto	$587.25
Rate for Payer: Multiplan Commercial	$587.25
Rate for Payer: Multiplan Workers Comp	$587.25
Rate for Payer: Parkland Medicaid	$650.49
Rate for Payer: Scott and White EPO/PPO	$451.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.49
Rate for Payer: Superior Health Plan EPO	$122.87

GUIDE PIN FREE-LOCK TROCAR 3.2MM

Facility

$454.54

Hospital Charge Code	146539
Hospital Revenue Code	272
Rate for Payer: Cash Price	$309.09

GUIDE PIN FREE-LOCK TROCAR 3.2MM

Facility

$454.54

Hospital Charge Code	146539
Hospital Revenue Code	272
Min. Negotiated Rate	$40.91
Max. Negotiated Rate	$327.27
Rate for Payer: Amerigroup CHIP/Medicaid	$40.91
Rate for Payer: BCBS of TX Blue Advantage	$136.36
Rate for Payer: BCBS of TX Blue Essentials	$163.63
Rate for Payer: BCBS of TX PPO	$181.82
Rate for Payer: Cash Price	$309.09
Rate for Payer: Cigna Medicaid	$327.27
Rate for Payer: Molina CHIP/Medicaid	$327.27
Rate for Payer: Multiplan Auto	$295.45
Rate for Payer: Multiplan Commercial	$295.45
Rate for Payer: Multiplan Workers Comp	$295.45
Rate for Payer: Parkland Medicaid	$327.27
Rate for Payer: Scott and White EPO/PPO	$227.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$327.27
Rate for Payer: Superior Health Plan EPO	$61.82

GUIDE PIN THEADED STERILE 3.2MM X 444MM

Facility

$681.00

Service Code	HCPCS C1713
Hospital Charge Code	146547
Hospital Revenue Code	278
Min. Negotiated Rate	$170.25
Max. Negotiated Rate	$340.50
Rate for Payer: Cash Price	$463.08
Rate for Payer: Cigna Commercial	$170.25
Rate for Payer: Multiplan Auto	$340.50
Rate for Payer: Multiplan Commercial	$340.50
Rate for Payer: Multiplan Workers Comp	$340.50
Rate for Payer: Scott and White EPO/PPO	$340.50

GUIDE PIN THEADED STERILE 3.2MM X 444MM

Facility

$681.00

Service Code	HCPCS C1713
Hospital Charge Code	146547
Hospital Revenue Code	278
Min. Negotiated Rate	$61.29
Max. Negotiated Rate	$490.32
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	$463.08
Rate for Payer: Cigna Medicaid	$490.32
Rate for Payer: Molina CHIP/Medicaid	$490.32
Rate for Payer: Multiplan Auto	$340.50
Rate for Payer: Multiplan Commercial	$340.50
Rate for Payer: Multiplan Workers Comp	$340.50
Rate for Payer: Parkland Medicaid	$490.32
Rate for Payer: Scott and White EPO/PPO	$340.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$490.32
Rate for Payer: Superior Health Plan EPO	$92.62

GUIDEWIRE

Facility

$1,380.16

Service Code	HCPCS C1769
Hospital Charge Code	993261
Hospital Revenue Code	278
Min. Negotiated Rate	$124.21
Max. Negotiated Rate	$993.72
Rate for Payer: Amerigroup CHIP/Medicaid	$124.21
Rate for Payer: BCBS of TX Blue Advantage	$414.05
Rate for Payer: BCBS of TX Blue Essentials	$496.86
Rate for Payer: BCBS of TX PPO	$552.06
Rate for Payer: Cash Price	$938.51
Rate for Payer: Cigna Medicaid	$993.72
Rate for Payer: Molina CHIP/Medicaid	$993.72
Rate for Payer: Multiplan Auto	$690.08
Rate for Payer: Multiplan Commercial	$690.08
Rate for Payer: Multiplan Workers Comp	$690.08
Rate for Payer: Parkland Medicaid	$993.72
Rate for Payer: Scott and White EPO/PPO	$690.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$993.72
Rate for Payer: Superior Health Plan EPO	$187.70

GUIDEWIRE

Facility

$1,380.16

Service Code	HCPCS C1769
Hospital Charge Code	993261
Hospital Revenue Code	278
Min. Negotiated Rate	$345.04
Max. Negotiated Rate	$690.08
Rate for Payer: Cash Price	$938.51
Rate for Payer: Cigna Commercial	$345.04
Rate for Payer: Multiplan Auto	$690.08
Rate for Payer: Multiplan Commercial	$690.08
Rate for Payer: Multiplan Workers Comp	$690.08
Rate for Payer: Scott and White EPO/PPO	$690.08

GUIDEWIRE .035X180CM DYNJGWIRE03

Facility

$37.09

Hospital Charge Code	145200
Hospital Revenue Code	272
Rate for Payer: Cash Price	$25.22

GUIDEWIRE .035X180CM DYNJGWIRE03

Facility

$37.09

Hospital Charge Code	145200
Hospital Revenue Code	272
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$26.70
Rate for Payer: Amerigroup CHIP/Medicaid	$3.34
Rate for Payer: BCBS of TX Blue Advantage	$11.13
Rate for Payer: BCBS of TX Blue Essentials	$13.35
Rate for Payer: BCBS of TX PPO	$14.84
Rate for Payer: Cash Price	$25.22
Rate for Payer: Cigna Medicaid	$26.70
Rate for Payer: Molina CHIP/Medicaid	$26.70
Rate for Payer: Multiplan Auto	$24.11
Rate for Payer: Multiplan Commercial	$24.11
Rate for Payer: Multiplan Workers Comp	$24.11
Rate for Payer: Parkland Medicaid	$26.70
Rate for Payer: Scott and White EPO/PPO	$18.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.70
Rate for Payer: Superior Health Plan EPO	$5.04

GUIDEWIRE .035X260 DYNJGWIRE20

Facility

$47.67

Hospital Charge Code	145201
Hospital Revenue Code	272
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$34.32
Rate for Payer: Amerigroup CHIP/Medicaid	$4.29
Rate for Payer: BCBS of TX Blue Advantage	$14.30
Rate for Payer: BCBS of TX Blue Essentials	$17.16
Rate for Payer: BCBS of TX PPO	$19.07
Rate for Payer: Cash Price	$32.42
Rate for Payer: Cigna Medicaid	$34.32
Rate for Payer: Molina CHIP/Medicaid	$34.32
Rate for Payer: Multiplan Auto	$30.99
Rate for Payer: Multiplan Commercial	$30.99
Rate for Payer: Multiplan Workers Comp	$30.99
Rate for Payer: Parkland Medicaid	$34.32
Rate for Payer: Scott and White EPO/PPO	$23.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.32
Rate for Payer: Superior Health Plan EPO	$6.48

GUIDEWIRE .035X260 DYNJGWIRE20

Facility

$47.67

Hospital Charge Code	145201
Hospital Revenue Code	272
Rate for Payer: Cash Price	$32.42

Know your out-of-pocket cost for care.

All Charges