White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GUIDE WIRE 3.2MM

Facility

$299.64

Hospital Charge Code	122965
Hospital Revenue Code	272
Min. Negotiated Rate	$26.97
Max. Negotiated Rate	$215.74
Rate for Payer: Amerigroup CHIP/Medicaid	$26.97
Rate for Payer: BCBS of TX Blue Advantage	$89.89
Rate for Payer: BCBS of TX Blue Essentials	$107.87
Rate for Payer: BCBS of TX PPO	$119.86
Rate for Payer: Cash Price	$203.76
Rate for Payer: Cigna Medicaid	$215.74
Rate for Payer: Molina CHIP/Medicaid	$215.74
Rate for Payer: Multiplan Auto	$194.77
Rate for Payer: Multiplan Commercial	$194.77
Rate for Payer: Multiplan Workers Comp	$194.77
Rate for Payer: Parkland Medicaid	$215.74
Rate for Payer: Scott and White EPO/PPO	$149.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$215.74
Rate for Payer: Superior Health Plan EPO	$40.75

GUIDE WIRE 3.2MM

Facility

$299.64

Hospital Charge Code	122965
Hospital Revenue Code	272
Rate for Payer: Cash Price	$203.76

GUIDEWIRE 3.2 X 300 702627S

Facility

$613.81

Hospital Charge Code	8720618
Hospital Revenue Code	272
Rate for Payer: Cash Price	$417.39

GUIDEWIRE 3.2 X 300 702627S

Facility

$613.81

Hospital Charge Code	8720618
Hospital Revenue Code	272
Min. Negotiated Rate	$55.24
Max. Negotiated Rate	$441.94
Rate for Payer: Amerigroup CHIP/Medicaid	$55.24
Rate for Payer: BCBS of TX Blue Advantage	$184.14
Rate for Payer: BCBS of TX Blue Essentials	$220.97
Rate for Payer: BCBS of TX PPO	$245.52
Rate for Payer: Cash Price	$417.39
Rate for Payer: Cigna Medicaid	$441.94
Rate for Payer: Molina CHIP/Medicaid	$441.94
Rate for Payer: Multiplan Auto	$398.98
Rate for Payer: Multiplan Commercial	$398.98
Rate for Payer: Multiplan Workers Comp	$398.98
Rate for Payer: Parkland Medicaid	$441.94
Rate for Payer: Scott and White EPO/PPO	$306.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$441.94
Rate for Payer: Superior Health Plan EPO	$83.48

GUIDEWIRE AMPLATZ SS .035X180 M00146525

Facility

$173.11

Hospital Charge Code	8550489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$117.71

GUIDEWIRE AMPLATZ SS .035X180 M00146525

Facility

$173.11

Hospital Charge Code	8550489
Hospital Revenue Code	272
Min. Negotiated Rate	$15.58
Max. Negotiated Rate	$124.64
Rate for Payer: Amerigroup CHIP/Medicaid	$15.58
Rate for Payer: BCBS of TX Blue Advantage	$51.93
Rate for Payer: BCBS of TX Blue Essentials	$62.32
Rate for Payer: BCBS of TX PPO	$69.24
Rate for Payer: Cash Price	$117.71
Rate for Payer: Cigna Medicaid	$124.64
Rate for Payer: Molina CHIP/Medicaid	$124.64
Rate for Payer: Multiplan Auto	$112.52
Rate for Payer: Multiplan Commercial	$112.52
Rate for Payer: Multiplan Workers Comp	$112.52
Rate for Payer: Parkland Medicaid	$124.64
Rate for Payer: Scott and White EPO/PPO	$86.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$124.64
Rate for Payer: Superior Health Plan EPO	$23.54

GUIDEWIRE AMPLATZ SS .05X260 M001465261

Facility

$179.64

Hospital Charge Code	8550490
Hospital Revenue Code	272
Min. Negotiated Rate	$16.17
Max. Negotiated Rate	$129.34
Rate for Payer: Amerigroup CHIP/Medicaid	$16.17
Rate for Payer: BCBS of TX Blue Advantage	$53.89
Rate for Payer: BCBS of TX Blue Essentials	$64.67
Rate for Payer: BCBS of TX PPO	$71.86
Rate for Payer: Cash Price	$122.16
Rate for Payer: Cigna Medicaid	$129.34
Rate for Payer: Molina CHIP/Medicaid	$129.34
Rate for Payer: Multiplan Auto	$116.77
Rate for Payer: Multiplan Commercial	$116.77
Rate for Payer: Multiplan Workers Comp	$116.77
Rate for Payer: Parkland Medicaid	$129.34
Rate for Payer: Scott and White EPO/PPO	$89.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$129.34
Rate for Payer: Superior Health Plan EPO	$24.43

GUIDEWIRE AMPLATZ SS .05X260 M001465261

Facility

$179.64

Hospital Charge Code	8550490
Hospital Revenue Code	272
Rate for Payer: Cash Price	$122.16

GUIDEWIRE BALL NOSE

Facility

$2,111.10

Hospital Charge Code	8428491
Hospital Revenue Code	272
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$1,519.99
Rate for Payer: Amerigroup CHIP/Medicaid	$190.00
Rate for Payer: BCBS of TX Blue Advantage	$633.33
Rate for Payer: BCBS of TX Blue Essentials	$760.00
Rate for Payer: BCBS of TX PPO	$844.44
Rate for Payer: Cash Price	$1,435.55
Rate for Payer: Cigna Medicaid	$1,519.99
Rate for Payer: Molina CHIP/Medicaid	$1,519.99
Rate for Payer: Multiplan Auto	$1,372.21
Rate for Payer: Multiplan Commercial	$1,372.21
Rate for Payer: Multiplan Workers Comp	$1,372.21
Rate for Payer: Parkland Medicaid	$1,519.99
Rate for Payer: Scott and White EPO/PPO	$1,055.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,519.99
Rate for Payer: Superior Health Plan EPO	$287.11

GUIDEWIRE BALL NOSE

Facility

$2,111.10

Hospital Charge Code	8428491
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,435.55

GUIDEWIRE BALL TIP

Facility

$1,380.16

Service Code	HCPCS C1769
Hospital Charge Code	993253
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 BALL TIP

Facility

$1,380.16

Service Code	HCPCS C1769
Hospital Charge Code	993253
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 BALL TIP 02.5 X 1000MM

Facility

$719.14

Hospital Charge Code	145339
Hospital Revenue Code	272
Rate for Payer: Cash Price	$489.02

GUIDEWIRE BALL TIP 02.5 X 1000MM

Facility

$719.14

Hospital Charge Code	145339
Hospital Revenue Code	272
Min. Negotiated Rate	$64.72
Max. Negotiated Rate	$517.78
Rate for Payer: Amerigroup CHIP/Medicaid	$64.72
Rate for Payer: BCBS of TX Blue Advantage	$215.74
Rate for Payer: BCBS of TX Blue Essentials	$258.89
Rate for Payer: BCBS of TX PPO	$287.66
Rate for Payer: Cash Price	$489.02
Rate for Payer: Cigna Medicaid	$517.78
Rate for Payer: Molina CHIP/Medicaid	$517.78
Rate for Payer: Multiplan Auto	$467.44
Rate for Payer: Multiplan Commercial	$467.44
Rate for Payer: Multiplan Workers Comp	$467.44
Rate for Payer: Parkland Medicaid	$517.78
Rate for Payer: Scott and White EPO/PPO	$359.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$517.78
Rate for Payer: Superior Health Plan EPO	$97.80

GUIDEWIRE BALLTIP 3.0 X 1000

Facility

$930.70

Hospital Charge Code	146678
Hospital Revenue Code	272
Rate for Payer: Cash Price	$632.88

GUIDEWIRE BALLTIP 3.0 X 1000

Facility

$930.70

Hospital Charge Code	146678
Hospital Revenue Code	272
Min. Negotiated Rate	$83.76
Max. Negotiated Rate	$670.10
Rate for Payer: Amerigroup CHIP/Medicaid	$83.76
Rate for Payer: BCBS of TX Blue Advantage	$279.21
Rate for Payer: BCBS of TX Blue Essentials	$335.05
Rate for Payer: BCBS of TX PPO	$372.28
Rate for Payer: Cash Price	$632.88
Rate for Payer: Cigna Medicaid	$670.10
Rate for Payer: Molina CHIP/Medicaid	$670.10
Rate for Payer: Multiplan Auto	$604.96
Rate for Payer: Multiplan Commercial	$604.96
Rate for Payer: Multiplan Workers Comp	$604.96
Rate for Payer: Parkland Medicaid	$670.10
Rate for Payer: Scott and White EPO/PPO	$465.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$670.10
Rate for Payer: Superior Health Plan EPO	$126.58

Guide wire ball tip 3,0X800mm sterile

Facility

$1,321.14

Service Code	HCPCS C1769
Hospital Charge Code	993383
Hospital Revenue Code	278
Min. Negotiated Rate	$330.29
Max. Negotiated Rate	$660.57
Rate for Payer: Cash Price	$898.38
Rate for Payer: Cigna Commercial	$330.29
Rate for Payer: Multiplan Auto	$660.57
Rate for Payer: Multiplan Commercial	$660.57
Rate for Payer: Multiplan Workers Comp	$660.57
Rate for Payer: Scott and White EPO/PPO	$660.57

Guide wire ball tip 3,0X800mm sterile

Facility

$1,321.14

Service Code	HCPCS C1769
Hospital Charge Code	993383
Hospital Revenue Code	278
Min. Negotiated Rate	$118.90
Max. Negotiated Rate	$951.22
Rate for Payer: Amerigroup CHIP/Medicaid	$118.90
Rate for Payer: BCBS of TX Blue Advantage	$396.34
Rate for Payer: BCBS of TX Blue Essentials	$475.61
Rate for Payer: BCBS of TX PPO	$528.46
Rate for Payer: Cash Price	$898.38
Rate for Payer: Cigna Medicaid	$951.22
Rate for Payer: Molina CHIP/Medicaid	$951.22
Rate for Payer: Multiplan Auto	$660.57
Rate for Payer: Multiplan Commercial	$660.57
Rate for Payer: Multiplan Workers Comp	$660.57
Rate for Payer: Parkland Medicaid	$951.22
Rate for Payer: Scott and White EPO/PPO	$660.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$951.22
Rate for Payer: Superior Health Plan EPO	$179.68

GUIDEWIRE BALL TIP 3X800

Facility

$1,144.62

Hospital Charge Code	122959
Hospital Revenue Code	272
Rate for Payer: Cash Price	$778.34

GUIDEWIRE BALL TIP 3X800

Facility

$1,144.62

Hospital Charge Code	122959
Hospital Revenue Code	272
Min. Negotiated Rate	$103.02
Max. Negotiated Rate	$824.13
Rate for Payer: Amerigroup CHIP/Medicaid	$103.02
Rate for Payer: BCBS of TX Blue Advantage	$343.39
Rate for Payer: BCBS of TX Blue Essentials	$412.06
Rate for Payer: BCBS of TX PPO	$457.85
Rate for Payer: Cash Price	$778.34
Rate for Payer: Cigna Medicaid	$824.13
Rate for Payer: Molina CHIP/Medicaid	$824.13
Rate for Payer: Multiplan Auto	$744.00
Rate for Payer: Multiplan Commercial	$744.00
Rate for Payer: Multiplan Workers Comp	$744.00
Rate for Payer: Parkland Medicaid	$824.13
Rate for Payer: Scott and White EPO/PPO	$572.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$824.13
Rate for Payer: Superior Health Plan EPO	$155.67

GUIDEWIRE BALL TIP ROD

Facility

$567.50

Hospital Charge Code	145469
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
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	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
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: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

GUIDEWIRE BALL TIP ROD

Facility

$567.50

Hospital Charge Code	145469
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

GUIDE WIRE BALL TIP SHEATH

Facility

$862.60

Hospital Charge Code	145157
Hospital Revenue Code	272
Min. Negotiated Rate	$77.63
Max. Negotiated Rate	$621.07
Rate for Payer: Amerigroup CHIP/Medicaid	$77.63
Rate for Payer: BCBS of TX Blue Advantage	$258.78
Rate for Payer: BCBS of TX Blue Essentials	$310.54
Rate for Payer: BCBS of TX PPO	$345.04
Rate for Payer: Cash Price	$586.57
Rate for Payer: Cigna Medicaid	$621.07
Rate for Payer: Molina CHIP/Medicaid	$621.07
Rate for Payer: Multiplan Auto	$560.69
Rate for Payer: Multiplan Commercial	$560.69
Rate for Payer: Multiplan Workers Comp	$560.69
Rate for Payer: Parkland Medicaid	$621.07
Rate for Payer: Scott and White EPO/PPO	$431.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$621.07
Rate for Payer: Superior Health Plan EPO	$117.31

GUIDE WIRE BALL TIP SHEATH

Facility

$862.60

Hospital Charge Code	145157
Hospital Revenue Code	272
Rate for Payer: Cash Price	$586.57

guidewire ball tip t2 3x1000mm

Facility

$668.29

Hospital Charge Code	8688546
Hospital Revenue Code	272
Min. Negotiated Rate	$60.15
Max. Negotiated Rate	$481.17
Rate for Payer: Amerigroup CHIP/Medicaid	$60.15
Rate for Payer: BCBS of TX Blue Advantage	$200.49
Rate for Payer: BCBS of TX Blue Essentials	$240.58
Rate for Payer: BCBS of TX PPO	$267.32
Rate for Payer: Cash Price	$454.44
Rate for Payer: Cigna Medicaid	$481.17
Rate for Payer: Molina CHIP/Medicaid	$481.17
Rate for Payer: Multiplan Auto	$434.39
Rate for Payer: Multiplan Commercial	$434.39
Rate for Payer: Multiplan Workers Comp	$434.39
Rate for Payer: Parkland Medicaid	$481.17
Rate for Payer: Scott and White EPO/PPO	$334.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$481.17
Rate for Payer: Superior Health Plan EPO	$90.89

Know your out-of-pocket cost for care.

All Charges