White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GUIDEWIRE ENDO .035 150CM STR FLX NTNL

Facility

$247.25

Hospital Charge Code	115990
Hospital Revenue Code	272
Min. Negotiated Rate	$22.25
Max. Negotiated Rate	$178.02
Rate for Payer: Amerigroup CHIP/Medicaid	$22.25
Rate for Payer: BCBS of TX Blue Advantage	$74.17
Rate for Payer: BCBS of TX Blue Essentials	$89.01
Rate for Payer: BCBS of TX PPO	$98.90
Rate for Payer: Cash Price	$168.13
Rate for Payer: Cigna Medicaid	$178.02
Rate for Payer: Molina CHIP/Medicaid	$178.02
Rate for Payer: Multiplan Auto	$160.71
Rate for Payer: Multiplan Commercial	$160.71
Rate for Payer: Multiplan Workers Comp	$160.71
Rate for Payer: Parkland Medicaid	$178.02
Rate for Payer: Scott and White EPO/PPO	$123.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$178.02
Rate for Payer: Superior Health Plan EPO	$33.63

GUIDEWIRE ENDO .035 150CM STR FLX NTNL

Facility

$247.25

Hospital Charge Code	115990
Hospital Revenue Code	272
Rate for Payer: Cash Price	$168.13

GUIDEWIRE, ENDOVAS HI-TORQUE COMMAND ES .014' 300C

Facility

$826.28

Service Code	HCPCS C1769
Hospital Charge Code	992473
Hospital Revenue Code	272
Rate for Payer: Cash Price	$561.87

GUIDEWIRE, ENDOVAS HI-TORQUE COMMAND ES .014' 300C

Facility

$749.10

Hospital Charge Code	82401670
Hospital Revenue Code	272
Min. Negotiated Rate	$67.42
Max. Negotiated Rate	$539.35
Rate for Payer: Amerigroup CHIP/Medicaid	$67.42
Rate for Payer: BCBS of TX Blue Advantage	$224.73
Rate for Payer: BCBS of TX Blue Essentials	$269.68
Rate for Payer: BCBS of TX PPO	$299.64
Rate for Payer: Cash Price	$509.39
Rate for Payer: Cigna Medicaid	$539.35
Rate for Payer: Molina CHIP/Medicaid	$539.35
Rate for Payer: Multiplan Auto	$486.92
Rate for Payer: Multiplan Commercial	$486.92
Rate for Payer: Multiplan Workers Comp	$486.92
Rate for Payer: Parkland Medicaid	$539.35
Rate for Payer: Scott and White EPO/PPO	$374.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$539.35
Rate for Payer: Superior Health Plan EPO	$101.88

GUIDEWIRE, ENDOVAS HI-TORQUE COMMAND ES .014' 300C

Facility

$826.28

Service Code	HCPCS C1769
Hospital Charge Code	992473
Hospital Revenue Code	272
Min. Negotiated Rate	$74.37
Max. Negotiated Rate	$594.92
Rate for Payer: Amerigroup CHIP/Medicaid	$74.37
Rate for Payer: BCBS of TX Blue Advantage	$247.88
Rate for Payer: BCBS of TX Blue Essentials	$297.46
Rate for Payer: BCBS of TX PPO	$330.51
Rate for Payer: Cash Price	$561.87
Rate for Payer: Cigna Medicaid	$594.92
Rate for Payer: Molina CHIP/Medicaid	$594.92
Rate for Payer: Multiplan Auto	$537.08
Rate for Payer: Multiplan Commercial	$537.08
Rate for Payer: Multiplan Workers Comp	$537.08
Rate for Payer: Parkland Medicaid	$594.92
Rate for Payer: Scott and White EPO/PPO	$413.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$594.92
Rate for Payer: Superior Health Plan EPO	$112.37

GUIDEWIRE, ENDOVAS HI-TORQUE COMMAND ES .014' 300C

Facility

$749.10

Hospital Charge Code	82401670
Hospital Revenue Code	272
Rate for Payer: Cash Price	$509.39

GUIDEWIRE EXCHANGE TUBE

Facility

$559.33

Hospital Charge Code	145340
Hospital Revenue Code	272
Min. Negotiated Rate	$50.34
Max. Negotiated Rate	$402.72
Rate for Payer: Amerigroup CHIP/Medicaid	$50.34
Rate for Payer: BCBS of TX Blue Advantage	$167.80
Rate for Payer: BCBS of TX Blue Essentials	$201.36
Rate for Payer: BCBS of TX PPO	$223.73
Rate for Payer: Cash Price	$380.34
Rate for Payer: Cigna Medicaid	$402.72
Rate for Payer: Molina CHIP/Medicaid	$402.72
Rate for Payer: Multiplan Auto	$363.56
Rate for Payer: Multiplan Commercial	$363.56
Rate for Payer: Multiplan Workers Comp	$363.56
Rate for Payer: Parkland Medicaid	$402.72
Rate for Payer: Scott and White EPO/PPO	$279.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$402.72
Rate for Payer: Superior Health Plan EPO	$76.07

GUIDEWIRE EXCHANGE TUBE

Facility

$559.33

Hospital Charge Code	145340
Hospital Revenue Code	272
Rate for Payer: Cash Price	$380.34

GUIDEWIRE HYD/JAGWIRE .035X260 M00556021

Facility

$895.47

Hospital Charge Code	145324
Hospital Revenue Code	272
Min. Negotiated Rate	$80.59
Max. Negotiated Rate	$644.74
Rate for Payer: Amerigroup CHIP/Medicaid	$80.59
Rate for Payer: BCBS of TX Blue Advantage	$268.64
Rate for Payer: BCBS of TX Blue Essentials	$322.37
Rate for Payer: BCBS of TX PPO	$358.19
Rate for Payer: Cash Price	$608.92
Rate for Payer: Cigna Medicaid	$644.74
Rate for Payer: Molina CHIP/Medicaid	$644.74
Rate for Payer: Multiplan Auto	$582.06
Rate for Payer: Multiplan Commercial	$582.06
Rate for Payer: Multiplan Workers Comp	$582.06
Rate for Payer: Parkland Medicaid	$644.74
Rate for Payer: Scott and White EPO/PPO	$447.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$644.74
Rate for Payer: Superior Health Plan EPO	$121.78

GUIDEWIRE HYD/JAGWIRE .035X260 M00556021

Facility

$895.47

Hospital Charge Code	145324
Hospital Revenue Code	272
Rate for Payer: Cash Price	$608.92

GUIDEWIRE LONG SPECIAL

Facility

$567.50

Hospital Charge Code	145475
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 LONG SPECIAL

Facility

$567.50

Hospital Charge Code	145475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

GUIDEWIRE NITINOL RD TIP 02.4X950

Facility

$559.33

Hospital Charge Code	145341
Hospital Revenue Code	272
Min. Negotiated Rate	$50.34
Max. Negotiated Rate	$402.72
Rate for Payer: Amerigroup CHIP/Medicaid	$50.34
Rate for Payer: BCBS of TX Blue Advantage	$167.80
Rate for Payer: BCBS of TX Blue Essentials	$201.36
Rate for Payer: BCBS of TX PPO	$223.73
Rate for Payer: Cash Price	$380.34
Rate for Payer: Cigna Medicaid	$402.72
Rate for Payer: Molina CHIP/Medicaid	$402.72
Rate for Payer: Multiplan Auto	$363.56
Rate for Payer: Multiplan Commercial	$363.56
Rate for Payer: Multiplan Workers Comp	$363.56
Rate for Payer: Parkland Medicaid	$402.72
Rate for Payer: Scott and White EPO/PPO	$279.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$402.72
Rate for Payer: Superior Health Plan EPO	$76.07

GUIDEWIRE NITINOL RD TIP 02.4X950

Facility

$559.33

Hospital Charge Code	145341
Hospital Revenue Code	272
Rate for Payer: Cash Price	$380.34

GUIDEWIRE NON-THREADED 1.1x150MM

Facility

$241.00

Service Code	HCPCS C1769
Hospital Charge Code	144642
Hospital Revenue Code	278
Min. Negotiated Rate	$60.25
Max. Negotiated Rate	$120.50
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cigna Commercial	$60.25
Rate for Payer: Multiplan Auto	$120.50
Rate for Payer: Multiplan Commercial	$120.50
Rate for Payer: Multiplan Workers Comp	$120.50
Rate for Payer: Scott and White EPO/PPO	$120.50

GUIDEWIRE NON-THREADED 1.1x150MM

Facility

$241.00

Service Code	HCPCS C1769
Hospital Charge Code	144642
Hospital Revenue Code	278
Min. Negotiated Rate	$21.69
Max. Negotiated Rate	$173.52
Rate for Payer: Amerigroup CHIP/Medicaid	$21.69
Rate for Payer: BCBS of TX Blue Advantage	$72.30
Rate for Payer: BCBS of TX Blue Essentials	$86.76
Rate for Payer: BCBS of TX PPO	$96.40
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cigna Medicaid	$173.52
Rate for Payer: Molina CHIP/Medicaid	$173.52
Rate for Payer: Multiplan Auto	$120.50
Rate for Payer: Multiplan Commercial	$120.50
Rate for Payer: Multiplan Workers Comp	$120.50
Rate for Payer: Parkland Medicaid	$173.52
Rate for Payer: Scott and White EPO/PPO	$120.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$173.52
Rate for Payer: Superior Health Plan EPO	$32.78

GUIDEWIRE ORTH 1.4X150MM UNTHRD

Facility

$1,107.76

Service Code	HCPCS C1769
Hospital Charge Code	993233
Hospital Revenue Code	278
Min. Negotiated Rate	$276.94
Max. Negotiated Rate	$553.88
Rate for Payer: Cash Price	$753.28
Rate for Payer: Cigna Commercial	$276.94
Rate for Payer: Multiplan Auto	$553.88
Rate for Payer: Multiplan Commercial	$553.88
Rate for Payer: Multiplan Workers Comp	$553.88
Rate for Payer: Scott and White EPO/PPO	$553.88

GUIDEWIRE ORTH 1.4X150MM UNTHRD

Facility

$1,107.76

Service Code	HCPCS C1769
Hospital Charge Code	993233
Hospital Revenue Code	278
Min. Negotiated Rate	$99.70
Max. Negotiated Rate	$797.59
Rate for Payer: Amerigroup CHIP/Medicaid	$99.70
Rate for Payer: BCBS of TX Blue Advantage	$332.33
Rate for Payer: BCBS of TX Blue Essentials	$398.79
Rate for Payer: BCBS of TX PPO	$443.10
Rate for Payer: Cash Price	$753.28
Rate for Payer: Cigna Medicaid	$797.59
Rate for Payer: Molina CHIP/Medicaid	$797.59
Rate for Payer: Multiplan Auto	$553.88
Rate for Payer: Multiplan Commercial	$553.88
Rate for Payer: Multiplan Workers Comp	$553.88
Rate for Payer: Parkland Medicaid	$797.59
Rate for Payer: Scott and White EPO/PPO	$553.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$797.59
Rate for Payer: Superior Health Plan EPO	$150.66

GUIDEWIRE ORTH 3.2X400MM TIB THRD CANN

Facility

$1,153.16

Hospital Charge Code	122941
Hospital Revenue Code	272
Min. Negotiated Rate	$103.78
Max. Negotiated Rate	$830.28
Rate for Payer: Amerigroup CHIP/Medicaid	$103.78
Rate for Payer: BCBS of TX Blue Advantage	$345.95
Rate for Payer: BCBS of TX Blue Essentials	$415.14
Rate for Payer: BCBS of TX PPO	$461.26
Rate for Payer: Cash Price	$784.15
Rate for Payer: Cigna Medicaid	$830.28
Rate for Payer: Molina CHIP/Medicaid	$830.28
Rate for Payer: Multiplan Auto	$749.55
Rate for Payer: Multiplan Commercial	$749.55
Rate for Payer: Multiplan Workers Comp	$749.55
Rate for Payer: Parkland Medicaid	$830.28
Rate for Payer: Scott and White EPO/PPO	$576.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$830.28
Rate for Payer: Superior Health Plan EPO	$156.83

GUIDEWIRE ORTH 3.2X400MM TIB THRD CANN

Facility

$1,153.16

Hospital Charge Code	122941
Hospital Revenue Code	272
Rate for Payer: Cash Price	$784.15

GUIDEWIRE ORTH 800MM 2.5MM T2 BALL TIP TIB NL SYS STRL

Facility

$1,253.04

Service Code	HCPCS C1769
Hospital Charge Code	993292
Hospital Revenue Code	278
Min. Negotiated Rate	$112.77
Max. Negotiated Rate	$902.19
Rate for Payer: Amerigroup CHIP/Medicaid	$112.77
Rate for Payer: BCBS of TX Blue Advantage	$375.91
Rate for Payer: BCBS of TX Blue Essentials	$451.09
Rate for Payer: BCBS of TX PPO	$501.22
Rate for Payer: Cash Price	$852.07
Rate for Payer: Cigna Medicaid	$902.19
Rate for Payer: Molina CHIP/Medicaid	$902.19
Rate for Payer: Multiplan Auto	$626.52
Rate for Payer: Multiplan Commercial	$626.52
Rate for Payer: Multiplan Workers Comp	$626.52
Rate for Payer: Parkland Medicaid	$902.19
Rate for Payer: Scott and White EPO/PPO	$626.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$902.19
Rate for Payer: Superior Health Plan EPO	$170.41

GUIDEWIRE ORTH 800MM 2.5MM T2 BALL TIP TIB NL SYS STRL

Facility

$1,253.04

Service Code	HCPCS C1769
Hospital Charge Code	993292
Hospital Revenue Code	278
Min. Negotiated Rate	$313.26
Max. Negotiated Rate	$626.52
Rate for Payer: Cash Price	$852.07
Rate for Payer: Cigna Commercial	$313.26
Rate for Payer: Multiplan Auto	$626.52
Rate for Payer: Multiplan Commercial	$626.52
Rate for Payer: Multiplan Workers Comp	$626.52
Rate for Payer: Scott and White EPO/PPO	$626.52

GUIDEWIRE ORTHOPEDIC 3MMX70CM BALL TIP STERILE

Facility

$572.40

Hospital Charge Code	146546
Hospital Revenue Code	272
Rate for Payer: Cash Price	$389.23

GUIDEWIRE ORTHOPEDIC 3MMX70CM BALL TIP STERILE

Facility

$572.40

Hospital Charge Code	146546
Hospital Revenue Code	272
Min. Negotiated Rate	$51.52
Max. Negotiated Rate	$412.13
Rate for Payer: Amerigroup CHIP/Medicaid	$51.52
Rate for Payer: BCBS of TX Blue Advantage	$171.72
Rate for Payer: BCBS of TX Blue Essentials	$206.06
Rate for Payer: BCBS of TX PPO	$228.96
Rate for Payer: Cash Price	$389.23
Rate for Payer: Cigna Medicaid	$412.13
Rate for Payer: Molina CHIP/Medicaid	$412.13
Rate for Payer: Multiplan Auto	$372.06
Rate for Payer: Multiplan Commercial	$372.06
Rate for Payer: Multiplan Workers Comp	$372.06
Rate for Payer: Parkland Medicaid	$412.13
Rate for Payer: Scott and White EPO/PPO	$286.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$412.13
Rate for Payer: Superior Health Plan EPO	$77.85

GUIDEWIRE PRELOAD CATHETER PROGREAT COAX

Facility

$2,542.40

Hospital Charge Code	8470499
Hospital Revenue Code	272
Min. Negotiated Rate	$228.82
Max. Negotiated Rate	$1,830.53
Rate for Payer: Amerigroup CHIP/Medicaid	$228.82
Rate for Payer: BCBS of TX Blue Advantage	$762.72
Rate for Payer: BCBS of TX Blue Essentials	$915.26
Rate for Payer: BCBS of TX PPO	$1,016.96
Rate for Payer: Cash Price	$1,728.83
Rate for Payer: Cigna Medicaid	$1,830.53
Rate for Payer: Molina CHIP/Medicaid	$1,830.53
Rate for Payer: Multiplan Auto	$1,652.56
Rate for Payer: Multiplan Commercial	$1,652.56
Rate for Payer: Multiplan Workers Comp	$1,652.56
Rate for Payer: Parkland Medicaid	$1,830.53
Rate for Payer: Scott and White EPO/PPO	$1,271.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,830.53
Rate for Payer: Superior Health Plan EPO	$345.77

Know your out-of-pocket cost for care.

All Charges