White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
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 ORTHOPEDIC 3MMX70CM BALL TIP STERILE

Facility

$572.40

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

GUIDEWIRE PRELOAD CATHETER PROGREAT COAX

Facility

$2,542.40

Hospital Charge Code	8470499
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,728.83

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

GUIDEWIRE SHORT

Facility

$454.00

Hospital Charge Code	145470
Hospital Revenue Code	272
Rate for Payer: Cash Price	$308.72

GUIDEWIRE SHORT

Facility

$454.00

Hospital Charge Code	145470
Hospital Revenue Code	272
Min. Negotiated Rate	$40.86
Max. Negotiated Rate	$326.88
Rate for Payer: Amerigroup CHIP/Medicaid	$40.86
Rate for Payer: BCBS of TX Blue Advantage	$136.20
Rate for Payer: BCBS of TX Blue Essentials	$163.44
Rate for Payer: BCBS of TX PPO	$181.60
Rate for Payer: Cash Price	$308.72
Rate for Payer: Cigna Medicaid	$326.88
Rate for Payer: Molina CHIP/Medicaid	$326.88
Rate for Payer: Multiplan Auto	$295.10
Rate for Payer: Multiplan Commercial	$295.10
Rate for Payer: Multiplan Workers Comp	$295.10
Rate for Payer: Parkland Medicaid	$326.88
Rate for Payer: Scott and White EPO/PPO	$227.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$326.88
Rate for Payer: Superior Health Plan EPO	$61.74

GUIDEWIRE SMOOTH TIP 2.2 X 800MM STRL

Facility

$1,175.86

Service Code	HCPCS C1769
Hospital Charge Code	993288
Hospital Revenue Code	278
Min. Negotiated Rate	$105.83
Max. Negotiated Rate	$846.62
Rate for Payer: Amerigroup CHIP/Medicaid	$105.83
Rate for Payer: BCBS of TX Blue Advantage	$352.76
Rate for Payer: BCBS of TX Blue Essentials	$423.31
Rate for Payer: BCBS of TX PPO	$470.34
Rate for Payer: Cash Price	$799.58
Rate for Payer: Cigna Medicaid	$846.62
Rate for Payer: Molina CHIP/Medicaid	$846.62
Rate for Payer: Multiplan Auto	$587.93
Rate for Payer: Multiplan Commercial	$587.93
Rate for Payer: Multiplan Workers Comp	$587.93
Rate for Payer: Parkland Medicaid	$846.62
Rate for Payer: Scott and White EPO/PPO	$587.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$846.62
Rate for Payer: Superior Health Plan EPO	$159.92

GUIDEWIRE SMOOTH TIP 2.2 X 800MM STRL

Facility

$1,175.86

Service Code	HCPCS C1769
Hospital Charge Code	993288
Hospital Revenue Code	278
Min. Negotiated Rate	$293.96
Max. Negotiated Rate	$587.93
Rate for Payer: Cash Price	$799.58
Rate for Payer: Cigna Commercial	$293.96
Rate for Payer: Multiplan Auto	$587.93
Rate for Payer: Multiplan Commercial	$587.93
Rate for Payer: Multiplan Workers Comp	$587.93
Rate for Payer: Scott and White EPO/PPO	$587.93

GUIDE WIRE SMOOTH TIP 3.0X800mm (STERILE)

Facility

$1,293.90

Service Code	HCPCS C1769
Hospital Charge Code	993418
Hospital Revenue Code	278
Min. Negotiated Rate	$116.45
Max. Negotiated Rate	$931.61
Rate for Payer: Amerigroup CHIP/Medicaid	$116.45
Rate for Payer: BCBS of TX Blue Advantage	$388.17
Rate for Payer: BCBS of TX Blue Essentials	$465.80
Rate for Payer: BCBS of TX PPO	$517.56
Rate for Payer: Cash Price	$879.85
Rate for Payer: Cigna Medicaid	$931.61
Rate for Payer: Molina CHIP/Medicaid	$931.61
Rate for Payer: Multiplan Auto	$646.95
Rate for Payer: Multiplan Commercial	$646.95
Rate for Payer: Multiplan Workers Comp	$646.95
Rate for Payer: Parkland Medicaid	$931.61
Rate for Payer: Scott and White EPO/PPO	$646.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$931.61
Rate for Payer: Superior Health Plan EPO	$175.97

GUIDE WIRE SMOOTH TIP 3.0X800mm (STERILE)

Facility

$1,293.90

Service Code	HCPCS C1769
Hospital Charge Code	993418
Hospital Revenue Code	278
Min. Negotiated Rate	$323.48
Max. Negotiated Rate	$646.95
Rate for Payer: Cash Price	$879.85
Rate for Payer: Cigna Commercial	$323.48
Rate for Payer: Multiplan Auto	$646.95
Rate for Payer: Multiplan Commercial	$646.95
Rate for Payer: Multiplan Workers Comp	$646.95
Rate for Payer: Scott and White EPO/PPO	$646.95

GUIDEWIRE SMOOTH TIP 3X800

Facility

$1,123.65

Hospital Charge Code	145505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$764.08

GUIDEWIRE SMOOTH TIP 3X800

Facility

$1,123.65

Hospital Charge Code	145505
Hospital Revenue Code	272
Min. Negotiated Rate	$101.13
Max. Negotiated Rate	$809.03
Rate for Payer: Amerigroup CHIP/Medicaid	$101.13
Rate for Payer: BCBS of TX Blue Advantage	$337.10
Rate for Payer: BCBS of TX Blue Essentials	$404.51
Rate for Payer: BCBS of TX PPO	$449.46
Rate for Payer: Cash Price	$764.08
Rate for Payer: Cigna Medicaid	$809.03
Rate for Payer: Molina CHIP/Medicaid	$809.03
Rate for Payer: Multiplan Auto	$730.37
Rate for Payer: Multiplan Commercial	$730.37
Rate for Payer: Multiplan Workers Comp	$730.37
Rate for Payer: Parkland Medicaid	$809.03
Rate for Payer: Scott and White EPO/PPO	$561.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$809.03
Rate for Payer: Superior Health Plan EPO	$152.82

GUIDEWIRE THREADED TIP 3.2MM

Facility

$1,239.42

Hospital Charge Code	146687
Hospital Revenue Code	272
Rate for Payer: Cash Price	$842.81

GUIDEWIRE THREADED TIP 3.2MM

Facility

$1,239.42

Hospital Charge Code	146687
Hospital Revenue Code	272
Min. Negotiated Rate	$111.55
Max. Negotiated Rate	$892.38
Rate for Payer: Amerigroup CHIP/Medicaid	$111.55
Rate for Payer: BCBS of TX Blue Advantage	$371.83
Rate for Payer: BCBS of TX Blue Essentials	$446.19
Rate for Payer: BCBS of TX PPO	$495.77
Rate for Payer: Cash Price	$842.81
Rate for Payer: Cigna Medicaid	$892.38
Rate for Payer: Molina CHIP/Medicaid	$892.38
Rate for Payer: Multiplan Auto	$805.62
Rate for Payer: Multiplan Commercial	$805.62
Rate for Payer: Multiplan Workers Comp	$805.62
Rate for Payer: Parkland Medicaid	$892.38
Rate for Payer: Scott and White EPO/PPO	$619.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$892.38
Rate for Payer: Superior Health Plan EPO	$168.56

GUIDE WIRE TROCAR TIP

Facility

$862.60

Hospital Charge Code	145156
Hospital Revenue Code	272
Rate for Payer: Cash Price	$586.57

GUIDE WIRE TROCAR TIP

Facility

$862.60

Hospital Charge Code	145156
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

GUIDEWIRE VASC .014 180CM STR SHP RNTHRU

Facility

$472.16

Service Code	HCPCS C1769
Hospital Charge Code	992480
Hospital Revenue Code	272
Rate for Payer: Cash Price	$321.07

GUIDEWIRE VASC .014 180CM STR SHP RNTHRU

Facility

$472.16

Service Code	HCPCS C1769
Hospital Charge Code	992480
Hospital Revenue Code	272
Min. Negotiated Rate	$42.49
Max. Negotiated Rate	$339.96
Rate for Payer: Amerigroup CHIP/Medicaid	$42.49
Rate for Payer: BCBS of TX Blue Advantage	$141.65
Rate for Payer: BCBS of TX Blue Essentials	$169.98
Rate for Payer: BCBS of TX PPO	$188.86
Rate for Payer: Cash Price	$321.07
Rate for Payer: Cigna Medicaid	$339.96
Rate for Payer: Molina CHIP/Medicaid	$339.96
Rate for Payer: Multiplan Auto	$306.90
Rate for Payer: Multiplan Commercial	$306.90
Rate for Payer: Multiplan Workers Comp	$306.90
Rate for Payer: Parkland Medicaid	$339.96
Rate for Payer: Scott and White EPO/PPO	$236.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$339.96
Rate for Payer: Superior Health Plan EPO	$64.21

GUIDEWIRE VASC .014 182CM STR CHC PT ICE

Facility

$374.10

Hospital Charge Code	107677
Hospital Revenue Code	272
Rate for Payer: Cash Price	$254.39

GUIDEWIRE VASC .014 182CM STR CHC PT ICE

Facility

$374.10

Hospital Charge Code	107677
Hospital Revenue Code	272
Min. Negotiated Rate	$33.67
Max. Negotiated Rate	$269.35
Rate for Payer: Amerigroup CHIP/Medicaid	$33.67
Rate for Payer: BCBS of TX Blue Advantage	$112.23
Rate for Payer: BCBS of TX Blue Essentials	$134.68
Rate for Payer: BCBS of TX PPO	$149.64
Rate for Payer: Cash Price	$254.39
Rate for Payer: Cigna Medicaid	$269.35
Rate for Payer: Molina CHIP/Medicaid	$269.35
Rate for Payer: Multiplan Auto	$243.16
Rate for Payer: Multiplan Commercial	$243.16
Rate for Payer: Multiplan Workers Comp	$243.16
Rate for Payer: Parkland Medicaid	$269.35
Rate for Payer: Scott and White EPO/PPO	$187.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$269.35
Rate for Payer: Superior Health Plan EPO	$50.88

GUIDEWIRE VASC .014 190CM STR PILT 150

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	992472
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

GUIDEWIRE VASC .014 190CM STR PILT 150

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	992472
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$359.57
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$339.59
Rate for Payer: Cigna Medicaid	$359.57
Rate for Payer: Molina CHIP/Medicaid	$359.57
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Parkland Medicaid	$359.57
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$359.57
Rate for Payer: Superior Health Plan EPO	$67.92

GUIDEWIRE VASC .014 190CM STR PILT 50

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	992471
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

Know your out-of-pocket cost for care.

All Charges