White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GUIDEWIRE VASC .014 190CM STR PILT 50

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	992471
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 WHSPR MS

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	992470
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

GUIDEWIRE VASC .014 190CM STR WHSPR MS

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	992470
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 TIP WRE ADV PNT VPR

Facility

$726.40

Service Code	HCPCS C1769
Hospital Charge Code	992479
Hospital Revenue Code	272
Rate for Payer: Cash Price	$493.95

GUIDEWIRE VASC .014 TIP WRE ADV PNT VPR

Facility

$726.40

Service Code	HCPCS C1769
Hospital Charge Code	992479
Hospital Revenue Code	272
Min. Negotiated Rate	$65.38
Max. Negotiated Rate	$523.01
Rate for Payer: Amerigroup CHIP/Medicaid	$65.38
Rate for Payer: BCBS of TX Blue Advantage	$217.92
Rate for Payer: BCBS of TX Blue Essentials	$261.50
Rate for Payer: BCBS of TX PPO	$290.56
Rate for Payer: Cash Price	$493.95
Rate for Payer: Cigna Medicaid	$523.01
Rate for Payer: Molina CHIP/Medicaid	$523.01
Rate for Payer: Multiplan Auto	$472.16
Rate for Payer: Multiplan Commercial	$472.16
Rate for Payer: Multiplan Workers Comp	$472.16
Rate for Payer: Parkland Medicaid	$523.01
Rate for Payer: Scott and White EPO/PPO	$363.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$523.01
Rate for Payer: Superior Health Plan EPO	$98.79

GUIDEWIRE VASC .016 180CM 35CM FTHM

Facility

$1,574.47

Hospital Charge Code	107628
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,070.64

GUIDEWIRE VASC .016 180CM 35CM FTHM

Facility

$1,574.47

Hospital Charge Code	107628
Hospital Revenue Code	272
Min. Negotiated Rate	$141.70
Max. Negotiated Rate	$1,133.62
Rate for Payer: Amerigroup CHIP/Medicaid	$141.70
Rate for Payer: BCBS of TX Blue Advantage	$472.34
Rate for Payer: BCBS of TX Blue Essentials	$566.81
Rate for Payer: BCBS of TX PPO	$629.79
Rate for Payer: Cash Price	$1,070.64
Rate for Payer: Cigna Medicaid	$1,133.62
Rate for Payer: Molina CHIP/Medicaid	$1,133.62
Rate for Payer: Multiplan Auto	$1,023.41
Rate for Payer: Multiplan Commercial	$1,023.41
Rate for Payer: Multiplan Workers Comp	$1,023.41
Rate for Payer: Parkland Medicaid	$1,133.62
Rate for Payer: Scott and White EPO/PPO	$787.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,133.62
Rate for Payer: Superior Health Plan EPO	$214.13

GUIDEWIRE VASC .035 180CM ANG STD GLDWR

Facility

$186.82

Hospital Charge Code	107737
Hospital Revenue Code	272
Min. Negotiated Rate	$16.81
Max. Negotiated Rate	$134.51
Rate for Payer: Amerigroup CHIP/Medicaid	$16.81
Rate for Payer: BCBS of TX Blue Advantage	$56.05
Rate for Payer: BCBS of TX Blue Essentials	$67.26
Rate for Payer: BCBS of TX PPO	$74.73
Rate for Payer: Cash Price	$127.04
Rate for Payer: Cigna Medicaid	$134.51
Rate for Payer: Molina CHIP/Medicaid	$134.51
Rate for Payer: Multiplan Auto	$121.43
Rate for Payer: Multiplan Commercial	$121.43
Rate for Payer: Multiplan Workers Comp	$121.43
Rate for Payer: Parkland Medicaid	$134.51
Rate for Payer: Scott and White EPO/PPO	$93.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.51
Rate for Payer: Superior Health Plan EPO	$25.41

GUIDEWIRE VASC .035 180CM ANG STD GLDWR

Facility

$186.82

Hospital Charge Code	107737
Hospital Revenue Code	272
Rate for Payer: Cash Price	$127.04

GUIDEWIRE VASC .035 180CM ANG STF GLDWR

Facility

$219.96

Hospital Charge Code	107744
Hospital Revenue Code	272
Rate for Payer: Cash Price	$149.57

GUIDEWIRE VASC .035 180CM ANG STF GLDWR

Facility

$219.96

Hospital Charge Code	107744
Hospital Revenue Code	272
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$158.37
Rate for Payer: Amerigroup CHIP/Medicaid	$19.80
Rate for Payer: BCBS of TX Blue Advantage	$65.99
Rate for Payer: BCBS of TX Blue Essentials	$79.19
Rate for Payer: BCBS of TX PPO	$87.98
Rate for Payer: Cash Price	$149.57
Rate for Payer: Cigna Medicaid	$158.37
Rate for Payer: Molina CHIP/Medicaid	$158.37
Rate for Payer: Multiplan Auto	$142.97
Rate for Payer: Multiplan Commercial	$142.97
Rate for Payer: Multiplan Workers Comp	$142.97
Rate for Payer: Parkland Medicaid	$158.37
Rate for Payer: Scott and White EPO/PPO	$109.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$158.37
Rate for Payer: Superior Health Plan EPO	$29.91

GUIDEWIRE VASC .035 260CM ANG STD GLDWR

Facility

$208.84

Hospital Charge Code	80732431
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.01

GUIDEWIRE VASC .035 260CM ANG STD GLDWR

Facility

$208.84

Hospital Charge Code	80732431
Hospital Revenue Code	272
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$150.36
Rate for Payer: Amerigroup CHIP/Medicaid	$18.80
Rate for Payer: BCBS of TX Blue Advantage	$62.65
Rate for Payer: BCBS of TX Blue Essentials	$75.18
Rate for Payer: BCBS of TX PPO	$83.54
Rate for Payer: Cash Price	$142.01
Rate for Payer: Cigna Medicaid	$150.36
Rate for Payer: Molina CHIP/Medicaid	$150.36
Rate for Payer: Multiplan Auto	$135.75
Rate for Payer: Multiplan Commercial	$135.75
Rate for Payer: Multiplan Workers Comp	$135.75
Rate for Payer: Parkland Medicaid	$150.36
Rate for Payer: Scott and White EPO/PPO	$104.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.36
Rate for Payer: Superior Health Plan EPO	$28.40

GUIDEWIRE VASC .035 260CM STF ANG GLDWR

Facility

$234.49

Hospital Charge Code	80732308
Hospital Revenue Code	272
Min. Negotiated Rate	$21.10
Max. Negotiated Rate	$168.83
Rate for Payer: Amerigroup CHIP/Medicaid	$21.10
Rate for Payer: BCBS of TX Blue Advantage	$70.35
Rate for Payer: BCBS of TX Blue Essentials	$84.42
Rate for Payer: BCBS of TX PPO	$93.80
Rate for Payer: Cash Price	$159.45
Rate for Payer: Cigna Medicaid	$168.83
Rate for Payer: Molina CHIP/Medicaid	$168.83
Rate for Payer: Multiplan Auto	$152.42
Rate for Payer: Multiplan Commercial	$152.42
Rate for Payer: Multiplan Workers Comp	$152.42
Rate for Payer: Parkland Medicaid	$168.83
Rate for Payer: Scott and White EPO/PPO	$117.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$168.83
Rate for Payer: Superior Health Plan EPO	$31.89

GUIDEWIRE VASC .035 260CM STF ANG GLDWR

Facility

$234.49

Hospital Charge Code	80732308
Hospital Revenue Code	272
Rate for Payer: Cash Price	$159.45

GUIDEWIRE VASC .035 260CM STR BNTSN STRT

Facility

$115.11

Service Code	HCPCS C1769
Hospital Charge Code	992358
Hospital Revenue Code	278
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$82.88
Rate for Payer: Amerigroup CHIP/Medicaid	$10.36
Rate for Payer: BCBS of TX Blue Advantage	$34.53
Rate for Payer: BCBS of TX Blue Essentials	$41.44
Rate for Payer: BCBS of TX PPO	$46.04
Rate for Payer: Cash Price	$78.27
Rate for Payer: Cigna Medicaid	$82.88
Rate for Payer: Molina CHIP/Medicaid	$82.88
Rate for Payer: Multiplan Auto	$57.55
Rate for Payer: Multiplan Commercial	$57.55
Rate for Payer: Multiplan Workers Comp	$57.55
Rate for Payer: Parkland Medicaid	$82.88
Rate for Payer: Scott and White EPO/PPO	$57.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$82.88
Rate for Payer: Superior Health Plan EPO	$15.65

GUIDEWIRE VASC .035 260CM STR BNTSN STRT

Facility

$115.11

Service Code	HCPCS C1769
Hospital Charge Code	992358
Hospital Revenue Code	278
Min. Negotiated Rate	$28.78
Max. Negotiated Rate	$57.55
Rate for Payer: Cash Price	$78.27
Rate for Payer: Cigna Commercial	$28.78
Rate for Payer: Multiplan Auto	$57.55
Rate for Payer: Multiplan Commercial	$57.55
Rate for Payer: Multiplan Workers Comp	$57.55
Rate for Payer: Scott and White EPO/PPO	$57.55

GUIDEWIRE VASC .035 300CM STR SUP COR 35

Facility

$363.20

Service Code	HCPCS C1769
Hospital Charge Code	992469
Hospital Revenue Code	272
Min. Negotiated Rate	$32.69
Max. Negotiated Rate	$261.50
Rate for Payer: Amerigroup CHIP/Medicaid	$32.69
Rate for Payer: BCBS of TX Blue Advantage	$108.96
Rate for Payer: BCBS of TX Blue Essentials	$130.75
Rate for Payer: BCBS of TX PPO	$145.28
Rate for Payer: Cash Price	$246.98
Rate for Payer: Cigna Medicaid	$261.50
Rate for Payer: Molina CHIP/Medicaid	$261.50
Rate for Payer: Multiplan Auto	$236.08
Rate for Payer: Multiplan Commercial	$236.08
Rate for Payer: Multiplan Workers Comp	$236.08
Rate for Payer: Parkland Medicaid	$261.50
Rate for Payer: Scott and White EPO/PPO	$181.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$261.50
Rate for Payer: Superior Health Plan EPO	$49.40

GUIDEWIRE VASC .035 300CM STR SUP COR 35

Facility

$363.20

Service Code	HCPCS C1769
Hospital Charge Code	992469
Hospital Revenue Code	272
Rate for Payer: Cash Price	$246.98

GUIDEWIRE VASC .035 75CM STR AMP SPST

Facility

$158.90

Service Code	HCPCS C1769
Hospital Charge Code	992478
Hospital Revenue Code	272
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$114.41
Rate for Payer: Amerigroup CHIP/Medicaid	$14.30
Rate for Payer: BCBS of TX Blue Advantage	$47.67
Rate for Payer: BCBS of TX Blue Essentials	$57.20
Rate for Payer: BCBS of TX PPO	$63.56
Rate for Payer: Cash Price	$108.05
Rate for Payer: Cigna Medicaid	$114.41
Rate for Payer: Molina CHIP/Medicaid	$114.41
Rate for Payer: Multiplan Auto	$103.28
Rate for Payer: Multiplan Commercial	$103.28
Rate for Payer: Multiplan Workers Comp	$103.28
Rate for Payer: Parkland Medicaid	$114.41
Rate for Payer: Scott and White EPO/PPO	$79.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$114.41
Rate for Payer: Superior Health Plan EPO	$21.61

GUIDEWIRE VASC .035 75CM STR AMP SPST

Facility

$158.90

Service Code	HCPCS C1769
Hospital Charge Code	992478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$108.05

GUIDEWIRE VASC 145CM HI-TORQ VERSACORE FLPY

Facility

$340.50

Hospital Charge Code	107612
Hospital Revenue Code	272
Rate for Payer: Cash Price	$231.54

GUIDEWIRE VASC 145CM HI-TORQ VERSACORE FLPY

Facility

$340.50

Hospital Charge Code	107612
Hospital Revenue Code	272
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$245.16
Rate for Payer: Amerigroup CHIP/Medicaid	$30.64
Rate for Payer: BCBS of TX Blue Advantage	$102.15
Rate for Payer: BCBS of TX Blue Essentials	$122.58
Rate for Payer: BCBS of TX PPO	$136.20
Rate for Payer: Cash Price	$231.54
Rate for Payer: Cigna Medicaid	$245.16
Rate for Payer: Molina CHIP/Medicaid	$245.16
Rate for Payer: Multiplan Auto	$221.32
Rate for Payer: Multiplan Commercial	$221.32
Rate for Payer: Multiplan Workers Comp	$221.32
Rate for Payer: Parkland Medicaid	$245.16
Rate for Payer: Scott and White EPO/PPO	$170.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$245.16
Rate for Payer: Superior Health Plan EPO	$46.31

GUIDEWIRE VASC 260CM ADV NTNL

Facility

$208.84

Hospital Charge Code	107731
Hospital Revenue Code	272
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$150.36
Rate for Payer: Amerigroup CHIP/Medicaid	$18.80
Rate for Payer: BCBS of TX Blue Advantage	$62.65
Rate for Payer: BCBS of TX Blue Essentials	$75.18
Rate for Payer: BCBS of TX PPO	$83.54
Rate for Payer: Cash Price	$142.01
Rate for Payer: Cigna Medicaid	$150.36
Rate for Payer: Molina CHIP/Medicaid	$150.36
Rate for Payer: Multiplan Auto	$135.75
Rate for Payer: Multiplan Commercial	$135.75
Rate for Payer: Multiplan Workers Comp	$135.75
Rate for Payer: Parkland Medicaid	$150.36
Rate for Payer: Scott and White EPO/PPO	$104.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.36
Rate for Payer: Superior Health Plan EPO	$28.40

GUIDEWIRE VASC 260CM ADV NTNL

Facility

$208.84

Hospital Charge Code	107731
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.01

Know your out-of-pocket cost for care.

All Charges