White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GUIDEWIRE VASC BMW 0.014X300CM

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	992468
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 BMW 0.014X300CM

Facility

$499.40

Service Code	HCPCS C1769
Hospital Charge Code	992468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

GUIDEWIRE VASC HI-TORQ WINN

Facility

$681.00

Hospital Charge Code	107812
Hospital Revenue Code	272
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	$442.65
Rate for Payer: Multiplan Commercial	$442.65
Rate for Payer: Multiplan Workers Comp	$442.65
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 VASC HI-TORQ WINN

Facility

$681.00

Hospital Charge Code	107812
Hospital Revenue Code	272
Rate for Payer: Cash Price	$463.08

GW 80730559 -- DHF

Facility

$487.79

Hospital Charge Code	80730559
Hospital Revenue Code	272
Rate for Payer: Cash Price	$331.70

GW 80730559 -- DHF

Facility

$487.79

Hospital Charge Code	80730559
Hospital Revenue Code	272
Min. Negotiated Rate	$43.90
Max. Negotiated Rate	$351.21
Rate for Payer: Amerigroup CHIP/Medicaid	$43.90
Rate for Payer: BCBS of TX Blue Advantage	$146.34
Rate for Payer: BCBS of TX Blue Essentials	$175.60
Rate for Payer: BCBS of TX PPO	$195.12
Rate for Payer: Cash Price	$331.70
Rate for Payer: Cigna Medicaid	$351.21
Rate for Payer: Molina CHIP/Medicaid	$351.21
Rate for Payer: Multiplan Auto	$317.06
Rate for Payer: Multiplan Commercial	$317.06
Rate for Payer: Multiplan Workers Comp	$317.06
Rate for Payer: Parkland Medicaid	$351.21
Rate for Payer: Scott and White EPO/PPO	$243.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.21
Rate for Payer: Superior Health Plan EPO	$66.34

GW 80730609 -- DHF

Facility

$161.55

Hospital Charge Code	80730609
Hospital Revenue Code	272
Min. Negotiated Rate	$14.54
Max. Negotiated Rate	$116.32
Rate for Payer: Amerigroup CHIP/Medicaid	$14.54
Rate for Payer: BCBS of TX Blue Advantage	$48.47
Rate for Payer: BCBS of TX Blue Essentials	$58.16
Rate for Payer: BCBS of TX PPO	$64.62
Rate for Payer: Cash Price	$109.85
Rate for Payer: Cigna Medicaid	$116.32
Rate for Payer: Molina CHIP/Medicaid	$116.32
Rate for Payer: Multiplan Auto	$105.01
Rate for Payer: Multiplan Commercial	$105.01
Rate for Payer: Multiplan Workers Comp	$105.01
Rate for Payer: Parkland Medicaid	$116.32
Rate for Payer: Scott and White EPO/PPO	$80.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$116.32
Rate for Payer: Superior Health Plan EPO	$21.97

GW 80730609 -- DHF

Facility

$161.55

Hospital Charge Code	80730609
Hospital Revenue Code	272
Rate for Payer: Cash Price	$109.85

GW 80730757 -- DHF

Facility

$225.38

Hospital Charge Code	80730757
Hospital Revenue Code	272
Rate for Payer: Cash Price	$153.26

GW 80730757 -- DHF

Facility

$225.38

Hospital Charge Code	80730757
Hospital Revenue Code	272
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$162.27
Rate for Payer: Amerigroup CHIP/Medicaid	$20.28
Rate for Payer: BCBS of TX Blue Advantage	$67.61
Rate for Payer: BCBS of TX Blue Essentials	$81.14
Rate for Payer: BCBS of TX PPO	$90.15
Rate for Payer: Cash Price	$153.26
Rate for Payer: Cigna Medicaid	$162.27
Rate for Payer: Molina CHIP/Medicaid	$162.27
Rate for Payer: Multiplan Auto	$146.50
Rate for Payer: Multiplan Commercial	$146.50
Rate for Payer: Multiplan Workers Comp	$146.50
Rate for Payer: Parkland Medicaid	$162.27
Rate for Payer: Scott and White EPO/PPO	$112.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$162.27
Rate for Payer: Superior Health Plan EPO	$30.65

GW 80730856 -- DHF

Facility

$759.06

Hospital Charge Code	80730856
Hospital Revenue Code	272
Rate for Payer: Cash Price	$516.16

GW 80730856 -- DHF

Facility

$759.06

Hospital Charge Code	80730856
Hospital Revenue Code	272
Min. Negotiated Rate	$68.32
Max. Negotiated Rate	$546.52
Rate for Payer: Amerigroup CHIP/Medicaid	$68.32
Rate for Payer: BCBS of TX Blue Advantage	$227.72
Rate for Payer: BCBS of TX Blue Essentials	$273.26
Rate for Payer: BCBS of TX PPO	$303.62
Rate for Payer: Cash Price	$516.16
Rate for Payer: Cigna Medicaid	$546.52
Rate for Payer: Molina CHIP/Medicaid	$546.52
Rate for Payer: Multiplan Auto	$493.39
Rate for Payer: Multiplan Commercial	$493.39
Rate for Payer: Multiplan Workers Comp	$493.39
Rate for Payer: Parkland Medicaid	$546.52
Rate for Payer: Scott and White EPO/PPO	$379.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.52
Rate for Payer: Superior Health Plan EPO	$103.23

GW 80730864 -- DHF

Facility

$267.72

Hospital Charge Code	80730864
Hospital Revenue Code	272
Rate for Payer: Cash Price	$182.05

GW 80730864 -- DHF

Facility

$267.72

Hospital Charge Code	80730864
Hospital Revenue Code	272
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$192.76
Rate for Payer: Amerigroup CHIP/Medicaid	$24.09
Rate for Payer: BCBS of TX Blue Advantage	$80.32
Rate for Payer: BCBS of TX Blue Essentials	$96.38
Rate for Payer: BCBS of TX PPO	$107.09
Rate for Payer: Cash Price	$182.05
Rate for Payer: Cigna Medicaid	$192.76
Rate for Payer: Molina CHIP/Medicaid	$192.76
Rate for Payer: Multiplan Auto	$174.02
Rate for Payer: Multiplan Commercial	$174.02
Rate for Payer: Multiplan Workers Comp	$174.02
Rate for Payer: Parkland Medicaid	$192.76
Rate for Payer: Scott and White EPO/PPO	$133.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$192.76
Rate for Payer: Superior Health Plan EPO	$36.41

GW DRILL TIP -- DHF

Facility

$53.01

Hospital Charge Code	80731441
Hospital Revenue Code	272
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$38.17
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: BCBS of TX Blue Advantage	$15.90
Rate for Payer: BCBS of TX Blue Essentials	$19.08
Rate for Payer: BCBS of TX PPO	$21.20
Rate for Payer: Cash Price	$36.05
Rate for Payer: Cigna Medicaid	$38.17
Rate for Payer: Molina CHIP/Medicaid	$38.17
Rate for Payer: Multiplan Auto	$34.46
Rate for Payer: Multiplan Commercial	$34.46
Rate for Payer: Multiplan Workers Comp	$34.46
Rate for Payer: Parkland Medicaid	$38.17
Rate for Payer: Scott and White EPO/PPO	$26.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.17
Rate for Payer: Superior Health Plan EPO	$7.21

GW DRILL TIP -- DHF

Facility

$53.01

Hospital Charge Code	80731441
Hospital Revenue Code	272
Rate for Payer: Cash Price	$36.05

GW EMBOSHIELD

Facility

$544.80

Hospital Charge Code	8452478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$370.46

GW EMBOSHIELD

Facility

$544.80

Hospital Charge Code	8452478
Hospital Revenue Code	272
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$370.46
Rate for Payer: Cigna Medicaid	$392.26
Rate for Payer: Molina CHIP/Medicaid	$392.26
Rate for Payer: Multiplan Auto	$354.12
Rate for Payer: Multiplan Commercial	$354.12
Rate for Payer: Multiplan Workers Comp	$354.12
Rate for Payer: Parkland Medicaid	$392.26
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$392.26
Rate for Payer: Superior Health Plan EPO	$74.09

GW GLIDEWIRE GOLD -- DHF

Facility

$567.50

Hospital Charge Code	82466657
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

GW GLIDEWIRE GOLD -- DHF

Facility

$567.50

Hospital Charge Code	82466657
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

GW HI-TORQ BALANCE MW -- DHF

Facility

$354.12

Hospital Charge Code	82412545
Hospital Revenue Code	272
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$254.97
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.24
Rate for Payer: BCBS of TX Blue Essentials	$127.48
Rate for Payer: BCBS of TX PPO	$141.65
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cigna Medicaid	$254.97
Rate for Payer: Molina CHIP/Medicaid	$254.97
Rate for Payer: Multiplan Auto	$230.18
Rate for Payer: Multiplan Commercial	$230.18
Rate for Payer: Multiplan Workers Comp	$230.18
Rate for Payer: Parkland Medicaid	$254.97
Rate for Payer: Scott and White EPO/PPO	$177.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$254.97
Rate for Payer: Superior Health Plan EPO	$48.16

GW HI-TORQ BALANCE MW -- DHF

Facility

$354.12

Hospital Charge Code	82412545
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.80

GW HI-TORQ IRONMAN -- DHF

Facility

$354.12

Hospital Charge Code	82412701
Hospital Revenue Code	272
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$254.97
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.24
Rate for Payer: BCBS of TX Blue Essentials	$127.48
Rate for Payer: BCBS of TX PPO	$141.65
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cigna Medicaid	$254.97
Rate for Payer: Molina CHIP/Medicaid	$254.97
Rate for Payer: Multiplan Auto	$230.18
Rate for Payer: Multiplan Commercial	$230.18
Rate for Payer: Multiplan Workers Comp	$230.18
Rate for Payer: Parkland Medicaid	$254.97
Rate for Payer: Scott and White EPO/PPO	$177.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$254.97
Rate for Payer: Superior Health Plan EPO	$48.16

GW HI-TORQ IRONMAN -- DHF

Facility

$354.12

Hospital Charge Code	82412701
Hospital Revenue Code	272
Rate for Payer: Cash Price	$240.80

GW HITORQ WHOLY J SYS260 -- DHF

Facility

$678.94

Hospital Charge Code	82466947
Hospital Revenue Code	272
Rate for Payer: Cash Price	$461.68

Know your out-of-pocket cost for care.

All Charges