White Rock Medical Center

All Charges

Charge

Type

Setting

Price

gabapentin 100 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585676
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

gabapentin 100 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585676
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

gabapentin 300 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585945
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

gabapentin 300 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585945
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

gabapentin 400 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77586096
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

gabapentin 400 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77586096
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Gabapentin (Neurontin), Serum SO

Facility

$187.00

Service Code	CPT 80171
Hospital Charge Code	8486567
Hospital Revenue Code	301
Min. Negotiated Rate	$8.45
Max. Negotiated Rate	$121.55
Rate for Payer: Aetna Commercial	$22.75
Rate for Payer: Aetna Medicare	$32.50
Rate for Payer: Amerigroup CHIP/Medicaid	$8.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.67
Rate for Payer: Amerigroup Medicare	$21.67
Rate for Payer: BCBS of TX Blue Advantage	$35.76
Rate for Payer: BCBS of TX Blue Essentials	$42.91
Rate for Payer: BCBS of TX Medicare	$21.67
Rate for Payer: BCBS of TX PPO	$47.89
Rate for Payer: Cash Price	$164.56
Rate for Payer: Cash Price	$164.56
Rate for Payer: Cigna Medicaid	$21.67
Rate for Payer: Cigna Medicare	$21.67
Rate for Payer: Employer Direct Commercial	$21.67
Rate for Payer: Humana Medicare/TRICARE	$21.67
Rate for Payer: Molina CHIP/Medicaid	$21.67
Rate for Payer: Molina Dual Medicare/Medicaid	$21.67
Rate for Payer: Molina Medicare	$21.67
Rate for Payer: Multiplan Auto	$121.55
Rate for Payer: Multiplan Commercial	$121.55
Rate for Payer: Multiplan Workers Comp	$121.55
Rate for Payer: Parkland Medicaid	$21.67
Rate for Payer: Scott and White EPO/PPO	$27.09
Rate for Payer: Scott and White Medicare	$21.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.67
Rate for Payer: Superior Health Plan EPO	$21.67
Rate for Payer: Superior Health Plan Medicare	$21.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.67
Rate for Payer: Universal American Medicare	$21.67
Rate for Payer: Wellcare Medicare	$21.67
Rate for Payer: Wellmed Medicare	$21.67

Gabapentin (Neurontin), Serum SO

Facility

$187.00

Service Code	CPT 80171
Hospital Charge Code	8486567
Hospital Revenue Code	301
Rate for Payer: Cash Price	$164.56

GAD-65 Autoantibody SO

Facility

$63.00

Service Code	CPT 86341
Hospital Charge Code	1707454
Hospital Revenue Code	302
Rate for Payer: Cash Price	$55.44

GAD-65 Autoantibody SO

Facility

$63.00

Service Code	CPT 86341
Hospital Charge Code	1707454
Hospital Revenue Code	302
Min. Negotiated Rate	$9.19
Max. Negotiated Rate	$52.09
Rate for Payer: Aetna Commercial	$24.74
Rate for Payer: Aetna Medicare	$35.36
Rate for Payer: Amerigroup CHIP/Medicaid	$9.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23.57
Rate for Payer: Amerigroup Medicare	$23.57
Rate for Payer: BCBS of TX Blue Advantage	$38.89
Rate for Payer: BCBS of TX Blue Essentials	$46.67
Rate for Payer: BCBS of TX Medicare	$23.57
Rate for Payer: BCBS of TX PPO	$52.09
Rate for Payer: Cash Price	$55.44
Rate for Payer: Cash Price	$55.44
Rate for Payer: Cigna Medicaid	$23.57
Rate for Payer: Cigna Medicare	$23.57
Rate for Payer: Employer Direct Commercial	$23.57
Rate for Payer: Humana Medicare/TRICARE	$23.57
Rate for Payer: Molina CHIP/Medicaid	$23.57
Rate for Payer: Molina Dual Medicare/Medicaid	$23.57
Rate for Payer: Molina Medicare	$23.57
Rate for Payer: Multiplan Auto	$40.95
Rate for Payer: Multiplan Commercial	$40.95
Rate for Payer: Multiplan Workers Comp	$40.95
Rate for Payer: Parkland Medicaid	$23.57
Rate for Payer: Scott and White EPO/PPO	$29.46
Rate for Payer: Scott and White Medicare	$23.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.57
Rate for Payer: Superior Health Plan EPO	$23.57
Rate for Payer: Superior Health Plan Medicare	$23.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$23.57
Rate for Payer: Universal American Medicare	$23.57
Rate for Payer: Wellcare Medicare	$23.57
Rate for Payer: Wellmed Medicare	$23.57

gadoteridol 279.3 mg/mL Inj Soln 5 mL

Facility

$60.50

Service Code	HCPCS A9577
Hospital Charge Code	77588110
Hospital Revenue Code	636
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$30.25
Rate for Payer: Cash Price	$41.14
Rate for Payer: Cigna Commercial	$15.12
Rate for Payer: Scott and White EPO/PPO	$30.25

gadoteridol 279.3 mg/mL Inj Soln 5 mL

Facility

$60.50

Service Code	HCPCS A9577
Hospital Charge Code	77588110
Hospital Revenue Code	636
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$39.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.44
Rate for Payer: BCBS of TX Blue Advantage	$3.13
Rate for Payer: BCBS of TX Blue Essentials	$3.76
Rate for Payer: BCBS of TX PPO	$4.17
Rate for Payer: Cash Price	$41.14
Rate for Payer: Cash Price	$41.14
Rate for Payer: Multiplan Auto	$39.32
Rate for Payer: Multiplan Commercial	$39.32
Rate for Payer: Multiplan Workers Comp	$39.32
Rate for Payer: Scott and White EPO/PPO	$30.25
Rate for Payer: Superior Health Plan EPO	$8.23

GAIT BELT ECONO

Facility

$14.89

Hospital Charge Code	8584505
Hospital Revenue Code	270
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$9.68
Rate for Payer: Aetna Commercial	$8.19
Rate for Payer: Amerigroup CHIP/Medicaid	$1.34
Rate for Payer: BCBS of TX Blue Advantage	$4.47
Rate for Payer: BCBS of TX Blue Essentials	$5.36
Rate for Payer: BCBS of TX PPO	$5.96
Rate for Payer: Cash Price	$13.10
Rate for Payer: Multiplan Auto	$9.68
Rate for Payer: Multiplan Commercial	$9.68
Rate for Payer: Multiplan Workers Comp	$9.68
Rate for Payer: Scott and White EPO/PPO	$7.44
Rate for Payer: Superior Health Plan EPO	$2.03

GAIT BELT ECONO

Facility

$14.89

Hospital Charge Code	8584505
Hospital Revenue Code	270
Rate for Payer: Cash Price	$13.10

GAMMAGLOBULIN;IGA,IGD,IGG,IGM EACH

Facility

$199.00

Service Code	CPT 82784
Hospital Charge Code	1602069
Hospital Revenue Code	301
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$129.35
Rate for Payer: Aetna Commercial	$9.76
Rate for Payer: Aetna Medicare	$13.95
Rate for Payer: Amerigroup CHIP/Medicaid	$3.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.30
Rate for Payer: Amerigroup Medicare	$9.30
Rate for Payer: BCBS of TX Blue Advantage	$15.34
Rate for Payer: BCBS of TX Blue Essentials	$18.41
Rate for Payer: BCBS of TX Medicare	$9.30
Rate for Payer: BCBS of TX PPO	$20.55
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cash Price	$175.12
Rate for Payer: Cigna Medicaid	$9.30
Rate for Payer: Cigna Medicare	$9.30
Rate for Payer: Employer Direct Commercial	$9.30
Rate for Payer: Humana Medicare/TRICARE	$9.30
Rate for Payer: Molina CHIP/Medicaid	$9.30
Rate for Payer: Molina Dual Medicare/Medicaid	$9.30
Rate for Payer: Molina Medicare	$9.30
Rate for Payer: Multiplan Auto	$129.35
Rate for Payer: Multiplan Commercial	$129.35
Rate for Payer: Multiplan Workers Comp	$129.35
Rate for Payer: Parkland Medicaid	$9.30
Rate for Payer: Scott and White EPO/PPO	$11.62
Rate for Payer: Scott and White Medicare	$9.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.30
Rate for Payer: Superior Health Plan EPO	$9.30
Rate for Payer: Superior Health Plan Medicare	$9.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.30
Rate for Payer: Universal American Medicare	$9.30
Rate for Payer: Wellcare Medicare	$9.30
Rate for Payer: Wellmed Medicare	$9.30

Gamma Glutamyl Transferase

Facility

$265.00

Service Code	CPT 82977
Hospital Charge Code	1601889
Hospital Revenue Code	301
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$172.25
Rate for Payer: Aetna Commercial	$7.56
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: Amerigroup CHIP/Medicaid	$2.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.20
Rate for Payer: Amerigroup Medicare	$7.20
Rate for Payer: BCBS of TX Blue Advantage	$11.88
Rate for Payer: BCBS of TX Blue Essentials	$14.26
Rate for Payer: BCBS of TX Medicare	$7.20
Rate for Payer: BCBS of TX PPO	$15.91
Rate for Payer: Cash Price	$233.20
Rate for Payer: Cash Price	$233.20
Rate for Payer: Cigna Medicaid	$7.20
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Employer Direct Commercial	$7.20
Rate for Payer: Humana Medicare/TRICARE	$7.20
Rate for Payer: Molina CHIP/Medicaid	$7.20
Rate for Payer: Molina Dual Medicare/Medicaid	$7.20
Rate for Payer: Molina Medicare	$7.20
Rate for Payer: Multiplan Auto	$172.25
Rate for Payer: Multiplan Commercial	$172.25
Rate for Payer: Multiplan Workers Comp	$172.25
Rate for Payer: Parkland Medicaid	$7.20
Rate for Payer: Scott and White EPO/PPO	$9.00
Rate for Payer: Scott and White Medicare	$7.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.20
Rate for Payer: Superior Health Plan EPO	$7.20
Rate for Payer: Superior Health Plan Medicare	$7.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.20
Rate for Payer: Universal American Medicare	$7.20
Rate for Payer: Wellcare Medicare	$7.20
Rate for Payer: Wellmed Medicare	$7.20

Gamma Glutamyl Transferase

Facility

$265.00

Service Code	CPT 82977
Hospital Charge Code	1601889
Hospital Revenue Code	301
Rate for Payer: Cash Price	$233.20

.Gamma-Hydroxybutyric Acid, CF SO

Facility

$260.00

Service Code	CPT 80375
Hospital Charge Code	1743024
Hospital Revenue Code	301
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$169.00
Rate for Payer: Aetna Commercial	$0.02
Rate for Payer: Amerigroup CHIP/Medicaid	$8.40
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cigna Medicaid	$21.53
Rate for Payer: Molina CHIP/Medicaid	$21.53
Rate for Payer: Multiplan Auto	$169.00
Rate for Payer: Multiplan Commercial	$169.00
Rate for Payer: Multiplan Workers Comp	$169.00
Rate for Payer: Parkland Medicaid	$21.53
Rate for Payer: Scott and White EPO/PPO	$130.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.53
Rate for Payer: Superior Health Plan EPO	$35.36

.Gamma-Hydroxybutyric Acid, CF SO

Facility

$260.00

Service Code	CPT 80375
Hospital Charge Code	1743024
Hospital Revenue Code	301
Rate for Payer: Cash Price	$228.80

GAMMA NAIL CLIP

Facility

$1,216.63

Service Code	HCPCS C1713
Hospital Charge Code	145317
Hospital Revenue Code	278
Min. Negotiated Rate	$304.16
Max. Negotiated Rate	$608.32
Rate for Payer: Aetna Commercial	$364.99
Rate for Payer: Cash Price	$1,070.63
Rate for Payer: Cigna Commercial	$304.16
Rate for Payer: Multiplan Auto	$608.32
Rate for Payer: Multiplan Commercial	$608.32
Rate for Payer: Multiplan Workers Comp	$608.32
Rate for Payer: Scott and White EPO/PPO	$608.32

GAMMA NAIL CLIP

Facility

$1,216.63

Service Code	HCPCS C1713
Hospital Charge Code	145317
Hospital Revenue Code	278
Min. Negotiated Rate	$109.50
Max. Negotiated Rate	$608.32
Rate for Payer: Aetna Commercial	$364.99
Rate for Payer: Amerigroup CHIP/Medicaid	$109.50
Rate for Payer: BCBS of TX Blue Advantage	$364.99
Rate for Payer: BCBS of TX Blue Essentials	$437.99
Rate for Payer: BCBS of TX PPO	$486.65
Rate for Payer: Cash Price	$1,070.63
Rate for Payer: Multiplan Auto	$608.32
Rate for Payer: Multiplan Commercial	$608.32
Rate for Payer: Multiplan Workers Comp	$608.32
Rate for Payer: Scott and White EPO/PPO	$608.32
Rate for Payer: Superior Health Plan EPO	$165.46

Gastrectomy, partial, distal with gastrojejunostomy

Facility

$10,000.00

Service Code	CPT 43632
Hospital Charge Code	36043632
Hospital Revenue Code	360
Min. Negotiated Rate	$3,555.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,017.00
Rate for Payer: BCBS of TX Blue Advantage	$3,555.75
Rate for Payer: BCBS of TX Blue Essentials	$4,258.38
Rate for Payer: BCBS of TX PPO	$5,365.56
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00

Gastrectomy, partial, distal; with Roux-en-Y reconstruction

Facility

$10,000.00

Service Code	CPT 43633
Hospital Charge Code	36043633
Hospital Revenue Code	360
Min. Negotiated Rate	$3,358.94
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,017.00
Rate for Payer: BCBS of TX Blue Advantage	$3,358.94
Rate for Payer: BCBS of TX Blue Essentials	$4,022.68
Rate for Payer: BCBS of TX PPO	$5,068.58
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00

Gastric restrictive procedure, open removal of subcutaneous port component only

Facility

$10,000.00

Service Code	CPT 43887
Hospital Charge Code	36043887
Hospital Revenue Code	360
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$709.01
Rate for Payer: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

Gastrin, Serum SO

Facility

$167.00

Service Code	CPT 82941
Hospital Charge Code	1701374
Hospital Revenue Code	301
Rate for Payer: Cash Price	$146.96

Know your out-of-pocket cost for care.

All Charges