White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GEL DRML WND 2 -- DHF

Facility

$60.46

Hospital Charge Code	80322845
Hospital Revenue Code	270
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$39.30
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Amerigroup CHIP/Medicaid	$5.44
Rate for Payer: BCBS of TX Blue Advantage	$18.14
Rate for Payer: BCBS of TX Blue Essentials	$21.77
Rate for Payer: BCBS of TX PPO	$24.18
Rate for Payer: Cash Price	$53.20
Rate for Payer: Multiplan Auto	$39.30
Rate for Payer: Multiplan Commercial	$39.30
Rate for Payer: Multiplan Workers Comp	$39.30
Rate for Payer: Scott and White EPO/PPO	$30.23
Rate for Payer: Superior Health Plan EPO	$8.22

GEL DRML WND 2 -- DHF

Facility

$60.46

Hospital Charge Code	80322845
Hospital Revenue Code	270
Rate for Payer: Cash Price	$53.20

GEL WOUND MEDIHONEY TB -- DHF

Facility

$62.95

Service Code	HCPCS A6240
Hospital Charge Code	80383227
Hospital Revenue Code	272
Rate for Payer: Cash Price	$55.40

GEL WOUND MEDIHONEY TB -- DHF

Facility

$62.95

Service Code	HCPCS A6240
Hospital Charge Code	80383227
Hospital Revenue Code	272
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$40.92
Rate for Payer: Aetna Commercial	$34.62
Rate for Payer: Amerigroup CHIP/Medicaid	$5.67
Rate for Payer: BCBS of TX Blue Advantage	$20.63
Rate for Payer: BCBS of TX Blue Essentials	$24.76
Rate for Payer: BCBS of TX PPO	$27.46
Rate for Payer: Cash Price	$55.40
Rate for Payer: Cash Price	$55.40
Rate for Payer: Multiplan Auto	$40.92
Rate for Payer: Multiplan Commercial	$40.92
Rate for Payer: Multiplan Workers Comp	$40.92
Rate for Payer: Scott and White EPO/PPO	$31.48
Rate for Payer: Superior Health Plan EPO	$8.56

gemfibrozil 600 mg Tab

Facility

$9.80

Service Code	HCPCS J3490
Hospital Charge Code	77589887
Hospital Revenue Code	250
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$6.37
Rate for Payer: Amerigroup CHIP/Medicaid	$0.88
Rate for Payer: BCBS of TX Blue Advantage	$2.94
Rate for Payer: BCBS of TX Blue Essentials	$3.53
Rate for Payer: BCBS of TX PPO	$3.92
Rate for Payer: Cash Price	$6.66
Rate for Payer: Multiplan Auto	$6.37
Rate for Payer: Multiplan Commercial	$6.37
Rate for Payer: Multiplan Workers Comp	$6.37
Rate for Payer: Scott and White EPO/PPO	$4.90
Rate for Payer: Superior Health Plan EPO	$1.33

gemfibrozil 600 mg Tab

Facility

$9.80

Service Code	HCPCS J3490
Hospital Charge Code	77589887
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.66

General Health Panel BCE

Facility

$546.00

Service Code	CPT 80050
Hospital Charge Code	4100052
Hospital Revenue Code	300
Min. Negotiated Rate	$13.70
Max. Negotiated Rate	$354.90
Rate for Payer: Aetna Commercial	$44.36
Rate for Payer: Amerigroup CHIP/Medicaid	$13.70
Rate for Payer: BCBS of TX Blue Advantage	$58.28
Rate for Payer: BCBS of TX Blue Essentials	$69.93
Rate for Payer: BCBS of TX PPO	$78.06
Rate for Payer: Cash Price	$480.48
Rate for Payer: Cash Price	$480.48
Rate for Payer: Multiplan Auto	$354.90
Rate for Payer: Multiplan Commercial	$354.90
Rate for Payer: Multiplan Workers Comp	$354.90
Rate for Payer: Scott and White EPO/PPO	$273.00
Rate for Payer: Superior Health Plan EPO	$74.26

General Health Panel BCE

Facility

$546.00

Service Code	CPT 80050
Hospital Charge Code	4100052
Hospital Revenue Code	300
Rate for Payer: Cash Price	$480.48

Genital Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107024
Hospital Revenue Code	306
Rate for Payer: Cash Price	$271.92

Genital Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107024
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$200.85
Rate for Payer: Aetna Commercial	$9.05
Rate for Payer: Aetna Medicare	$12.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$14.22
Rate for Payer: BCBS of TX Blue Essentials	$17.07
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$19.05
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cigna Medicaid	$8.62
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$8.62
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$8.62
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.62
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

gentamicin 0.1% Cream 15 g

Facility

$133.85

Service Code	HCPCS J3490
Hospital Charge Code	77589995
Hospital Revenue Code	250
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$87.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.05
Rate for Payer: BCBS of TX Blue Advantage	$40.16
Rate for Payer: BCBS of TX Blue Essentials	$48.19
Rate for Payer: BCBS of TX PPO	$53.54
Rate for Payer: Cash Price	$91.02
Rate for Payer: Multiplan Auto	$87.00
Rate for Payer: Multiplan Commercial	$87.00
Rate for Payer: Multiplan Workers Comp	$87.00
Rate for Payer: Scott and White EPO/PPO	$66.92
Rate for Payer: Superior Health Plan EPO	$18.20

gentamicin 0.1% Cream 15 g

Facility

$133.85

Service Code	HCPCS J3490
Hospital Charge Code	77589995
Hospital Revenue Code	250
Rate for Payer: Cash Price	$91.02

gentamicin 10 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J1580
Hospital Charge Code	77590421
Hospital Revenue Code	250
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.39
Rate for Payer: BCBS of TX Blue Essentials	$2.87
Rate for Payer: BCBS of TX PPO	$3.18
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

gentamicin 10 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J1580
Hospital Charge Code	77590421
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

gentamicin 40 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J1580
Hospital Charge Code	77590751
Hospital Revenue Code	250
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.39
Rate for Payer: BCBS of TX Blue Essentials	$2.87
Rate for Payer: BCBS of TX PPO	$3.18
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

gentamicin 40 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J1580
Hospital Charge Code	77590751
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

Gentamicin Level

Facility

$384.00

Service Code	CPT 80170
Hospital Charge Code	1602739
Hospital Revenue Code	300
Rate for Payer: Cash Price	$337.92

Gentamicin Level

Facility

$384.00

Service Code	CPT 80170
Hospital Charge Code	1602739
Hospital Revenue Code	300
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$249.60
Rate for Payer: Aetna Commercial	$17.20
Rate for Payer: Aetna Medicare	$24.57
Rate for Payer: Amerigroup CHIP/Medicaid	$6.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.38
Rate for Payer: Amerigroup Medicare	$16.38
Rate for Payer: BCBS of TX Blue Advantage	$27.03
Rate for Payer: BCBS of TX Blue Essentials	$32.43
Rate for Payer: BCBS of TX Medicare	$16.38
Rate for Payer: BCBS of TX PPO	$36.20
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cigna Medicaid	$16.38
Rate for Payer: Cigna Medicare	$16.38
Rate for Payer: Employer Direct Commercial	$16.38
Rate for Payer: Humana Medicare/TRICARE	$16.38
Rate for Payer: Molina CHIP/Medicaid	$16.38
Rate for Payer: Molina Dual Medicare/Medicaid	$16.38
Rate for Payer: Molina Medicare	$16.38
Rate for Payer: Multiplan Auto	$249.60
Rate for Payer: Multiplan Commercial	$249.60
Rate for Payer: Multiplan Workers Comp	$249.60
Rate for Payer: Parkland Medicaid	$16.38
Rate for Payer: Scott and White EPO/PPO	$20.48
Rate for Payer: Scott and White Medicare	$16.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.38
Rate for Payer: Superior Health Plan EPO	$16.38
Rate for Payer: Superior Health Plan Medicare	$16.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.38
Rate for Payer: Universal American Medicare	$16.38
Rate for Payer: Wellcare Medicare	$16.38
Rate for Payer: Wellmed Medicare	$16.38

Gentamicin Level Peak

Facility

$384.00

Service Code	CPT 80170
Hospital Charge Code	1602739
Hospital Revenue Code	300
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$249.60
Rate for Payer: Aetna Commercial	$17.20
Rate for Payer: Aetna Medicare	$24.57
Rate for Payer: Amerigroup CHIP/Medicaid	$6.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.38
Rate for Payer: Amerigroup Medicare	$16.38
Rate for Payer: BCBS of TX Blue Advantage	$27.03
Rate for Payer: BCBS of TX Blue Essentials	$32.43
Rate for Payer: BCBS of TX Medicare	$16.38
Rate for Payer: BCBS of TX PPO	$36.20
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cigna Medicaid	$16.38
Rate for Payer: Cigna Medicare	$16.38
Rate for Payer: Employer Direct Commercial	$16.38
Rate for Payer: Humana Medicare/TRICARE	$16.38
Rate for Payer: Molina CHIP/Medicaid	$16.38
Rate for Payer: Molina Dual Medicare/Medicaid	$16.38
Rate for Payer: Molina Medicare	$16.38
Rate for Payer: Multiplan Auto	$249.60
Rate for Payer: Multiplan Commercial	$249.60
Rate for Payer: Multiplan Workers Comp	$249.60
Rate for Payer: Parkland Medicaid	$16.38
Rate for Payer: Scott and White EPO/PPO	$20.48
Rate for Payer: Scott and White Medicare	$16.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.38
Rate for Payer: Superior Health Plan EPO	$16.38
Rate for Payer: Superior Health Plan Medicare	$16.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.38
Rate for Payer: Universal American Medicare	$16.38
Rate for Payer: Wellcare Medicare	$16.38
Rate for Payer: Wellmed Medicare	$16.38

Gentamicin Level Trough

Facility

$384.00

Service Code	CPT 80170
Hospital Charge Code	1602739
Hospital Revenue Code	300
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$249.60
Rate for Payer: Aetna Commercial	$17.20
Rate for Payer: Aetna Medicare	$24.57
Rate for Payer: Amerigroup CHIP/Medicaid	$6.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.38
Rate for Payer: Amerigroup Medicare	$16.38
Rate for Payer: BCBS of TX Blue Advantage	$27.03
Rate for Payer: BCBS of TX Blue Essentials	$32.43
Rate for Payer: BCBS of TX Medicare	$16.38
Rate for Payer: BCBS of TX PPO	$36.20
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cigna Medicaid	$16.38
Rate for Payer: Cigna Medicare	$16.38
Rate for Payer: Employer Direct Commercial	$16.38
Rate for Payer: Humana Medicare/TRICARE	$16.38
Rate for Payer: Molina CHIP/Medicaid	$16.38
Rate for Payer: Molina Dual Medicare/Medicaid	$16.38
Rate for Payer: Molina Medicare	$16.38
Rate for Payer: Multiplan Auto	$249.60
Rate for Payer: Multiplan Commercial	$249.60
Rate for Payer: Multiplan Workers Comp	$249.60
Rate for Payer: Parkland Medicaid	$16.38
Rate for Payer: Scott and White EPO/PPO	$20.48
Rate for Payer: Scott and White Medicare	$16.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.38
Rate for Payer: Superior Health Plan EPO	$16.38
Rate for Payer: Superior Health Plan Medicare	$16.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.38
Rate for Payer: Universal American Medicare	$16.38
Rate for Payer: Wellcare Medicare	$16.38
Rate for Payer: Wellmed Medicare	$16.38

gentamicin ophthalmic 0.3%

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78405471
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

gentamicin ophthalmic 0.3%

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	78405471
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

GERIATRIC E&M-EST. PATIENT-LVL I BCE

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	3914006
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$73.45
Rate for Payer: Aetna Commercial	$62.15
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$16.30
Rate for Payer: BCBS of TX Blue Essentials	$19.49
Rate for Payer: BCBS of TX PPO	$21.74
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cigna Medicaid	$12.41
Rate for Payer: Molina CHIP/Medicaid	$12.41
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$12.41
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.41

GERIATRIC E&M-EST. PATIENT-LVL I BCE

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	3914006
Hospital Revenue Code	510
Rate for Payer: Cash Price	$99.44

GERIATRIC E&M-EST. PATIENT-LVL II BCE

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	3914007
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$113.10
Rate for Payer: Aetna Commercial	$95.70
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$45.15
Rate for Payer: BCBS of TX Blue Essentials	$53.98
Rate for Payer: BCBS of TX PPO	$60.20
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cigna Medicaid	$20.78
Rate for Payer: Molina CHIP/Medicaid	$20.78
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$20.78
Rate for Payer: Scott and White EPO/PPO	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.78

Know your out-of-pocket cost for care.

All Charges