White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GI cocktail 30 mL

Facility

$97.60

Service Code	HCPCS J3490
Hospital Charge Code	78921429
Hospital Revenue Code	250
Rate for Payer: Cash Price	$66.37

GI cocktail 30 mL

Facility

$97.60

Service Code	HCPCS J3490
Hospital Charge Code	78921429
Hospital Revenue Code	250
Min. Negotiated Rate	$8.78
Max. Negotiated Rate	$63.44
Rate for Payer: Amerigroup CHIP/Medicaid	$8.78
Rate for Payer: BCBS of TX Blue Advantage	$29.28
Rate for Payer: BCBS of TX Blue Essentials	$35.14
Rate for Payer: BCBS of TX PPO	$39.04
Rate for Payer: Cash Price	$66.37
Rate for Payer: Multiplan Auto	$63.44
Rate for Payer: Multiplan Commercial	$63.44
Rate for Payer: Multiplan Workers Comp	$63.44
Rate for Payer: Scott and White EPO/PPO	$48.80
Rate for Payer: Superior Health Plan EPO	$13.27

GINTRO RAMP -- DHF

Facility

$900.24

Service Code	HCPCS C1893
Hospital Charge Code	82411604
Hospital Revenue Code	272
Rate for Payer: Cash Price	$792.21

GINTRO RAMP -- DHF

Facility

$900.24

Service Code	HCPCS C1893
Hospital Charge Code	82411604
Hospital Revenue Code	272
Min. Negotiated Rate	$81.02
Max. Negotiated Rate	$585.16
Rate for Payer: Aetna Commercial	$495.13
Rate for Payer: Amerigroup CHIP/Medicaid	$81.02
Rate for Payer: BCBS of TX Blue Advantage	$270.07
Rate for Payer: BCBS of TX Blue Essentials	$324.09
Rate for Payer: BCBS of TX PPO	$360.10
Rate for Payer: Cash Price	$792.21
Rate for Payer: Multiplan Auto	$585.16
Rate for Payer: Multiplan Commercial	$585.16
Rate for Payer: Multiplan Workers Comp	$585.16
Rate for Payer: Scott and White EPO/PPO	$450.12
Rate for Payer: Superior Health Plan EPO	$122.43

Gliadin IgG/IgA Ab Prof, EIA SO

Facility

$215.00

Service Code	CPT 83516
Hospital Charge Code	1706019
Hospital Revenue Code	301
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$139.75
Rate for Payer: Aetna Commercial	$12.11
Rate for Payer: Aetna Medicare	$17.30
Rate for Payer: Amerigroup CHIP/Medicaid	$4.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.53
Rate for Payer: Amerigroup Medicare	$11.53
Rate for Payer: BCBS of TX Blue Advantage	$19.02
Rate for Payer: BCBS of TX Blue Essentials	$22.83
Rate for Payer: BCBS of TX Medicare	$11.53
Rate for Payer: BCBS of TX PPO	$25.48
Rate for Payer: Cash Price	$189.20
Rate for Payer: Cash Price	$189.20
Rate for Payer: Cigna Medicaid	$11.53
Rate for Payer: Cigna Medicare	$11.53
Rate for Payer: Employer Direct Commercial	$11.53
Rate for Payer: Humana Medicare/TRICARE	$11.53
Rate for Payer: Molina CHIP/Medicaid	$11.53
Rate for Payer: Molina Dual Medicare/Medicaid	$11.53
Rate for Payer: Molina Medicare	$11.53
Rate for Payer: Multiplan Auto	$139.75
Rate for Payer: Multiplan Commercial	$139.75
Rate for Payer: Multiplan Workers Comp	$139.75
Rate for Payer: Parkland Medicaid	$11.53
Rate for Payer: Scott and White EPO/PPO	$14.41
Rate for Payer: Scott and White Medicare	$11.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.53
Rate for Payer: Superior Health Plan EPO	$11.53
Rate for Payer: Superior Health Plan Medicare	$11.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.53
Rate for Payer: Universal American Medicare	$11.53
Rate for Payer: Wellcare Medicare	$11.53
Rate for Payer: Wellmed Medicare	$11.53

GLIDE/BRONCHOSCOPE BLEX 5.0 0570-0375

Facility

$1,221.26

Hospital Charge Code	144279
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,074.71

GLIDE/BRONCHOSCOPE BLEX 5.0 0570-0375

Facility

$1,221.26

Hospital Charge Code	144279
Hospital Revenue Code	272
Min. Negotiated Rate	$109.91
Max. Negotiated Rate	$793.82
Rate for Payer: Aetna Commercial	$671.69
Rate for Payer: Amerigroup CHIP/Medicaid	$109.91
Rate for Payer: BCBS of TX Blue Advantage	$366.38
Rate for Payer: BCBS of TX Blue Essentials	$439.65
Rate for Payer: BCBS of TX PPO	$488.50
Rate for Payer: Cash Price	$1,074.71
Rate for Payer: Multiplan Auto	$793.82
Rate for Payer: Multiplan Commercial	$793.82
Rate for Payer: Multiplan Workers Comp	$793.82
Rate for Payer: Scott and White EPO/PPO	$610.63
Rate for Payer: Superior Health Plan EPO	$166.09

GLIDEWIRE VASC .035 X 180 ANG/REG

Facility

$186.82

Service Code	HCPCS C1769
Hospital Charge Code	107737
Hospital Revenue Code	272
Min. Negotiated Rate	$16.81
Max. Negotiated Rate	$121.43
Rate for Payer: Aetna Commercial	$102.75
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	$164.40
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: Scott and White EPO/PPO	$93.41
Rate for Payer: Superior Health Plan EPO	$25.41

GLIDEWIRE VASC .035 X 180 ANG/REG

Facility

$186.82

Service Code	HCPCS C1769
Hospital Charge Code	107737
Hospital Revenue Code	272
Rate for Payer: Cash Price	$164.40

GLIDEWIRE VASC .035 X 180CM ANG/STIFF

Facility

$219.96

Service Code	HCPCS C1769
Hospital Charge Code	107744
Hospital Revenue Code	272
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$142.97
Rate for Payer: Aetna Commercial	$120.98
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	$193.56
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: Scott and White EPO/PPO	$109.98
Rate for Payer: Superior Health Plan EPO	$29.91

GLIDEWIRE VASC .035 X 180CM ANG/STIFF

Facility

$219.96

Service Code	HCPCS C1769
Hospital Charge Code	107744
Hospital Revenue Code	272
Rate for Payer: Cash Price	$193.56

GLIDEWIRE VASC .035 X 260CM ANG/REG

Facility

$208.84

Service Code	HCPCS C1769
Hospital Charge Code	80732431
Hospital Revenue Code	272
Rate for Payer: Cash Price	$183.78

GLIDEWIRE VASC .035 X 260CM ANG/REG

Facility

$208.84

Service Code	HCPCS C1769
Hospital Charge Code	80732431
Hospital Revenue Code	272
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$135.75
Rate for Payer: Aetna Commercial	$114.86
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	$183.78
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: Scott and White EPO/PPO	$104.42
Rate for Payer: Superior Health Plan EPO	$28.40

glipiZIDE 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78402736
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

glipiZIDE 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78402736
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

glucagon recombinant 1 mg Inj

Facility

$526.85

Service Code	HCPCS J1610
Hospital Charge Code	77592572
Hospital Revenue Code	636
Min. Negotiated Rate	$47.42
Max. Negotiated Rate	$342.45
Rate for Payer: Aetna Medicare	$282.55
Rate for Payer: Amerigroup CHIP/Medicaid	$47.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$188.37
Rate for Payer: Amerigroup Medicare	$188.37
Rate for Payer: BCBS of TX Blue Advantage	$119.83
Rate for Payer: BCBS of TX Blue Essentials	$143.79
Rate for Payer: BCBS of TX Medicare	$188.37
Rate for Payer: BCBS of TX PPO	$159.50
Rate for Payer: Cash Price	$358.26
Rate for Payer: Cash Price	$358.26
Rate for Payer: Cigna Medicare	$188.37
Rate for Payer: Employer Direct Commercial	$188.37
Rate for Payer: Humana Medicare/TRICARE	$188.37
Rate for Payer: Molina Dual Medicare/Medicaid	$188.37
Rate for Payer: Molina Medicare	$188.37
Rate for Payer: Multiplan Auto	$342.45
Rate for Payer: Multiplan Commercial	$342.45
Rate for Payer: Multiplan Workers Comp	$342.45
Rate for Payer: Scott and White EPO/PPO	$263.42
Rate for Payer: Scott and White Medicare	$188.37
Rate for Payer: Superior Health Plan EPO	$188.37
Rate for Payer: Superior Health Plan Medicare	$188.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$188.37
Rate for Payer: Universal American Medicare	$188.37
Rate for Payer: Wellcare Medicare	$188.37
Rate for Payer: Wellmed Medicare	$188.37

glucagon recombinant 1 mg Inj

Facility

$526.85

Service Code	HCPCS J1610
Hospital Charge Code	77592572
Hospital Revenue Code	636
Min. Negotiated Rate	$131.71
Max. Negotiated Rate	$263.42
Rate for Payer: Cash Price	$358.26
Rate for Payer: Cigna Commercial	$131.71
Rate for Payer: Scott and White EPO/PPO	$263.42

Glucose 1 Hour

Facility

$379.00

Service Code	CPT 82951
Hospital Charge Code	1602853
Hospital Revenue Code	301
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$246.35
Rate for Payer: Aetna Commercial	$13.51
Rate for Payer: Aetna Medicare	$19.30
Rate for Payer: Amerigroup CHIP/Medicaid	$5.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.87
Rate for Payer: Amerigroup Medicare	$12.87
Rate for Payer: BCBS of TX Blue Advantage	$21.24
Rate for Payer: BCBS of TX Blue Essentials	$25.48
Rate for Payer: BCBS of TX Medicare	$12.87
Rate for Payer: BCBS of TX PPO	$28.44
Rate for Payer: Cash Price	$333.52
Rate for Payer: Cash Price	$333.52
Rate for Payer: Cigna Medicaid	$12.87
Rate for Payer: Cigna Medicare	$12.87
Rate for Payer: Employer Direct Commercial	$12.87
Rate for Payer: Humana Medicare/TRICARE	$12.87
Rate for Payer: Molina CHIP/Medicaid	$12.87
Rate for Payer: Molina Dual Medicare/Medicaid	$12.87
Rate for Payer: Molina Medicare	$12.87
Rate for Payer: Multiplan Auto	$246.35
Rate for Payer: Multiplan Commercial	$246.35
Rate for Payer: Multiplan Workers Comp	$246.35
Rate for Payer: Parkland Medicaid	$12.87
Rate for Payer: Scott and White EPO/PPO	$16.09
Rate for Payer: Scott and White Medicare	$12.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.87
Rate for Payer: Superior Health Plan EPO	$12.87
Rate for Payer: Superior Health Plan Medicare	$12.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.87
Rate for Payer: Universal American Medicare	$12.87
Rate for Payer: Wellcare Medicare	$12.87
Rate for Payer: Wellmed Medicare	$12.87

Glucose 1 Hour Post Prandial

Facility

$106.00

Service Code	CPT 82950
Hospital Charge Code	1602861
Hospital Revenue Code	301
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$68.90
Rate for Payer: Aetna Commercial	$4.99
Rate for Payer: Aetna Medicare	$7.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.75
Rate for Payer: Amerigroup Medicare	$4.75
Rate for Payer: BCBS of TX Blue Advantage	$7.84
Rate for Payer: BCBS of TX Blue Essentials	$9.40
Rate for Payer: BCBS of TX Medicare	$4.75
Rate for Payer: BCBS of TX PPO	$10.50
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$4.75
Rate for Payer: Cigna Medicare	$4.75
Rate for Payer: Employer Direct Commercial	$4.75
Rate for Payer: Humana Medicare/TRICARE	$4.75
Rate for Payer: Molina CHIP/Medicaid	$4.75
Rate for Payer: Molina Dual Medicare/Medicaid	$4.75
Rate for Payer: Molina Medicare	$4.75
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$4.75
Rate for Payer: Scott and White EPO/PPO	$5.94
Rate for Payer: Scott and White Medicare	$4.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.75
Rate for Payer: Superior Health Plan EPO	$4.75
Rate for Payer: Superior Health Plan Medicare	$4.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.75
Rate for Payer: Universal American Medicare	$4.75
Rate for Payer: Wellcare Medicare	$4.75
Rate for Payer: Wellmed Medicare	$4.75

Glucose 2 Hour

Facility

$379.00

Service Code	CPT 82951
Hospital Charge Code	1602853
Hospital Revenue Code	301
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$246.35
Rate for Payer: Aetna Commercial	$13.51
Rate for Payer: Aetna Medicare	$19.30
Rate for Payer: Amerigroup CHIP/Medicaid	$5.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.87
Rate for Payer: Amerigroup Medicare	$12.87
Rate for Payer: BCBS of TX Blue Advantage	$21.24
Rate for Payer: BCBS of TX Blue Essentials	$25.48
Rate for Payer: BCBS of TX Medicare	$12.87
Rate for Payer: BCBS of TX PPO	$28.44
Rate for Payer: Cash Price	$333.52
Rate for Payer: Cash Price	$333.52
Rate for Payer: Cigna Medicaid	$12.87
Rate for Payer: Cigna Medicare	$12.87
Rate for Payer: Employer Direct Commercial	$12.87
Rate for Payer: Humana Medicare/TRICARE	$12.87
Rate for Payer: Molina CHIP/Medicaid	$12.87
Rate for Payer: Molina Dual Medicare/Medicaid	$12.87
Rate for Payer: Molina Medicare	$12.87
Rate for Payer: Multiplan Auto	$246.35
Rate for Payer: Multiplan Commercial	$246.35
Rate for Payer: Multiplan Workers Comp	$246.35
Rate for Payer: Parkland Medicaid	$12.87
Rate for Payer: Scott and White EPO/PPO	$16.09
Rate for Payer: Scott and White Medicare	$12.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.87
Rate for Payer: Superior Health Plan EPO	$12.87
Rate for Payer: Superior Health Plan Medicare	$12.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.87
Rate for Payer: Universal American Medicare	$12.87
Rate for Payer: Wellcare Medicare	$12.87
Rate for Payer: Wellmed Medicare	$12.87

Glucose 2 Hour Post Prandial

Facility

$106.00

Service Code	CPT 82950
Hospital Charge Code	1602861
Hospital Revenue Code	301
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$68.90
Rate for Payer: Aetna Commercial	$4.99
Rate for Payer: Aetna Medicare	$7.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.75
Rate for Payer: Amerigroup Medicare	$4.75
Rate for Payer: BCBS of TX Blue Advantage	$7.84
Rate for Payer: BCBS of TX Blue Essentials	$9.40
Rate for Payer: BCBS of TX Medicare	$4.75
Rate for Payer: BCBS of TX PPO	$10.50
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cash Price	$93.28
Rate for Payer: Cigna Medicaid	$4.75
Rate for Payer: Cigna Medicare	$4.75
Rate for Payer: Employer Direct Commercial	$4.75
Rate for Payer: Humana Medicare/TRICARE	$4.75
Rate for Payer: Molina CHIP/Medicaid	$4.75
Rate for Payer: Molina Dual Medicare/Medicaid	$4.75
Rate for Payer: Molina Medicare	$4.75
Rate for Payer: Multiplan Auto	$68.90
Rate for Payer: Multiplan Commercial	$68.90
Rate for Payer: Multiplan Workers Comp	$68.90
Rate for Payer: Parkland Medicaid	$4.75
Rate for Payer: Scott and White EPO/PPO	$5.94
Rate for Payer: Scott and White Medicare	$4.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.75
Rate for Payer: Superior Health Plan EPO	$4.75
Rate for Payer: Superior Health Plan Medicare	$4.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.75
Rate for Payer: Universal American Medicare	$4.75
Rate for Payer: Wellcare Medicare	$4.75
Rate for Payer: Wellmed Medicare	$4.75

Glucose 2 Hour Post Prandial

Facility

$106.00

Service Code	CPT 82950
Hospital Charge Code	1602861
Hospital Revenue Code	301
Rate for Payer: Cash Price	$93.28

Glucose 3 Hour

Facility

$379.00

Service Code	CPT 82951
Hospital Charge Code	1602853
Hospital Revenue Code	301
Rate for Payer: Cash Price	$333.52

Glucose 3 Hour

Facility

$379.00

Service Code	CPT 82951
Hospital Charge Code	1602853
Hospital Revenue Code	301
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$246.35
Rate for Payer: Aetna Commercial	$13.51
Rate for Payer: Aetna Medicare	$19.30
Rate for Payer: Amerigroup CHIP/Medicaid	$5.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.87
Rate for Payer: Amerigroup Medicare	$12.87
Rate for Payer: BCBS of TX Blue Advantage	$21.24
Rate for Payer: BCBS of TX Blue Essentials	$25.48
Rate for Payer: BCBS of TX Medicare	$12.87
Rate for Payer: BCBS of TX PPO	$28.44
Rate for Payer: Cash Price	$333.52
Rate for Payer: Cash Price	$333.52
Rate for Payer: Cigna Medicaid	$12.87
Rate for Payer: Cigna Medicare	$12.87
Rate for Payer: Employer Direct Commercial	$12.87
Rate for Payer: Humana Medicare/TRICARE	$12.87
Rate for Payer: Molina CHIP/Medicaid	$12.87
Rate for Payer: Molina Dual Medicare/Medicaid	$12.87
Rate for Payer: Molina Medicare	$12.87
Rate for Payer: Multiplan Auto	$246.35
Rate for Payer: Multiplan Commercial	$246.35
Rate for Payer: Multiplan Workers Comp	$246.35
Rate for Payer: Parkland Medicaid	$12.87
Rate for Payer: Scott and White EPO/PPO	$16.09
Rate for Payer: Scott and White Medicare	$12.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.87
Rate for Payer: Superior Health Plan EPO	$12.87
Rate for Payer: Superior Health Plan Medicare	$12.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.87
Rate for Payer: Universal American Medicare	$12.87
Rate for Payer: Wellcare Medicare	$12.87
Rate for Payer: Wellmed Medicare	$12.87

glucose 40% Oral Gel 37.5 g

Facility

$17.15

Service Code	HCPCS J3490
Hospital Charge Code	77593410
Hospital Revenue Code	250
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$11.15
Rate for Payer: Amerigroup CHIP/Medicaid	$1.54
Rate for Payer: BCBS of TX Blue Advantage	$5.14
Rate for Payer: BCBS of TX Blue Essentials	$6.17
Rate for Payer: BCBS of TX PPO	$6.86
Rate for Payer: Cash Price	$11.66
Rate for Payer: Multiplan Auto	$11.15
Rate for Payer: Multiplan Commercial	$11.15
Rate for Payer: Multiplan Workers Comp	$11.15
Rate for Payer: Scott and White EPO/PPO	$8.58
Rate for Payer: Superior Health Plan EPO	$2.33

Know your out-of-pocket cost for care.

All Charges