White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$43.56
Rate for Payer: Amerigroup CHIP/Medicaid	$5.45
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: Cigna Medicaid	$43.56
Rate for Payer: Molina CHIP/Medicaid	$43.56
Rate for Payer: Multiplan Auto	$39.33
Rate for Payer: Multiplan Commercial	$39.33
Rate for Payer: Multiplan Workers Comp	$39.33
Rate for Payer: Parkland Medicaid	$43.56
Rate for Payer: Scott and White EPO/PPO	$30.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.56
Rate for Payer: Superior Health Plan EPO	$8.23

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 IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS A9579
Hospital Charge Code	77587874
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

gadoteridol 279.3 mg/mL IV Soln 10 mL

Facility

$128.00

Service Code	HCPCS A9579
Hospital Charge Code	77587874
Hospital Revenue Code	636
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$2.57
Rate for Payer: BCBS of TX Blue Essentials	$3.08
Rate for Payer: BCBS of TX PPO	$3.42
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

GAIT BELT ECONO

Facility

$14.89

Hospital Charge Code	8584505
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.13

GAIT BELT ECONO

Facility

$14.89

Hospital Charge Code	8584505
Hospital Revenue Code	270
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$10.72
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	$10.13
Rate for Payer: Cigna Medicaid	$10.72
Rate for Payer: Molina CHIP/Medicaid	$10.72
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: Parkland Medicaid	$10.72
Rate for Payer: Scott and White EPO/PPO	$7.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.72
Rate for Payer: Superior Health Plan EPO	$2.03

Gallant DR CDDRA500Q

Facility

$65,136.00

Service Code	HCPCS C1721
Hospital Charge Code	8414460
Hospital Revenue Code	278
Min. Negotiated Rate	$5,862.24
Max. Negotiated Rate	$46,897.92
Rate for Payer: Amerigroup CHIP/Medicaid	$5,862.24
Rate for Payer: BCBS of TX Blue Advantage	$19,540.80
Rate for Payer: BCBS of TX Blue Essentials	$23,448.96
Rate for Payer: BCBS of TX PPO	$26,054.40
Rate for Payer: Cash Price	$44,292.48
Rate for Payer: Cigna Medicaid	$46,897.92
Rate for Payer: Molina CHIP/Medicaid	$46,897.92
Rate for Payer: Multiplan Auto	$32,568.00
Rate for Payer: Multiplan Commercial	$32,568.00
Rate for Payer: Multiplan Workers Comp	$32,568.00
Rate for Payer: Parkland Medicaid	$46,897.92
Rate for Payer: Scott and White EPO/PPO	$32,568.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,897.92
Rate for Payer: Superior Health Plan EPO	$8,858.50

Gallant DR CDDRA500Q

Facility

$65,136.00

Service Code	HCPCS C1721
Hospital Charge Code	8414460
Hospital Revenue Code	278
Min. Negotiated Rate	$16,284.00
Max. Negotiated Rate	$32,568.00
Rate for Payer: Cash Price	$44,292.48
Rate for Payer: Cigna Commercial	$16,284.00
Rate for Payer: Multiplan Auto	$32,568.00
Rate for Payer: Multiplan Commercial	$32,568.00
Rate for Payer: Multiplan Workers Comp	$32,568.00
Rate for Payer: Scott and White EPO/PPO	$32,568.00

GAMMA 3 S NAIL RIGHT 10 X 360 MM X 125

Facility

$21,240.96

Service Code	HCPCS C1713
Hospital Charge Code	993146
Hospital Revenue Code	278
Min. Negotiated Rate	$5,310.24
Max. Negotiated Rate	$10,620.48
Rate for Payer: Cash Price	$14,443.85
Rate for Payer: Cigna Commercial	$5,310.24
Rate for Payer: Multiplan Auto	$10,620.48
Rate for Payer: Multiplan Commercial	$10,620.48
Rate for Payer: Multiplan Workers Comp	$10,620.48
Rate for Payer: Scott and White EPO/PPO	$10,620.48

GAMMA 3 S NAIL RIGHT 10 X 360 MM X 125

Facility

$21,240.96

Service Code	HCPCS C1713
Hospital Charge Code	993146
Hospital Revenue Code	278
Min. Negotiated Rate	$1,911.69
Max. Negotiated Rate	$15,293.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1,911.69
Rate for Payer: BCBS of TX Blue Advantage	$6,372.29
Rate for Payer: BCBS of TX Blue Essentials	$7,646.75
Rate for Payer: BCBS of TX PPO	$8,496.38
Rate for Payer: Cash Price	$14,443.85
Rate for Payer: Cigna Medicaid	$15,293.49
Rate for Payer: Molina CHIP/Medicaid	$15,293.49
Rate for Payer: Multiplan Auto	$10,620.48
Rate for Payer: Multiplan Commercial	$10,620.48
Rate for Payer: Multiplan Workers Comp	$10,620.48
Rate for Payer: Parkland Medicaid	$15,293.49
Rate for Payer: Scott and White EPO/PPO	$10,620.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,293.49
Rate for Payer: Superior Health Plan EPO	$2,888.77

GAMMA CLIP

Facility

$1,403.61

Service Code	HCPCS C1734
Hospital Charge Code	992144
Hospital Revenue Code	278
Min. Negotiated Rate	$350.90
Max. Negotiated Rate	$701.80
Rate for Payer: Cash Price	$954.45
Rate for Payer: Cigna Commercial	$350.90
Rate for Payer: Multiplan Auto	$701.80
Rate for Payer: Multiplan Commercial	$701.80
Rate for Payer: Multiplan Workers Comp	$701.80
Rate for Payer: Scott and White EPO/PPO	$701.80

GAMMA CLIP

Facility

$1,403.61

Service Code	HCPCS C1734
Hospital Charge Code	992144
Hospital Revenue Code	278
Min. Negotiated Rate	$126.32
Max. Negotiated Rate	$1,010.60
Rate for Payer: Amerigroup CHIP/Medicaid	$126.32
Rate for Payer: BCBS of TX Blue Advantage	$421.08
Rate for Payer: BCBS of TX Blue Essentials	$505.30
Rate for Payer: BCBS of TX PPO	$561.44
Rate for Payer: Cash Price	$954.45
Rate for Payer: Cigna Medicaid	$1,010.60
Rate for Payer: Molina CHIP/Medicaid	$1,010.60
Rate for Payer: Multiplan Auto	$701.80
Rate for Payer: Multiplan Commercial	$701.80
Rate for Payer: Multiplan Workers Comp	$701.80
Rate for Payer: Parkland Medicaid	$1,010.60
Rate for Payer: Scott and White EPO/PPO	$701.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,010.60
Rate for Payer: Superior Health Plan EPO	$190.89

Gamma Glutamyl Transferase

Facility

$265.00

Service Code	HCPCS 82977 QW
Hospital Charge Code	1601889
Hospital Revenue Code	301
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$190.80
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	$79.50
Rate for Payer: BCBS of TX Blue Essentials	$95.40
Rate for Payer: BCBS of TX Medicare	$7.20
Rate for Payer: BCBS of TX PPO	$106.00
Rate for Payer: Cash Price	$180.20
Rate for Payer: Cash Price	$180.20
Rate for Payer: Cigna Medicaid	$190.80
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	$190.80
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	$190.80
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	$190.80
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	HCPCS 82977 QW
Hospital Charge Code	1601889
Hospital Revenue Code	301
Rate for Payer: Cash Price	$180.20

.Gamma-Hydroxybutyric Acid, CF SO

Facility

$260.00

Service Code	HCPCS 80375
Hospital Charge Code	1743024
Hospital Revenue Code	301
Rate for Payer: Cash Price	$176.80

.Gamma-Hydroxybutyric Acid, CF SO

Facility

$260.00

Service Code	HCPCS 80375
Hospital Charge Code	1743024
Hospital Revenue Code	301
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$187.20
Rate for Payer: Amerigroup CHIP/Medicaid	$8.40
Rate for Payer: BCBS of TX Blue Advantage	$78.00
Rate for Payer: BCBS of TX Blue Essentials	$93.60
Rate for Payer: BCBS of TX PPO	$104.00
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cigna Medicaid	$187.20
Rate for Payer: Molina CHIP/Medicaid	$187.20
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	$187.20
Rate for Payer: Scott and White EPO/PPO	$130.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$187.20
Rate for Payer: Superior Health Plan EPO	$35.36

GAMMA NAIL CLIP

Facility

$1,217.00

Service Code	HCPCS C1776
Hospital Charge Code	145317
Hospital Revenue Code	278
Min. Negotiated Rate	$109.53
Max. Negotiated Rate	$876.24
Rate for Payer: Amerigroup CHIP/Medicaid	$109.53
Rate for Payer: BCBS of TX Blue Advantage	$365.10
Rate for Payer: BCBS of TX Blue Essentials	$438.12
Rate for Payer: BCBS of TX PPO	$486.80
Rate for Payer: Cash Price	$827.56
Rate for Payer: Cigna Medicaid	$876.24
Rate for Payer: Molina CHIP/Medicaid	$876.24
Rate for Payer: Multiplan Auto	$608.50
Rate for Payer: Multiplan Commercial	$608.50
Rate for Payer: Multiplan Workers Comp	$608.50
Rate for Payer: Parkland Medicaid	$876.24
Rate for Payer: Scott and White EPO/PPO	$608.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$876.24
Rate for Payer: Superior Health Plan EPO	$165.51

GAMMA NAIL CLIP

Facility

$1,217.00

Service Code	HCPCS C1776
Hospital Charge Code	145317
Hospital Revenue Code	278
Min. Negotiated Rate	$304.25
Max. Negotiated Rate	$608.50
Rate for Payer: Cash Price	$827.56
Rate for Payer: Cigna Commercial	$304.25
Rate for Payer: Multiplan Auto	$608.50
Rate for Payer: Multiplan Commercial	$608.50
Rate for Payer: Multiplan Workers Comp	$608.50
Rate for Payer: Scott and White EPO/PPO	$608.50

GARMENT, CALF, VASO, GREEN, BARI, SZ UPTO, 32'

Facility

$46.65

Hospital Charge Code	993029
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.72

GARMENT, CALF, VASO, GREEN, BARI, SZ UPTO, 32'

Facility

$46.65

Hospital Charge Code	993029
Hospital Revenue Code	270
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$33.59
Rate for Payer: Amerigroup CHIP/Medicaid	$4.20
Rate for Payer: BCBS of TX Blue Advantage	$13.99
Rate for Payer: BCBS of TX Blue Essentials	$16.79
Rate for Payer: BCBS of TX PPO	$18.66
Rate for Payer: Cash Price	$31.72
Rate for Payer: Cigna Medicaid	$33.59
Rate for Payer: Molina CHIP/Medicaid	$33.59
Rate for Payer: Multiplan Auto	$30.32
Rate for Payer: Multiplan Commercial	$30.32
Rate for Payer: Multiplan Workers Comp	$30.32
Rate for Payer: Parkland Medicaid	$33.59
Rate for Payer: Scott and White EPO/PPO	$23.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.59
Rate for Payer: Superior Health Plan EPO	$6.34

GARMENT CALF VASOPRESS, LARGE

Facility

$10.57

Hospital Charge Code	993177
Hospital Revenue Code	270
Rate for Payer: Cash Price	$7.19

GARMENT CALF VASOPRESS, LARGE

Facility

$10.57

Hospital Charge Code	993177
Hospital Revenue Code	270
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$7.61
Rate for Payer: Amerigroup CHIP/Medicaid	$0.95
Rate for Payer: BCBS of TX Blue Advantage	$3.17
Rate for Payer: BCBS of TX Blue Essentials	$3.81
Rate for Payer: BCBS of TX PPO	$4.23
Rate for Payer: Cash Price	$7.19
Rate for Payer: Cigna Medicaid	$7.61
Rate for Payer: Molina CHIP/Medicaid	$7.61
Rate for Payer: Multiplan Auto	$6.87
Rate for Payer: Multiplan Commercial	$6.87
Rate for Payer: Multiplan Workers Comp	$6.87
Rate for Payer: Parkland Medicaid	$7.61
Rate for Payer: Scott and White EPO/PPO	$5.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.61
Rate for Payer: Superior Health Plan EPO	$1.44

GAS, HELIUM I40L 2200PSI CYLINDER DISPOSABLE

Facility

$1,969.09

Hospital Charge Code	993803
Hospital Revenue Code	270
Min. Negotiated Rate	$177.22
Max. Negotiated Rate	$1,417.74
Rate for Payer: Amerigroup CHIP/Medicaid	$177.22
Rate for Payer: BCBS of TX Blue Advantage	$590.73
Rate for Payer: BCBS of TX Blue Essentials	$708.87
Rate for Payer: BCBS of TX PPO	$787.64
Rate for Payer: Cash Price	$1,338.98
Rate for Payer: Cigna Medicaid	$1,417.74
Rate for Payer: Molina CHIP/Medicaid	$1,417.74
Rate for Payer: Multiplan Auto	$1,279.91
Rate for Payer: Multiplan Commercial	$1,279.91
Rate for Payer: Multiplan Workers Comp	$1,279.91
Rate for Payer: Parkland Medicaid	$1,417.74
Rate for Payer: Scott and White EPO/PPO	$984.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,417.74
Rate for Payer: Superior Health Plan EPO	$267.80

GAS, HELIUM I40L 2200PSI CYLINDER DISPOSABLE

Facility

$1,969.09

Hospital Charge Code	993803
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,338.98

GASPAK EZ ANAEROBIC POUCH SYSTEM

Facility

$107.77

Hospital Charge Code	993102
Hospital Revenue Code	270
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$77.59
Rate for Payer: Amerigroup CHIP/Medicaid	$9.70
Rate for Payer: BCBS of TX Blue Advantage	$32.33
Rate for Payer: BCBS of TX Blue Essentials	$38.80
Rate for Payer: BCBS of TX PPO	$43.11
Rate for Payer: Cash Price	$73.28
Rate for Payer: Cigna Medicaid	$77.59
Rate for Payer: Molina CHIP/Medicaid	$77.59
Rate for Payer: Multiplan Auto	$70.05
Rate for Payer: Multiplan Commercial	$70.05
Rate for Payer: Multiplan Workers Comp	$70.05
Rate for Payer: Parkland Medicaid	$77.59
Rate for Payer: Scott and White EPO/PPO	$53.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.59
Rate for Payer: Superior Health Plan EPO	$14.66

Know your out-of-pocket cost for care.

All Charges