White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$7.06
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: Cigna Medicaid	$7.06
Rate for Payer: Molina CHIP/Medicaid	$7.06
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: Parkland Medicaid	$7.06
Rate for Payer: Scott and White EPO/PPO	$4.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.06
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

GEM PAK 75/Full Panel

Facility

$7,993.21

Hospital Charge Code	993844
Hospital Revenue Code	270
Min. Negotiated Rate	$719.39
Max. Negotiated Rate	$5,755.11
Rate for Payer: Amerigroup CHIP/Medicaid	$719.39
Rate for Payer: BCBS of TX Blue Advantage	$2,397.96
Rate for Payer: BCBS of TX Blue Essentials	$2,877.56
Rate for Payer: BCBS of TX PPO	$3,197.28
Rate for Payer: Cash Price	$5,435.38
Rate for Payer: Cigna Medicaid	$5,755.11
Rate for Payer: Molina CHIP/Medicaid	$5,755.11
Rate for Payer: Multiplan Auto	$5,195.59
Rate for Payer: Multiplan Commercial	$5,195.59
Rate for Payer: Multiplan Workers Comp	$5,195.59
Rate for Payer: Parkland Medicaid	$5,755.11
Rate for Payer: Scott and White EPO/PPO	$3,996.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,755.11
Rate for Payer: Superior Health Plan EPO	$1,087.08

GEM PAK 75/Full Panel

Facility

$7,993.21

Hospital Charge Code	993844
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5,435.38

General Health Panel BCE

Facility

$546.00

Service Code	HCPCS 80050
Hospital Charge Code	4100052
Hospital Revenue Code	300
Rate for Payer: Cash Price	$371.28

General Health Panel BCE

Facility

$546.00

Service Code	HCPCS 80050
Hospital Charge Code	4100052
Hospital Revenue Code	300
Min. Negotiated Rate	$13.70
Max. Negotiated Rate	$393.12
Rate for Payer: Amerigroup CHIP/Medicaid	$13.70
Rate for Payer: BCBS of TX Blue Advantage	$163.80
Rate for Payer: BCBS of TX Blue Essentials	$196.56
Rate for Payer: BCBS of TX PPO	$218.40
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cigna Medicaid	$393.12
Rate for Payer: Molina CHIP/Medicaid	$393.12
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: Parkland Medicaid	$393.12
Rate for Payer: Scott and White EPO/PPO	$273.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$393.12
Rate for Payer: Superior Health Plan EPO	$74.26

GENESIS PRO STENT 10X29

Facility

$4,269.58

Service Code	HCPCS C1876
Hospital Charge Code	991297
Hospital Revenue Code	278
Min. Negotiated Rate	$1,067.39
Max. Negotiated Rate	$2,134.79
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Commercial	$1,067.39
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Scott and White EPO/PPO	$2,134.79

GENESIS PRO STENT 10X29

Facility

$4,269.58

Service Code	HCPCS C1876
Hospital Charge Code	991297
Hospital Revenue Code	278
Min. Negotiated Rate	$384.26
Max. Negotiated Rate	$3,074.10
Rate for Payer: Amerigroup CHIP/Medicaid	$384.26
Rate for Payer: BCBS of TX Blue Advantage	$1,280.87
Rate for Payer: BCBS of TX Blue Essentials	$1,537.05
Rate for Payer: BCBS of TX PPO	$1,707.83
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Medicaid	$3,074.10
Rate for Payer: Molina CHIP/Medicaid	$3,074.10
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Parkland Medicaid	$3,074.10
Rate for Payer: Scott and White EPO/PPO	$2,134.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,074.10
Rate for Payer: Superior Health Plan EPO	$580.66

Genital Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107024
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

Genital Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107024
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
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	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
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	$222.48
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	$222.48
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	$222.48
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	$96.37
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: Cigna Medicaid	$96.37
Rate for Payer: Molina CHIP/Medicaid	$96.37
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: Parkland Medicaid	$96.37
Rate for Payer: Scott and White EPO/PPO	$66.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.37
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
Rate for Payer: Cash Price	$87.16

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	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$3.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$3.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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 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	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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

Gentamicin Trough, Serum SO

Facility

$255.00

Service Code	HCPCS 80170
Hospital Charge Code	1602739
Hospital Revenue Code	300
Rate for Payer: Cash Price	$173.40

Gentamicin Trough, Serum SO

Facility

$255.00

Service Code	HCPCS 80170
Hospital Charge Code	1602739
Hospital Revenue Code	300
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$183.60
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	$76.50
Rate for Payer: BCBS of TX Blue Essentials	$91.80
Rate for Payer: BCBS of TX Medicare	$16.38
Rate for Payer: BCBS of TX PPO	$102.00
Rate for Payer: Cash Price	$173.40
Rate for Payer: Cash Price	$173.40
Rate for Payer: Cigna Medicaid	$183.60
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	$183.60
Rate for Payer: Molina Dual Medicare/Medicaid	$16.38
Rate for Payer: Molina Medicare	$16.38
Rate for Payer: Multiplan Auto	$165.75
Rate for Payer: Multiplan Commercial	$165.75
Rate for Payer: Multiplan Workers Comp	$165.75
Rate for Payer: Parkland Medicaid	$183.60
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	$183.60
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

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

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	3914006
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

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

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	3914006
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Molina CHIP/Medicaid	$81.36
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	$81.36
Rate for Payer: Scott and White EPO/PPO	$10.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

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

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	3914007
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

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

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	3914007
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$125.28
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$52.20
Rate for Payer: BCBS of TX Blue Essentials	$62.64
Rate for Payer: BCBS of TX PPO	$69.60
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cigna Medicaid	$125.28
Rate for Payer: Molina CHIP/Medicaid	$125.28
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	$125.28
Rate for Payer: Scott and White EPO/PPO	$43.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28

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

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	3914013
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$151.92
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$63.30
Rate for Payer: BCBS of TX Blue Essentials	$75.96
Rate for Payer: BCBS of TX PPO	$84.40
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cigna Medicaid	$151.92
Rate for Payer: Molina CHIP/Medicaid	$151.92
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$151.92
Rate for Payer: Scott and White EPO/PPO	$80.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.92

Know your out-of-pocket cost for care.

All Charges