White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GLIDEWIRE STD 0.035 260CM 3CM TPR ANG

Facility

$456.09

Service Code	HCPCS C1769
Hospital Charge Code	993708
Hospital Revenue Code	272
Rate for Payer: Cash Price	$310.14

GLIDEWIRE STD 0.035 260CM 3CM TPR ANG

Facility

$456.09

Service Code	HCPCS C1769
Hospital Charge Code	993708
Hospital Revenue Code	272
Min. Negotiated Rate	$41.05
Max. Negotiated Rate	$328.38
Rate for Payer: Amerigroup CHIP/Medicaid	$41.05
Rate for Payer: BCBS of TX Blue Advantage	$136.83
Rate for Payer: BCBS of TX Blue Essentials	$164.19
Rate for Payer: BCBS of TX PPO	$182.44
Rate for Payer: Cash Price	$310.14
Rate for Payer: Cigna Medicaid	$328.38
Rate for Payer: Molina CHIP/Medicaid	$328.38
Rate for Payer: Multiplan Auto	$296.46
Rate for Payer: Multiplan Commercial	$296.46
Rate for Payer: Multiplan Workers Comp	$296.46
Rate for Payer: Parkland Medicaid	$328.38
Rate for Payer: Scott and White EPO/PPO	$228.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.38
Rate for Payer: Superior Health Plan EPO	$62.03

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	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

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

GLOVE, EXAM, NITRL, PF,TXT FNGR, L

Facility

$0.27

Hospital Charge Code	992940
Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.19
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.08
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.11
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna Medicaid	$0.19
Rate for Payer: Molina CHIP/Medicaid	$0.19
Rate for Payer: Multiplan Auto	$0.18
Rate for Payer: Multiplan Commercial	$0.18
Rate for Payer: Multiplan Workers Comp	$0.18
Rate for Payer: Parkland Medicaid	$0.19
Rate for Payer: Scott and White EPO/PPO	$0.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.19
Rate for Payer: Superior Health Plan EPO	$0.04

GLOVE, EXAM, NITRL, PF,TXT FNGR, L

Facility

$0.27

Hospital Charge Code	992940
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.18

GLOVE, EXAM, NITRL, PF,TXT FNGR, M

Facility

$0.27

Hospital Charge Code	992941
Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.19
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.08
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.11
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna Medicaid	$0.19
Rate for Payer: Molina CHIP/Medicaid	$0.19
Rate for Payer: Multiplan Auto	$0.18
Rate for Payer: Multiplan Commercial	$0.18
Rate for Payer: Multiplan Workers Comp	$0.18
Rate for Payer: Parkland Medicaid	$0.19
Rate for Payer: Scott and White EPO/PPO	$0.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.19
Rate for Payer: Superior Health Plan EPO	$0.04

GLOVE, EXAM, NITRL, PF,TXT FNGR, M

Facility

$0.27

Hospital Charge Code	992941
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.18

GLOVE, EXAM, NITRL, PF, TXT, FNGR, S

Facility

$0.27

Hospital Charge Code	992995
Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.19
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.08
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.11
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna Medicaid	$0.19
Rate for Payer: Molina CHIP/Medicaid	$0.19
Rate for Payer: Multiplan Auto	$0.18
Rate for Payer: Multiplan Commercial	$0.18
Rate for Payer: Multiplan Workers Comp	$0.18
Rate for Payer: Parkland Medicaid	$0.19
Rate for Payer: Scott and White EPO/PPO	$0.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.19
Rate for Payer: Superior Health Plan EPO	$0.04

GLOVE, EXAM, NITRL, PF, TXT, FNGR, S

Facility

$0.27

Hospital Charge Code	992995
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.18

GLOVE, EXAM, NITRL, PF, TXT FNGR, XL

Facility

$0.29

Hospital Charge Code	992992
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.20

GLOVE, EXAM, NITRL, PF, TXT FNGR, XL

Facility

$0.29

Hospital Charge Code	992992
Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.21
Rate for Payer: Amerigroup CHIP/Medicaid	$0.03
Rate for Payer: BCBS of TX Blue Advantage	$0.09
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.12
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna Medicaid	$0.21
Rate for Payer: Molina CHIP/Medicaid	$0.21
Rate for Payer: Multiplan Auto	$0.19
Rate for Payer: Multiplan Commercial	$0.19
Rate for Payer: Multiplan Workers Comp	$0.19
Rate for Payer: Parkland Medicaid	$0.21
Rate for Payer: Scott and White EPO/PPO	$0.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.21
Rate for Payer: Superior Health Plan EPO	$0.04

GLOVES EXAM PLUS NITRILE, PERIWNKL, PWDR FREE, LRG

Facility

$0.67

Hospital Charge Code	993032
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.46

GLOVES EXAM PLUS NITRILE, PERIWNKL, PWDR FREE, LRG

Facility

$0.67

Hospital Charge Code	993032
Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.48
Rate for Payer: Amerigroup CHIP/Medicaid	$0.06
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna Medicaid	$0.48
Rate for Payer: Molina CHIP/Medicaid	$0.48
Rate for Payer: Multiplan Auto	$0.44
Rate for Payer: Multiplan Commercial	$0.44
Rate for Payer: Multiplan Workers Comp	$0.44
Rate for Payer: Parkland Medicaid	$0.48
Rate for Payer: Scott and White EPO/PPO	$0.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.48
Rate for Payer: Superior Health Plan EPO	$0.09

GLOVES EXAM PLUS NITRILE, PERIWNKL, PWDR FREE, MD

Facility

$0.67

Hospital Charge Code	993033
Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.48
Rate for Payer: Amerigroup CHIP/Medicaid	$0.06
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna Medicaid	$0.48
Rate for Payer: Molina CHIP/Medicaid	$0.48
Rate for Payer: Multiplan Auto	$0.44
Rate for Payer: Multiplan Commercial	$0.44
Rate for Payer: Multiplan Workers Comp	$0.44
Rate for Payer: Parkland Medicaid	$0.48
Rate for Payer: Scott and White EPO/PPO	$0.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.48
Rate for Payer: Superior Health Plan EPO	$0.09

GLOVES EXAM PLUS NITRILE, PERIWNKL, PWDR FREE, MD

Facility

$0.67

Hospital Charge Code	993033
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.46

GLOVES EXAM PLUS NITRILE, PERIWNKL, PWDR FREE, SML

Facility

$0.67

Hospital Charge Code	993034
Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.48
Rate for Payer: Amerigroup CHIP/Medicaid	$0.06
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna Medicaid	$0.48
Rate for Payer: Molina CHIP/Medicaid	$0.48
Rate for Payer: Multiplan Auto	$0.44
Rate for Payer: Multiplan Commercial	$0.44
Rate for Payer: Multiplan Workers Comp	$0.44
Rate for Payer: Parkland Medicaid	$0.48
Rate for Payer: Scott and White EPO/PPO	$0.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.48
Rate for Payer: Superior Health Plan EPO	$0.09

GLOVES EXAM PLUS NITRILE, PERIWNKL, PWDR FREE, SML

Facility

$0.67

Hospital Charge Code	993034
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.46

GLOVE, SURGICAL BIOGEL PI IND SZ 6.0

Facility

$1.88

Hospital Charge Code	992800
Hospital Revenue Code	272
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$1.35
Rate for Payer: Amerigroup CHIP/Medicaid	$0.17
Rate for Payer: BCBS of TX Blue Advantage	$0.56
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
Rate for Payer: Cash Price	$1.28
Rate for Payer: Cigna Medicaid	$1.35
Rate for Payer: Molina CHIP/Medicaid	$1.35
Rate for Payer: Multiplan Auto	$1.22
Rate for Payer: Multiplan Commercial	$1.22
Rate for Payer: Multiplan Workers Comp	$1.22
Rate for Payer: Parkland Medicaid	$1.35
Rate for Payer: Scott and White EPO/PPO	$0.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.35
Rate for Payer: Superior Health Plan EPO	$0.26

GLOVE, SURGICAL BIOGEL PI IND SZ 6.0

Facility

$1.88

Hospital Charge Code	992800
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.28

GLOVE, SURGICAL BIOGEL PI IND SZ 6.5

Facility

$7.46

Hospital Charge Code	992867
Hospital Revenue Code	272
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$5.37
Rate for Payer: Amerigroup CHIP/Medicaid	$0.67
Rate for Payer: BCBS of TX Blue Advantage	$2.24
Rate for Payer: BCBS of TX Blue Essentials	$2.69
Rate for Payer: BCBS of TX PPO	$2.98
Rate for Payer: Cash Price	$5.07
Rate for Payer: Cigna Medicaid	$5.37
Rate for Payer: Molina CHIP/Medicaid	$5.37
Rate for Payer: Multiplan Auto	$4.85
Rate for Payer: Multiplan Commercial	$4.85
Rate for Payer: Multiplan Workers Comp	$4.85
Rate for Payer: Parkland Medicaid	$5.37
Rate for Payer: Scott and White EPO/PPO	$3.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.37
Rate for Payer: Superior Health Plan EPO	$1.01

GLOVE, SURGICAL BIOGEL PI IND SZ 6.5

Facility

$7.46

Hospital Charge Code	992867
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.07

GLOVE, SURGICAL BIOGEL PI IND SZ 7.0

Facility

$7.46

Hospital Charge Code	992768
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.07

GLOVE, SURGICAL BIOGEL PI IND SZ 7.0

Facility

$7.46

Hospital Charge Code	992768
Hospital Revenue Code	272
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$5.37
Rate for Payer: Amerigroup CHIP/Medicaid	$0.67
Rate for Payer: BCBS of TX Blue Advantage	$2.24
Rate for Payer: BCBS of TX Blue Essentials	$2.69
Rate for Payer: BCBS of TX PPO	$2.98
Rate for Payer: Cash Price	$5.07
Rate for Payer: Cigna Medicaid	$5.37
Rate for Payer: Molina CHIP/Medicaid	$5.37
Rate for Payer: Multiplan Auto	$4.85
Rate for Payer: Multiplan Commercial	$4.85
Rate for Payer: Multiplan Workers Comp	$4.85
Rate for Payer: Parkland Medicaid	$5.37
Rate for Payer: Scott and White EPO/PPO	$3.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.37
Rate for Payer: Superior Health Plan EPO	$1.01

GLOVE, SURGICAL BIOGEL PI IND SZ 7.5

Facility

$7.46

Hospital Charge Code	992870
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.07

Know your out-of-pocket cost for care.

All Charges