White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GLOVE, SURGICAL BIOGEL PI IND SZ 7.5

Facility

$7.46

Hospital Charge Code	992870
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 8.5

Facility

$7.46

Hospital Charge Code	992769
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 8.5

Facility

$7.46

Hospital Charge Code	992769
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.07

GLOVE, SURGICAL, BIOGEL, ULTRATOUCH, PF

Facility

$8.40

Hospital Charge Code	992815
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.71

GLOVE, SURGICAL, BIOGEL, ULTRATOUCH, PF

Facility

$8.40

Hospital Charge Code	992815
Hospital Revenue Code	272
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$6.05
Rate for Payer: Amerigroup CHIP/Medicaid	$0.76
Rate for Payer: BCBS of TX Blue Advantage	$2.52
Rate for Payer: BCBS of TX Blue Essentials	$3.02
Rate for Payer: BCBS of TX PPO	$3.36
Rate for Payer: Cash Price	$5.71
Rate for Payer: Cigna Medicaid	$6.05
Rate for Payer: Molina CHIP/Medicaid	$6.05
Rate for Payer: Multiplan Auto	$5.46
Rate for Payer: Multiplan Commercial	$5.46
Rate for Payer: Multiplan Workers Comp	$5.46
Rate for Payer: Parkland Medicaid	$6.05
Rate for Payer: Scott and White EPO/PPO	$4.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.05
Rate for Payer: Superior Health Plan EPO	$1.14

GLOVE SURGICAL LATEX BIOGEL PF 6

Facility

$5.97

Hospital Charge Code	992875
Hospital Revenue Code	272
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$4.30
Rate for Payer: Amerigroup CHIP/Medicaid	$0.54
Rate for Payer: BCBS of TX Blue Advantage	$1.79
Rate for Payer: BCBS of TX Blue Essentials	$2.15
Rate for Payer: BCBS of TX PPO	$2.39
Rate for Payer: Cash Price	$4.06
Rate for Payer: Cigna Medicaid	$4.30
Rate for Payer: Molina CHIP/Medicaid	$4.30
Rate for Payer: Multiplan Auto	$3.88
Rate for Payer: Multiplan Commercial	$3.88
Rate for Payer: Multiplan Workers Comp	$3.88
Rate for Payer: Parkland Medicaid	$4.30
Rate for Payer: Scott and White EPO/PPO	$2.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.30
Rate for Payer: Superior Health Plan EPO	$0.81

GLOVE SURGICAL LATEX BIOGEL PF 6

Facility

$5.97

Hospital Charge Code	992875
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.06

GLOVE, SURGICAL, LATEX, BIOGEL, PF, 7

Facility

$5.97

Hospital Charge Code	992770
Hospital Revenue Code	272
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$4.30
Rate for Payer: Amerigroup CHIP/Medicaid	$0.54
Rate for Payer: BCBS of TX Blue Advantage	$1.79
Rate for Payer: BCBS of TX Blue Essentials	$2.15
Rate for Payer: BCBS of TX PPO	$2.39
Rate for Payer: Cash Price	$4.06
Rate for Payer: Cigna Medicaid	$4.30
Rate for Payer: Molina CHIP/Medicaid	$4.30
Rate for Payer: Multiplan Auto	$3.88
Rate for Payer: Multiplan Commercial	$3.88
Rate for Payer: Multiplan Workers Comp	$3.88
Rate for Payer: Parkland Medicaid	$4.30
Rate for Payer: Scott and White EPO/PPO	$2.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.30
Rate for Payer: Superior Health Plan EPO	$0.81

GLOVE, SURGICAL, LATEX, BIOGEL, PF, 7

Facility

$5.97

Hospital Charge Code	992770
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.06

GLOVE, SURGICAL, LATEX, BIOGEL, PF, 7.5

Facility

$5.97

Hospital Charge Code	992771
Hospital Revenue Code	272
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$4.30
Rate for Payer: Amerigroup CHIP/Medicaid	$0.54
Rate for Payer: BCBS of TX Blue Advantage	$1.79
Rate for Payer: BCBS of TX Blue Essentials	$2.15
Rate for Payer: BCBS of TX PPO	$2.39
Rate for Payer: Cash Price	$4.06
Rate for Payer: Cigna Medicaid	$4.30
Rate for Payer: Molina CHIP/Medicaid	$4.30
Rate for Payer: Multiplan Auto	$3.88
Rate for Payer: Multiplan Commercial	$3.88
Rate for Payer: Multiplan Workers Comp	$3.88
Rate for Payer: Parkland Medicaid	$4.30
Rate for Payer: Scott and White EPO/PPO	$2.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.30
Rate for Payer: Superior Health Plan EPO	$0.81

GLOVE, SURGICAL, LATEX, BIOGEL, PF, 7.5

Facility

$5.97

Hospital Charge Code	992771
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.06

GLOVE,SURGICAL,LATEX,BIOGEL,PF,8

Facility

$7.92

Hospital Charge Code	993115
Hospital Revenue Code	270
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$5.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.71
Rate for Payer: BCBS of TX Blue Advantage	$2.38
Rate for Payer: BCBS of TX Blue Essentials	$2.85
Rate for Payer: BCBS of TX PPO	$3.17
Rate for Payer: Cash Price	$5.39
Rate for Payer: Cigna Medicaid	$5.70
Rate for Payer: Molina CHIP/Medicaid	$5.70
Rate for Payer: Multiplan Auto	$5.15
Rate for Payer: Multiplan Commercial	$5.15
Rate for Payer: Multiplan Workers Comp	$5.15
Rate for Payer: Parkland Medicaid	$5.70
Rate for Payer: Scott and White EPO/PPO	$3.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.70
Rate for Payer: Superior Health Plan EPO	$1.08

GLOVE,SURGICAL,LATEX,BIOGEL,PF,8

Facility

$7.92

Hospital Charge Code	993115
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.39

GLOvE, SURGICAL, LATEX, BIOGEL, SURGICAL, PF, 8.5

Facility

$5.97

Hospital Charge Code	992823
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.06

GLOvE, SURGICAL, LATEX, BIOGEL, SURGICAL, PF, 8.5

Facility

$5.97

Hospital Charge Code	992823
Hospital Revenue Code	272
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$4.30
Rate for Payer: Amerigroup CHIP/Medicaid	$0.54
Rate for Payer: BCBS of TX Blue Advantage	$1.79
Rate for Payer: BCBS of TX Blue Essentials	$2.15
Rate for Payer: BCBS of TX PPO	$2.39
Rate for Payer: Cash Price	$4.06
Rate for Payer: Cigna Medicaid	$4.30
Rate for Payer: Molina CHIP/Medicaid	$4.30
Rate for Payer: Multiplan Auto	$3.88
Rate for Payer: Multiplan Commercial	$3.88
Rate for Payer: Multiplan Workers Comp	$3.88
Rate for Payer: Parkland Medicaid	$4.30
Rate for Payer: Scott and White EPO/PPO	$2.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.30
Rate for Payer: Superior Health Plan EPO	$0.81

GLOVE, SURG, PROTEXIS LATEX 7.5 PF

Facility

$3.89

Hospital Charge Code	993063
Hospital Revenue Code	270
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$2.80
Rate for Payer: Amerigroup CHIP/Medicaid	$0.35
Rate for Payer: BCBS of TX Blue Advantage	$1.17
Rate for Payer: BCBS of TX Blue Essentials	$1.40
Rate for Payer: BCBS of TX PPO	$1.56
Rate for Payer: Cash Price	$2.65
Rate for Payer: Cigna Medicaid	$2.80
Rate for Payer: Molina CHIP/Medicaid	$2.80
Rate for Payer: Multiplan Auto	$2.53
Rate for Payer: Multiplan Commercial	$2.53
Rate for Payer: Multiplan Workers Comp	$2.53
Rate for Payer: Parkland Medicaid	$2.80
Rate for Payer: Scott and White EPO/PPO	$1.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.80
Rate for Payer: Superior Health Plan EPO	$0.53

GLOVE, SURG, PROTEXIS LATEX 7.5 PF

Facility

$3.89

Hospital Charge Code	993063
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2.65

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	$263.43
Rate for Payer: Cash Price	$358.26
Rate for Payer: Cigna Commercial	$131.71
Rate for Payer: Scott and White EPO/PPO	$263.43

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	$379.33
Rate for Payer: Amerigroup CHIP/Medicaid	$47.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$117.33
Rate for Payer: Amerigroup Medicare	$117.33
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	$117.33
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 Medicaid	$379.33
Rate for Payer: Cigna Medicare	$117.33
Rate for Payer: Employer Direct Commercial	$117.33
Rate for Payer: Humana Medicare/TRICARE	$117.33
Rate for Payer: Molina CHIP/Medicaid	$379.33
Rate for Payer: Molina Dual Medicare/Medicaid	$117.33
Rate for Payer: Molina Medicare	$117.33
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: Parkland Medicaid	$379.33
Rate for Payer: Scott and White EPO/PPO	$263.43
Rate for Payer: Scott and White Medicare	$117.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$379.33
Rate for Payer: Superior Health Plan EPO	$117.33
Rate for Payer: Superior Health Plan Medicare	$117.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$117.33
Rate for Payer: Universal American Medicare	$117.33
Rate for Payer: Wellcare Medicare	$117.33
Rate for Payer: Wellmed Medicare	$117.33

Glucose 2 Hour Post Prandial

Facility

$106.00

Service Code	HCPCS 82950 QW
Hospital Charge Code	1602861
Hospital Revenue Code	301
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$76.32
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	$31.80
Rate for Payer: BCBS of TX Blue Essentials	$38.16
Rate for Payer: BCBS of TX Medicare	$4.75
Rate for Payer: BCBS of TX PPO	$42.40
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cash Price	$72.08
Rate for Payer: Cigna Medicaid	$76.32
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	$76.32
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	$76.32
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	$76.32
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	HCPCS 82950 QW
Hospital Charge Code	1602861
Hospital Revenue Code	301
Rate for Payer: Cash Price	$72.08

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	$12.35
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: Cigna Medicaid	$12.35
Rate for Payer: Molina CHIP/Medicaid	$12.35
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: Parkland Medicaid	$12.35
Rate for Payer: Scott and White EPO/PPO	$8.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.35
Rate for Payer: Superior Health Plan EPO	$2.33

glucose 40% Oral Gel 37.5 g

Facility

$17.15

Service Code	HCPCS J3490
Hospital Charge Code	77593410
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.66

Glucose; blood, reagent strip

Facility

$156.00

Service Code	HCPCS 82948
Hospital Charge Code	994123
Hospital Revenue Code	301
Rate for Payer: Cash Price	$106.08

Glucose; blood, reagent strip

Facility

$156.00

Service Code	HCPCS 82948
Hospital Charge Code	994123
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$112.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.04
Rate for Payer: Amerigroup Medicare	$5.04
Rate for Payer: BCBS of TX Blue Advantage	$46.80
Rate for Payer: BCBS of TX Blue Essentials	$56.16
Rate for Payer: BCBS of TX Medicare	$5.04
Rate for Payer: BCBS of TX PPO	$62.40
Rate for Payer: Cash Price	$106.08
Rate for Payer: Cash Price	$106.08
Rate for Payer: Cigna Medicaid	$112.32
Rate for Payer: Cigna Medicare	$5.04
Rate for Payer: Employer Direct Commercial	$5.04
Rate for Payer: Humana Medicare/TRICARE	$5.04
Rate for Payer: Molina CHIP/Medicaid	$112.32
Rate for Payer: Molina Dual Medicare/Medicaid	$5.04
Rate for Payer: Molina Medicare	$5.04
Rate for Payer: Multiplan Auto	$101.40
Rate for Payer: Multiplan Commercial	$101.40
Rate for Payer: Multiplan Workers Comp	$101.40
Rate for Payer: Parkland Medicaid	$112.32
Rate for Payer: Scott and White EPO/PPO	$6.30
Rate for Payer: Scott and White Medicare	$5.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$112.32
Rate for Payer: Superior Health Plan EPO	$5.04
Rate for Payer: Superior Health Plan Medicare	$5.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.04
Rate for Payer: Universal American Medicare	$5.04
Rate for Payer: Wellcare Medicare	$5.04
Rate for Payer: Wellmed Medicare	$5.04

Know your out-of-pocket cost for care.

All Charges