White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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; 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

GLUCOSE BLOOD TEST

Facility

$43.00

Service Code	HCPCS 82962
Hospital Charge Code	8910555
Hospital Revenue Code	301
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$30.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.28
Rate for Payer: Amerigroup Medicare	$3.28
Rate for Payer: BCBS of TX Blue Advantage	$12.90
Rate for Payer: BCBS of TX Blue Essentials	$15.48
Rate for Payer: BCBS of TX Medicare	$3.28
Rate for Payer: BCBS of TX PPO	$17.20
Rate for Payer: Cash Price	$29.24
Rate for Payer: Cash Price	$29.24
Rate for Payer: Cigna Medicaid	$30.96
Rate for Payer: Cigna Medicare	$3.28
Rate for Payer: Employer Direct Commercial	$3.28
Rate for Payer: Humana Medicare/TRICARE	$3.28
Rate for Payer: Molina CHIP/Medicaid	$30.96
Rate for Payer: Molina Dual Medicare/Medicaid	$3.28
Rate for Payer: Molina Medicare	$3.28
Rate for Payer: Multiplan Auto	$27.95
Rate for Payer: Multiplan Commercial	$27.95
Rate for Payer: Multiplan Workers Comp	$27.95
Rate for Payer: Parkland Medicaid	$30.96
Rate for Payer: Scott and White EPO/PPO	$4.10
Rate for Payer: Scott and White Medicare	$3.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.96
Rate for Payer: Superior Health Plan EPO	$3.28
Rate for Payer: Superior Health Plan Medicare	$3.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.28
Rate for Payer: Universal American Medicare	$3.28
Rate for Payer: Wellcare Medicare	$3.28
Rate for Payer: Wellmed Medicare	$3.28

GLUCOSE BLOOD TEST

Facility

$43.00

Service Code	HCPCS 82962
Hospital Charge Code	8910555
Hospital Revenue Code	301
Rate for Payer: Cash Price	$29.24

GLUCOSE BLOOD TEST

Facility

$43.00

Service Code	HCPCS 82962
Hospital Charge Code	7150733
Hospital Revenue Code	301
Rate for Payer: Cash Price	$29.24

GLUCOSE BLOOD TEST

Facility

$43.00

Service Code	HCPCS 82962
Hospital Charge Code	7150733
Hospital Revenue Code	301
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$30.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.28
Rate for Payer: Amerigroup Medicare	$3.28
Rate for Payer: BCBS of TX Blue Advantage	$12.90
Rate for Payer: BCBS of TX Blue Essentials	$15.48
Rate for Payer: BCBS of TX Medicare	$3.28
Rate for Payer: BCBS of TX PPO	$17.20
Rate for Payer: Cash Price	$29.24
Rate for Payer: Cash Price	$29.24
Rate for Payer: Cigna Medicaid	$30.96
Rate for Payer: Cigna Medicare	$3.28
Rate for Payer: Employer Direct Commercial	$3.28
Rate for Payer: Humana Medicare/TRICARE	$3.28
Rate for Payer: Molina CHIP/Medicaid	$30.96
Rate for Payer: Molina Dual Medicare/Medicaid	$3.28
Rate for Payer: Molina Medicare	$3.28
Rate for Payer: Multiplan Auto	$27.95
Rate for Payer: Multiplan Commercial	$27.95
Rate for Payer: Multiplan Workers Comp	$27.95
Rate for Payer: Parkland Medicaid	$30.96
Rate for Payer: Scott and White EPO/PPO	$4.10
Rate for Payer: Scott and White Medicare	$3.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.96
Rate for Payer: Superior Health Plan EPO	$3.28
Rate for Payer: Superior Health Plan Medicare	$3.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.28
Rate for Payer: Universal American Medicare	$3.28
Rate for Payer: Wellcare Medicare	$3.28
Rate for Payer: Wellmed Medicare	$3.28

Glucose Body Fluid

Facility

$156.00

Service Code	HCPCS 82945
Hospital Charge Code	1602549
Hospital Revenue Code	301
Rate for Payer: Cash Price	$106.08

Glucose Body Fluid

Facility

$156.00

Service Code	HCPCS 82945
Hospital Charge Code	1602549
Hospital Revenue Code	301
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$112.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.93
Rate for Payer: Amerigroup Medicare	$3.93
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	$3.93
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	$3.93
Rate for Payer: Employer Direct Commercial	$3.93
Rate for Payer: Humana Medicare/TRICARE	$3.93
Rate for Payer: Molina CHIP/Medicaid	$112.32
Rate for Payer: Molina Dual Medicare/Medicaid	$3.93
Rate for Payer: Molina Medicare	$3.93
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	$4.91
Rate for Payer: Scott and White Medicare	$3.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$112.32
Rate for Payer: Superior Health Plan EPO	$3.93
Rate for Payer: Superior Health Plan Medicare	$3.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.93
Rate for Payer: Universal American Medicare	$3.93
Rate for Payer: Wellcare Medicare	$3.93
Rate for Payer: Wellmed Medicare	$3.93

Glucose CSF

Facility

$156.00

Service Code	HCPCS 82945
Hospital Charge Code	4102945
Hospital Revenue Code	301
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$112.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.93
Rate for Payer: Amerigroup Medicare	$3.93
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	$3.93
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	$3.93
Rate for Payer: Employer Direct Commercial	$3.93
Rate for Payer: Humana Medicare/TRICARE	$3.93
Rate for Payer: Molina CHIP/Medicaid	$112.32
Rate for Payer: Molina Dual Medicare/Medicaid	$3.93
Rate for Payer: Molina Medicare	$3.93
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	$4.91
Rate for Payer: Scott and White Medicare	$3.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$112.32
Rate for Payer: Superior Health Plan EPO	$3.93
Rate for Payer: Superior Health Plan Medicare	$3.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.93
Rate for Payer: Universal American Medicare	$3.93
Rate for Payer: Wellcare Medicare	$3.93
Rate for Payer: Wellmed Medicare	$3.93

Glucose CSF

Facility

$156.00

Service Code	HCPCS 82945
Hospital Charge Code	4102945
Hospital Revenue Code	301
Rate for Payer: Cash Price	$106.08

Glucose Fasting

Facility

$156.00

Service Code	HCPCS 82947
Hospital Charge Code	1601368
Hospital Revenue Code	301
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$112.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.93
Rate for Payer: Amerigroup Medicare	$3.93
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	$3.93
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	$3.93
Rate for Payer: Employer Direct Commercial	$3.93
Rate for Payer: Humana Medicare/TRICARE	$3.93
Rate for Payer: Molina CHIP/Medicaid	$112.32
Rate for Payer: Molina Dual Medicare/Medicaid	$3.93
Rate for Payer: Molina Medicare	$3.93
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	$4.91
Rate for Payer: Scott and White Medicare	$3.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$112.32
Rate for Payer: Superior Health Plan EPO	$3.93
Rate for Payer: Superior Health Plan Medicare	$3.93
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.93
Rate for Payer: Universal American Medicare	$3.93
Rate for Payer: Wellcare Medicare	$3.93
Rate for Payer: Wellmed Medicare	$3.93

Glucose Fasting

Facility

$156.00

Service Code	HCPCS 82947
Hospital Charge Code	1601368
Hospital Revenue Code	301
Rate for Payer: Cash Price	$106.08

Glucose Monitor Continuous

Facility

$153.00

Service Code	HCPCS 95250
Hospital Charge Code	3535250
Hospital Revenue Code	920
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$282.70
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.74
Rate for Payer: Amerigroup Medicare	$133.74
Rate for Payer: BCBS of TX Blue Advantage	$45.90
Rate for Payer: BCBS of TX Blue Essentials	$55.08
Rate for Payer: BCBS of TX Medicare	$133.74
Rate for Payer: BCBS of TX PPO	$61.20
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cigna Commercial	$282.70
Rate for Payer: Cigna Medicaid	$110.16
Rate for Payer: Cigna Medicare	$133.74
Rate for Payer: Employer Direct Commercial	$133.74
Rate for Payer: Humana Medicare/TRICARE	$133.74
Rate for Payer: Molina CHIP/Medicaid	$110.16
Rate for Payer: Molina Dual Medicare/Medicaid	$133.74
Rate for Payer: Molina Medicare	$133.74
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Parkland Medicaid	$110.16
Rate for Payer: Scott and White EPO/PPO	$182.38
Rate for Payer: Scott and White Medicare	$133.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$133.74
Rate for Payer: Superior Health Plan Medicare	$133.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.74
Rate for Payer: Universal American Medicare	$133.74
Rate for Payer: Wellcare Medicare	$133.74
Rate for Payer: Wellmed Medicare	$133.74

Glucose Monitor Continuous

Facility

$153.00

Service Code	HCPCS 95250
Hospital Charge Code	3535250
Hospital Revenue Code	920
Rate for Payer: Cash Price	$104.04

glyBURIDE 2.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77594079
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

glyBURIDE 2.5 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77594079
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

glycerin pediatric Rectal Supp

Facility

$8.00

Service Code	HCPCS J8498
Hospital Charge Code	77595439
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

glycerin pediatric Rectal Supp

Facility

$8.00

Service Code	HCPCS J8498
Hospital Charge Code	77595439
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

glycopyrrolate 0.2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1596
Hospital Charge Code	77595759
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

glycopyrrolate 0.2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1596
Hospital Charge Code	7446179
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.99
Rate for Payer: BCBS of TX Blue Essentials	$1.18
Rate for Payer: BCBS of TX PPO	$1.31
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	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

glycopyrrolate 0.2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1596
Hospital Charge Code	77595759
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.99
Rate for Payer: BCBS of TX Blue Essentials	$1.18
Rate for Payer: BCBS of TX PPO	$1.31
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	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

glycopyrrolate 0.2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1596
Hospital Charge Code	7446179
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

GN BROTH, 15 X 103MM TUBES, 6MKL

Facility

$21.13

Hospital Charge Code	993099
Hospital Revenue Code	270
Rate for Payer: Cash Price	$14.37

GN BROTH, 15 X 103MM TUBES, 6MKL

Facility

$21.13

Hospital Charge Code	993099
Hospital Revenue Code	270
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$15.21
Rate for Payer: Amerigroup CHIP/Medicaid	$1.90
Rate for Payer: BCBS of TX Blue Advantage	$6.34
Rate for Payer: BCBS of TX Blue Essentials	$7.61
Rate for Payer: BCBS of TX PPO	$8.45
Rate for Payer: Cash Price	$14.37
Rate for Payer: Cigna Medicaid	$15.21
Rate for Payer: Molina CHIP/Medicaid	$15.21
Rate for Payer: Multiplan Auto	$13.73
Rate for Payer: Multiplan Commercial	$13.73
Rate for Payer: Multiplan Workers Comp	$13.73
Rate for Payer: Parkland Medicaid	$15.21
Rate for Payer: Scott and White EPO/PPO	$10.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.21
Rate for Payer: Superior Health Plan EPO	$2.87

Know your out-of-pocket cost for care.

All Charges