White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LENS MORGAN -- DHF

Facility

$648.34

Hospital Charge Code	80326200
Hospital Revenue Code	270
Rate for Payer: Cash Price	$570.54

Leukemia Lymphoma Panel SO

Facility

$438.00

Service Code	CPT 88184
Hospital Charge Code	1709468
Hospital Revenue Code	311
Rate for Payer: Cash Price	$385.44

Leukemia Lymphoma Panel SO

Facility

$438.00

Service Code	CPT 88184
Hospital Charge Code	1709468
Hospital Revenue Code	311
Min. Negotiated Rate	$5.88
Max. Negotiated Rate	$744.67
Rate for Payer: Aetna Commercial	$74.22
Rate for Payer: Aetna Medicare	$493.10
Rate for Payer: Amerigroup CHIP/Medicaid	$26.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$328.73
Rate for Payer: Amerigroup Medicare	$328.73
Rate for Payer: BCBS of TX Blue Advantage	$467.63
Rate for Payer: BCBS of TX Blue Essentials	$561.15
Rate for Payer: BCBS of TX Medicare	$328.73
Rate for Payer: BCBS of TX PPO	$626.34
Rate for Payer: Cash Price	$385.44
Rate for Payer: Cash Price	$385.44
Rate for Payer: Cash Price	$385.44
Rate for Payer: Cigna Commercial	$744.67
Rate for Payer: Cigna Medicare	$328.73
Rate for Payer: Employer Direct Commercial	$328.73
Rate for Payer: Humana Medicare/TRICARE	$328.73
Rate for Payer: Molina Dual Medicare/Medicaid	$328.73
Rate for Payer: Molina Medicare	$328.73
Rate for Payer: Multiplan Auto	$284.70
Rate for Payer: Multiplan Commercial	$284.70
Rate for Payer: Multiplan Workers Comp	$284.70
Rate for Payer: Scott and White EPO/PPO	$5.88
Rate for Payer: Scott and White Medicare	$328.73
Rate for Payer: Superior Health Plan EPO	$328.73
Rate for Payer: Superior Health Plan Medicare	$328.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$328.73
Rate for Payer: Universal American Medicare	$328.73
Rate for Payer: Wellcare Medicare	$328.73
Rate for Payer: Wellmed Medicare	$328.73

levalbuterol 1.25 mg/3 mL Inh Soln 3 mL

Facility

$25.50

Service Code	HCPCS J7614
Hospital Charge Code	7447369
Hospital Revenue Code	636
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$16.58
Rate for Payer: Amerigroup CHIP/Medicaid	$2.30
Rate for Payer: BCBS of TX Blue Advantage	$1.68
Rate for Payer: BCBS of TX Blue Essentials	$2.02
Rate for Payer: BCBS of TX PPO	$2.24
Rate for Payer: Cash Price	$17.34
Rate for Payer: Cash Price	$17.34
Rate for Payer: Multiplan Auto	$16.58
Rate for Payer: Multiplan Commercial	$16.58
Rate for Payer: Multiplan Workers Comp	$16.58
Rate for Payer: Scott and White EPO/PPO	$12.75
Rate for Payer: Superior Health Plan EPO	$3.47

levalbuterol 1.25 mg/3 mL Inh Soln 3 mL

Facility

$25.50

Service Code	HCPCS J7614
Hospital Charge Code	7447369
Hospital Revenue Code	636
Min. Negotiated Rate	$6.38
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$17.34
Rate for Payer: Cigna Commercial	$6.38
Rate for Payer: Scott and White EPO/PPO	$12.75

levETIRAcetam 100 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS J1953
Hospital Charge Code	77658709
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.16
Rate for Payer: BCBS of TX Blue Essentials	$0.19
Rate for Payer: BCBS of TX PPO	$0.21
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

levETIRAcetam 100 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS J1953
Hospital Charge Code	77658709
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

levETIRAcetam 100 mg/mL Oral Soln 5 mL

Facility

$30.10

Service Code	HCPCS J3490
Hospital Charge Code	77658817
Hospital Revenue Code	250
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$19.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2.71
Rate for Payer: BCBS of TX Blue Advantage	$9.03
Rate for Payer: BCBS of TX Blue Essentials	$10.84
Rate for Payer: BCBS of TX PPO	$12.04
Rate for Payer: Cash Price	$20.47
Rate for Payer: Multiplan Auto	$19.56
Rate for Payer: Multiplan Commercial	$19.56
Rate for Payer: Multiplan Workers Comp	$19.56
Rate for Payer: Scott and White EPO/PPO	$15.05
Rate for Payer: Superior Health Plan EPO	$4.09

levETIRAcetam 100 mg/mL Oral Soln 5 mL

Facility

$30.10

Service Code	HCPCS J3490
Hospital Charge Code	77658817
Hospital Revenue Code	250
Rate for Payer: Cash Price	$20.47

levETIRAcetam 500 mg/NaCl 0.82% 100 mL

Facility

$128.17

Service Code	HCPCS J1953
Hospital Charge Code	77659241
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.16
Rate for Payer: BCBS of TX Blue Essentials	$0.19
Rate for Payer: BCBS of TX PPO	$0.21
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

levETIRAcetam 500 mg/NaCl 0.82% 100 mL

Facility

$128.17

Service Code	HCPCS J1953
Hospital Charge Code	77659241
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

levETIRAcetam 500 mg Tab

Facility

$15.30

Service Code	HCPCS J3490
Hospital Charge Code	77659186
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.40

levETIRAcetam 500 mg Tab

Facility

$15.30

Service Code	HCPCS J3490
Hospital Charge Code	77659186
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$9.94
Rate for Payer: Amerigroup CHIP/Medicaid	$1.38
Rate for Payer: BCBS of TX Blue Advantage	$4.59
Rate for Payer: BCBS of TX Blue Essentials	$5.51
Rate for Payer: BCBS of TX PPO	$6.12
Rate for Payer: Cash Price	$10.40
Rate for Payer: Multiplan Auto	$9.94
Rate for Payer: Multiplan Commercial	$9.94
Rate for Payer: Multiplan Workers Comp	$9.94
Rate for Payer: Scott and White EPO/PPO	$7.65
Rate for Payer: Superior Health Plan EPO	$2.08

Levetiracetam (Keppra), S SO

Facility

$303.00

Service Code	CPT 80177
Hospital Charge Code	1740991
Hospital Revenue Code	301
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$196.95
Rate for Payer: Aetna Commercial	$13.91
Rate for Payer: Aetna Medicare	$19.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.25
Rate for Payer: Amerigroup Medicare	$13.25
Rate for Payer: BCBS of TX Blue Advantage	$21.86
Rate for Payer: BCBS of TX Blue Essentials	$26.24
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$29.28
Rate for Payer: Cash Price	$266.64
Rate for Payer: Cash Price	$266.64
Rate for Payer: Cigna Medicaid	$13.25
Rate for Payer: Cigna Medicare	$13.25
Rate for Payer: Employer Direct Commercial	$13.25
Rate for Payer: Humana Medicare/TRICARE	$13.25
Rate for Payer: Molina CHIP/Medicaid	$13.25
Rate for Payer: Molina Dual Medicare/Medicaid	$13.25
Rate for Payer: Molina Medicare	$13.25
Rate for Payer: Multiplan Auto	$196.95
Rate for Payer: Multiplan Commercial	$196.95
Rate for Payer: Multiplan Workers Comp	$196.95
Rate for Payer: Parkland Medicaid	$13.25
Rate for Payer: Scott and White EPO/PPO	$16.56
Rate for Payer: Scott and White Medicare	$13.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.25
Rate for Payer: Superior Health Plan EPO	$13.25
Rate for Payer: Superior Health Plan Medicare	$13.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.25
Rate for Payer: Universal American Medicare	$13.25
Rate for Payer: Wellcare Medicare	$13.25
Rate for Payer: Wellmed Medicare	$13.25

Levetiracetam (Keppra), S SO

Facility

$303.00

Service Code	CPT 80177
Hospital Charge Code	1740991
Hospital Revenue Code	301
Rate for Payer: Cash Price	$266.64

levoFLOXacin 250 mg Tab

Facility

$21.76

Service Code	HCPCS J3490
Hospital Charge Code	77660460
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.80

levoFLOXacin 250 mg Tab

Facility

$21.76

Service Code	HCPCS J3490
Hospital Charge Code	77660460
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$14.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1.96
Rate for Payer: BCBS of TX Blue Advantage	$6.53
Rate for Payer: BCBS of TX Blue Essentials	$7.83
Rate for Payer: BCBS of TX PPO	$8.70
Rate for Payer: Cash Price	$14.80
Rate for Payer: Multiplan Auto	$14.14
Rate for Payer: Multiplan Commercial	$14.14
Rate for Payer: Multiplan Workers Comp	$14.14
Rate for Payer: Scott and White EPO/PPO	$10.88
Rate for Payer: Superior Health Plan EPO	$2.96

levofloxacin 500 mg/100 mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J1956
Hospital Charge Code	77660625
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.09
Rate for Payer: BCBS of TX Blue Essentials	$2.51
Rate for Payer: BCBS of TX PPO	$2.78
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

levofloxacin 500 mg/100 mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J1956
Hospital Charge Code	77660625
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

levoFLOXacin 500 mg Tab

Facility

$28.70

Service Code	HCPCS J3490
Hospital Charge Code	7.7660574E7
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.52

levoFLOXacin 500 mg Tab

Facility

$28.70

Service Code	HCPCS J3490
Hospital Charge Code	7.7660574E7
Hospital Revenue Code	250
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$18.66
Rate for Payer: Amerigroup CHIP/Medicaid	$2.58
Rate for Payer: BCBS of TX Blue Advantage	$8.61
Rate for Payer: BCBS of TX Blue Essentials	$10.33
Rate for Payer: BCBS of TX PPO	$11.48
Rate for Payer: Cash Price	$19.52
Rate for Payer: Multiplan Auto	$18.66
Rate for Payer: Multiplan Commercial	$18.66
Rate for Payer: Multiplan Workers Comp	$18.66
Rate for Payer: Scott and White EPO/PPO	$14.35
Rate for Payer: Superior Health Plan EPO	$3.90

levoFLOXacin 750 mg/150 mL IV Soln 150 mL

Facility

$128.17

Service Code	HCPCS J1956
Hospital Charge Code	77660739
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

levoFLOXacin 750 mg/150 mL IV Soln 150 mL

Facility

$128.17

Service Code	HCPCS J1956
Hospital Charge Code	77660739
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.09
Rate for Payer: BCBS of TX Blue Essentials	$2.51
Rate for Payer: BCBS of TX PPO	$2.78
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

levoFLOXacin 750 mg Tab

Facility

$61.64

Service Code	HCPCS J3490
Hospital Charge Code	77660684
Hospital Revenue Code	250
Min. Negotiated Rate	$5.55
Max. Negotiated Rate	$40.07
Rate for Payer: Amerigroup CHIP/Medicaid	$5.55
Rate for Payer: BCBS of TX Blue Advantage	$18.49
Rate for Payer: BCBS of TX Blue Essentials	$22.19
Rate for Payer: BCBS of TX PPO	$24.66
Rate for Payer: Cash Price	$41.92
Rate for Payer: Multiplan Auto	$40.07
Rate for Payer: Multiplan Commercial	$40.07
Rate for Payer: Multiplan Workers Comp	$40.07
Rate for Payer: Scott and White EPO/PPO	$30.82
Rate for Payer: Superior Health Plan EPO	$8.38

levoFLOXacin 750 mg Tab

Facility

$61.64

Service Code	HCPCS J3490
Hospital Charge Code	77660684
Hospital Revenue Code	250
Rate for Payer: Cash Price	$41.92

Know your out-of-pocket cost for care.

All Charges