White Rock Medical Center

All Charges

Charge

Type

Setting

Price

levothyroxine 100 mcg (0.1 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77661610
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

levothyroxine 100 mcg (0.1 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77661610
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

levothyroxine 112 mcg (0.112 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77661712
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

levothyroxine 112 mcg (0.112 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77661712
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

levothyroxine 125 mcg (0.125 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77661816
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

levothyroxine 125 mcg (0.125 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77661816
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

levothyroxine 25 mcg (0.025 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77662430
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

levothyroxine 25 mcg (0.025 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77662430
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

levothyroxine 50 mcg (0.05 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77662587
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

levothyroxine 50 mcg (0.05 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77662587
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

levothyroxine 75 mcg (0.075 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77662738
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

levothyroxine 75 mcg (0.075 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77662738
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

levothyroxine 88 mcg (0.088 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77662842
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

levothyroxine 88 mcg (0.088 mg) Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77662842
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

lidocaine 0.5% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77663005
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

lidocaine 0.5% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77663005
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

lidocaine 1% Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J2003
Hospital Charge Code	77663372
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

lidocaine 1% Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J2003
Hospital Charge Code	77663372
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

lidocaine 1% Inj Soln 20 mL

Facility

$128.17

Service Code	HCPCS J2003
Hospital Charge Code	77663482
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

lidocaine 1% Inj Soln 20 mL

Facility

$128.17

Service Code	HCPCS J2003
Hospital Charge Code	77663482
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

lidocaine 1% Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77663427
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

lidocaine 1% Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77663427
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

lidocaine 1% Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J2003
Hospital Charge Code	77663588
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

lidocaine 1% Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J2003
Hospital Charge Code	77663588
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

lidocaine 1% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77663696
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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

Know your out-of-pocket cost for care.

All Charges