White Rock Medical Center

All Charges

Charge

Type

Setting

Price

lidocaine 1% Inj Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77663696
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

lidocaine 1% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J2003
Hospital Charge Code	77663908
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% PF Inj Soln 30 mL

Facility

$128.17

Service Code	HCPCS J2003
Hospital Charge Code	77663908
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% PF Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77663963
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

lidocaine 1% PF Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77663963
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 2% Inj Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77664395
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

lidocaine 2% Inj Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77664395
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 2% Mucous Membrane Soln 15 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78365379
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

lidocaine 2% Mucous Membrane Soln 15 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78365379
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

lidocaine 2% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77664558
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

lidocaine 2% PF Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77664558
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 2% PF Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77664676
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 2% PF Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77664676
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

lidocaine 2% Topical Gel with applicator 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77664886
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

lidocaine 2% Topical Gel with applicator 5 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77664886
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

lidocaine 4% Mucous Membrane Soln 4 mL

Facility

$19.90

Service Code	HCPCS J3490
Hospital Charge Code	78349613
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$12.94
Rate for Payer: Amerigroup CHIP/Medicaid	$1.79
Rate for Payer: BCBS of TX Blue Advantage	$5.97
Rate for Payer: BCBS of TX Blue Essentials	$7.16
Rate for Payer: BCBS of TX PPO	$7.96
Rate for Payer: Cash Price	$13.53
Rate for Payer: Multiplan Auto	$12.94
Rate for Payer: Multiplan Commercial	$12.94
Rate for Payer: Multiplan Workers Comp	$12.94
Rate for Payer: Scott and White EPO/PPO	$9.95
Rate for Payer: Superior Health Plan EPO	$2.71

lidocaine 4% Mucous Membrane Soln 4 mL

Facility

$19.90

Service Code	HCPCS J3490
Hospital Charge Code	78349613
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.53

lidocaine 5% Cream 30 g

Facility

$75.90

Service Code	HCPCS J3490
Hospital Charge Code	77665929
Hospital Revenue Code	250
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$49.34
Rate for Payer: Amerigroup CHIP/Medicaid	$6.83
Rate for Payer: BCBS of TX Blue Advantage	$22.77
Rate for Payer: BCBS of TX Blue Essentials	$27.32
Rate for Payer: BCBS of TX PPO	$30.36
Rate for Payer: Cash Price	$51.61
Rate for Payer: Multiplan Auto	$49.34
Rate for Payer: Multiplan Commercial	$49.34
Rate for Payer: Multiplan Workers Comp	$49.34
Rate for Payer: Scott and White EPO/PPO	$37.95
Rate for Payer: Superior Health Plan EPO	$10.32

lidocaine 5% Cream 30 g

Facility

$75.90

Service Code	HCPCS J3490
Hospital Charge Code	77665929
Hospital Revenue Code	250
Rate for Payer: Cash Price	$51.61

lidocaine 5% Topical Oint 30 g

Facility

$390.00

Service Code	HCPCS J3490
Hospital Charge Code	77666078
Hospital Revenue Code	250
Rate for Payer: Cash Price	$265.20

lidocaine 5% Topical Oint 30 g

Facility

$390.00

Service Code	HCPCS J3490
Hospital Charge Code	77666078
Hospital Revenue Code	250
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$253.50
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$117.00
Rate for Payer: BCBS of TX Blue Essentials	$140.40
Rate for Payer: BCBS of TX PPO	$156.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Multiplan Auto	$253.50
Rate for Payer: Multiplan Commercial	$253.50
Rate for Payer: Multiplan Workers Comp	$253.50
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan EPO	$53.04

lidocaine-prilocaine 2.5%-2.5% Cream 5 g

Facility

$33.70

Service Code	HCPCS J3490
Hospital Charge Code	77666480
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$21.90
Rate for Payer: Amerigroup CHIP/Medicaid	$3.03
Rate for Payer: BCBS of TX Blue Advantage	$10.11
Rate for Payer: BCBS of TX Blue Essentials	$12.13
Rate for Payer: BCBS of TX PPO	$13.48
Rate for Payer: Cash Price	$22.92
Rate for Payer: Multiplan Auto	$21.90
Rate for Payer: Multiplan Commercial	$21.90
Rate for Payer: Multiplan Workers Comp	$21.90
Rate for Payer: Scott and White EPO/PPO	$16.85
Rate for Payer: Superior Health Plan EPO	$4.58

lidocaine-prilocaine 2.5%-2.5% Cream 5 g

Facility

$33.70

Service Code	HCPCS J3490
Hospital Charge Code	77666480
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.92

lidocaine topical 4% Topical Film

Facility

$8.09

Service Code	HCPCS J3490
Hospital Charge Code	78869009
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.50

lidocaine topical 4% Topical Film

Facility

$8.09

Service Code	HCPCS J3490
Hospital Charge Code	78869009
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$5.26
Rate for Payer: Amerigroup CHIP/Medicaid	$0.73
Rate for Payer: BCBS of TX Blue Advantage	$2.43
Rate for Payer: BCBS of TX Blue Essentials	$2.91
Rate for Payer: BCBS of TX PPO	$3.24
Rate for Payer: Cash Price	$5.50
Rate for Payer: Multiplan Auto	$5.26
Rate for Payer: Multiplan Commercial	$5.26
Rate for Payer: Multiplan Workers Comp	$5.26
Rate for Payer: Scott and White EPO/PPO	$4.04
Rate for Payer: Superior Health Plan EPO	$1.10

Know your out-of-pocket cost for care.

All Charges