White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Lithium Level

Facility

$334.00

Service Code	CPT 80178
Hospital Charge Code	1602820
Hospital Revenue Code	300
Rate for Payer: Cash Price	$293.92

Liver-Kidney Microsomal Ab SO

Facility

$173.00

Service Code	CPT 86376
Hospital Charge Code	1703644
Hospital Revenue Code	302
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$112.45
Rate for Payer: Aetna Commercial	$15.28
Rate for Payer: Aetna Medicare	$21.82
Rate for Payer: Amerigroup CHIP/Medicaid	$5.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.55
Rate for Payer: Amerigroup Medicare	$14.55
Rate for Payer: BCBS of TX Blue Advantage	$24.01
Rate for Payer: BCBS of TX Blue Essentials	$28.81
Rate for Payer: BCBS of TX Medicare	$14.55
Rate for Payer: BCBS of TX PPO	$32.16
Rate for Payer: Cash Price	$152.24
Rate for Payer: Cash Price	$152.24
Rate for Payer: Cigna Medicaid	$14.55
Rate for Payer: Cigna Medicare	$14.55
Rate for Payer: Employer Direct Commercial	$14.55
Rate for Payer: Humana Medicare/TRICARE	$14.55
Rate for Payer: Molina CHIP/Medicaid	$14.55
Rate for Payer: Molina Dual Medicare/Medicaid	$14.55
Rate for Payer: Molina Medicare	$14.55
Rate for Payer: Multiplan Auto	$112.45
Rate for Payer: Multiplan Commercial	$112.45
Rate for Payer: Multiplan Workers Comp	$112.45
Rate for Payer: Parkland Medicaid	$14.55
Rate for Payer: Scott and White EPO/PPO	$18.19
Rate for Payer: Scott and White Medicare	$14.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.55
Rate for Payer: Superior Health Plan EPO	$14.55
Rate for Payer: Superior Health Plan Medicare	$14.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.55
Rate for Payer: Universal American Medicare	$14.55
Rate for Payer: Wellcare Medicare	$14.55
Rate for Payer: Wellmed Medicare	$14.55

LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT

Facility

$196,650.00

Service Code	MSDRG 005
Min. Negotiated Rate	$76,713.01
Max. Negotiated Rate	$196,650.00
Rate for Payer: Aetna Commercial	$116,437.50
Rate for Payer: Aetna Medicare	$115,069.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$76,713.01
Rate for Payer: Amerigroup Medicare	$76,713.01
Rate for Payer: BCBS of TX Blue Advantage	$88,340.06
Rate for Payer: BCBS of TX Blue Essentials	$105,816.19
Rate for Payer: BCBS of TX Medicare	$76,713.01
Rate for Payer: BCBS of TX PPO	$117,578.10
Rate for Payer: Cigna Commercial	$133,308.00
Rate for Payer: Cigna Medicare	$76,713.01
Rate for Payer: Employer Direct Commercial	$76,713.01
Rate for Payer: Molina Dual Medicare/Medicaid	$76,713.01
Rate for Payer: Molina Medicare	$76,713.01
Rate for Payer: Multiplan Auto	$196,650.00
Rate for Payer: Multiplan Commercial	$196,650.00
Rate for Payer: Multiplan Workers Comp	$196,650.00
Rate for Payer: Scott and White EPO/PPO	$90,562.50
Rate for Payer: Scott and White Medicare	$76,713.01
Rate for Payer: Superior Health Plan EPO	$76,713.01
Rate for Payer: Superior Health Plan Medicare	$76,713.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$76,713.01
Rate for Payer: Universal American Medicare	$76,713.01
Rate for Payer: Wellcare Medicare	$76,713.01
Rate for Payer: Wellmed Medicare	$76,713.01

LIVER TRANSPLANT WITHOUT MCC

Facility

$91,901.10

Service Code	MSDRG 006
Min. Negotiated Rate	$37,371.19
Max. Negotiated Rate	$91,901.10
Rate for Payer: Aetna Commercial	$54,415.12
Rate for Payer: Aetna Medicare	$56,056.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37,371.19
Rate for Payer: Amerigroup Medicare	$37,371.19
Rate for Payer: BCBS of TX Blue Advantage	$41,361.70
Rate for Payer: BCBS of TX Blue Essentials	$50,207.09
Rate for Payer: BCBS of TX Medicare	$37,371.19
Rate for Payer: BCBS of TX PPO	$55,787.82
Rate for Payer: Cigna Commercial	$62,299.27
Rate for Payer: Cigna Medicare	$37,371.19
Rate for Payer: Employer Direct Commercial	$37,371.19
Rate for Payer: Molina Dual Medicare/Medicaid	$37,371.19
Rate for Payer: Molina Medicare	$37,371.19
Rate for Payer: Multiplan Auto	$91,901.10
Rate for Payer: Multiplan Commercial	$91,901.10
Rate for Payer: Multiplan Workers Comp	$91,901.10
Rate for Payer: Scott and White EPO/PPO	$42,322.88
Rate for Payer: Scott and White Medicare	$37,371.19
Rate for Payer: Superior Health Plan EPO	$37,371.19
Rate for Payer: Superior Health Plan Medicare	$37,371.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$37,371.19
Rate for Payer: Universal American Medicare	$37,371.19
Rate for Payer: Wellcare Medicare	$37,371.19
Rate for Payer: Wellmed Medicare	$37,371.19

LMA SUPREME #4

Facility

$102.65

Hospital Charge Code	112228
Hospital Revenue Code	272
Rate for Payer: Cash Price	$90.33

LMA SUPREME #4

Facility

$102.65

Hospital Charge Code	112228
Hospital Revenue Code	272
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$66.72
Rate for Payer: Aetna Commercial	$56.46
Rate for Payer: Amerigroup CHIP/Medicaid	$9.24
Rate for Payer: BCBS of TX Blue Advantage	$30.80
Rate for Payer: BCBS of TX Blue Essentials	$36.95
Rate for Payer: BCBS of TX PPO	$41.06
Rate for Payer: Cash Price	$90.33
Rate for Payer: Multiplan Auto	$66.72
Rate for Payer: Multiplan Commercial	$66.72
Rate for Payer: Multiplan Workers Comp	$66.72
Rate for Payer: Scott and White EPO/PPO	$51.32
Rate for Payer: Superior Health Plan EPO	$13.96

LOADING UNIT, GIA ROTICULATOR 60MM RELOAD 2.5 WHT -- DHF

Facility

$2,982.78

Hospital Charge Code	81366619
Hospital Revenue Code	272
Min. Negotiated Rate	$268.45
Max. Negotiated Rate	$1,938.81
Rate for Payer: Aetna Commercial	$1,640.53
Rate for Payer: Amerigroup CHIP/Medicaid	$268.45
Rate for Payer: BCBS of TX Blue Advantage	$894.83
Rate for Payer: BCBS of TX Blue Essentials	$1,073.80
Rate for Payer: BCBS of TX PPO	$1,193.11
Rate for Payer: Cash Price	$2,624.85
Rate for Payer: Multiplan Auto	$1,938.81
Rate for Payer: Multiplan Commercial	$1,938.81
Rate for Payer: Multiplan Workers Comp	$1,938.81
Rate for Payer: Scott and White EPO/PPO	$1,491.39
Rate for Payer: Superior Health Plan EPO	$405.66

LOADING UNIT, GIA ROTICULATOR 60MM RELOAD 2.5 WHT -- DHF

Facility

$2,982.78

Hospital Charge Code	81366619
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,624.85

LOADING UNIT, LINEAR CUTTER 75MM STAPLES TITANIUM -- DHF

Facility

$2,293.43

Hospital Charge Code	81910150
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,018.22

LOADING UNIT, LINEAR CUTTER 75MM STAPLES TITANIUM -- DHF

Facility

$2,293.43

Hospital Charge Code	81910150
Hospital Revenue Code	272
Min. Negotiated Rate	$206.41
Max. Negotiated Rate	$1,490.73
Rate for Payer: Aetna Commercial	$1,261.39
Rate for Payer: Amerigroup CHIP/Medicaid	$206.41
Rate for Payer: BCBS of TX Blue Advantage	$688.03
Rate for Payer: BCBS of TX Blue Essentials	$825.63
Rate for Payer: BCBS of TX PPO	$917.37
Rate for Payer: Cash Price	$2,018.22
Rate for Payer: Multiplan Auto	$1,490.73
Rate for Payer: Multiplan Commercial	$1,490.73
Rate for Payer: Multiplan Workers Comp	$1,490.73
Rate for Payer: Scott and White EPO/PPO	$1,146.72
Rate for Payer: Superior Health Plan EPO	$311.91

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC

Facility

$37,762.50

Service Code	MSDRG 496
Min. Negotiated Rate	$15,426.68
Max. Negotiated Rate	$37,762.50
Rate for Payer: Aetna Commercial	$22,359.38
Rate for Payer: Aetna Medicare	$25,556.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,037.70
Rate for Payer: Amerigroup Medicare	$17,037.70
Rate for Payer: BCBS of TX Blue Advantage	$15,426.68
Rate for Payer: BCBS of TX Blue Essentials	$20,234.53
Rate for Payer: BCBS of TX Medicare	$17,037.70
Rate for Payer: BCBS of TX PPO	$22,483.68
Rate for Payer: Cigna Commercial	$25,599.00
Rate for Payer: Cigna Medicare	$17,037.70
Rate for Payer: Employer Direct Commercial	$17,037.70
Rate for Payer: Humana Medicare/TRICARE	$17,037.70
Rate for Payer: Molina Dual Medicare/Medicaid	$17,037.70
Rate for Payer: Molina Medicare	$17,037.70
Rate for Payer: Multiplan Auto	$37,762.50
Rate for Payer: Multiplan Commercial	$37,762.50
Rate for Payer: Multiplan Workers Comp	$37,762.50
Rate for Payer: Scott and White EPO/PPO	$17,390.62
Rate for Payer: Scott and White Medicare	$17,037.70
Rate for Payer: Superior Health Plan EPO	$17,037.70
Rate for Payer: Superior Health Plan Medicare	$17,037.70
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,037.70
Rate for Payer: Universal American Medicare	$17,037.70
Rate for Payer: Wellcare Medicare	$17,037.70
Rate for Payer: Wellmed Medicare	$17,037.70

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC

Facility

$68,042.80

Service Code	MSDRG 495
Min. Negotiated Rate	$26,498.32
Max. Negotiated Rate	$68,042.80
Rate for Payer: Aetna Commercial	$40,288.50
Rate for Payer: Aetna Medicare	$42,615.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,410.44
Rate for Payer: Amerigroup Medicare	$28,410.44
Rate for Payer: BCBS of TX Blue Advantage	$26,498.32
Rate for Payer: BCBS of TX Blue Essentials	$35,727.47
Rate for Payer: BCBS of TX Medicare	$28,410.44
Rate for Payer: BCBS of TX PPO	$39,698.73
Rate for Payer: Cigna Commercial	$46,125.86
Rate for Payer: Cigna Medicare	$28,410.44
Rate for Payer: Employer Direct Commercial	$28,410.44
Rate for Payer: Humana Medicare/TRICARE	$28,410.44
Rate for Payer: Molina Dual Medicare/Medicaid	$28,410.44
Rate for Payer: Molina Medicare	$28,410.44
Rate for Payer: Multiplan Auto	$68,042.80
Rate for Payer: Multiplan Commercial	$68,042.80
Rate for Payer: Multiplan Workers Comp	$68,042.80
Rate for Payer: Scott and White EPO/PPO	$31,335.50
Rate for Payer: Scott and White Medicare	$28,410.44
Rate for Payer: Superior Health Plan EPO	$28,410.44
Rate for Payer: Superior Health Plan Medicare	$28,410.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,410.44
Rate for Payer: Universal American Medicare	$28,410.44
Rate for Payer: Wellcare Medicare	$28,410.44
Rate for Payer: Wellmed Medicare	$28,410.44

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC

Facility

$27,120.60

Service Code	MSDRG 497
Min. Negotiated Rate	$10,883.30
Max. Negotiated Rate	$27,120.60
Rate for Payer: Aetna Commercial	$16,058.25
Rate for Payer: Aetna Medicare	$19,561.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,040.79
Rate for Payer: Amerigroup Medicare	$13,040.79
Rate for Payer: BCBS of TX Blue Advantage	$10,883.30
Rate for Payer: BCBS of TX Blue Essentials	$14,807.76
Rate for Payer: BCBS of TX Medicare	$13,040.79
Rate for Payer: BCBS of TX PPO	$16,453.71
Rate for Payer: Cigna Commercial	$18,384.91
Rate for Payer: Cigna Medicare	$13,040.79
Rate for Payer: Employer Direct Commercial	$13,040.79
Rate for Payer: Humana Medicare/TRICARE	$13,040.79
Rate for Payer: Molina Dual Medicare/Medicaid	$13,040.79
Rate for Payer: Molina Medicare	$13,040.79
Rate for Payer: Multiplan Auto	$27,120.60
Rate for Payer: Multiplan Commercial	$27,120.60
Rate for Payer: Multiplan Workers Comp	$27,120.60
Rate for Payer: Scott and White EPO/PPO	$12,489.75
Rate for Payer: Scott and White Medicare	$13,040.79
Rate for Payer: Superior Health Plan EPO	$13,040.79
Rate for Payer: Superior Health Plan Medicare	$13,040.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,040.79
Rate for Payer: Universal American Medicare	$13,040.79
Rate for Payer: Wellcare Medicare	$13,040.79
Rate for Payer: Wellmed Medicare	$13,040.79

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC

Facility

$49,609.00

Service Code	MSDRG 498
Min. Negotiated Rate	$20,369.10
Max. Negotiated Rate	$49,609.00
Rate for Payer: Aetna Commercial	$29,373.75
Rate for Payer: Aetna Medicare	$32,230.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,487.03
Rate for Payer: Amerigroup Medicare	$21,487.03
Rate for Payer: BCBS of TX Blue Advantage	$20,369.10
Rate for Payer: BCBS of TX Blue Essentials	$23,506.68
Rate for Payer: BCBS of TX Medicare	$21,487.03
Rate for Payer: BCBS of TX PPO	$26,119.55
Rate for Payer: Cigna Commercial	$33,629.68
Rate for Payer: Cigna Medicare	$21,487.03
Rate for Payer: Employer Direct Commercial	$21,487.03
Rate for Payer: Humana Medicare/TRICARE	$21,487.03
Rate for Payer: Molina Dual Medicare/Medicaid	$21,487.03
Rate for Payer: Molina Medicare	$21,487.03
Rate for Payer: Multiplan Auto	$49,609.00
Rate for Payer: Multiplan Commercial	$49,609.00
Rate for Payer: Multiplan Workers Comp	$49,609.00
Rate for Payer: Scott and White EPO/PPO	$22,846.25
Rate for Payer: Scott and White Medicare	$21,487.03
Rate for Payer: Superior Health Plan EPO	$21,487.03
Rate for Payer: Superior Health Plan Medicare	$21,487.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,487.03
Rate for Payer: Universal American Medicare	$21,487.03
Rate for Payer: Wellcare Medicare	$21,487.03
Rate for Payer: Wellmed Medicare	$21,487.03

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC

Facility

$24,506.20

Service Code	MSDRG 499
Min. Negotiated Rate	$9,785.94
Max. Negotiated Rate	$24,506.20
Rate for Payer: Aetna Commercial	$14,510.25
Rate for Payer: Aetna Medicare	$18,088.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,058.87
Rate for Payer: Amerigroup Medicare	$12,058.87
Rate for Payer: BCBS of TX Blue Advantage	$9,785.94
Rate for Payer: BCBS of TX Blue Essentials	$11,549.02
Rate for Payer: BCBS of TX Medicare	$12,058.87
Rate for Payer: BCBS of TX PPO	$12,832.75
Rate for Payer: Cigna Commercial	$16,612.62
Rate for Payer: Cigna Medicare	$12,058.87
Rate for Payer: Employer Direct Commercial	$12,058.87
Rate for Payer: Humana Medicare/TRICARE	$12,058.87
Rate for Payer: Molina Dual Medicare/Medicaid	$12,058.87
Rate for Payer: Molina Medicare	$12,058.87
Rate for Payer: Multiplan Auto	$24,506.20
Rate for Payer: Multiplan Commercial	$24,506.20
Rate for Payer: Multiplan Workers Comp	$24,506.20
Rate for Payer: Scott and White EPO/PPO	$11,285.75
Rate for Payer: Scott and White Medicare	$12,058.87
Rate for Payer: Superior Health Plan EPO	$12,058.87
Rate for Payer: Superior Health Plan Medicare	$12,058.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,058.87
Rate for Payer: Universal American Medicare	$12,058.87
Rate for Payer: Wellcare Medicare	$12,058.87
Rate for Payer: Wellmed Medicare	$12,058.87

LOCM 300-399MG/ML IODINE PER ML

Facility

$6.69

Service Code	HCPCS Q9967
Hospital Charge Code	2330021
Hospital Revenue Code	255
Rate for Payer: Cash Price	$5.89

LOCM 300-399MG/ML IODINE PER ML

Facility

$6.69

Service Code	HCPCS Q9967
Hospital Charge Code	2330021
Hospital Revenue Code	255
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$4.35
Rate for Payer: Amerigroup CHIP/Medicaid	$0.60
Rate for Payer: BCBS of TX Blue Advantage	$0.46
Rate for Payer: BCBS of TX Blue Essentials	$0.56
Rate for Payer: BCBS of TX PPO	$0.62
Rate for Payer: Cash Price	$5.89
Rate for Payer: Cash Price	$5.89
Rate for Payer: Multiplan Auto	$4.35
Rate for Payer: Multiplan Commercial	$4.35
Rate for Payer: Multiplan Workers Comp	$4.35
Rate for Payer: Scott and White EPO/PPO	$3.34
Rate for Payer: Superior Health Plan EPO	$0.91

LOOP VESSEL AS -- DHF

Facility

$170.09

Hospital Charge Code	81751653
Hospital Revenue Code	272
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$110.56
Rate for Payer: Aetna Commercial	$93.55
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: BCBS of TX Blue Advantage	$51.03
Rate for Payer: BCBS of TX Blue Essentials	$61.23
Rate for Payer: BCBS of TX PPO	$68.04
Rate for Payer: Cash Price	$149.68
Rate for Payer: Multiplan Auto	$110.56
Rate for Payer: Multiplan Commercial	$110.56
Rate for Payer: Multiplan Workers Comp	$110.56
Rate for Payer: Scott and White EPO/PPO	$85.04
Rate for Payer: Superior Health Plan EPO	$23.13

LOOP VESSEL AS -- DHF

Facility

$170.09

Hospital Charge Code	81751653
Hospital Revenue Code	272
Rate for Payer: Cash Price	$149.68

loperamide 2mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78438367
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

loperamide 2mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78438367
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

loratadine 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78433462
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

loratadine 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78433462
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

LORazepam 1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77671456
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

LORazepam 1 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77671456
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges