White Rock Medical Center

All Charges

Charge

Type

Setting

Price

labetalol 200 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77649925
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

labetalol 200 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77649925
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

labetalol 5 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650245
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.39
Rate for Payer: BCBS of TX Blue Essentials	$0.47
Rate for Payer: BCBS of TX PPO	$0.52
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

labetalol 5 mg/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650245
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

labetalol 5 mg/mL IV Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650190
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.39
Rate for Payer: BCBS of TX Blue Essentials	$0.47
Rate for Payer: BCBS of TX PPO	$0.52
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

labetalol 5 mg/mL IV Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1920
Hospital Charge Code	77650190
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

Labor Level Complex 1st Hour -> Yes

Facility

$2,345.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Min. Negotiated Rate	$211.05
Max. Negotiated Rate	$1,688.40
Rate for Payer: Amerigroup CHIP/Medicaid	$211.05
Rate for Payer: BCBS of TX Blue Advantage	$703.50
Rate for Payer: BCBS of TX Blue Essentials	$844.20
Rate for Payer: BCBS of TX PPO	$938.00
Rate for Payer: Cash Price	$1,594.60
Rate for Payer: Cigna Medicaid	$1,688.40
Rate for Payer: Molina CHIP/Medicaid	$1,688.40
Rate for Payer: Multiplan Auto	$1,524.25
Rate for Payer: Multiplan Commercial	$1,524.25
Rate for Payer: Multiplan Workers Comp	$1,524.25
Rate for Payer: Parkland Medicaid	$1,688.40
Rate for Payer: Scott and White EPO/PPO	$1,172.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,688.40
Rate for Payer: Superior Health Plan EPO	$318.92

Labor Level Complex 1st Hour -> Yes

Facility

$2,345.00

Hospital Charge Code	300038
Hospital Revenue Code	720
Rate for Payer: Cash Price	$1,594.60

Labor Level Intermediate 1st Hour -> Yes

Facility

$1,060.00

Hospital Charge Code	3101206
Hospital Revenue Code	720
Min. Negotiated Rate	$95.40
Max. Negotiated Rate	$763.20
Rate for Payer: Amerigroup CHIP/Medicaid	$95.40
Rate for Payer: BCBS of TX Blue Advantage	$318.00
Rate for Payer: BCBS of TX Blue Essentials	$381.60
Rate for Payer: BCBS of TX PPO	$424.00
Rate for Payer: Cash Price	$720.80
Rate for Payer: Cigna Medicaid	$763.20
Rate for Payer: Molina CHIP/Medicaid	$763.20
Rate for Payer: Multiplan Auto	$689.00
Rate for Payer: Multiplan Commercial	$689.00
Rate for Payer: Multiplan Workers Comp	$689.00
Rate for Payer: Parkland Medicaid	$763.20
Rate for Payer: Scott and White EPO/PPO	$530.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$763.20
Rate for Payer: Superior Health Plan EPO	$144.16

Labor Level Intermediate 1st Hour -> Yes

Facility

$1,060.00

Hospital Charge Code	3101206
Hospital Revenue Code	720
Rate for Payer: Cash Price	$720.80

Labor Level Intermediate Additonal Hour

Facility

$850.00

Hospital Charge Code	3101207
Hospital Revenue Code	720
Rate for Payer: Cash Price	$578.00

Labor Level Intermediate Additonal Hour

Facility

$850.00

Hospital Charge Code	3101207
Hospital Revenue Code	720
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$612.00
Rate for Payer: Amerigroup CHIP/Medicaid	$76.50
Rate for Payer: BCBS of TX Blue Advantage	$255.00
Rate for Payer: BCBS of TX Blue Essentials	$306.00
Rate for Payer: BCBS of TX PPO	$340.00
Rate for Payer: Cash Price	$578.00
Rate for Payer: Cigna Medicaid	$612.00
Rate for Payer: Molina CHIP/Medicaid	$612.00
Rate for Payer: Multiplan Auto	$552.50
Rate for Payer: Multiplan Commercial	$552.50
Rate for Payer: Multiplan Workers Comp	$552.50
Rate for Payer: Parkland Medicaid	$612.00
Rate for Payer: Scott and White EPO/PPO	$425.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$612.00
Rate for Payer: Superior Health Plan EPO	$115.60

Labor Level Simple Additional Hour

Facility

$430.00

Hospital Charge Code	300020
Hospital Revenue Code	720
Rate for Payer: Cash Price	$292.40

Labor Level Simple Additional Hour

Facility

$430.00

Hospital Charge Code	300020
Hospital Revenue Code	720
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$309.60
Rate for Payer: Amerigroup CHIP/Medicaid	$38.70
Rate for Payer: BCBS of TX Blue Advantage	$129.00
Rate for Payer: BCBS of TX Blue Essentials	$154.80
Rate for Payer: BCBS of TX PPO	$172.00
Rate for Payer: Cash Price	$292.40
Rate for Payer: Cigna Medicaid	$309.60
Rate for Payer: Molina CHIP/Medicaid	$309.60
Rate for Payer: Multiplan Auto	$279.50
Rate for Payer: Multiplan Commercial	$279.50
Rate for Payer: Multiplan Workers Comp	$279.50
Rate for Payer: Parkland Medicaid	$309.60
Rate for Payer: Scott and White EPO/PPO	$215.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$309.60
Rate for Payer: Superior Health Plan EPO	$58.48

LACERATION/ I&D TRAY

Facility

$68.09

Hospital Charge Code	993213
Hospital Revenue Code	270
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$49.02
Rate for Payer: Amerigroup CHIP/Medicaid	$6.13
Rate for Payer: BCBS of TX Blue Advantage	$20.43
Rate for Payer: BCBS of TX Blue Essentials	$24.51
Rate for Payer: BCBS of TX PPO	$27.24
Rate for Payer: Cash Price	$46.30
Rate for Payer: Cigna Medicaid	$49.02
Rate for Payer: Molina CHIP/Medicaid	$49.02
Rate for Payer: Multiplan Auto	$44.26
Rate for Payer: Multiplan Commercial	$44.26
Rate for Payer: Multiplan Workers Comp	$44.26
Rate for Payer: Parkland Medicaid	$49.02
Rate for Payer: Scott and White EPO/PPO	$34.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.02
Rate for Payer: Superior Health Plan EPO	$9.26

LACERATION/ I&D TRAY

Facility

$68.09

Hospital Charge Code	993213
Hospital Revenue Code	270
Rate for Payer: Cash Price	$46.30

LACERATION TRAY

Facility

$36.36

Hospital Charge Code	993881
Hospital Revenue Code	272
Rate for Payer: Cash Price	$24.72

LACERATION TRAY

Facility

$36.36

Hospital Charge Code	993881
Hospital Revenue Code	272
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$26.18
Rate for Payer: Amerigroup CHIP/Medicaid	$3.27
Rate for Payer: BCBS of TX Blue Advantage	$10.91
Rate for Payer: BCBS of TX Blue Essentials	$13.09
Rate for Payer: BCBS of TX PPO	$14.54
Rate for Payer: Cash Price	$24.72
Rate for Payer: Cigna Medicaid	$26.18
Rate for Payer: Molina CHIP/Medicaid	$26.18
Rate for Payer: Multiplan Auto	$23.63
Rate for Payer: Multiplan Commercial	$23.63
Rate for Payer: Multiplan Workers Comp	$23.63
Rate for Payer: Parkland Medicaid	$26.18
Rate for Payer: Scott and White EPO/PPO	$18.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.18
Rate for Payer: Superior Health Plan EPO	$4.94

lacosamide 200 mg Tab

Facility

$44.74

Service Code	HCPCS J3490
Hospital Charge Code	77650547
Hospital Revenue Code	250
Rate for Payer: Cash Price	$30.42

lacosamide 200 mg Tab

Facility

$44.74

Service Code	HCPCS J3490
Hospital Charge Code	77650547
Hospital Revenue Code	250
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$32.21
Rate for Payer: Amerigroup CHIP/Medicaid	$4.03
Rate for Payer: BCBS of TX Blue Advantage	$13.42
Rate for Payer: BCBS of TX Blue Essentials	$16.11
Rate for Payer: BCBS of TX PPO	$17.90
Rate for Payer: Cash Price	$30.42
Rate for Payer: Cigna Medicaid	$32.21
Rate for Payer: Molina CHIP/Medicaid	$32.21
Rate for Payer: Multiplan Auto	$29.08
Rate for Payer: Multiplan Commercial	$29.08
Rate for Payer: Multiplan Workers Comp	$29.08
Rate for Payer: Parkland Medicaid	$32.21
Rate for Payer: Scott and White EPO/PPO	$22.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.21
Rate for Payer: Superior Health Plan EPO	$6.08

lacosamide 50 mg Tab

Facility

$19.60

Service Code	HCPCS J3490
Hospital Charge Code	77650647
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$14.11
Rate for Payer: Amerigroup CHIP/Medicaid	$1.76
Rate for Payer: BCBS of TX Blue Advantage	$5.88
Rate for Payer: BCBS of TX Blue Essentials	$7.06
Rate for Payer: BCBS of TX PPO	$7.84
Rate for Payer: Cash Price	$13.33
Rate for Payer: Cigna Medicaid	$14.11
Rate for Payer: Molina CHIP/Medicaid	$14.11
Rate for Payer: Multiplan Auto	$12.74
Rate for Payer: Multiplan Commercial	$12.74
Rate for Payer: Multiplan Workers Comp	$12.74
Rate for Payer: Parkland Medicaid	$14.11
Rate for Payer: Scott and White EPO/PPO	$9.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.11
Rate for Payer: Superior Health Plan EPO	$2.67

lacosamide 50 mg Tab

Facility

$19.60

Service Code	HCPCS J3490
Hospital Charge Code	77650647
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.33

Lacosamide SO

Facility

$196.00

Service Code	HCPCS 80235
Hospital Charge Code	8486565
Hospital Revenue Code	301
Rate for Payer: Cash Price	$133.28

Lacosamide SO

Facility

$196.00

Service Code	HCPCS 80235
Hospital Charge Code	8486565
Hospital Revenue Code	301
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$141.12
Rate for Payer: Amerigroup CHIP/Medicaid	$10.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.11
Rate for Payer: Amerigroup Medicare	$27.11
Rate for Payer: BCBS of TX Blue Advantage	$58.80
Rate for Payer: BCBS of TX Blue Essentials	$70.56
Rate for Payer: BCBS of TX Medicare	$27.11
Rate for Payer: BCBS of TX PPO	$78.40
Rate for Payer: Cash Price	$133.28
Rate for Payer: Cash Price	$133.28
Rate for Payer: Cigna Medicaid	$141.12
Rate for Payer: Cigna Medicare	$27.11
Rate for Payer: Employer Direct Commercial	$27.11
Rate for Payer: Humana Medicare/TRICARE	$27.11
Rate for Payer: Molina CHIP/Medicaid	$141.12
Rate for Payer: Molina Dual Medicare/Medicaid	$27.11
Rate for Payer: Molina Medicare	$27.11
Rate for Payer: Multiplan Auto	$127.40
Rate for Payer: Multiplan Commercial	$127.40
Rate for Payer: Multiplan Workers Comp	$127.40
Rate for Payer: Parkland Medicaid	$141.12
Rate for Payer: Scott and White EPO/PPO	$33.89
Rate for Payer: Scott and White Medicare	$27.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$141.12
Rate for Payer: Superior Health Plan EPO	$27.11
Rate for Payer: Superior Health Plan Medicare	$27.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.11
Rate for Payer: Universal American Medicare	$27.11
Rate for Payer: Wellcare Medicare	$27.11
Rate for Payer: Wellmed Medicare	$27.11

Lactate Dehydrogenase

Facility

$254.00

Service Code	HCPCS 83615
Hospital Charge Code	1602093
Hospital Revenue Code	301
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$182.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.04
Rate for Payer: Amerigroup Medicare	$6.04
Rate for Payer: BCBS of TX Blue Advantage	$76.20
Rate for Payer: BCBS of TX Blue Essentials	$91.44
Rate for Payer: BCBS of TX Medicare	$6.04
Rate for Payer: BCBS of TX PPO	$101.60
Rate for Payer: Cash Price	$172.72
Rate for Payer: Cash Price	$172.72
Rate for Payer: Cigna Medicaid	$182.88
Rate for Payer: Cigna Medicare	$6.04
Rate for Payer: Employer Direct Commercial	$6.04
Rate for Payer: Humana Medicare/TRICARE	$6.04
Rate for Payer: Molina CHIP/Medicaid	$182.88
Rate for Payer: Molina Dual Medicare/Medicaid	$6.04
Rate for Payer: Molina Medicare	$6.04
Rate for Payer: Multiplan Auto	$165.10
Rate for Payer: Multiplan Commercial	$165.10
Rate for Payer: Multiplan Workers Comp	$165.10
Rate for Payer: Parkland Medicaid	$182.88
Rate for Payer: Scott and White EPO/PPO	$7.55
Rate for Payer: Scott and White Medicare	$6.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$182.88
Rate for Payer: Superior Health Plan EPO	$6.04
Rate for Payer: Superior Health Plan Medicare	$6.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.04
Rate for Payer: Universal American Medicare	$6.04
Rate for Payer: Wellcare Medicare	$6.04
Rate for Payer: Wellmed Medicare	$6.04

Know your out-of-pocket cost for care.

All Charges