White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Levetir Lvl SO

Facility

$303.00

Service Code	HCPCS 80177
Hospital Charge Code	1740991
Hospital Revenue Code	301
Rate for Payer: Cash Price	$206.04

Levetir Lvl SO

Facility

$303.00

Service Code	HCPCS 80177
Hospital Charge Code	1740991
Hospital Revenue Code	301
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$218.16
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	$90.90
Rate for Payer: BCBS of TX Blue Essentials	$109.08
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$121.20
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cash Price	$206.04
Rate for Payer: Cigna Medicaid	$218.16
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	$218.16
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	$218.16
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	$218.16
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

Levita Magnetic Grasper (Single)

Facility

$2,038.46

Hospital Charge Code	992742
Hospital Revenue Code	272
Min. Negotiated Rate	$183.46
Max. Negotiated Rate	$1,467.69
Rate for Payer: Amerigroup CHIP/Medicaid	$183.46
Rate for Payer: BCBS of TX Blue Advantage	$611.54
Rate for Payer: BCBS of TX Blue Essentials	$733.85
Rate for Payer: BCBS of TX PPO	$815.38
Rate for Payer: Cash Price	$1,386.15
Rate for Payer: Cigna Medicaid	$1,467.69
Rate for Payer: Molina CHIP/Medicaid	$1,467.69
Rate for Payer: Multiplan Auto	$1,325.00
Rate for Payer: Multiplan Commercial	$1,325.00
Rate for Payer: Multiplan Workers Comp	$1,325.00
Rate for Payer: Parkland Medicaid	$1,467.69
Rate for Payer: Scott and White EPO/PPO	$1,019.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,467.69
Rate for Payer: Superior Health Plan EPO	$277.23

Levita Magnetic Grasper (Single)

Facility

$2,038.46

Hospital Charge Code	992742
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,386.15

levoFLOXacin 250 mg/50 mL IV Soln 50 mL

Facility

$128.00

Service Code	HCPCS J1956
Hospital Charge Code	77660515
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
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	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

levoFLOXacin 250 mg/50 mL IV Soln 50 mL

Facility

$128.00

Service Code	HCPCS J1956
Hospital Charge Code	77660515
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

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	$15.67
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: Cigna Medicaid	$15.67
Rate for Payer: Molina CHIP/Medicaid	$15.67
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: Parkland Medicaid	$15.67
Rate for Payer: Scott and White EPO/PPO	$10.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.67
Rate for Payer: Superior Health Plan EPO	$2.96

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 500 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77660574
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

levoFLOXacin 500 mg Tab

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77660574
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

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	77660625
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$92.28
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: 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

levoFLOXacin 750 mg/150 mL IV Soln 150 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 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	$92.28
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: 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

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	$44.38
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: Cigna Medicaid	$44.38
Rate for Payer: Molina CHIP/Medicaid	$44.38
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: Parkland Medicaid	$44.38
Rate for Payer: Scott and White EPO/PPO	$30.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.38
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

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	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

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 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	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
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	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
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	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
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

Know your out-of-pocket cost for care.

All Charges