White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$92.28
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: 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

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 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% 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	$92.28
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: 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

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	$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

lidocaine 4% Topical Soln 50 mL

Facility

$110.53

Service Code	HCPCS J3490
Hospital Charge Code	77665831
Hospital Revenue Code	250
Min. Negotiated Rate	$9.95
Max. Negotiated Rate	$79.58
Rate for Payer: Amerigroup CHIP/Medicaid	$9.95
Rate for Payer: BCBS of TX Blue Advantage	$33.16
Rate for Payer: BCBS of TX Blue Essentials	$39.79
Rate for Payer: BCBS of TX PPO	$44.21
Rate for Payer: Cash Price	$75.16
Rate for Payer: Cigna Medicaid	$79.58
Rate for Payer: Molina CHIP/Medicaid	$79.58
Rate for Payer: Multiplan Auto	$71.84
Rate for Payer: Multiplan Commercial	$71.84
Rate for Payer: Multiplan Workers Comp	$71.84
Rate for Payer: Parkland Medicaid	$79.58
Rate for Payer: Scott and White EPO/PPO	$55.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.58
Rate for Payer: Superior Health Plan EPO	$15.03

lidocaine 4% Topical Soln 50 mL

Facility

$110.53

Service Code	HCPCS J3490
Hospital Charge Code	77665831
Hospital Revenue Code	250
Rate for Payer: Cash Price	$75.16

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% 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	$54.65
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: Cigna Medicaid	$54.65
Rate for Payer: Molina CHIP/Medicaid	$54.65
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: Parkland Medicaid	$54.65
Rate for Payer: Scott and White EPO/PPO	$37.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$54.65
Rate for Payer: Superior Health Plan EPO	$10.32

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	$280.80
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: Cigna Medicaid	$280.80
Rate for Payer: Molina CHIP/Medicaid	$280.80
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: Parkland Medicaid	$280.80
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.80
Rate for Payer: Superior Health Plan EPO	$53.04

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-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	$24.26
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: Cigna Medicaid	$24.26
Rate for Payer: Molina CHIP/Medicaid	$24.26
Rate for Payer: Multiplan Auto	$21.91
Rate for Payer: Multiplan Commercial	$21.91
Rate for Payer: Multiplan Workers Comp	$21.91
Rate for Payer: Parkland Medicaid	$24.26
Rate for Payer: Scott and White EPO/PPO	$16.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.26
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	$5.82
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: Cigna Medicaid	$5.82
Rate for Payer: Molina CHIP/Medicaid	$5.82
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: Parkland Medicaid	$5.82
Rate for Payer: Scott and White EPO/PPO	$4.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.82
Rate for Payer: Superior Health Plan EPO	$1.10

LIFT V40 Femoral Head (OD: 28mm, OFFST: -4mm)

Facility

$2,710.84

Service Code	HCPCS C1734
Hospital Charge Code	992184
Hospital Revenue Code	278
Min. Negotiated Rate	$243.98
Max. Negotiated Rate	$1,951.80
Rate for Payer: Amerigroup CHIP/Medicaid	$243.98
Rate for Payer: BCBS of TX Blue Advantage	$813.25
Rate for Payer: BCBS of TX Blue Essentials	$975.90
Rate for Payer: BCBS of TX PPO	$1,084.34
Rate for Payer: Cash Price	$1,843.37
Rate for Payer: Cigna Medicaid	$1,951.80
Rate for Payer: Molina CHIP/Medicaid	$1,951.80
Rate for Payer: Multiplan Auto	$1,355.42
Rate for Payer: Multiplan Commercial	$1,355.42
Rate for Payer: Multiplan Workers Comp	$1,355.42
Rate for Payer: Parkland Medicaid	$1,951.80
Rate for Payer: Scott and White EPO/PPO	$1,355.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,951.80
Rate for Payer: Superior Health Plan EPO	$368.67

LIFT V40 Femoral Head (OD: 28mm, OFFST: -4mm)

Facility

$2,710.84

Service Code	HCPCS C1734
Hospital Charge Code	992184
Hospital Revenue Code	278
Min. Negotiated Rate	$677.71
Max. Negotiated Rate	$1,355.42
Rate for Payer: Cash Price	$1,843.37
Rate for Payer: Cigna Commercial	$677.71
Rate for Payer: Multiplan Auto	$1,355.42
Rate for Payer: Multiplan Commercial	$1,355.42
Rate for Payer: Multiplan Workers Comp	$1,355.42
Rate for Payer: Scott and White EPO/PPO	$1,355.42

Ligaclip Applier Clip, Endoscopic, Rotating Shaft

Facility

$300.65

Hospital Charge Code	992861
Hospital Revenue Code	272
Min. Negotiated Rate	$27.06
Max. Negotiated Rate	$216.47
Rate for Payer: Amerigroup CHIP/Medicaid	$27.06
Rate for Payer: BCBS of TX Blue Advantage	$90.19
Rate for Payer: BCBS of TX Blue Essentials	$108.23
Rate for Payer: BCBS of TX PPO	$120.26
Rate for Payer: Cash Price	$204.44
Rate for Payer: Cigna Medicaid	$216.47
Rate for Payer: Molina CHIP/Medicaid	$216.47
Rate for Payer: Multiplan Auto	$195.42
Rate for Payer: Multiplan Commercial	$195.42
Rate for Payer: Multiplan Workers Comp	$195.42
Rate for Payer: Parkland Medicaid	$216.47
Rate for Payer: Scott and White EPO/PPO	$150.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.47
Rate for Payer: Superior Health Plan EPO	$40.89

Ligaclip Applier Clip, Endoscopic, Rotating Shaft

Facility

$300.65

Hospital Charge Code	992861
Hospital Revenue Code	272
Rate for Payer: Cash Price	$204.44

LIGACLIP SMALL

Facility

$222.46

Hospital Charge Code	992690
Hospital Revenue Code	272
Min. Negotiated Rate	$20.02
Max. Negotiated Rate	$160.17
Rate for Payer: Amerigroup CHIP/Medicaid	$20.02
Rate for Payer: BCBS of TX Blue Advantage	$66.74
Rate for Payer: BCBS of TX Blue Essentials	$80.09
Rate for Payer: BCBS of TX PPO	$88.98
Rate for Payer: Cash Price	$151.27
Rate for Payer: Cigna Medicaid	$160.17
Rate for Payer: Molina CHIP/Medicaid	$160.17
Rate for Payer: Multiplan Auto	$144.60
Rate for Payer: Multiplan Commercial	$144.60
Rate for Payer: Multiplan Workers Comp	$144.60
Rate for Payer: Parkland Medicaid	$160.17
Rate for Payer: Scott and White EPO/PPO	$111.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$160.17
Rate for Payer: Superior Health Plan EPO	$30.25

LIGACLIP SMALL

Facility

$222.46

Hospital Charge Code	992690
Hospital Revenue Code	272
Rate for Payer: Cash Price	$151.27

Ligamentous reconstruction (augmentation), knee; extra-articular

Facility

$20,302.00

Service Code	HCPCS 27427
Hospital Charge Code	9900406
Hospital Revenue Code	360
Min. Negotiated Rate	$3,170.89
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,170.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$13,805.36
Rate for Payer: Cash Price	$13,805.36
Rate for Payer: Cash Price	$13,805.36
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$14,617.44
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$14,617.44
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$14,617.44
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,617.44
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Ligamentous reconstruction (augmentation), knee; extra-articular

Facility

$15,408.22

Service Code	CPT 27427
Hospital Charge Code	36027427
Hospital Revenue Code	360
Min. Negotiated Rate	$3,170.89
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,170.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Ligamentous reconstruction (augmentation), knee; extra-articular

Facility

$20,302.00

Service Code	HCPCS 27427
Hospital Charge Code	9900406
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,805.36

Know your out-of-pocket cost for care.

All Charges