White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LINQ II Medtronic Loop Recorder

Facility

$27,981.92

Service Code	HCPCS C1764
Hospital Charge Code	145066
Hospital Revenue Code	278
Min. Negotiated Rate	$2,518.37
Max. Negotiated Rate	$20,146.98
Rate for Payer: Amerigroup CHIP/Medicaid	$2,518.37
Rate for Payer: BCBS of TX Blue Advantage	$8,394.58
Rate for Payer: BCBS of TX Blue Essentials	$10,073.49
Rate for Payer: BCBS of TX PPO	$11,192.77
Rate for Payer: Cash Price	$19,027.71
Rate for Payer: Cigna Medicaid	$20,146.98
Rate for Payer: Molina CHIP/Medicaid	$20,146.98
Rate for Payer: Multiplan Auto	$13,990.96
Rate for Payer: Multiplan Commercial	$13,990.96
Rate for Payer: Multiplan Workers Comp	$13,990.96
Rate for Payer: Parkland Medicaid	$20,146.98
Rate for Payer: Scott and White EPO/PPO	$13,990.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,146.98
Rate for Payer: Superior Health Plan EPO	$3,805.54

LINQ II Medtronic Loop Recorder

Facility

$27,981.92

Service Code	HCPCS C1764
Hospital Charge Code	145066
Hospital Revenue Code	278
Min. Negotiated Rate	$6,995.48
Max. Negotiated Rate	$13,990.96
Rate for Payer: Cash Price	$19,027.71
Rate for Payer: Cigna Commercial	$6,995.48
Rate for Payer: Multiplan Auto	$13,990.96
Rate for Payer: Multiplan Commercial	$13,990.96
Rate for Payer: Multiplan Workers Comp	$13,990.96
Rate for Payer: Scott and White EPO/PPO	$13,990.96

liothyronine 5 mcg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77667667
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

liothyronine 5 mcg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77667667
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

Lipase Level

Facility

$274.00

Service Code	HCPCS 83690
Hospital Charge Code	1602127
Hospital Revenue Code	301
Rate for Payer: Cash Price	$186.32

Lipase Level

Facility

$274.00

Service Code	HCPCS 83690
Hospital Charge Code	1602127
Hospital Revenue Code	301
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$197.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.89
Rate for Payer: Amerigroup Medicare	$6.89
Rate for Payer: BCBS of TX Blue Advantage	$82.20
Rate for Payer: BCBS of TX Blue Essentials	$98.64
Rate for Payer: BCBS of TX Medicare	$6.89
Rate for Payer: BCBS of TX PPO	$109.60
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cigna Medicaid	$197.28
Rate for Payer: Cigna Medicare	$6.89
Rate for Payer: Employer Direct Commercial	$6.89
Rate for Payer: Humana Medicare/TRICARE	$6.89
Rate for Payer: Molina CHIP/Medicaid	$197.28
Rate for Payer: Molina Dual Medicare/Medicaid	$6.89
Rate for Payer: Molina Medicare	$6.89
Rate for Payer: Multiplan Auto	$178.10
Rate for Payer: Multiplan Commercial	$178.10
Rate for Payer: Multiplan Workers Comp	$178.10
Rate for Payer: Parkland Medicaid	$197.28
Rate for Payer: Scott and White EPO/PPO	$8.61
Rate for Payer: Scott and White Medicare	$6.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$197.28
Rate for Payer: Superior Health Plan EPO	$6.89
Rate for Payer: Superior Health Plan Medicare	$6.89
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.89
Rate for Payer: Universal American Medicare	$6.89
Rate for Payer: Wellcare Medicare	$6.89
Rate for Payer: Wellmed Medicare	$6.89

Lipid Panel

Facility

$438.00

Service Code	HCPCS 80061
Hospital Charge Code	1601004
Hospital Revenue Code	301
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$315.36
Rate for Payer: Amerigroup CHIP/Medicaid	$5.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.39
Rate for Payer: Amerigroup Medicare	$13.39
Rate for Payer: BCBS of TX Blue Advantage	$131.40
Rate for Payer: BCBS of TX Blue Essentials	$157.68
Rate for Payer: BCBS of TX Medicare	$13.39
Rate for Payer: BCBS of TX PPO	$175.20
Rate for Payer: Cash Price	$297.84
Rate for Payer: Cash Price	$297.84
Rate for Payer: Cigna Medicaid	$315.36
Rate for Payer: Cigna Medicare	$13.39
Rate for Payer: Employer Direct Commercial	$13.39
Rate for Payer: Humana Medicare/TRICARE	$13.39
Rate for Payer: Molina CHIP/Medicaid	$315.36
Rate for Payer: Molina Dual Medicare/Medicaid	$13.39
Rate for Payer: Molina Medicare	$13.39
Rate for Payer: Multiplan Auto	$284.70
Rate for Payer: Multiplan Commercial	$284.70
Rate for Payer: Multiplan Workers Comp	$284.70
Rate for Payer: Parkland Medicaid	$315.36
Rate for Payer: Scott and White EPO/PPO	$16.74
Rate for Payer: Scott and White Medicare	$13.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$315.36
Rate for Payer: Superior Health Plan EPO	$13.39
Rate for Payer: Superior Health Plan Medicare	$13.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.39
Rate for Payer: Universal American Medicare	$13.39
Rate for Payer: Wellcare Medicare	$13.39
Rate for Payer: Wellmed Medicare	$13.39

Lipid Panel

Facility

$438.00

Service Code	HCPCS 80061
Hospital Charge Code	1601004
Hospital Revenue Code	301
Rate for Payer: Cash Price	$297.84

Lipoprotein (a) SO

Facility

$150.00

Service Code	HCPCS 83695
Hospital Charge Code	1740299
Hospital Revenue Code	301
Min. Negotiated Rate	$5.58
Max. Negotiated Rate	$108.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.32
Rate for Payer: Amerigroup Medicare	$14.32
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX Medicare	$14.32
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Cigna Medicare	$14.32
Rate for Payer: Employer Direct Commercial	$14.32
Rate for Payer: Humana Medicare/TRICARE	$14.32
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Molina Dual Medicare/Medicaid	$14.32
Rate for Payer: Molina Medicare	$14.32
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$17.90
Rate for Payer: Scott and White Medicare	$14.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00
Rate for Payer: Superior Health Plan EPO	$14.32
Rate for Payer: Superior Health Plan Medicare	$14.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.32
Rate for Payer: Universal American Medicare	$14.32
Rate for Payer: Wellcare Medicare	$14.32
Rate for Payer: Wellmed Medicare	$14.32

Lipoprotein (a) SO

Facility

$150.00

Service Code	HCPCS 83695
Hospital Charge Code	1740299
Hospital Revenue Code	301
Rate for Payer: Cash Price	$102.00

LIQUID ADHESIVE 2/3CC

Facility

$8.11

Hospital Charge Code	992803
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.51

LIQUID ADHESIVE 2/3CC

Facility

$8.11

Hospital Charge Code	992803
Hospital Revenue Code	272
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$5.84
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	$2.92
Rate for Payer: BCBS of TX PPO	$3.24
Rate for Payer: Cash Price	$5.51
Rate for Payer: Cigna Medicaid	$5.84
Rate for Payer: Molina CHIP/Medicaid	$5.84
Rate for Payer: Multiplan Auto	$5.27
Rate for Payer: Multiplan Commercial	$5.27
Rate for Payer: Multiplan Workers Comp	$5.27
Rate for Payer: Parkland Medicaid	$5.84
Rate for Payer: Scott and White EPO/PPO	$4.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.84
Rate for Payer: Superior Health Plan EPO	$1.10

lisinopril 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77668489
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

lisinopril 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77668489
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

lisinopril 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77668597
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

lisinopril 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77668597
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

lisinopril 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77668762
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

lisinopril 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77668762
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

lithium 150 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77668815
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

lithium 150 mg Cap

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77668815
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

Lithium Level

Facility

$334.00

Service Code	HCPCS 80178
Hospital Charge Code	1602820
Hospital Revenue Code	300
Rate for Payer: Cash Price	$227.12

Lithium Level

Facility

$334.00

Service Code	HCPCS 80178
Hospital Charge Code	1602820
Hospital Revenue Code	300
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$240.48
Rate for Payer: Amerigroup CHIP/Medicaid	$2.58
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.61
Rate for Payer: Amerigroup Medicare	$6.61
Rate for Payer: BCBS of TX Blue Advantage	$100.20
Rate for Payer: BCBS of TX Blue Essentials	$120.24
Rate for Payer: BCBS of TX Medicare	$6.61
Rate for Payer: BCBS of TX PPO	$133.60
Rate for Payer: Cash Price	$227.12
Rate for Payer: Cash Price	$227.12
Rate for Payer: Cigna Medicaid	$240.48
Rate for Payer: Cigna Medicare	$6.61
Rate for Payer: Employer Direct Commercial	$6.61
Rate for Payer: Humana Medicare/TRICARE	$6.61
Rate for Payer: Molina CHIP/Medicaid	$240.48
Rate for Payer: Molina Dual Medicare/Medicaid	$6.61
Rate for Payer: Molina Medicare	$6.61
Rate for Payer: Multiplan Auto	$217.10
Rate for Payer: Multiplan Commercial	$217.10
Rate for Payer: Multiplan Workers Comp	$217.10
Rate for Payer: Parkland Medicaid	$240.48
Rate for Payer: Scott and White EPO/PPO	$8.26
Rate for Payer: Scott and White Medicare	$6.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$240.48
Rate for Payer: Superior Health Plan EPO	$6.61
Rate for Payer: Superior Health Plan Medicare	$6.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.61
Rate for Payer: Universal American Medicare	$6.61
Rate for Payer: Wellcare Medicare	$6.61
Rate for Payer: Wellmed Medicare	$6.61

LITTLE SUCKER NASAL TIP

Facility

$9.25

Hospital Charge Code	993630
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$6.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.83
Rate for Payer: BCBS of TX Blue Advantage	$2.77
Rate for Payer: BCBS of TX Blue Essentials	$3.33
Rate for Payer: BCBS of TX PPO	$3.70
Rate for Payer: Cash Price	$6.29
Rate for Payer: Cigna Medicaid	$6.66
Rate for Payer: Molina CHIP/Medicaid	$6.66
Rate for Payer: Multiplan Auto	$6.01
Rate for Payer: Multiplan Commercial	$6.01
Rate for Payer: Multiplan Workers Comp	$6.01
Rate for Payer: Parkland Medicaid	$6.66
Rate for Payer: Scott and White EPO/PPO	$4.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.66
Rate for Payer: Superior Health Plan EPO	$1.26

LITTLE SUCKER NASAL TIP

Facility

$9.25

Hospital Charge Code	993630
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.29

Liver Fibrosis Risk Profile SO-Hepatic Function Panel

Facility

$842.23

Service Code	HCPCS 80076
Hospital Charge Code	8993057
Hospital Revenue Code	301
Min. Negotiated Rate	$3.19
Max. Negotiated Rate	$606.41
Rate for Payer: Amerigroup CHIP/Medicaid	$3.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.17
Rate for Payer: Amerigroup Medicare	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$252.67
Rate for Payer: BCBS of TX Blue Essentials	$303.20
Rate for Payer: BCBS of TX Medicare	$8.17
Rate for Payer: BCBS of TX PPO	$336.89
Rate for Payer: Cash Price	$572.72
Rate for Payer: Cash Price	$572.72
Rate for Payer: Cigna Medicaid	$606.41
Rate for Payer: Cigna Medicare	$8.17
Rate for Payer: Employer Direct Commercial	$8.17
Rate for Payer: Humana Medicare/TRICARE	$8.17
Rate for Payer: Molina CHIP/Medicaid	$606.41
Rate for Payer: Molina Dual Medicare/Medicaid	$8.17
Rate for Payer: Molina Medicare	$8.17
Rate for Payer: Multiplan Auto	$547.45
Rate for Payer: Multiplan Commercial	$547.45
Rate for Payer: Multiplan Workers Comp	$547.45
Rate for Payer: Parkland Medicaid	$606.41
Rate for Payer: Scott and White EPO/PPO	$10.21
Rate for Payer: Scott and White Medicare	$8.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$606.41
Rate for Payer: Superior Health Plan EPO	$8.17
Rate for Payer: Superior Health Plan Medicare	$8.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.17
Rate for Payer: Universal American Medicare	$8.17
Rate for Payer: Wellcare Medicare	$8.17
Rate for Payer: Wellmed Medicare	$8.17

Know your out-of-pocket cost for care.

All Charges