White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LO-PRO SCRW, TM SS 2.7X 18MM CORTEX

Facility

$451.81

Service Code	HCPCS C1713
Hospital Charge Code	992247
Hospital Revenue Code	278
Min. Negotiated Rate	$40.66
Max. Negotiated Rate	$325.30
Rate for Payer: Amerigroup CHIP/Medicaid	$40.66
Rate for Payer: BCBS of TX Blue Advantage	$135.54
Rate for Payer: BCBS of TX Blue Essentials	$162.65
Rate for Payer: BCBS of TX PPO	$180.72
Rate for Payer: Cash Price	$307.23
Rate for Payer: Cigna Medicaid	$325.30
Rate for Payer: Molina CHIP/Medicaid	$325.30
Rate for Payer: Multiplan Auto	$225.91
Rate for Payer: Multiplan Commercial	$225.91
Rate for Payer: Multiplan Workers Comp	$225.91
Rate for Payer: Parkland Medicaid	$325.30
Rate for Payer: Scott and White EPO/PPO	$225.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$325.30
Rate for Payer: Superior Health Plan EPO	$61.45

LO-PRO SCRW, TM SS 2.7X 18MM CORTEX

Facility

$451.81

Service Code	HCPCS C1713
Hospital Charge Code	992247
Hospital Revenue Code	278
Min. Negotiated Rate	$112.95
Max. Negotiated Rate	$225.91
Rate for Payer: Cash Price	$307.23
Rate for Payer: Cigna Commercial	$112.95
Rate for Payer: Multiplan Auto	$225.91
Rate for Payer: Multiplan Commercial	$225.91
Rate for Payer: Multiplan Workers Comp	$225.91
Rate for Payer: Scott and White EPO/PPO	$225.91

LO-PRO SCRW, TM SS 2.7X 22MM CORTEX

Facility

$451.81

Service Code	HCPCS C1713
Hospital Charge Code	992248
Hospital Revenue Code	278
Min. Negotiated Rate	$40.66
Max. Negotiated Rate	$325.30
Rate for Payer: Amerigroup CHIP/Medicaid	$40.66
Rate for Payer: BCBS of TX Blue Advantage	$135.54
Rate for Payer: BCBS of TX Blue Essentials	$162.65
Rate for Payer: BCBS of TX PPO	$180.72
Rate for Payer: Cash Price	$307.23
Rate for Payer: Cigna Medicaid	$325.30
Rate for Payer: Molina CHIP/Medicaid	$325.30
Rate for Payer: Multiplan Auto	$225.91
Rate for Payer: Multiplan Commercial	$225.91
Rate for Payer: Multiplan Workers Comp	$225.91
Rate for Payer: Parkland Medicaid	$325.30
Rate for Payer: Scott and White EPO/PPO	$225.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$325.30
Rate for Payer: Superior Health Plan EPO	$61.45

LO-PRO SCRW, TM SS 2.7X 22MM CORTEX

Facility

$451.81

Service Code	HCPCS C1713
Hospital Charge Code	992248
Hospital Revenue Code	278
Min. Negotiated Rate	$112.95
Max. Negotiated Rate	$225.91
Rate for Payer: Cash Price	$307.23
Rate for Payer: Cigna Commercial	$112.95
Rate for Payer: Multiplan Auto	$225.91
Rate for Payer: Multiplan Commercial	$225.91
Rate for Payer: Multiplan Workers Comp	$225.91
Rate for Payer: Scott and White EPO/PPO	$225.91

LO-PRO SCRW, TM SS 3.5X 14MM CORT

Facility

$352.41

Service Code	HCPCS C1713
Hospital Charge Code	992249
Hospital Revenue Code	278
Min. Negotiated Rate	$31.72
Max. Negotiated Rate	$253.74
Rate for Payer: Amerigroup CHIP/Medicaid	$31.72
Rate for Payer: BCBS of TX Blue Advantage	$105.72
Rate for Payer: BCBS of TX Blue Essentials	$126.87
Rate for Payer: BCBS of TX PPO	$140.96
Rate for Payer: Cash Price	$239.64
Rate for Payer: Cigna Medicaid	$253.74
Rate for Payer: Molina CHIP/Medicaid	$253.74
Rate for Payer: Multiplan Auto	$176.21
Rate for Payer: Multiplan Commercial	$176.21
Rate for Payer: Multiplan Workers Comp	$176.21
Rate for Payer: Parkland Medicaid	$253.74
Rate for Payer: Scott and White EPO/PPO	$176.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$253.74
Rate for Payer: Superior Health Plan EPO	$47.93

LO-PRO SCRW, TM SS 3.5X 14MM CORT

Facility

$352.41

Service Code	HCPCS C1713
Hospital Charge Code	992249
Hospital Revenue Code	278
Min. Negotiated Rate	$88.10
Max. Negotiated Rate	$176.21
Rate for Payer: Cash Price	$239.64
Rate for Payer: Cigna Commercial	$88.10
Rate for Payer: Multiplan Auto	$176.21
Rate for Payer: Multiplan Commercial	$176.21
Rate for Payer: Multiplan Workers Comp	$176.21
Rate for Payer: Scott and White EPO/PPO	$176.21

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

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	$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

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

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	$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

LORazepam 2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2060
Hospital Charge Code	77671729
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

LORazepam 2 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2060
Hospital Charge Code	77671729
Hospital Revenue Code	636
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.54
Rate for Payer: BCBS of TX Blue Essentials	$0.64
Rate for Payer: BCBS of TX PPO	$0.71
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

LORazepam 2 mg Tab

Facility

$9.15

Service Code	HCPCS J3490
Hospital Charge Code	77671674
Hospital Revenue Code	250
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$6.59
Rate for Payer: Amerigroup CHIP/Medicaid	$0.82
Rate for Payer: BCBS of TX Blue Advantage	$2.75
Rate for Payer: BCBS of TX Blue Essentials	$3.29
Rate for Payer: BCBS of TX PPO	$3.66
Rate for Payer: Cash Price	$6.22
Rate for Payer: Cigna Medicaid	$6.59
Rate for Payer: Molina CHIP/Medicaid	$6.59
Rate for Payer: Multiplan Auto	$5.95
Rate for Payer: Multiplan Commercial	$5.95
Rate for Payer: Multiplan Workers Comp	$5.95
Rate for Payer: Parkland Medicaid	$6.59
Rate for Payer: Scott and White EPO/PPO	$4.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.59
Rate for Payer: Superior Health Plan EPO	$1.24

LORazepam 2 mg Tab

Facility

$9.15

Service Code	HCPCS J3490
Hospital Charge Code	77671674
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.22

LORazepam 4 mg/mL Inj

Facility

$128.17

Service Code	HCPCS J2060
Hospital Charge Code	77672008
Hospital Revenue Code	636
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.54
Rate for Payer: BCBS of TX Blue Essentials	$0.64
Rate for Payer: BCBS of TX PPO	$0.71
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

LORazepam 4 mg/mL Inj

Facility

$128.17

Service Code	HCPCS J2060
Hospital Charge Code	77672008
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

LORazepam 4 mg/mL Inj

Facility

$128.00

Service Code	HCPCS J2060
Hospital Charge Code	77672088
Hospital Revenue Code	636
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.54
Rate for Payer: BCBS of TX Blue Essentials	$0.64
Rate for Payer: BCBS of TX PPO	$0.71
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

LORazepam 4 mg/mL Inj

Facility

$128.00

Service Code	HCPCS J2060
Hospital Charge Code	77672088
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

losartan 25 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77672230
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

losartan 25 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77672230
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

losartan 50 mg Tab

Facility

$9.85

Service Code	HCPCS J3490
Hospital Charge Code	77672285
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$7.09
Rate for Payer: Amerigroup CHIP/Medicaid	$0.89
Rate for Payer: BCBS of TX Blue Advantage	$2.96
Rate for Payer: BCBS of TX Blue Essentials	$3.55
Rate for Payer: BCBS of TX PPO	$3.94
Rate for Payer: Cash Price	$6.70
Rate for Payer: Cigna Medicaid	$7.09
Rate for Payer: Molina CHIP/Medicaid	$7.09
Rate for Payer: Multiplan Auto	$6.40
Rate for Payer: Multiplan Commercial	$6.40
Rate for Payer: Multiplan Workers Comp	$6.40
Rate for Payer: Parkland Medicaid	$7.09
Rate for Payer: Scott and White EPO/PPO	$4.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.09
Rate for Payer: Superior Health Plan EPO	$1.34

losartan 50 mg Tab

Facility

$9.85

Service Code	HCPCS J3490
Hospital Charge Code	77672285
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.70

LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W CC

Facility

$45,140.20

Service Code	MSDRG 493
Min. Negotiated Rate	$19,316.46
Max. Negotiated Rate	$45,140.20
Rate for Payer: BCBS of TX Blue Advantage	$19,316.46
Rate for Payer: BCBS of TX Blue Essentials	$23,177.51
Rate for Payer: BCBS of TX PPO	$25,753.78

LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W MCC

Facility

$66,232.10

Service Code	MSDRG 492
Min. Negotiated Rate	$29,158.30
Max. Negotiated Rate	$66,232.10
Rate for Payer: BCBS of TX Blue Advantage	$29,158.30
Rate for Payer: BCBS of TX Blue Essentials	$34,986.57
Rate for Payer: BCBS of TX PPO	$38,875.47

LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W/O CC/MCC

Facility

$35,887.20

Service Code	MSDRG 494
Min. Negotiated Rate	$15,083.54
Max. Negotiated Rate	$35,887.20
Rate for Payer: BCBS of TX Blue Advantage	$15,083.54
Rate for Payer: BCBS of TX Blue Essentials	$18,098.49
Rate for Payer: BCBS of TX PPO	$20,110.22

Know your out-of-pocket cost for care.

All Charges