White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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
Rate for Payer: Cash Price	$6.22

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 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
Rate for Payer: Cash Price	$6.70

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

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

Facility

$48,185.90

Service Code	MSDRG 493
Min. Negotiated Rate	$19,316.46
Max. Negotiated Rate	$48,185.90
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

$69,760.40

Service Code	MSDRG 492
Min. Negotiated Rate	$29,158.30
Max. Negotiated Rate	$69,760.40
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

$38,123.50

Service Code	MSDRG 494
Min. Negotiated Rate	$15,083.54
Max. Negotiated Rate	$38,123.50
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

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$48,185.90

Service Code	MSDRG 493
Min. Negotiated Rate	$19,316.46
Max. Negotiated Rate	$48,185.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,347.23
Rate for Payer: Amerigroup Medicare	$23,347.23
Rate for Payer: BCBS of TX Medicare	$23,347.23
Rate for Payer: Cigna Commercial	$32,664.97
Rate for Payer: Cigna Medicare	$23,347.23
Rate for Payer: Employer Direct Commercial	$23,347.23
Rate for Payer: Humana Medicare/TRICARE	$23,347.23
Rate for Payer: Molina Dual Medicare/Medicaid	$23,347.23
Rate for Payer: Molina Medicare	$23,347.23
Rate for Payer: Multiplan Auto	$48,185.90
Rate for Payer: Multiplan Commercial	$48,185.90
Rate for Payer: Multiplan Workers Comp	$48,185.90
Rate for Payer: Scott and White EPO/PPO	$22,190.88
Rate for Payer: Scott and White Medicare	$23,347.23
Rate for Payer: Superior Health Plan EPO	$23,347.23
Rate for Payer: Superior Health Plan Medicare	$23,347.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,347.23
Rate for Payer: Universal American Medicare	$23,347.23
Rate for Payer: Wellcare Medicare	$23,347.23
Rate for Payer: Wellmed Medicare	$23,347.23

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC

Facility

$69,760.40

Service Code	MSDRG 492
Min. Negotiated Rate	$29,158.30
Max. Negotiated Rate	$69,760.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,669.33
Rate for Payer: Amerigroup Medicare	$31,669.33
Rate for Payer: BCBS of TX Medicare	$31,669.33
Rate for Payer: Cigna Commercial	$47,290.21
Rate for Payer: Cigna Medicare	$31,669.33
Rate for Payer: Employer Direct Commercial	$31,669.33
Rate for Payer: Humana Medicare/TRICARE	$31,669.33
Rate for Payer: Molina Dual Medicare/Medicaid	$31,669.33
Rate for Payer: Molina Medicare	$31,669.33
Rate for Payer: Multiplan Auto	$69,760.40
Rate for Payer: Multiplan Commercial	$69,760.40
Rate for Payer: Multiplan Workers Comp	$69,760.40
Rate for Payer: Scott and White EPO/PPO	$32,126.50
Rate for Payer: Scott and White Medicare	$31,669.33
Rate for Payer: Superior Health Plan EPO	$31,669.33
Rate for Payer: Superior Health Plan Medicare	$31,669.33
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,669.33
Rate for Payer: Universal American Medicare	$31,669.33
Rate for Payer: Wellcare Medicare	$31,669.33
Rate for Payer: Wellmed Medicare	$31,669.33

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC

Facility

$38,123.50

Service Code	MSDRG 494
Min. Negotiated Rate	$15,083.54
Max. Negotiated Rate	$38,123.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,465.77
Rate for Payer: Amerigroup Medicare	$19,465.77
Rate for Payer: BCBS of TX Medicare	$19,465.77
Rate for Payer: Cigna Commercial	$25,843.72
Rate for Payer: Cigna Medicare	$19,465.77
Rate for Payer: Employer Direct Commercial	$19,465.77
Rate for Payer: Humana Medicare/TRICARE	$19,465.77
Rate for Payer: Molina Dual Medicare/Medicaid	$19,465.77
Rate for Payer: Molina Medicare	$19,465.77
Rate for Payer: Multiplan Auto	$38,123.50
Rate for Payer: Multiplan Commercial	$38,123.50
Rate for Payer: Multiplan Workers Comp	$38,123.50
Rate for Payer: Scott and White EPO/PPO	$17,556.88
Rate for Payer: Scott and White Medicare	$19,465.77
Rate for Payer: Superior Health Plan EPO	$19,465.77
Rate for Payer: Superior Health Plan Medicare	$19,465.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,465.77
Rate for Payer: Universal American Medicare	$19,465.77
Rate for Payer: Wellcare Medicare	$19,465.77
Rate for Payer: Wellmed Medicare	$19,465.77

LOWER EXTREMITY ARTERIAL PROCEDURES

Facility

$17,351.07

Service Code	APR-DRG 1813
Min. Negotiated Rate	$16,359.20
Max. Negotiated Rate	$17,351.07
Rate for Payer: Amerigroup CHIP/Medicaid	$16,359.20
Rate for Payer: Cigna Medicaid	$16,359.20
Rate for Payer: Molina CHIP/Medicaid	$16,359.20
Rate for Payer: Parkland Medicaid	$16,359.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,351.07

Know your out-of-pocket cost for care.

All Charges