White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ocular lubricant preserved Ophth Soln 15 mL

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77732973
Hospital Revenue Code	250
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$18.85
Rate for Payer: Amerigroup CHIP/Medicaid	$2.61
Rate for Payer: BCBS of TX Blue Advantage	$8.70
Rate for Payer: BCBS of TX Blue Essentials	$10.44
Rate for Payer: BCBS of TX PPO	$11.60
Rate for Payer: Cash Price	$19.72
Rate for Payer: Multiplan Auto	$18.85
Rate for Payer: Multiplan Commercial	$18.85
Rate for Payer: Multiplan Workers Comp	$18.85
Rate for Payer: Scott and White EPO/PPO	$14.50
Rate for Payer: Superior Health Plan EPO	$3.94

ocular lubricant preserved Ophth Soln 15 mL

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	77732973
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.72

Ocular surface reconstruction amniotic membrane transplantation, multiple layers

Facility

$10,000.00

Service Code	CPT 65780
Hospital Charge Code	36065780
Hospital Revenue Code	360
Min. Negotiated Rate	$77.99
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$5,303.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1,427.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Amerigroup Medicare	$3,535.99
Rate for Payer: BCBS of TX Blue Advantage	$5,222.19
Rate for Payer: BCBS of TX Blue Essentials	$6,254.12
Rate for Payer: BCBS of TX Medicare	$3,535.99
Rate for Payer: BCBS of TX PPO	$7,880.19
Rate for Payer: Cigna Commercial	$8,010.04
Rate for Payer: Cigna Medicaid	$1,427.68
Rate for Payer: Cigna Medicare	$3,535.99
Rate for Payer: Employer Direct Commercial	$3,535.99
Rate for Payer: Humana Medicare/TRICARE	$3,535.99
Rate for Payer: Molina CHIP/Medicaid	$1,427.68
Rate for Payer: Molina Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Molina Medicare	$3,535.99
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	$1,427.68
Rate for Payer: Scott and White EPO/PPO	$77.99
Rate for Payer: Scott and White Medicare	$3,535.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,427.68
Rate for Payer: Superior Health Plan EPO	$3,535.99
Rate for Payer: Superior Health Plan Medicare	$3,535.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,535.99
Rate for Payer: Universal American Medicare	$3,535.99
Rate for Payer: Wellcare Medicare	$3,535.99
Rate for Payer: Wellmed Medicare	$3,535.99

ofloxacin 0.3% Ophth Soln 5 mL

Facility

$268.47

Service Code	HCPCS J3490
Hospital Charge Code	77733456
Hospital Revenue Code	250
Rate for Payer: Cash Price	$182.56

ofloxacin 0.3% Ophth Soln 5 mL

Facility

$268.47

Service Code	HCPCS J3490
Hospital Charge Code	77733456
Hospital Revenue Code	250
Min. Negotiated Rate	$24.16
Max. Negotiated Rate	$174.51
Rate for Payer: Amerigroup CHIP/Medicaid	$24.16
Rate for Payer: BCBS of TX Blue Advantage	$80.54
Rate for Payer: BCBS of TX Blue Essentials	$96.65
Rate for Payer: BCBS of TX PPO	$107.39
Rate for Payer: Cash Price	$182.56
Rate for Payer: Multiplan Auto	$174.51
Rate for Payer: Multiplan Commercial	$174.51
Rate for Payer: Multiplan Workers Comp	$174.51
Rate for Payer: Scott and White EPO/PPO	$134.24
Rate for Payer: Superior Health Plan EPO	$36.51

OH CATH B AORTIC -- DHF

Facility

$4,234.73

Hospital Charge Code	81758401
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,726.56

OH CATH B AORTIC -- DHF

Facility

$4,234.73

Hospital Charge Code	81758401
Hospital Revenue Code	272
Min. Negotiated Rate	$381.13
Max. Negotiated Rate	$2,752.57
Rate for Payer: Aetna Commercial	$2,329.10
Rate for Payer: Amerigroup CHIP/Medicaid	$381.13
Rate for Payer: BCBS of TX Blue Advantage	$1,270.42
Rate for Payer: BCBS of TX Blue Essentials	$1,524.50
Rate for Payer: BCBS of TX PPO	$1,693.89
Rate for Payer: Cash Price	$3,726.56
Rate for Payer: Multiplan Auto	$2,752.57
Rate for Payer: Multiplan Commercial	$2,752.57
Rate for Payer: Multiplan Workers Comp	$2,752.57
Rate for Payer: Scott and White EPO/PPO	$2,117.36
Rate for Payer: Superior Health Plan EPO	$575.92

OH NDL CARDIO -- DHF

Facility

$276.09

Hospital Charge Code	81758906
Hospital Revenue Code	272
Min. Negotiated Rate	$24.85
Max. Negotiated Rate	$179.46
Rate for Payer: Aetna Commercial	$151.85
Rate for Payer: Amerigroup CHIP/Medicaid	$24.85
Rate for Payer: BCBS of TX Blue Advantage	$82.83
Rate for Payer: BCBS of TX Blue Essentials	$99.39
Rate for Payer: BCBS of TX PPO	$110.44
Rate for Payer: Cash Price	$242.96
Rate for Payer: Multiplan Auto	$179.46
Rate for Payer: Multiplan Commercial	$179.46
Rate for Payer: Multiplan Workers Comp	$179.46
Rate for Payer: Scott and White EPO/PPO	$138.04
Rate for Payer: Superior Health Plan EPO	$37.55

OH NDL CARDIO -- DHF

Facility

$276.09

Hospital Charge Code	81758906
Hospital Revenue Code	272
Rate for Payer: Cash Price	$242.96

OH TUBING PUMP -- DHF

Facility

$473.26

Hospital Charge Code	81759250
Hospital Revenue Code	272
Min. Negotiated Rate	$42.59
Max. Negotiated Rate	$307.62
Rate for Payer: Aetna Commercial	$260.29
Rate for Payer: Amerigroup CHIP/Medicaid	$42.59
Rate for Payer: BCBS of TX Blue Advantage	$141.98
Rate for Payer: BCBS of TX Blue Essentials	$170.37
Rate for Payer: BCBS of TX PPO	$189.30
Rate for Payer: Cash Price	$416.47
Rate for Payer: Multiplan Auto	$307.62
Rate for Payer: Multiplan Commercial	$307.62
Rate for Payer: Multiplan Workers Comp	$307.62
Rate for Payer: Scott and White EPO/PPO	$236.63
Rate for Payer: Superior Health Plan EPO	$64.36

OH TUBING PUMP -- DHF

Facility

$473.26

Hospital Charge Code	81759250
Hospital Revenue Code	272
Rate for Payer: Cash Price	$416.47

OLANZapine 10 mg IM Inj

Facility

$81.00

Service Code	HCPCS J3490
Hospital Charge Code	77733827
Hospital Revenue Code	250
Rate for Payer: Cash Price	$55.08

OLANZapine 10 mg IM Inj

Facility

$81.00

Service Code	HCPCS J3490
Hospital Charge Code	77733827
Hospital Revenue Code	250
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$52.65
Rate for Payer: Amerigroup CHIP/Medicaid	$7.29
Rate for Payer: BCBS of TX Blue Advantage	$24.30
Rate for Payer: BCBS of TX Blue Essentials	$29.16
Rate for Payer: BCBS of TX PPO	$32.40
Rate for Payer: Cash Price	$55.08
Rate for Payer: Multiplan Auto	$52.65
Rate for Payer: Multiplan Commercial	$52.65
Rate for Payer: Multiplan Workers Comp	$52.65
Rate for Payer: Scott and White EPO/PPO	$40.50
Rate for Payer: Superior Health Plan EPO	$11.02

Oligoclonal Banding, Serum+CSF SO

Facility

$241.00

Service Code	CPT 83916
Hospital Charge Code	1709062
Hospital Revenue Code	301
Min. Negotiated Rate	$10.68
Max. Negotiated Rate	$156.65
Rate for Payer: Aetna Commercial	$28.75
Rate for Payer: Aetna Medicare	$41.08
Rate for Payer: Amerigroup CHIP/Medicaid	$10.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.39
Rate for Payer: Amerigroup Medicare	$27.39
Rate for Payer: BCBS of TX Blue Advantage	$45.19
Rate for Payer: BCBS of TX Blue Essentials	$54.23
Rate for Payer: BCBS of TX Medicare	$27.39
Rate for Payer: BCBS of TX PPO	$60.53
Rate for Payer: Cash Price	$212.08
Rate for Payer: Cash Price	$212.08
Rate for Payer: Cigna Medicaid	$27.39
Rate for Payer: Cigna Medicare	$27.39
Rate for Payer: Employer Direct Commercial	$27.39
Rate for Payer: Humana Medicare/TRICARE	$27.39
Rate for Payer: Molina CHIP/Medicaid	$27.39
Rate for Payer: Molina Dual Medicare/Medicaid	$27.39
Rate for Payer: Molina Medicare	$27.39
Rate for Payer: Multiplan Auto	$156.65
Rate for Payer: Multiplan Commercial	$156.65
Rate for Payer: Multiplan Workers Comp	$156.65
Rate for Payer: Parkland Medicaid	$27.39
Rate for Payer: Scott and White EPO/PPO	$34.24
Rate for Payer: Scott and White Medicare	$27.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.39
Rate for Payer: Superior Health Plan EPO	$27.39
Rate for Payer: Superior Health Plan Medicare	$27.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.39
Rate for Payer: Universal American Medicare	$27.39
Rate for Payer: Wellcare Medicare	$27.39
Rate for Payer: Wellmed Medicare	$27.39

Oligoclonal Banding, Serum+CSF SO

Facility

$241.00

Service Code	CPT 83916
Hospital Charge Code	1709062
Hospital Revenue Code	301
Rate for Payer: Cash Price	$212.08

OLMESARTAN 20mg

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77734518
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
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: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

OLMESARTAN 20mg

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77734518
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Omentectomy, epiploectomy, resection of omentum (separate procedure)

Facility

$10,000.00

Service Code	CPT 49255
Hospital Charge Code	36049255
Hospital Revenue Code	360
Min. Negotiated Rate	$1,380.05
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: BCBS of TX Blue Advantage	$1,380.05
Rate for Payer: BCBS of TX Blue Essentials	$1,652.76
Rate for Payer: BCBS of TX PPO	$2,082.48
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

omeprazole 20 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	9140976
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

omeprazole 20 mg DR Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	9140976
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Onc Facility Eval, New Patient Level 2 99202 BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	7003106
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna Commercial	$149.60
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cigna Medicaid	$37.80
Rate for Payer: Molina CHIP/Medicaid	$37.80
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$37.80
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.80

Onc Facility Eval, New Patient Level 4 99204 BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	7003114
Hospital Revenue Code	510
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$317.20
Rate for Payer: Aetna Commercial	$268.40
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: BCBS of TX Blue Advantage	$228.25
Rate for Payer: BCBS of TX Blue Essentials	$272.85
Rate for Payer: BCBS of TX PPO	$304.34
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cigna Medicaid	$74.74
Rate for Payer: Molina CHIP/Medicaid	$74.74
Rate for Payer: Multiplan Auto	$317.20
Rate for Payer: Multiplan Commercial	$317.20
Rate for Payer: Multiplan Workers Comp	$317.20
Rate for Payer: Parkland Medicaid	$74.74
Rate for Payer: Scott and White EPO/PPO	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.74

Onc Facility Eval, New Patient Level 5 99205 BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	7000029
Hospital Revenue Code	510
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$397.16
Rate for Payer: Aetna Commercial	$327.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$297.87
Rate for Payer: BCBS of TX Blue Essentials	$356.08
Rate for Payer: BCBS of TX PPO	$397.16
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cigna Medicaid	$92.92
Rate for Payer: Molina CHIP/Medicaid	$92.92
Rate for Payer: Multiplan Auto	$387.40
Rate for Payer: Multiplan Commercial	$387.40
Rate for Payer: Multiplan Workers Comp	$387.40
Rate for Payer: Parkland Medicaid	$92.92
Rate for Payer: Scott and White EPO/PPO	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.92

Onc MYH9 Sequence Analysis BCE

Facility

$1,093.00

Service Code	CPT 81479
Hospital Charge Code	7002125
Hospital Revenue Code	310
Rate for Payer: Cash Price	$961.84

Onc MYH9 Sequence Analysis BCE

Facility

$1,093.00

Service Code	CPT 81479
Hospital Charge Code	7002125
Hospital Revenue Code	310
Min. Negotiated Rate	$42.32
Max. Negotiated Rate	$710.45
Rate for Payer: Aetna Commercial	$601.15
Rate for Payer: Amerigroup CHIP/Medicaid	$98.37
Rate for Payer: BCBS of TX Blue Advantage	$42.32
Rate for Payer: BCBS of TX Blue Essentials	$50.79
Rate for Payer: BCBS of TX PPO	$56.69
Rate for Payer: Cash Price	$961.84
Rate for Payer: Cash Price	$961.84
Rate for Payer: Multiplan Auto	$710.45
Rate for Payer: Multiplan Commercial	$710.45
Rate for Payer: Multiplan Workers Comp	$710.45
Rate for Payer: Scott and White EPO/PPO	$546.50
Rate for Payer: Superior Health Plan EPO	$148.65

Know your out-of-pocket cost for care.

All Charges