White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Organism ID, Bacteria SO

Facility

$238.00

Service Code	CPT 87077
Hospital Charge Code	1603646
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$154.70
Rate for Payer: Aetna Commercial	$8.49
Rate for Payer: Aetna Medicare	$12.12
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.08
Rate for Payer: Amerigroup Medicare	$8.08
Rate for Payer: BCBS of TX Blue Advantage	$13.33
Rate for Payer: BCBS of TX Blue Essentials	$16.00
Rate for Payer: BCBS of TX Medicare	$8.08
Rate for Payer: BCBS of TX PPO	$17.86
Rate for Payer: Cash Price	$209.44
Rate for Payer: Cash Price	$209.44
Rate for Payer: Cigna Medicaid	$8.08
Rate for Payer: Cigna Medicare	$8.08
Rate for Payer: Employer Direct Commercial	$8.08
Rate for Payer: Humana Medicare/TRICARE	$8.08
Rate for Payer: Molina CHIP/Medicaid	$8.08
Rate for Payer: Molina Dual Medicare/Medicaid	$8.08
Rate for Payer: Molina Medicare	$8.08
Rate for Payer: Multiplan Auto	$154.70
Rate for Payer: Multiplan Commercial	$154.70
Rate for Payer: Multiplan Workers Comp	$154.70
Rate for Payer: Parkland Medicaid	$8.08
Rate for Payer: Scott and White EPO/PPO	$10.10
Rate for Payer: Scott and White Medicare	$8.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.08
Rate for Payer: Superior Health Plan EPO	$8.08
Rate for Payer: Superior Health Plan Medicare	$8.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.08
Rate for Payer: Universal American Medicare	$8.08
Rate for Payer: Wellcare Medicare	$8.08
Rate for Payer: Wellmed Medicare	$8.08

Organism ID, Bacteria SO

Facility

$238.00

Service Code	CPT 87077
Hospital Charge Code	1603646
Hospital Revenue Code	306
Rate for Payer: Cash Price	$209.44

.Organism ID by Sequencing 183757 SO

Facility

$275.00

Service Code	CPT 87153
Hospital Charge Code	1700032
Hospital Revenue Code	300
Rate for Payer: Cash Price	$242.00

.Organism ID by Sequencing 183757 SO

Facility

$275.00

Service Code	CPT 87153
Hospital Charge Code	1700032
Hospital Revenue Code	300
Min. Negotiated Rate	$44.99
Max. Negotiated Rate	$254.95
Rate for Payer: Aetna Commercial	$121.14
Rate for Payer: Aetna Medicare	$173.04
Rate for Payer: Amerigroup CHIP/Medicaid	$44.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$115.36
Rate for Payer: Amerigroup Medicare	$115.36
Rate for Payer: BCBS of TX Blue Advantage	$190.34
Rate for Payer: BCBS of TX Blue Essentials	$228.41
Rate for Payer: BCBS of TX Medicare	$115.36
Rate for Payer: BCBS of TX PPO	$254.95
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cigna Medicaid	$115.36
Rate for Payer: Cigna Medicare	$115.36
Rate for Payer: Employer Direct Commercial	$115.36
Rate for Payer: Humana Medicare/TRICARE	$115.36
Rate for Payer: Molina CHIP/Medicaid	$115.36
Rate for Payer: Molina Dual Medicare/Medicaid	$115.36
Rate for Payer: Molina Medicare	$115.36
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Parkland Medicaid	$115.36
Rate for Payer: Scott and White EPO/PPO	$144.20
Rate for Payer: Scott and White Medicare	$115.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.36
Rate for Payer: Superior Health Plan EPO	$115.36
Rate for Payer: Superior Health Plan Medicare	$115.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$115.36
Rate for Payer: Universal American Medicare	$115.36
Rate for Payer: Wellcare Medicare	$115.36
Rate for Payer: Wellmed Medicare	$115.36

Organism Identification, Yeast SO

Facility

$191.00

Service Code	CPT 87106
Hospital Charge Code	1603679
Hospital Revenue Code	306
Rate for Payer: Cash Price	$168.08

Organism Identification, Yeast SO

Facility

$191.00

Service Code	CPT 87106
Hospital Charge Code	1603679
Hospital Revenue Code	306
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$124.15
Rate for Payer: Aetna Commercial	$10.83
Rate for Payer: Aetna Medicare	$15.48
Rate for Payer: Amerigroup CHIP/Medicaid	$4.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.32
Rate for Payer: Amerigroup Medicare	$10.32
Rate for Payer: BCBS of TX Blue Advantage	$17.03
Rate for Payer: BCBS of TX Blue Essentials	$20.43
Rate for Payer: BCBS of TX Medicare	$10.32
Rate for Payer: BCBS of TX PPO	$22.81
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cigna Medicaid	$10.32
Rate for Payer: Cigna Medicare	$10.32
Rate for Payer: Employer Direct Commercial	$10.32
Rate for Payer: Humana Medicare/TRICARE	$10.32
Rate for Payer: Molina CHIP/Medicaid	$10.32
Rate for Payer: Molina Dual Medicare/Medicaid	$10.32
Rate for Payer: Molina Medicare	$10.32
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Parkland Medicaid	$10.32
Rate for Payer: Scott and White EPO/PPO	$12.90
Rate for Payer: Scott and White Medicare	$10.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.32
Rate for Payer: Superior Health Plan EPO	$10.32
Rate for Payer: Superior Health Plan Medicare	$10.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.32
Rate for Payer: Universal American Medicare	$10.32
Rate for Payer: Wellcare Medicare	$10.32
Rate for Payer: Wellmed Medicare	$10.32

Organism ID, Mold SO

Facility

$158.00

Service Code	CPT 87107
Hospital Charge Code	8654548
Hospital Revenue Code	306
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$102.70
Rate for Payer: Aetna Commercial	$10.83
Rate for Payer: Aetna Medicare	$15.48
Rate for Payer: Amerigroup CHIP/Medicaid	$4.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.32
Rate for Payer: Amerigroup Medicare	$10.32
Rate for Payer: BCBS of TX Blue Advantage	$17.03
Rate for Payer: BCBS of TX Blue Essentials	$20.43
Rate for Payer: BCBS of TX Medicare	$10.32
Rate for Payer: BCBS of TX PPO	$22.81
Rate for Payer: Cash Price	$139.04
Rate for Payer: Cash Price	$139.04
Rate for Payer: Cigna Medicaid	$10.32
Rate for Payer: Cigna Medicare	$10.32
Rate for Payer: Employer Direct Commercial	$10.32
Rate for Payer: Humana Medicare/TRICARE	$10.32
Rate for Payer: Molina CHIP/Medicaid	$10.32
Rate for Payer: Molina Dual Medicare/Medicaid	$10.32
Rate for Payer: Molina Medicare	$10.32
Rate for Payer: Multiplan Auto	$102.70
Rate for Payer: Multiplan Commercial	$102.70
Rate for Payer: Multiplan Workers Comp	$102.70
Rate for Payer: Parkland Medicaid	$10.32
Rate for Payer: Scott and White EPO/PPO	$12.90
Rate for Payer: Scott and White Medicare	$10.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.32
Rate for Payer: Superior Health Plan EPO	$10.32
Rate for Payer: Superior Health Plan Medicare	$10.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.32
Rate for Payer: Universal American Medicare	$10.32
Rate for Payer: Wellcare Medicare	$10.32
Rate for Payer: Wellmed Medicare	$10.32

Organism ID, Mold SO

Facility

$158.00

Service Code	CPT 87107
Hospital Charge Code	8654548
Hospital Revenue Code	306
Rate for Payer: Cash Price	$139.04

.Org ID by Sequencing Rflx AST 182865 SO

Facility

$275.00

Service Code	CPT 87153
Hospital Charge Code	1700032
Hospital Revenue Code	300
Min. Negotiated Rate	$44.99
Max. Negotiated Rate	$254.95
Rate for Payer: Aetna Commercial	$121.14
Rate for Payer: Aetna Medicare	$173.04
Rate for Payer: Amerigroup CHIP/Medicaid	$44.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$115.36
Rate for Payer: Amerigroup Medicare	$115.36
Rate for Payer: BCBS of TX Blue Advantage	$190.34
Rate for Payer: BCBS of TX Blue Essentials	$228.41
Rate for Payer: BCBS of TX Medicare	$115.36
Rate for Payer: BCBS of TX PPO	$254.95
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cigna Medicaid	$115.36
Rate for Payer: Cigna Medicare	$115.36
Rate for Payer: Employer Direct Commercial	$115.36
Rate for Payer: Humana Medicare/TRICARE	$115.36
Rate for Payer: Molina CHIP/Medicaid	$115.36
Rate for Payer: Molina Dual Medicare/Medicaid	$115.36
Rate for Payer: Molina Medicare	$115.36
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Parkland Medicaid	$115.36
Rate for Payer: Scott and White EPO/PPO	$144.20
Rate for Payer: Scott and White Medicare	$115.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.36
Rate for Payer: Superior Health Plan EPO	$115.36
Rate for Payer: Superior Health Plan Medicare	$115.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$115.36
Rate for Payer: Universal American Medicare	$115.36
Rate for Payer: Wellcare Medicare	$115.36
Rate for Payer: Wellmed Medicare	$115.36

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$21,646.37

Service Code	MSDRG 620
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$21,646.37
Rate for Payer: Aetna Commercial	$18,249.75
Rate for Payer: Aetna Medicare	$21,646.37
Rate for Payer: BARInet Commercial	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$15,368.20
Rate for Payer: BCBS of TX Blue Essentials	$18,673.26
Rate for Payer: BCBS of TX PPO	$20,748.87
Rate for Payer: Cigna Commercial	$20,893.94

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$33,488.75

Service Code	MSDRG 619
Min. Negotiated Rate	$26,549.92
Max. Negotiated Rate	$33,488.75
Rate for Payer: Aetna Commercial	$29,120.62
Rate for Payer: Aetna Medicare	$32,139.56
Rate for Payer: BCBS of TX Blue Advantage	$26,549.92
Rate for Payer: BCBS of TX Blue Essentials	$30,138.70
Rate for Payer: BCBS of TX PPO	$33,488.75
Rate for Payer: Cigna Commercial	$33,339.88

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$20,523.47

Service Code	MSDRG 621
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$20,523.47
Rate for Payer: Aetna Commercial	$17,069.62
Rate for Payer: Aetna Medicare	$20,523.47
Rate for Payer: BARInet Commercial	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$13,348.92
Rate for Payer: BCBS of TX Blue Essentials	$16,286.48
Rate for Payer: BCBS of TX PPO	$18,096.79
Rate for Payer: Cigna Commercial	$19,542.82

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$27,905.81

Service Code	MSDRG 940
Min. Negotiated Rate	$16,976.40
Max. Negotiated Rate	$27,905.81
Rate for Payer: Aetna Commercial	$24,374.25
Rate for Payer: Aetna Medicare	$27,473.64
Rate for Payer: BCBS of TX Blue Advantage	$16,976.40
Rate for Payer: BCBS of TX Blue Essentials	$22,438.67
Rate for Payer: BCBS of TX PPO	$24,932.82
Rate for Payer: Cigna Commercial	$27,905.81

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$41,413.06

Service Code	MSDRG 939
Min. Negotiated Rate	$28,438.48
Max. Negotiated Rate	$41,413.06
Rate for Payer: Aetna Commercial	$36,172.12
Rate for Payer: Aetna Medicare	$38,699.03
Rate for Payer: BCBS of TX Blue Advantage	$28,438.48
Rate for Payer: BCBS of TX Blue Essentials	$33,832.91
Rate for Payer: BCBS of TX PPO	$37,593.57
Rate for Payer: Cigna Commercial	$41,413.06

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$24,148.95

Service Code	MSDRG 941
Min. Negotiated Rate	$12,333.26
Max. Negotiated Rate	$24,148.95
Rate for Payer: Aetna Commercial	$20,880.00
Rate for Payer: Aetna Medicare	$24,148.95
Rate for Payer: BCBS of TX Blue Advantage	$12,333.26
Rate for Payer: BCBS of TX Blue Essentials	$19,104.60
Rate for Payer: BCBS of TX PPO	$21,228.15
Rate for Payer: Cigna Commercial	$23,905.28

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$48,061.72

Service Code	MSDRG 876
Min. Negotiated Rate	$29,405.98
Max. Negotiated Rate	$48,061.72
Rate for Payer: Aetna Commercial	$41,979.38
Rate for Payer: Aetna Medicare	$44,224.49
Rate for Payer: BCBS of TX Blue Advantage	$29,405.98
Rate for Payer: BCBS of TX Blue Essentials	$34,067.15
Rate for Payer: BCBS of TX PPO	$37,853.85
Rate for Payer: Cigna Commercial	$48,061.72

oseltamivir 30 mg Cap

Facility

$23.94

Service Code	HCPCS J3490
Hospital Charge Code	77738222
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$15.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2.15
Rate for Payer: BCBS of TX Blue Advantage	$7.18
Rate for Payer: BCBS of TX Blue Essentials	$8.62
Rate for Payer: BCBS of TX PPO	$9.58
Rate for Payer: Cash Price	$16.28
Rate for Payer: Multiplan Auto	$15.56
Rate for Payer: Multiplan Commercial	$15.56
Rate for Payer: Multiplan Workers Comp	$15.56
Rate for Payer: Scott and White EPO/PPO	$11.97
Rate for Payer: Superior Health Plan EPO	$3.26

oseltamivir 30 mg Cap

Facility

$23.94

Service Code	HCPCS J3490
Hospital Charge Code	77738222
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.28

oseltamivir 75 mg Cap

Facility

$54.55

Service Code	HCPCS J3490
Hospital Charge Code	77738369
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.09

oseltamivir 75 mg Cap

Facility

$54.55

Service Code	HCPCS J3490
Hospital Charge Code	77738369
Hospital Revenue Code	250
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$35.46
Rate for Payer: Amerigroup CHIP/Medicaid	$4.91
Rate for Payer: BCBS of TX Blue Advantage	$16.36
Rate for Payer: BCBS of TX Blue Essentials	$19.64
Rate for Payer: BCBS of TX PPO	$21.82
Rate for Payer: Cash Price	$37.09
Rate for Payer: Multiplan Auto	$35.46
Rate for Payer: Multiplan Commercial	$35.46
Rate for Payer: Multiplan Workers Comp	$35.46
Rate for Payer: Scott and White EPO/PPO	$27.27
Rate for Payer: Superior Health Plan EPO	$7.42

Osmolality

Facility

$286.00

Service Code	CPT 83930
Hospital Charge Code	1602168
Hospital Revenue Code	301
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$185.90
Rate for Payer: Aetna Commercial	$6.95
Rate for Payer: Aetna Medicare	$9.91
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	$10.91
Rate for Payer: BCBS of TX Blue Essentials	$13.09
Rate for Payer: BCBS of TX Medicare	$6.61
Rate for Payer: BCBS of TX PPO	$14.61
Rate for Payer: Cash Price	$251.68
Rate for Payer: Cash Price	$251.68
Rate for Payer: Cigna Medicaid	$6.61
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	$6.61
Rate for Payer: Molina Dual Medicare/Medicaid	$6.61
Rate for Payer: Molina Medicare	$6.61
Rate for Payer: Multiplan Auto	$185.90
Rate for Payer: Multiplan Commercial	$185.90
Rate for Payer: Multiplan Workers Comp	$185.90
Rate for Payer: Parkland Medicaid	$6.61
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	$6.61
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

Osmolality

Facility

$286.00

Service Code	CPT 83930
Hospital Charge Code	1602168
Hospital Revenue Code	301
Rate for Payer: Cash Price	$251.68

Osmolality, Fecal SO

Facility

$123.00

Service Code	CPT 84999
Hospital Charge Code	1700301
Hospital Revenue Code	301
Min. Negotiated Rate	$11.07
Max. Negotiated Rate	$79.95
Rate for Payer: Aetna Commercial	$67.65
Rate for Payer: Amerigroup CHIP/Medicaid	$11.07
Rate for Payer: Cash Price	$108.24
Rate for Payer: Multiplan Auto	$79.95
Rate for Payer: Multiplan Commercial	$79.95
Rate for Payer: Multiplan Workers Comp	$79.95
Rate for Payer: Scott and White EPO/PPO	$61.50
Rate for Payer: Superior Health Plan EPO	$16.73

Osmolality Urine

Facility

$272.00

Service Code	CPT 83935
Hospital Charge Code	1602564
Hospital Revenue Code	301
Rate for Payer: Cash Price	$239.36

Osmolality Urine

Facility

$272.00

Service Code	CPT 83935
Hospital Charge Code	1602564
Hospital Revenue Code	301
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna Commercial	$7.16
Rate for Payer: Aetna Medicare	$10.23
Rate for Payer: Amerigroup CHIP/Medicaid	$2.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.82
Rate for Payer: Amerigroup Medicare	$6.82
Rate for Payer: BCBS of TX Blue Advantage	$11.25
Rate for Payer: BCBS of TX Blue Essentials	$13.50
Rate for Payer: BCBS of TX Medicare	$6.82
Rate for Payer: BCBS of TX PPO	$15.07
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cigna Medicaid	$6.82
Rate for Payer: Cigna Medicare	$6.82
Rate for Payer: Employer Direct Commercial	$6.82
Rate for Payer: Humana Medicare/TRICARE	$6.82
Rate for Payer: Molina CHIP/Medicaid	$6.82
Rate for Payer: Molina Dual Medicare/Medicaid	$6.82
Rate for Payer: Molina Medicare	$6.82
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	$6.82
Rate for Payer: Scott and White EPO/PPO	$8.53
Rate for Payer: Scott and White Medicare	$6.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.82
Rate for Payer: Superior Health Plan EPO	$6.82
Rate for Payer: Superior Health Plan Medicare	$6.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.82
Rate for Payer: Universal American Medicare	$6.82
Rate for Payer: Wellcare Medicare	$6.82
Rate for Payer: Wellmed Medicare	$6.82

Know your out-of-pocket cost for care.

All Charges