White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OT Unattended E-Stim Assistant Units

Facility

$160.00

Service Code	CPT 97014 CO,GO
Hospital Charge Code	4300007
Hospital Revenue Code	430
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$21.76

OT Unattended E-Stim Assistant Units BCE

Facility

$160.00

Service Code	CPT 97014 CO,GO
Hospital Charge Code	4300007
Hospital Revenue Code	430
Rate for Payer: Cash Price	$140.80

OT Unattended E-Stim Assistant Units BCE

Facility

$160.00

Service Code	CPT 97014 CO,GO
Hospital Charge Code	4300007
Hospital Revenue Code	430
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$21.76

OT Unattended E-Stim Units

Facility

$160.00

Service Code	CPT 97014 GO
Hospital Charge Code	4300041
Hospital Revenue Code	430
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$21.76

OT Unattended E-Stim Units BCE

Facility

$160.00

Service Code	CPT 97014 GO
Hospital Charge Code	4300041
Hospital Revenue Code	430
Rate for Payer: Cash Price	$140.80

OT Unattended E-Stim Units BCE

Facility

$160.00

Service Code	CPT 97014 GO
Hospital Charge Code	4300041
Hospital Revenue Code	430
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$21.76

Outborn placenta delivery

Facility

$5,138.00

Service Code	CPT 59414
Hospital Charge Code	10090
Hospital Revenue Code	361
Min. Negotiated Rate	$63.06
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,288.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,063.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,859.20
Rate for Payer: Amerigroup Medicare	$2,859.20
Rate for Payer: BCBS of TX Blue Advantage	$4,171.83
Rate for Payer: BCBS of TX Blue Essentials	$4,996.20
Rate for Payer: BCBS of TX Medicare	$2,859.20
Rate for Payer: BCBS of TX PPO	$6,295.21
Rate for Payer: Cash Price	$4,521.44
Rate for Payer: Cash Price	$4,521.44
Rate for Payer: Cigna Commercial	$6,476.93
Rate for Payer: Cigna Medicaid	$1,063.52
Rate for Payer: Cigna Medicare	$2,859.20
Rate for Payer: Employer Direct Commercial	$2,859.20
Rate for Payer: Humana Medicare/TRICARE	$2,859.20
Rate for Payer: Molina CHIP/Medicaid	$1,063.52
Rate for Payer: Molina Dual Medicare/Medicaid	$2,859.20
Rate for Payer: Molina Medicare	$2,859.20
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	$1,063.52
Rate for Payer: Scott and White EPO/PPO	$63.06
Rate for Payer: Scott and White Medicare	$2,859.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,063.52
Rate for Payer: Superior Health Plan EPO	$2,859.20
Rate for Payer: Superior Health Plan Medicare	$2,859.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,859.20
Rate for Payer: Universal American Medicare	$2,859.20
Rate for Payer: Wellcare Medicare	$2,859.20
Rate for Payer: Wellmed Medicare	$2,859.20

Outborn placenta delivery BCE

Facility

$5,138.00

Service Code	CPT 59414
Hospital Charge Code	10090
Hospital Revenue Code	361
Min. Negotiated Rate	$63.06
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,288.80
Rate for Payer: Amerigroup CHIP/Medicaid	$1,063.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,859.20
Rate for Payer: Amerigroup Medicare	$2,859.20
Rate for Payer: BCBS of TX Blue Advantage	$4,171.83
Rate for Payer: BCBS of TX Blue Essentials	$4,996.20
Rate for Payer: BCBS of TX Medicare	$2,859.20
Rate for Payer: BCBS of TX PPO	$6,295.21
Rate for Payer: Cash Price	$4,521.44
Rate for Payer: Cash Price	$4,521.44
Rate for Payer: Cigna Commercial	$6,476.93
Rate for Payer: Cigna Medicaid	$1,063.52
Rate for Payer: Cigna Medicare	$2,859.20
Rate for Payer: Employer Direct Commercial	$2,859.20
Rate for Payer: Humana Medicare/TRICARE	$2,859.20
Rate for Payer: Molina CHIP/Medicaid	$1,063.52
Rate for Payer: Molina Dual Medicare/Medicaid	$2,859.20
Rate for Payer: Molina Medicare	$2,859.20
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	$1,063.52
Rate for Payer: Scott and White EPO/PPO	$63.06
Rate for Payer: Scott and White Medicare	$2,859.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,063.52
Rate for Payer: Superior Health Plan EPO	$2,859.20
Rate for Payer: Superior Health Plan Medicare	$2,859.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,859.20
Rate for Payer: Universal American Medicare	$2,859.20
Rate for Payer: Wellcare Medicare	$2,859.20
Rate for Payer: Wellmed Medicare	$2,859.20

Outborn placenta delivery BCE

Facility

$5,138.00

Service Code	CPT 59414
Hospital Charge Code	10090
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,521.44

Ova + Parasite Exam SO

Facility

$155.00

Service Code	CPT 87177
Hospital Charge Code	1604081
Hospital Revenue Code	306
Rate for Payer: Cash Price	$136.40

Ova + Parasite Exam SO

Facility

$155.00

Service Code	CPT 87177
Hospital Charge Code	1604081
Hospital Revenue Code	306
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$100.75
Rate for Payer: Aetna Commercial	$9.34
Rate for Payer: Aetna Medicare	$13.35
Rate for Payer: Amerigroup CHIP/Medicaid	$3.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.90
Rate for Payer: Amerigroup Medicare	$8.90
Rate for Payer: BCBS of TX Blue Advantage	$14.68
Rate for Payer: BCBS of TX Blue Essentials	$17.62
Rate for Payer: BCBS of TX Medicare	$8.90
Rate for Payer: BCBS of TX PPO	$19.67
Rate for Payer: Cash Price	$136.40
Rate for Payer: Cash Price	$136.40
Rate for Payer: Cigna Medicaid	$8.90
Rate for Payer: Cigna Medicare	$8.90
Rate for Payer: Employer Direct Commercial	$8.90
Rate for Payer: Humana Medicare/TRICARE	$8.90
Rate for Payer: Molina CHIP/Medicaid	$8.90
Rate for Payer: Molina Dual Medicare/Medicaid	$8.90
Rate for Payer: Molina Medicare	$8.90
Rate for Payer: Multiplan Auto	$100.75
Rate for Payer: Multiplan Commercial	$100.75
Rate for Payer: Multiplan Workers Comp	$100.75
Rate for Payer: Parkland Medicaid	$8.90
Rate for Payer: Scott and White EPO/PPO	$11.12
Rate for Payer: Scott and White Medicare	$8.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.90
Rate for Payer: Superior Health Plan EPO	$8.90
Rate for Payer: Superior Health Plan Medicare	$8.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.90
Rate for Payer: Universal American Medicare	$8.90
Rate for Payer: Wellcare Medicare	$8.90
Rate for Payer: Wellmed Medicare	$8.90

OVERTUBE, ENDOSCOPIC GASTRIC 8.6-10.0MM 25CM L -- DHF

Facility

$753.64

Hospital Charge Code	80321474
Hospital Revenue Code	272
Min. Negotiated Rate	$67.83
Max. Negotiated Rate	$489.87
Rate for Payer: Aetna Commercial	$414.50
Rate for Payer: Amerigroup CHIP/Medicaid	$67.83
Rate for Payer: BCBS of TX Blue Advantage	$226.09
Rate for Payer: BCBS of TX Blue Essentials	$271.31
Rate for Payer: BCBS of TX PPO	$301.46
Rate for Payer: Cash Price	$663.20
Rate for Payer: Multiplan Auto	$489.87
Rate for Payer: Multiplan Commercial	$489.87
Rate for Payer: Multiplan Workers Comp	$489.87
Rate for Payer: Scott and White EPO/PPO	$376.82
Rate for Payer: Superior Health Plan EPO	$102.50

OVERTUBE, ENDOSCOPIC GASTRIC 8.6-10.0MM 25CM L -- DHF

Facility

$753.64

Hospital Charge Code	80321474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$663.20

OXALATE

Facility

$129.00

Service Code	CPT 83945
Hospital Charge Code	1702133
Hospital Revenue Code	301
Rate for Payer: Cash Price	$113.52

OXALATE

Facility

$129.00

Service Code	CPT 83945
Hospital Charge Code	1702133
Hospital Revenue Code	301
Min. Negotiated Rate	$5.64
Max. Negotiated Rate	$83.85
Rate for Payer: Aetna Commercial	$15.17
Rate for Payer: Aetna Medicare	$21.68
Rate for Payer: Amerigroup CHIP/Medicaid	$5.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.45
Rate for Payer: Amerigroup Medicare	$14.45
Rate for Payer: BCBS of TX Blue Advantage	$23.84
Rate for Payer: BCBS of TX Blue Essentials	$28.61
Rate for Payer: BCBS of TX Medicare	$14.45
Rate for Payer: BCBS of TX PPO	$31.93
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cigna Medicaid	$14.45
Rate for Payer: Cigna Medicare	$14.45
Rate for Payer: Employer Direct Commercial	$14.45
Rate for Payer: Humana Medicare/TRICARE	$14.45
Rate for Payer: Molina CHIP/Medicaid	$14.45
Rate for Payer: Molina Dual Medicare/Medicaid	$14.45
Rate for Payer: Molina Medicare	$14.45
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Parkland Medicaid	$14.45
Rate for Payer: Scott and White EPO/PPO	$18.06
Rate for Payer: Scott and White Medicare	$14.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.45
Rate for Payer: Superior Health Plan EPO	$14.45
Rate for Payer: Superior Health Plan Medicare	$14.45
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.45
Rate for Payer: Universal American Medicare	$14.45
Rate for Payer: Wellcare Medicare	$14.45
Rate for Payer: Wellmed Medicare	$14.45

Oxcarbazepine (Trileptal),S SO

Facility

$236.00

Service Code	CPT 80183
Hospital Charge Code	1740993
Hospital Revenue Code	301
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$153.40
Rate for Payer: Aetna Commercial	$13.91
Rate for Payer: Aetna Medicare	$19.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.25
Rate for Payer: Amerigroup Medicare	$13.25
Rate for Payer: BCBS of TX Blue Advantage	$21.86
Rate for Payer: BCBS of TX Blue Essentials	$26.24
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$29.28
Rate for Payer: Cash Price	$207.68
Rate for Payer: Cash Price	$207.68
Rate for Payer: Cigna Medicaid	$13.25
Rate for Payer: Cigna Medicare	$13.25
Rate for Payer: Employer Direct Commercial	$13.25
Rate for Payer: Humana Medicare/TRICARE	$13.25
Rate for Payer: Molina CHIP/Medicaid	$13.25
Rate for Payer: Molina Dual Medicare/Medicaid	$13.25
Rate for Payer: Molina Medicare	$13.25
Rate for Payer: Multiplan Auto	$153.40
Rate for Payer: Multiplan Commercial	$153.40
Rate for Payer: Multiplan Workers Comp	$153.40
Rate for Payer: Parkland Medicaid	$13.25
Rate for Payer: Scott and White EPO/PPO	$16.56
Rate for Payer: Scott and White Medicare	$13.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.25
Rate for Payer: Superior Health Plan EPO	$13.25
Rate for Payer: Superior Health Plan Medicare	$13.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.25
Rate for Payer: Universal American Medicare	$13.25
Rate for Payer: Wellcare Medicare	$13.25
Rate for Payer: Wellmed Medicare	$13.25

Oxcarbazepine (Trileptal),S SO

Facility

$236.00

Service Code	CPT 80183
Hospital Charge Code	1740993
Hospital Revenue Code	301
Rate for Payer: Cash Price	$207.68

oxybutynin 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77740289
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

oxybutynin 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77740289
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

oxyCODONE 10 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77740613
Hospital Revenue Code	636
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

oxyCODONE 10 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77740613
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

oxyCODONE 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77740666
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

oxyCODONE 10 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77740666
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

oxyCODONE 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77741233
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

oxyCODONE 5 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77741233
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

Know your out-of-pocket cost for care.

All Charges