White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OLANZapine ODT 5 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77734357
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

OLANZapine ODT 5 mg tablet

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77734357
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

Oligoclonal Banding, Serum+CSF SO

Facility

$241.00

Service Code	HCPCS 83916
Hospital Charge Code	1709062
Hospital Revenue Code	301
Rate for Payer: Cash Price	$163.88

Oligoclonal Banding, Serum+CSF SO

Facility

$241.00

Service Code	HCPCS 83916
Hospital Charge Code	1709062
Hospital Revenue Code	301
Min. Negotiated Rate	$10.68
Max. Negotiated Rate	$173.52
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	$72.30
Rate for Payer: BCBS of TX Blue Essentials	$86.76
Rate for Payer: BCBS of TX Medicare	$27.39
Rate for Payer: BCBS of TX PPO	$96.40
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cigna Medicaid	$173.52
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	$173.52
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	$173.52
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	$173.52
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

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	$5.76
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

OLMESARTAN 20mg

Facility

$8.00

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

Omental flap, intra-abdominal (List separately in addition to code for primary procedure)

Facility

$44,600.00

Service Code	HCPCS 49905
Hospital Charge Code	990931
Hospital Revenue Code	360
Min. Negotiated Rate	$616.90
Max. Negotiated Rate	$32,112.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,014.00
Rate for Payer: BCBS of TX Blue Advantage	$616.90
Rate for Payer: BCBS of TX Blue Essentials	$738.80
Rate for Payer: BCBS of TX PPO	$930.89
Rate for Payer: Cash Price	$30,328.00
Rate for Payer: Cash Price	$30,328.00
Rate for Payer: Cash Price	$30,328.00
Rate for Payer: Cigna Medicaid	$32,112.00
Rate for Payer: Molina CHIP/Medicaid	$32,112.00
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	$32,112.00
Rate for Payer: Scott and White EPO/PPO	$22,300.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32,112.00
Rate for Payer: Superior Health Plan EPO	$6,065.60

Omental flap, intra-abdominal (List separately in addition to code for primary procedure)

Facility

$44,600.00

Service Code	HCPCS 49905
Hospital Charge Code	990931
Hospital Revenue Code	360
Rate for Payer: Cash Price	$30,328.00

Omentectomy, epiploectomy, resection of omentum (separate procedure)

Facility

$13,746.84

Service Code	CPT 49255
Hospital Charge Code	36049255
Hospital Revenue Code	360
Min. Negotiated Rate	$1,380.05
Max. Negotiated Rate	$13,746.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Amerigroup Medicare	$6,503.32
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 Medicare	$6,503.32
Rate for Payer: BCBS of TX PPO	$2,082.48
Rate for Payer: Cigna Commercial	$13,746.84
Rate for Payer: Cigna Medicare	$6,503.32
Rate for Payer: Employer Direct Commercial	$6,503.32
Rate for Payer: Humana Medicare/TRICARE	$6,503.32
Rate for Payer: Molina Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Molina Medicare	$6,503.32
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: Scott and White EPO/PPO	$12,031.14
Rate for Payer: Scott and White Medicare	$6,503.32
Rate for Payer: Superior Health Plan EPO	$6,503.32
Rate for Payer: Superior Health Plan Medicare	$6,503.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Universal American Medicare	$6,503.32
Rate for Payer: Wellcare Medicare	$6,503.32
Rate for Payer: Wellmed Medicare	$6,503.32

Omentectomy, epiploectomy, resection of omentum (separate procedure)

Facility

$14,325.35

Service Code	HCPCS 49255
Hospital Charge Code	9900708
Hospital Revenue Code	360
Min. Negotiated Rate	$1,289.28
Max. Negotiated Rate	$13,746.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,289.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Amerigroup Medicare	$6,503.32
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 Medicare	$6,503.32
Rate for Payer: BCBS of TX PPO	$2,082.48
Rate for Payer: Cash Price	$9,741.24
Rate for Payer: Cash Price	$9,741.24
Rate for Payer: Cash Price	$9,741.24
Rate for Payer: Cigna Commercial	$13,746.84
Rate for Payer: Cigna Medicaid	$10,314.25
Rate for Payer: Cigna Medicare	$6,503.32
Rate for Payer: Employer Direct Commercial	$6,503.32
Rate for Payer: Humana Medicare/TRICARE	$6,503.32
Rate for Payer: Molina CHIP/Medicaid	$10,314.25
Rate for Payer: Molina Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Molina Medicare	$6,503.32
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	$10,314.25
Rate for Payer: Scott and White EPO/PPO	$12,031.14
Rate for Payer: Scott and White Medicare	$6,503.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,314.25
Rate for Payer: Superior Health Plan EPO	$6,503.32
Rate for Payer: Superior Health Plan Medicare	$6,503.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,503.32
Rate for Payer: Universal American Medicare	$6,503.32
Rate for Payer: Wellcare Medicare	$6,503.32
Rate for Payer: Wellmed Medicare	$6,503.32

Omentectomy, epiploectomy, resection of omentum (separate procedure)

Facility

$14,325.35

Service Code	HCPCS 49255
Hospital Charge Code	9900708
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,741.24

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	$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

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

omni stent

Facility

$15,638.55

Service Code	HCPCS C1876
Hospital Charge Code	991280
Hospital Revenue Code	278
Min. Negotiated Rate	$3,909.64
Max. Negotiated Rate	$7,819.27
Rate for Payer: Cash Price	$10,634.21
Rate for Payer: Cigna Commercial	$3,909.64
Rate for Payer: Multiplan Auto	$7,819.27
Rate for Payer: Multiplan Commercial	$7,819.27
Rate for Payer: Multiplan Workers Comp	$7,819.27
Rate for Payer: Scott and White EPO/PPO	$7,819.27

omni stent

Facility

$15,638.55

Service Code	HCPCS C1876
Hospital Charge Code	991280
Hospital Revenue Code	278
Min. Negotiated Rate	$1,407.47
Max. Negotiated Rate	$11,259.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,407.47
Rate for Payer: BCBS of TX Blue Advantage	$4,691.56
Rate for Payer: BCBS of TX Blue Essentials	$5,629.88
Rate for Payer: BCBS of TX PPO	$6,255.42
Rate for Payer: Cash Price	$10,634.21
Rate for Payer: Cigna Medicaid	$11,259.76
Rate for Payer: Molina CHIP/Medicaid	$11,259.76
Rate for Payer: Multiplan Auto	$7,819.27
Rate for Payer: Multiplan Commercial	$7,819.27
Rate for Payer: Multiplan Workers Comp	$7,819.27
Rate for Payer: Parkland Medicaid	$11,259.76
Rate for Payer: Scott and White EPO/PPO	$7,819.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,259.76
Rate for Payer: Superior Health Plan EPO	$2,126.84

omni stent

Facility

$15,638.55

Service Code	HCPCS C1876
Hospital Charge Code	992126
Hospital Revenue Code	278
Min. Negotiated Rate	$3,909.64
Max. Negotiated Rate	$7,819.27
Rate for Payer: Cash Price	$10,634.21
Rate for Payer: Cigna Commercial	$3,909.64
Rate for Payer: Multiplan Auto	$7,819.27
Rate for Payer: Multiplan Commercial	$7,819.27
Rate for Payer: Multiplan Workers Comp	$7,819.27
Rate for Payer: Scott and White EPO/PPO	$7,819.27

omni stent

Facility

$15,638.55

Service Code	HCPCS C1876
Hospital Charge Code	992126
Hospital Revenue Code	278
Min. Negotiated Rate	$1,407.47
Max. Negotiated Rate	$11,259.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,407.47
Rate for Payer: BCBS of TX Blue Advantage	$4,691.56
Rate for Payer: BCBS of TX Blue Essentials	$5,629.88
Rate for Payer: BCBS of TX PPO	$6,255.42
Rate for Payer: Cash Price	$10,634.21
Rate for Payer: Cigna Medicaid	$11,259.76
Rate for Payer: Molina CHIP/Medicaid	$11,259.76
Rate for Payer: Multiplan Auto	$7,819.27
Rate for Payer: Multiplan Commercial	$7,819.27
Rate for Payer: Multiplan Workers Comp	$7,819.27
Rate for Payer: Parkland Medicaid	$11,259.76
Rate for Payer: Scott and White EPO/PPO	$7,819.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,259.76
Rate for Payer: Superior Health Plan EPO	$2,126.84

OMNLINK ELITE VASCULAR 80CM

Facility

$5,891.57

Service Code	HCPCS C1876
Hospital Charge Code	991291
Hospital Revenue Code	278
Min. Negotiated Rate	$530.24
Max. Negotiated Rate	$4,241.93
Rate for Payer: Amerigroup CHIP/Medicaid	$530.24
Rate for Payer: BCBS of TX Blue Advantage	$1,767.47
Rate for Payer: BCBS of TX Blue Essentials	$2,120.97
Rate for Payer: BCBS of TX PPO	$2,356.63
Rate for Payer: Cash Price	$4,006.27
Rate for Payer: Cigna Medicaid	$4,241.93
Rate for Payer: Molina CHIP/Medicaid	$4,241.93
Rate for Payer: Multiplan Auto	$2,945.78
Rate for Payer: Multiplan Commercial	$2,945.78
Rate for Payer: Multiplan Workers Comp	$2,945.78
Rate for Payer: Parkland Medicaid	$4,241.93
Rate for Payer: Scott and White EPO/PPO	$2,945.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,241.93
Rate for Payer: Superior Health Plan EPO	$801.25

OMNLINK ELITE VASCULAR 80CM

Facility

$5,891.57

Service Code	HCPCS C1876
Hospital Charge Code	991291
Hospital Revenue Code	278
Min. Negotiated Rate	$1,472.89
Max. Negotiated Rate	$2,945.78
Rate for Payer: Cash Price	$4,006.27
Rate for Payer: Cigna Commercial	$1,472.89
Rate for Payer: Multiplan Auto	$2,945.78
Rate for Payer: Multiplan Commercial	$2,945.78
Rate for Payer: Multiplan Workers Comp	$2,945.78
Rate for Payer: Scott and White EPO/PPO	$2,945.78

Onc MYH9 Sequence Analysis BCE

Facility

$1,093.00

Service Code	HCPCS 81479
Hospital Charge Code	7002125
Hospital Revenue Code	310
Min. Negotiated Rate	$98.37
Max. Negotiated Rate	$786.96
Rate for Payer: Amerigroup CHIP/Medicaid	$98.37
Rate for Payer: BCBS of TX Blue Advantage	$327.90
Rate for Payer: BCBS of TX Blue Essentials	$393.48
Rate for Payer: BCBS of TX PPO	$437.20
Rate for Payer: Cash Price	$743.24
Rate for Payer: Cigna Medicaid	$786.96
Rate for Payer: Molina CHIP/Medicaid	$786.96
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: Parkland Medicaid	$786.96
Rate for Payer: Scott and White EPO/PPO	$546.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$786.96
Rate for Payer: Superior Health Plan EPO	$148.65

Onc MYH9 Sequence Analysis BCE

Facility

$1,093.00

Service Code	HCPCS 81479
Hospital Charge Code	7002125
Hospital Revenue Code	310
Rate for Payer: Cash Price	$743.24

ondansetron 2 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J2405
Hospital Charge Code	77736468
Hospital Revenue Code	636
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$0.86
Rate for Payer: BCBS of TX Blue Essentials	$1.03
Rate for Payer: BCBS of TX PPO	$1.14
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

ondansetron 2 mg/mL Inj Soln 2 mL

Facility

$128.00

Service Code	HCPCS J2405
Hospital Charge Code	77736468
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

ondansetron 4 mg Tab

Facility

$7.65

Service Code	HCPCS Q0162
Hospital Charge Code	77736810
Hospital Revenue Code	636
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$0.33
Rate for Payer: BCBS of TX Blue Essentials	$0.40
Rate for Payer: BCBS of TX PPO	$0.44
Rate for Payer: Cash Price	$5.20
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

ondansetron 4 mg Tab

Facility

$7.65

Service Code	HCPCS Q0162
Hospital Charge Code	77736698
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

Know your out-of-pocket cost for care.

All Charges