White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ORBIT AND EYE PROCEDURES

Facility

$24,974.06

Service Code	APR-DRG 0734
Min. Negotiated Rate	$23,546.42
Max. Negotiated Rate	$24,974.06
Rate for Payer: Amerigroup CHIP/Medicaid	$23,546.42
Rate for Payer: Cigna Medicaid	$23,546.42
Rate for Payer: Molina CHIP/Medicaid	$23,546.42
Rate for Payer: Parkland Medicaid	$23,546.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,974.06

ORBIT AND EYE PROCEDURES

Facility

$9,748.45

Service Code	APR-DRG 0733
Min. Negotiated Rate	$9,191.18
Max. Negotiated Rate	$9,748.45
Rate for Payer: Amerigroup CHIP/Medicaid	$9,191.18
Rate for Payer: Cigna Medicaid	$9,191.18
Rate for Payer: Molina CHIP/Medicaid	$9,191.18
Rate for Payer: Parkland Medicaid	$9,191.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,748.45

ORBIT AND EYE PROCEDURES

Facility

$6,804.87

Service Code	APR-DRG 0732
Min. Negotiated Rate	$6,415.87
Max. Negotiated Rate	$6,804.87
Rate for Payer: Amerigroup CHIP/Medicaid	$6,415.87
Rate for Payer: Cigna Medicaid	$6,415.87
Rate for Payer: Molina CHIP/Medicaid	$6,415.87
Rate for Payer: Parkland Medicaid	$6,415.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,804.87

ORBIT AND EYE PROCEDURES

Facility

$4,995.87

Service Code	APR-DRG 0731
Min. Negotiated Rate	$4,710.28
Max. Negotiated Rate	$4,995.87
Rate for Payer: Amerigroup CHIP/Medicaid	$4,710.28
Rate for Payer: Cigna Medicaid	$4,710.28
Rate for Payer: Molina CHIP/Medicaid	$4,710.28
Rate for Payer: Parkland Medicaid	$4,710.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,995.87

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$30,569.10

Service Code	MSDRG 884
Min. Negotiated Rate	$11,591.94
Max. Negotiated Rate	$30,569.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,551.76
Rate for Payer: Amerigroup Medicare	$16,551.76
Rate for Payer: BCBS of TX Medicare	$16,551.76
Rate for Payer: Cigna Commercial	$20,722.63
Rate for Payer: Cigna Medicare	$16,551.76
Rate for Payer: Employer Direct Commercial	$16,551.76
Rate for Payer: Molina Dual Medicare/Medicaid	$16,551.76
Rate for Payer: Molina Medicare	$16,551.76
Rate for Payer: Multiplan Auto	$30,569.10
Rate for Payer: Multiplan Commercial	$30,569.10
Rate for Payer: Multiplan Workers Comp	$30,569.10
Rate for Payer: Scott and White EPO/PPO	$14,077.88
Rate for Payer: Scott and White Medicare	$16,551.76
Rate for Payer: Superior Health Plan EPO	$16,551.76
Rate for Payer: Superior Health Plan Medicare	$16,551.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,551.76
Rate for Payer: Universal American Medicare	$16,551.76
Rate for Payer: Wellcare Medicare	$16,551.76
Rate for Payer: Wellmed Medicare	$16,551.76

ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY

Facility

$30,569.10

Service Code	MSDRG 884
Min. Negotiated Rate	$11,591.94
Max. Negotiated Rate	$30,569.10
Rate for Payer: BCBS of TX Blue Advantage	$11,591.94
Rate for Payer: BCBS of TX Blue Essentials	$13,908.98
Rate for Payer: BCBS of TX PPO	$15,455.02

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$4,848.39

Service Code	APR-DRG 7572
Min. Negotiated Rate	$4,571.23
Max. Negotiated Rate	$4,848.39
Rate for Payer: Amerigroup CHIP/Medicaid	$4,571.23
Rate for Payer: Cigna Medicaid	$4,571.23
Rate for Payer: Molina CHIP/Medicaid	$4,571.23
Rate for Payer: Parkland Medicaid	$4,571.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,848.39

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$15,495.30

Service Code	APR-DRG 7574
Min. Negotiated Rate	$14,609.51
Max. Negotiated Rate	$15,495.30
Rate for Payer: Amerigroup CHIP/Medicaid	$14,609.51
Rate for Payer: Cigna Medicaid	$14,609.51
Rate for Payer: Molina CHIP/Medicaid	$14,609.51
Rate for Payer: Parkland Medicaid	$14,609.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,495.30

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$6,871.63

Service Code	APR-DRG 7573
Min. Negotiated Rate	$6,478.81
Max. Negotiated Rate	$6,871.63
Rate for Payer: Amerigroup CHIP/Medicaid	$6,478.81
Rate for Payer: Cigna Medicaid	$6,478.81
Rate for Payer: Molina CHIP/Medicaid	$6,478.81
Rate for Payer: Parkland Medicaid	$6,478.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,871.63

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$1,653.97

Service Code	APR-DRG 7571
Min. Negotiated Rate	$1,559.42
Max. Negotiated Rate	$1,653.97
Rate for Payer: Amerigroup CHIP/Medicaid	$1,559.42
Rate for Payer: Cigna Medicaid	$1,559.42
Rate for Payer: Molina CHIP/Medicaid	$1,559.42
Rate for Payer: Parkland Medicaid	$1,559.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,653.97

Organism ID, Bacteria SO

Facility

$238.00

Service Code	HCPCS 87077 QW
Hospital Charge Code	1603646
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$171.36
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	$71.40
Rate for Payer: BCBS of TX Blue Essentials	$85.68
Rate for Payer: BCBS of TX Medicare	$8.08
Rate for Payer: BCBS of TX PPO	$95.20
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cigna Medicaid	$171.36
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	$171.36
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	$171.36
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	$171.36
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	HCPCS 87077 QW
Hospital Charge Code	1603646
Hospital Revenue Code	306
Rate for Payer: Cash Price	$161.84

Organism Identification, Yeast SO

Facility

$191.00

Service Code	HCPCS 87106
Hospital Charge Code	1603679
Hospital Revenue Code	306
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$137.52
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	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX Medicare	$10.32
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Medicaid	$137.52
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	$137.52
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	$137.52
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	$137.52
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 Identification, Yeast SO

Facility

$191.00

Service Code	HCPCS 87106
Hospital Charge Code	1603679
Hospital Revenue Code	306
Rate for Payer: Cash Price	$129.88

Organism ID, Mold SO

Facility

$158.00

Service Code	HCPCS 87107
Hospital Charge Code	8654548
Hospital Revenue Code	306
Rate for Payer: Cash Price	$107.44

Organism ID, Mold SO

Facility

$158.00

Service Code	HCPCS 87107
Hospital Charge Code	8654548
Hospital Revenue Code	306
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$113.76
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	$47.40
Rate for Payer: BCBS of TX Blue Essentials	$56.88
Rate for Payer: BCBS of TX Medicare	$10.32
Rate for Payer: BCBS of TX PPO	$63.20
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cigna Medicaid	$113.76
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	$113.76
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	$113.76
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	$113.76
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

ORGANON TEKNIKA AIRWAY NEEDLE

Facility

$5,143.01

Hospital Charge Code	993106
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3,497.25

ORGANON TEKNIKA AIRWAY NEEDLE

Facility

$5,143.01

Hospital Charge Code	993106
Hospital Revenue Code	270
Min. Negotiated Rate	$462.87
Max. Negotiated Rate	$3,702.97
Rate for Payer: Amerigroup CHIP/Medicaid	$462.87
Rate for Payer: BCBS of TX Blue Advantage	$1,542.90
Rate for Payer: BCBS of TX Blue Essentials	$1,851.48
Rate for Payer: BCBS of TX PPO	$2,057.20
Rate for Payer: Cash Price	$3,497.25
Rate for Payer: Cigna Medicaid	$3,702.97
Rate for Payer: Molina CHIP/Medicaid	$3,702.97
Rate for Payer: Multiplan Auto	$3,342.96
Rate for Payer: Multiplan Commercial	$3,342.96
Rate for Payer: Multiplan Workers Comp	$3,342.96
Rate for Payer: Parkland Medicaid	$3,702.97
Rate for Payer: Scott and White EPO/PPO	$2,571.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,702.97
Rate for Payer: Superior Health Plan EPO	$699.45

.Org ID by Sequencing Rflx AST 182865 SO

Facility

$275.00

Service Code	HCPCS 87153
Hospital Charge Code	9059005
Hospital Revenue Code	300
Min. Negotiated Rate	$44.99
Max. Negotiated Rate	$198.00
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	$82.50
Rate for Payer: BCBS of TX Blue Essentials	$99.00
Rate for Payer: BCBS of TX Medicare	$115.36
Rate for Payer: BCBS of TX PPO	$110.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cigna Medicaid	$198.00
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	$198.00
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	$198.00
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	$198.00
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

.Org ID by Sequencing Rflx AST 182865 SO

Facility

$275.00

Service Code	HCPCS 87153
Hospital Charge Code	9059005
Hospital Revenue Code	300
Rate for Payer: Cash Price	$187.00

O.R. PROCEDURES FOR OBESITY W CC

Facility

$30,405.70

Service Code	MSDRG 620
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$30,405.70
Rate for Payer: BCBS of TX Blue Advantage	$15,562.56
Rate for Payer: BCBS of TX Blue Essentials	$18,673.26
Rate for Payer: BCBS of TX PPO	$20,748.87

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$30,405.70

Service Code	MSDRG 620
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$30,405.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,488.72
Rate for Payer: Amerigroup Medicare	$16,488.72
Rate for Payer: BARInet Commercial	$10,000.00
Rate for Payer: BCBS of TX Medicare	$16,488.72
Rate for Payer: Cigna Commercial	$20,611.86
Rate for Payer: Cigna Medicare	$16,488.72
Rate for Payer: Employer Direct Commercial	$16,488.72
Rate for Payer: Humana Medicare/TRICARE	$16,488.72
Rate for Payer: Molina Dual Medicare/Medicaid	$16,488.72
Rate for Payer: Molina Medicare	$16,488.72
Rate for Payer: Multiplan Auto	$30,405.70
Rate for Payer: Multiplan Commercial	$30,405.70
Rate for Payer: Multiplan Workers Comp	$30,405.70
Rate for Payer: Scott and White EPO/PPO	$14,002.62
Rate for Payer: Scott and White Medicare	$16,488.72
Rate for Payer: Superior Health Plan EPO	$16,488.72
Rate for Payer: Superior Health Plan Medicare	$16,488.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,488.72
Rate for Payer: Universal American Medicare	$16,488.72
Rate for Payer: Wellcare Medicare	$16,488.72
Rate for Payer: Wellmed Medicare	$16,488.72

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$54,860.60

Service Code	MSDRG 619
Min. Negotiated Rate	$25,118.02
Max. Negotiated Rate	$54,860.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25,921.91
Rate for Payer: Amerigroup Medicare	$25,921.91
Rate for Payer: BCBS of TX Medicare	$25,921.91
Rate for Payer: Cigna Commercial	$37,189.71
Rate for Payer: Cigna Medicare	$25,921.91
Rate for Payer: Employer Direct Commercial	$25,921.91
Rate for Payer: Humana Medicare/TRICARE	$25,921.91
Rate for Payer: Molina Dual Medicare/Medicaid	$25,921.91
Rate for Payer: Molina Medicare	$25,921.91
Rate for Payer: Multiplan Auto	$54,860.60
Rate for Payer: Multiplan Commercial	$54,860.60
Rate for Payer: Multiplan Workers Comp	$54,860.60
Rate for Payer: Scott and White EPO/PPO	$25,264.75
Rate for Payer: Scott and White Medicare	$25,921.91
Rate for Payer: Superior Health Plan EPO	$25,921.91
Rate for Payer: Superior Health Plan Medicare	$25,921.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$25,921.91
Rate for Payer: Universal American Medicare	$25,921.91
Rate for Payer: Wellcare Medicare	$25,921.91
Rate for Payer: Wellmed Medicare	$25,921.91

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$28,659.60

Service Code	MSDRG 621
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$28,659.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,815.19
Rate for Payer: Amerigroup Medicare	$15,815.19
Rate for Payer: BARInet Commercial	$10,000.00
Rate for Payer: BCBS of TX Medicare	$15,815.19
Rate for Payer: Cigna Commercial	$19,428.19
Rate for Payer: Cigna Medicare	$15,815.19
Rate for Payer: Employer Direct Commercial	$15,815.19
Rate for Payer: Humana Medicare/TRICARE	$15,815.19
Rate for Payer: Molina Dual Medicare/Medicaid	$15,815.19
Rate for Payer: Molina Medicare	$15,815.19
Rate for Payer: Multiplan Auto	$28,659.60
Rate for Payer: Multiplan Commercial	$28,659.60
Rate for Payer: Multiplan Workers Comp	$28,659.60
Rate for Payer: Scott and White EPO/PPO	$13,198.50
Rate for Payer: Scott and White Medicare	$15,815.19
Rate for Payer: Superior Health Plan EPO	$15,815.19
Rate for Payer: Superior Health Plan Medicare	$15,815.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,815.19
Rate for Payer: Universal American Medicare	$15,815.19
Rate for Payer: Wellcare Medicare	$15,815.19
Rate for Payer: Wellmed Medicare	$15,815.19

O.R. PROCEDURES FOR OBESITY W MCC

Facility

$54,860.60

Service Code	MSDRG 619
Min. Negotiated Rate	$25,118.02
Max. Negotiated Rate	$54,860.60
Rate for Payer: BCBS of TX Blue Advantage	$25,118.02
Rate for Payer: BCBS of TX Blue Essentials	$30,138.70
Rate for Payer: BCBS of TX PPO	$33,488.75

Know your out-of-pocket cost for care.

All Charges