White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
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

ORGANON TEKNIKA AIRWAY NEEDLE

Facility

$5,143.01

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

.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

$32,026.40

Service Code	MSDRG 620
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$32,026.40
Rate for Payer: BARInet Commercial	$10,000.00
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

$32,026.40

Service Code	MSDRG 620
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$32,026.40
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	$32,026.40
Rate for Payer: Multiplan Commercial	$32,026.40
Rate for Payer: Multiplan Workers Comp	$32,026.40
Rate for Payer: Scott and White EPO/PPO	$14,749.00
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

$54,942.30

Service Code	MSDRG 619
Min. Negotiated Rate	$25,118.02
Max. Negotiated Rate	$54,942.30
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	$54,942.30
Rate for Payer: Multiplan Commercial	$54,942.30
Rate for Payer: Multiplan Workers Comp	$54,942.30
Rate for Payer: Scott and White EPO/PPO	$25,302.38
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

$29,545.00

Service Code	MSDRG 621
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$29,545.00
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	$29,545.00
Rate for Payer: Multiplan Commercial	$29,545.00
Rate for Payer: Multiplan Workers Comp	$29,545.00
Rate for Payer: Scott and White EPO/PPO	$13,606.25
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

$54,942.30

Service Code	MSDRG 619
Min. Negotiated Rate	$25,118.02
Max. Negotiated Rate	$54,942.30
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

O.R. PROCEDURES FOR OBESITY W/O CC/MCC

Facility

$29,545.00

Service Code	MSDRG 621
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$29,545.00
Rate for Payer: BARInet Commercial	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$13,573.38
Rate for Payer: BCBS of TX Blue Essentials	$16,286.48
Rate for Payer: BCBS of TX PPO	$18,096.79

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

Facility

$41,862.70

Service Code	MSDRG 940
Min. Negotiated Rate	$18,700.70
Max. Negotiated Rate	$41,862.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,887.28
Rate for Payer: Amerigroup Medicare	$21,887.28
Rate for Payer: BCBS of TX Medicare	$21,887.28
Rate for Payer: Cigna Commercial	$30,099.27
Rate for Payer: Cigna Medicare	$21,887.28
Rate for Payer: Employer Direct Commercial	$21,887.28
Rate for Payer: Humana Medicare/TRICARE	$21,887.28
Rate for Payer: Molina Dual Medicare/Medicaid	$21,887.28
Rate for Payer: Molina Medicare	$21,887.28
Rate for Payer: Multiplan Auto	$41,862.70
Rate for Payer: Multiplan Commercial	$41,862.70
Rate for Payer: Multiplan Workers Comp	$41,862.70
Rate for Payer: Scott and White EPO/PPO	$19,278.88
Rate for Payer: Scott and White Medicare	$21,887.28
Rate for Payer: Superior Health Plan EPO	$21,887.28
Rate for Payer: Superior Health Plan Medicare	$21,887.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,887.28
Rate for Payer: Universal American Medicare	$21,887.28
Rate for Payer: Wellcare Medicare	$21,887.28
Rate for Payer: Wellmed Medicare	$21,887.28

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

Facility

$58,844.90

Service Code	MSDRG 939
Min. Negotiated Rate	$27,099.62
Max. Negotiated Rate	$58,844.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,353.46
Rate for Payer: Amerigroup Medicare	$31,353.46
Rate for Payer: BCBS of TX Medicare	$31,353.46
Rate for Payer: Cigna Commercial	$46,735.08
Rate for Payer: Cigna Medicare	$31,353.46
Rate for Payer: Employer Direct Commercial	$31,353.46
Rate for Payer: Humana Medicare/TRICARE	$31,353.46
Rate for Payer: Molina Dual Medicare/Medicaid	$31,353.46
Rate for Payer: Molina Medicare	$31,353.46
Rate for Payer: Multiplan Auto	$58,844.90
Rate for Payer: Multiplan Commercial	$58,844.90
Rate for Payer: Multiplan Workers Comp	$58,844.90
Rate for Payer: Scott and White EPO/PPO	$27,099.62
Rate for Payer: Scott and White Medicare	$31,353.46
Rate for Payer: Superior Health Plan EPO	$31,353.46
Rate for Payer: Superior Health Plan Medicare	$31,353.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,353.46
Rate for Payer: Universal American Medicare	$31,353.46
Rate for Payer: Wellcare Medicare	$31,353.46
Rate for Payer: Wellmed Medicare	$31,353.46

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

Facility

$35,860.60

Service Code	MSDRG 941
Min. Negotiated Rate	$15,922.04
Max. Negotiated Rate	$35,860.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,621.15
Rate for Payer: Amerigroup Medicare	$19,621.15
Rate for Payer: BCBS of TX Medicare	$19,621.15
Rate for Payer: Cigna Commercial	$26,116.78
Rate for Payer: Cigna Medicare	$19,621.15
Rate for Payer: Employer Direct Commercial	$19,621.15
Rate for Payer: Humana Medicare/TRICARE	$19,621.15
Rate for Payer: Molina Dual Medicare/Medicaid	$19,621.15
Rate for Payer: Molina Medicare	$19,621.15
Rate for Payer: Multiplan Auto	$35,860.60
Rate for Payer: Multiplan Commercial	$35,860.60
Rate for Payer: Multiplan Workers Comp	$35,860.60
Rate for Payer: Scott and White EPO/PPO	$16,514.75
Rate for Payer: Scott and White Medicare	$19,621.15
Rate for Payer: Superior Health Plan EPO	$19,621.15
Rate for Payer: Superior Health Plan Medicare	$19,621.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,621.15
Rate for Payer: Universal American Medicare	$19,621.15
Rate for Payer: Wellcare Medicare	$19,621.15
Rate for Payer: Wellmed Medicare	$19,621.15

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$60,729.70

Service Code	MSDRG 876
Min. Negotiated Rate	$27,967.62
Max. Negotiated Rate	$60,729.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$33,086.04
Rate for Payer: Amerigroup Medicare	$33,086.04
Rate for Payer: BCBS of TX Medicare	$33,086.04
Rate for Payer: Cigna Commercial	$49,779.91
Rate for Payer: Cigna Medicare	$33,086.04
Rate for Payer: Employer Direct Commercial	$33,086.04
Rate for Payer: Molina Dual Medicare/Medicaid	$33,086.04
Rate for Payer: Molina Medicare	$33,086.04
Rate for Payer: Multiplan Auto	$60,729.70
Rate for Payer: Multiplan Commercial	$60,729.70
Rate for Payer: Multiplan Workers Comp	$60,729.70
Rate for Payer: Scott and White EPO/PPO	$27,967.62
Rate for Payer: Scott and White Medicare	$33,086.04
Rate for Payer: Superior Health Plan EPO	$33,086.04
Rate for Payer: Superior Health Plan Medicare	$33,086.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$33,086.04
Rate for Payer: Universal American Medicare	$33,086.04
Rate for Payer: Wellcare Medicare	$33,086.04
Rate for Payer: Wellmed Medicare	$33,086.04

O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS

Facility

$60,729.70

Service Code	MSDRG 876
Min. Negotiated Rate	$27,967.62
Max. Negotiated Rate	$60,729.70
Rate for Payer: BCBS of TX Blue Advantage	$28,392.04
Rate for Payer: BCBS of TX Blue Essentials	$34,067.15
Rate for Payer: BCBS of TX PPO	$37,853.85

O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC

Facility

$41,862.70

Service Code	MSDRG 940
Min. Negotiated Rate	$18,700.70
Max. Negotiated Rate	$41,862.70
Rate for Payer: BCBS of TX Blue Advantage	$18,700.70
Rate for Payer: BCBS of TX Blue Essentials	$22,438.67
Rate for Payer: BCBS of TX PPO	$24,932.82

O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W MCC

Facility

$58,844.90

Service Code	MSDRG 939
Min. Negotiated Rate	$27,099.62
Max. Negotiated Rate	$58,844.90
Rate for Payer: BCBS of TX Blue Advantage	$28,196.82
Rate for Payer: BCBS of TX Blue Essentials	$33,832.91
Rate for Payer: BCBS of TX PPO	$37,593.57

O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC

Facility

$35,860.60

Service Code	MSDRG 941
Min. Negotiated Rate	$15,922.04
Max. Negotiated Rate	$35,860.60
Rate for Payer: BCBS of TX Blue Advantage	$15,922.04
Rate for Payer: BCBS of TX Blue Essentials	$19,104.60
Rate for Payer: BCBS of TX PPO	$21,228.15

ORTHO OFC/OUTPT E&M ESTAB FOCUSED BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	9220088
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$125.28
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$52.20
Rate for Payer: BCBS of TX Blue Essentials	$62.64
Rate for Payer: BCBS of TX PPO	$69.60
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cigna Medicaid	$125.28
Rate for Payer: Molina CHIP/Medicaid	$125.28
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$125.28
Rate for Payer: Scott and White EPO/PPO	$43.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28

ORTHO OFC/OUTPT E&M ESTAB FOCUSED BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	9220088
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

ORTHO OFC/OUTPT E&M ESTAB MINIMAL BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	9220070
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Molina CHIP/Medicaid	$81.36
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$81.36
Rate for Payer: Scott and White EPO/PPO	$10.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

ORTHO OFC/OUTPT E&M ESTAB MINIMAL BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	9220070
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

Know your out-of-pocket cost for care.

All Charges