White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ORTHO OFC/OUTPT E&M EST HIGH COMPLEXITY BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	9220112
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$306.72
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$127.80
Rate for Payer: BCBS of TX Blue Essentials	$153.36
Rate for Payer: BCBS of TX PPO	$170.40
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cigna Medicaid	$306.72
Rate for Payer: Molina CHIP/Medicaid	$306.72
Rate for Payer: Multiplan Auto	$276.90
Rate for Payer: Multiplan Commercial	$276.90
Rate for Payer: Multiplan Workers Comp	$276.90
Rate for Payer: Parkland Medicaid	$306.72
Rate for Payer: Scott and White EPO/PPO	$176.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.72

ORTHO OFC/OUTPT E&M EST HIGH COMPLEXITY BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	9220112
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

ORTHO OFC/OUTPT E&M EST LOW COMPLEXITY BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	9220096
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$151.92
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$63.30
Rate for Payer: BCBS of TX Blue Essentials	$75.96
Rate for Payer: BCBS of TX PPO	$84.40
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cigna Medicaid	$151.92
Rate for Payer: Molina CHIP/Medicaid	$151.92
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$151.92
Rate for Payer: Scott and White EPO/PPO	$80.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.92

ORTHO OFC/OUTPT E&M EST LOW COMPLEXITY BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	9220096
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

ORTHO OFC/OUTPT E&M EST MOD COMPLEXITY BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	9220104
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

ORTHO OFC/OUTPT E&M EST MOD COMPLEXITY BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	9220104
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$280.80
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$117.00
Rate for Payer: BCBS of TX Blue Essentials	$140.40
Rate for Payer: BCBS of TX PPO	$156.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cigna Medicaid	$280.80
Rate for Payer: Molina CHIP/Medicaid	$280.80
Rate for Payer: Multiplan Auto	$253.50
Rate for Payer: Multiplan Commercial	$253.50
Rate for Payer: Multiplan Workers Comp	$253.50
Rate for Payer: Parkland Medicaid	$280.80
Rate for Payer: Scott and White EPO/PPO	$118.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.80

ORTHO OFC/OUTPT E&M NEW DETAILED VISIT BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	9220062
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

ORTHO OFC/OUTPT E&M NEW DETAILED VISIT BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	9220062
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$295.92
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$123.30
Rate for Payer: BCBS of TX Blue Essentials	$147.96
Rate for Payer: BCBS of TX PPO	$164.40
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cigna Medicaid	$295.92
Rate for Payer: Molina CHIP/Medicaid	$295.92
Rate for Payer: Multiplan Auto	$267.15
Rate for Payer: Multiplan Commercial	$267.15
Rate for Payer: Multiplan Workers Comp	$267.15
Rate for Payer: Parkland Medicaid	$295.92
Rate for Payer: Scott and White EPO/PPO	$99.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92

ORTHO OFC/OUTPT E&M NEW EXP PROB FOCUSED BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	9220054
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$195.84
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$81.60
Rate for Payer: BCBS of TX Blue Essentials	$97.92
Rate for Payer: BCBS of TX PPO	$108.80
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cigna Medicaid	$195.84
Rate for Payer: Molina CHIP/Medicaid	$195.84
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	$195.84
Rate for Payer: Scott and White EPO/PPO	$57.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84

ORTHO OFC/OUTPT E&M NEW EXP PROB FOCUSED BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	9220054
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

ORTHO OFC/OUTPT E&M NEW HI COMPLEXITY BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	9220245
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

ORTHO OFC/OUTPT E&M NEW HI COMPLEXITY BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	9220245
Hospital Revenue Code	510
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$429.12
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$178.80
Rate for Payer: BCBS of TX Blue Essentials	$214.56
Rate for Payer: BCBS of TX PPO	$238.40
Rate for Payer: Cash Price	$405.28
Rate for Payer: Cash Price	$405.28
Rate for Payer: Cigna Medicaid	$429.12
Rate for Payer: Molina CHIP/Medicaid	$429.12
Rate for Payer: Multiplan Auto	$387.40
Rate for Payer: Multiplan Commercial	$387.40
Rate for Payer: Multiplan Workers Comp	$387.40
Rate for Payer: Parkland Medicaid	$429.12
Rate for Payer: Scott and White EPO/PPO	$221.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$429.12

ORTHO OFC/OUTPT E&M NEW MOD COMPLEXITY BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	9220244
Hospital Revenue Code	510
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$351.36
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: BCBS of TX Blue Advantage	$146.40
Rate for Payer: BCBS of TX Blue Essentials	$175.68
Rate for Payer: BCBS of TX PPO	$195.20
Rate for Payer: Cash Price	$331.84
Rate for Payer: Cash Price	$331.84
Rate for Payer: Cigna Medicaid	$351.36
Rate for Payer: Molina CHIP/Medicaid	$351.36
Rate for Payer: Multiplan Auto	$317.20
Rate for Payer: Multiplan Commercial	$317.20
Rate for Payer: Multiplan Workers Comp	$317.20
Rate for Payer: Parkland Medicaid	$351.36
Rate for Payer: Scott and White EPO/PPO	$162.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.36

ORTHO OFC/OUTPT E&M NEW MOD COMPLEXITY BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	9220244
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

Orthopedic Cast Application Foot/Ankle BCE

Facility

$579.92

Service Code	HCPCS 29405
Hospital Charge Code	9220238
Hospital Revenue Code	361
Min. Negotiated Rate	$39.03
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$39.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$280.97
Rate for Payer: Amerigroup Medicare	$280.97
Rate for Payer: BCBS of TX Blue Advantage	$80.76
Rate for Payer: BCBS of TX Blue Essentials	$96.72
Rate for Payer: BCBS of TX Medicare	$280.97
Rate for Payer: BCBS of TX PPO	$121.87
Rate for Payer: Cash Price	$394.35
Rate for Payer: Cash Price	$394.35
Rate for Payer: Cash Price	$394.35
Rate for Payer: Cigna Commercial	$593.92
Rate for Payer: Cigna Medicaid	$417.54
Rate for Payer: Cigna Medicare	$280.97
Rate for Payer: Employer Direct Commercial	$280.97
Rate for Payer: Humana Medicare/TRICARE	$280.97
Rate for Payer: Molina CHIP/Medicaid	$417.54
Rate for Payer: Molina Dual Medicare/Medicaid	$280.97
Rate for Payer: Molina Medicare	$280.97
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	$417.54
Rate for Payer: Scott and White EPO/PPO	$454.38
Rate for Payer: Scott and White Medicare	$280.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$417.54
Rate for Payer: Superior Health Plan EPO	$280.97
Rate for Payer: Superior Health Plan Medicare	$280.97
Rate for Payer: Universal American Dual Medicare/Medicaid	$280.97
Rate for Payer: Universal American Medicare	$280.97
Rate for Payer: Wellcare Medicare	$280.97
Rate for Payer: Wellmed Medicare	$280.97

Orthopedic Cast Application Foot/Ankle BCE

Facility

$579.92

Service Code	HCPCS 29405
Hospital Charge Code	9220238
Hospital Revenue Code	361
Rate for Payer: Cash Price	$394.35

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 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	$17.24
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: Cigna Medicaid	$17.24
Rate for Payer: Molina CHIP/Medicaid	$17.24
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: Parkland Medicaid	$17.24
Rate for Payer: Scott and White EPO/PPO	$11.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.24
Rate for Payer: Superior Health Plan EPO	$3.26

oseltamivir 6 mg/mL Oral suspension 5 mL REPACK

Facility

$7.65

Service Code	HCPCS J8499
Hospital Charge Code	79165964
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

oseltamivir 6 mg/mL Oral suspension 5 mL REPACK

Facility

$7.65

Service Code	HCPCS J8499
Hospital Charge Code	79165964
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

oseltamivir 75 mg Cap

Facility

$54.55

Service Code	HCPCS J8499
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 J8499
Hospital Charge Code	77738369
Hospital Revenue Code	250
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$39.28
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: Cigna Medicaid	$39.28
Rate for Payer: Molina CHIP/Medicaid	$39.28
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: Parkland Medicaid	$39.28
Rate for Payer: Scott and White EPO/PPO	$27.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.28
Rate for Payer: Superior Health Plan EPO	$7.42

Osmolality, Fecal SO

Facility

$123.00

Service Code	HCPCS 84999
Hospital Charge Code	1700301
Hospital Revenue Code	301
Rate for Payer: Cash Price	$83.64

Osmolality, Fecal SO

Facility

$123.00

Service Code	HCPCS 84999
Hospital Charge Code	1700301
Hospital Revenue Code	301
Min. Negotiated Rate	$11.07
Max. Negotiated Rate	$88.56
Rate for Payer: Amerigroup CHIP/Medicaid	$11.07
Rate for Payer: BCBS of TX Blue Advantage	$36.90
Rate for Payer: BCBS of TX Blue Essentials	$44.28
Rate for Payer: BCBS of TX PPO	$49.20
Rate for Payer: Cash Price	$83.64
Rate for Payer: Cigna Medicaid	$88.56
Rate for Payer: Molina CHIP/Medicaid	$88.56
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: Parkland Medicaid	$88.56
Rate for Payer: Scott and White EPO/PPO	$61.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.56
Rate for Payer: Superior Health Plan EPO	$16.73

Osmolality SO

Facility

$72.00

Service Code	HCPCS 83930
Hospital Charge Code	1602168
Hospital Revenue Code	301
Rate for Payer: Cash Price	$48.96

Know your out-of-pocket cost for care.

All Charges