White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OT Ultrasound Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4300448
Hospital Revenue Code	430
Rate for Payer: Cash Price	$74.80

OT Ultrasound Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4300448
Hospital Revenue Code	430
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.90
Rate for Payer: BCBS of TX Blue Advantage	$33.00
Rate for Payer: BCBS of TX Blue Essentials	$39.60
Rate for Payer: BCBS of TX PPO	$44.00
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.20
Rate for Payer: Molina CHIP/Medicaid	$79.20
Rate for Payer: Multiplan Auto	$71.50
Rate for Payer: Multiplan Commercial	$71.50
Rate for Payer: Multiplan Workers Comp	$71.50
Rate for Payer: Parkland Medicaid	$79.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

OT Unattended E-Stim Assistant Units

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	4300007
Hospital Revenue Code	430
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Molina CHIP/Medicaid	$115.20
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: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$21.76

OT Unattended E-Stim Assistant Units

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	4300007
Hospital Revenue Code	430
Rate for Payer: Cash Price	$108.80

OT Unattended E-Stim Units

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	4300041
Hospital Revenue Code	430
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Molina CHIP/Medicaid	$115.20
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: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$21.76

OT Unattended E-Stim Units

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	4300041
Hospital Revenue Code	430
Rate for Payer: Cash Price	$108.80

Ova + Parasite Exam SO

Facility

$155.00

Service Code	HCPCS 87177
Hospital Charge Code	1604081
Hospital Revenue Code	306
Rate for Payer: Cash Price	$105.40

Ova + Parasite Exam SO

Facility

$155.00

Service Code	HCPCS 87177
Hospital Charge Code	1604081
Hospital Revenue Code	306
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$111.60
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	$46.50
Rate for Payer: BCBS of TX Blue Essentials	$55.80
Rate for Payer: BCBS of TX Medicare	$8.90
Rate for Payer: BCBS of TX PPO	$62.00
Rate for Payer: Cash Price	$105.40
Rate for Payer: Cash Price	$105.40
Rate for Payer: Cigna Medicaid	$111.60
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	$111.60
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	$111.60
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	$111.60
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	$542.62
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	$512.48
Rate for Payer: Cigna Medicaid	$542.62
Rate for Payer: Molina CHIP/Medicaid	$542.62
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: Parkland Medicaid	$542.62
Rate for Payer: Scott and White EPO/PPO	$376.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$542.62
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	$512.48

OXcarbazepine 300 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77739502
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

OXcarbazepine 300 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77739502
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

Oxcarbazepine (Trileptal),S SO

Facility

$236.00

Service Code	HCPCS 80183
Hospital Charge Code	1740993
Hospital Revenue Code	301
Rate for Payer: Cash Price	$160.48

Oxcarbazepine (Trileptal),S SO

Facility

$236.00

Service Code	HCPCS 80183
Hospital Charge Code	1740993
Hospital Revenue Code	301
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$169.92
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	$70.80
Rate for Payer: BCBS of TX Blue Essentials	$84.96
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$94.40
Rate for Payer: Cash Price	$160.48
Rate for Payer: Cash Price	$160.48
Rate for Payer: Cigna Medicaid	$169.92
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	$169.92
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	$169.92
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	$169.92
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

OXIMETER, PULSE FINGERTIP AUTO-POWER BLACK

Facility

$882.30

Hospital Charge Code	993375
Hospital Revenue Code	270
Min. Negotiated Rate	$79.41
Max. Negotiated Rate	$635.26
Rate for Payer: Amerigroup CHIP/Medicaid	$79.41
Rate for Payer: BCBS of TX Blue Advantage	$264.69
Rate for Payer: BCBS of TX Blue Essentials	$317.63
Rate for Payer: BCBS of TX PPO	$352.92
Rate for Payer: Cash Price	$599.96
Rate for Payer: Cigna Medicaid	$635.26
Rate for Payer: Molina CHIP/Medicaid	$635.26
Rate for Payer: Multiplan Auto	$573.50
Rate for Payer: Multiplan Commercial	$573.50
Rate for Payer: Multiplan Workers Comp	$573.50
Rate for Payer: Parkland Medicaid	$635.26
Rate for Payer: Scott and White EPO/PPO	$441.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$635.26
Rate for Payer: Superior Health Plan EPO	$119.99

OXIMETER, PULSE FINGERTIP AUTO-POWER BLACK

Facility

$882.30

Hospital Charge Code	993375
Hospital Revenue Code	270
Rate for Payer: Cash Price	$599.96

OXIMETER, PULSE FINGERTIP AUTO-POWER BLUE

Facility

$882.30

Hospital Charge Code	993376
Hospital Revenue Code	270
Min. Negotiated Rate	$79.41
Max. Negotiated Rate	$635.26
Rate for Payer: Amerigroup CHIP/Medicaid	$79.41
Rate for Payer: BCBS of TX Blue Advantage	$264.69
Rate for Payer: BCBS of TX Blue Essentials	$317.63
Rate for Payer: BCBS of TX PPO	$352.92
Rate for Payer: Cash Price	$599.96
Rate for Payer: Cigna Medicaid	$635.26
Rate for Payer: Molina CHIP/Medicaid	$635.26
Rate for Payer: Multiplan Auto	$573.50
Rate for Payer: Multiplan Commercial	$573.50
Rate for Payer: Multiplan Workers Comp	$573.50
Rate for Payer: Parkland Medicaid	$635.26
Rate for Payer: Scott and White EPO/PPO	$441.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$635.26
Rate for Payer: Superior Health Plan EPO	$119.99

OXIMETER, PULSE FINGERTIP AUTO-POWER BLUE

Facility

$882.30

Hospital Charge Code	993376
Hospital Revenue Code	270
Rate for Payer: Cash Price	$599.96

OXIMETER PULSE FINGERTIP AUTO-POWER RED

Facility

$794.50

Hospital Charge Code	993530
Hospital Revenue Code	270
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$572.04
Rate for Payer: Amerigroup CHIP/Medicaid	$71.50
Rate for Payer: BCBS of TX Blue Advantage	$238.35
Rate for Payer: BCBS of TX Blue Essentials	$286.02
Rate for Payer: BCBS of TX PPO	$317.80
Rate for Payer: Cash Price	$540.26
Rate for Payer: Cigna Medicaid	$572.04
Rate for Payer: Molina CHIP/Medicaid	$572.04
Rate for Payer: Multiplan Auto	$516.42
Rate for Payer: Multiplan Commercial	$516.42
Rate for Payer: Multiplan Workers Comp	$516.42
Rate for Payer: Parkland Medicaid	$572.04
Rate for Payer: Scott and White EPO/PPO	$397.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.04
Rate for Payer: Superior Health Plan EPO	$108.05

OXIMETER PULSE FINGERTIP AUTO-POWER RED

Facility

$794.50

Hospital Charge Code	993530
Hospital Revenue Code	270
Rate for Payer: Cash Price	$540.26

Oximetry Sensor Adult Not Made With Natural Rubber Latex

Facility

$43.40

Hospital Charge Code	993550
Hospital Revenue Code	270
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$31.25
Rate for Payer: Amerigroup CHIP/Medicaid	$3.91
Rate for Payer: BCBS of TX Blue Advantage	$13.02
Rate for Payer: BCBS of TX Blue Essentials	$15.62
Rate for Payer: BCBS of TX PPO	$17.36
Rate for Payer: Cash Price	$29.51
Rate for Payer: Cigna Medicaid	$31.25
Rate for Payer: Molina CHIP/Medicaid	$31.25
Rate for Payer: Multiplan Auto	$28.21
Rate for Payer: Multiplan Commercial	$28.21
Rate for Payer: Multiplan Workers Comp	$28.21
Rate for Payer: Parkland Medicaid	$31.25
Rate for Payer: Scott and White EPO/PPO	$21.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.25
Rate for Payer: Superior Health Plan EPO	$5.90

Oximetry Sensor Adult Not Made With Natural Rubber Latex

Facility

$43.40

Hospital Charge Code	993550
Hospital Revenue Code	270
Rate for Payer: Cash Price	$29.51

oxybutynin 5 mg/24 hours ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77740342
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

oxybutynin 5 mg/24 hours ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	7740342
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

oxybutynin 5 mg/24 hours ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77740342
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

Know your out-of-pocket cost for care.

All Charges