When Maxxzandra Ford's baby boy arrived in February, a number of unexpected hospital bills arrived with him.
"They don't tell you how much the anesthesiologist is going to cost," said Ford, who gave birth at St. Joseph's Women's Hospital in Tampa. "If you get an epidural or pain medicine, there's an extra charge there."
There were other surprise charges from doctors along the way, like $250 for each ultrasound.
Welcome to the mysterious world of health care pricing. Patients frequently receive medical services without knowing the cost — and remain in the dark until the bill arrives.
Sometimes even doctors don't know how much procedures cost.
"My fees are controlled by the payers," said Dr. Michael Wasylik, an orthopedic surgeon who practices in Tampa.
Pricing is complicated, in part because of the vast array of procedures, providers and payment systems. But as a larger share of health care costs shifts to patients, there is new pressure on doctors and insurance companies to increase transparency.
"This is information that can be very useful to consumers," said Caitlin Morris, of the nonprofit Families USA, adding that greater transparency could also drive larger efforts to bring down cost and improve quality.
Price transparency isn't exactly Florida's forte.
Lawmakers passed legislation in 2011 requiring urgent care clinics to display the prices of their most frequently provided services, and encouraging primary care physicians to do the same.
But a report published this month gave Florida an F for failing to adopt more thorough transparency laws and regulations.
Florida wasn't the only low performer. All but five states received failing grades from the nonprofit authors of the report, Catalyst for Payment Reform in California and the Health Care Incentives Improvement Institute in Connecticut.
The lone A went to New Hampshire. The state was singled out for having a website that estimates medical costs based on procedure, insurance carrier and deductible.
Why aren't more states doing better?
The complex payment system is partly to blame. Patients can settle up using cash, private insurance or government programs such as Medicaid and Medicare. Each has a unique set of rates that can vary from hospital to hospital, and even patient to patient.
But there are also incentives to keep prices out of the public eye.
Insurance companies negotiate substantial discounts for their members, but say releasing that information would put them at a competitive disadvantage. As a result, figures are often cloaked in trade secret protections or gag clauses in the agreements with providers.
The lack of transparency is a problem now that many patients have plans with higher deductibles, said Dr. Tim Carlson, who practices family medicine in St. Petersburg.
"Our patients are becoming very educated because they have to be," Carlson said.
Some insurance companies are offering new online tools to help customers estimate costs.
UnitedHealthcare, which has 3.2 million customers in Florida, has a Web-based platform that can estimate the cost of medical services as performed by specific physicians. It can factor in the user's insurance coverage, too.
"We're actually telling people not just overall what (a procedure) costs, but what it will cost you," vice president Craig Hankins said.
Florida's Agency for Health Care Administration, or AHCA, has a less-detailed site that lets users compare the average prices at hospitals and ambulatory surgery centers. The site, Floridahealthfinder.gov, also provides limited information on individual physicians.
AHCA is considering other ways to increase transparency. A panel of physicians, consumers and employers known as the Consumer Health Information and Policy Advisory Council recently discussed creating a database of all health care claims, but decided the potential cost was too high.
"To drill down that much takes a tremendous amount of effort and money," said Wasylik, the orthopedic surgeon from Tampa who serves as the committee's chairman.
Legislative efforts may also be afoot.
State Rep. Jason Brodeur, a Sanford Republican who chairs the House Health and Human Services Committee, said he plans to focus on price transparency during the forthcoming session, which begins in January.
Brodeur pointed out that most other industries "get a better result for a better price when the consumer has more information."
"Once we do little things, like posting the prices for routine procedures in the emergency room, and complex things, like reimbursing hospitals for outcomes rather than activity, we will get to a place where health care is more affordable and accessible," he said.
Consumer groups and employers are encouraged. But Karen van Caulil, CEO of the Florida Health Care Coalition, which represents some of the state's largest employers, said better price transparency is only "part of what we need to see."
"We have to see data on quality, too," van Caulil said. "Without it, consumers will assume higher cost means higher quality, and that's not always the case."
Staff researcher Caryn Baird contributed to this report. Contact Kathleen McGrory at firstname.lastname@example.org or (727) 893-8330. Follow @kmcgrory.