White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GERIATRIC E&M-EST. PATIENT-LVL II BCE

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	3914007
Hospital Revenue Code	510
Rate for Payer: Cash Price	$153.12

GERIATRIC E&M-EST. PATIENT-LVL III BCE

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	3914013
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$137.15
Rate for Payer: Aetna Commercial	$116.05
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$90.31
Rate for Payer: BCBS of TX Blue Essentials	$107.95
Rate for Payer: BCBS of TX PPO	$120.41
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cigna Medicaid	$31.23
Rate for Payer: Molina CHIP/Medicaid	$31.23
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	$31.23
Rate for Payer: Scott and White EPO/PPO	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.23

GERIATRIC E&M-EST. PATIENT-LVL III BCE

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	3914013
Hospital Revenue Code	510
Rate for Payer: Cash Price	$185.68

GERIATRIC E&M-EST. PATIENT-LVL IV BCE

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	3914019
Hospital Revenue Code	510
Rate for Payer: Cash Price	$343.20

GERIATRIC E&M-EST. PATIENT-LVL IV BCE

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	3914019
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$253.50
Rate for Payer: Aetna Commercial	$214.50
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$139.22
Rate for Payer: BCBS of TX Blue Essentials	$166.42
Rate for Payer: BCBS of TX PPO	$185.62
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cigna Medicaid	$43.87
Rate for Payer: Molina CHIP/Medicaid	$43.87
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	$43.87
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.87

GERIATRIC E&M-EST. PATIENT-LVL V BCE

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	3914023
Hospital Revenue Code	510
Rate for Payer: Cash Price	$374.88

GERIATRIC E&M-EST. PATIENT-LVL V BCE

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	3914023
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$276.90
Rate for Payer: Aetna Commercial	$234.30
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$196.27
Rate for Payer: BCBS of TX Blue Essentials	$234.62
Rate for Payer: BCBS of TX PPO	$261.70
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cigna Medicaid	$67.53
Rate for Payer: Molina CHIP/Medicaid	$67.53
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	$67.53
Rate for Payer: Scott and White EPO/PPO	$213.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.53

GERIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	3910002
Hospital Revenue Code	510
Rate for Payer: Cash Price	$239.36

GERIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	3910002
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna Commercial	$149.60
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cigna Medicaid	$37.80
Rate for Payer: Molina CHIP/Medicaid	$37.80
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	$37.80
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.80

GERIATRIC E&M-NEW PATIENT-LVL III BCE

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	3910003
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$267.15
Rate for Payer: Aetna Commercial	$226.05
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$134.82
Rate for Payer: BCBS of TX Blue Essentials	$161.16
Rate for Payer: BCBS of TX PPO	$179.75
Rate for Payer: Cash Price	$361.68
Rate for Payer: Cash Price	$361.68
Rate for Payer: Cigna Medicaid	$51.08
Rate for Payer: Molina CHIP/Medicaid	$51.08
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	$51.08
Rate for Payer: Scott and White EPO/PPO	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.08

GERIATRIC E&M-NEW PATIENT-LVL III BCE

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	3910003
Hospital Revenue Code	510
Rate for Payer: Cash Price	$361.68

GERIATRIC E&M-NEW PATIENT-LVL IV BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	3910007
Hospital Revenue Code	510
Rate for Payer: Cash Price	$429.44

GERIATRIC E&M-NEW PATIENT-LVL IV BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	3910007
Hospital Revenue Code	510
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$317.20
Rate for Payer: Aetna Commercial	$268.40
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: BCBS of TX Blue Advantage	$228.25
Rate for Payer: BCBS of TX Blue Essentials	$272.85
Rate for Payer: BCBS of TX PPO	$304.34
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cigna Medicaid	$74.74
Rate for Payer: Molina CHIP/Medicaid	$74.74
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	$74.74
Rate for Payer: Scott and White EPO/PPO	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.74

GERIATRIC E&M-NEW PATIENT-LVL V BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	3910005
Hospital Revenue Code	510
Rate for Payer: Cash Price	$524.48

GERIATRIC E&M-NEW PATIENT-LVL V BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	3910005
Hospital Revenue Code	510
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$397.16
Rate for Payer: Aetna Commercial	$327.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$297.87
Rate for Payer: BCBS of TX Blue Essentials	$356.08
Rate for Payer: BCBS of TX PPO	$397.16
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cigna Medicaid	$92.92
Rate for Payer: Molina CHIP/Medicaid	$92.92
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	$92.92
Rate for Payer: Scott and White EPO/PPO	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.92

GERIATRIC SURG PROC LEVEL I BCE

Facility

$238.00

Hospital Charge Code	3913000
Hospital Revenue Code	510
Rate for Payer: Cash Price	$209.44

GERIATRIC SURG PROC LEVEL I BCE

Facility

$238.00

Hospital Charge Code	3913000
Hospital Revenue Code	510
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$154.70
Rate for Payer: Aetna Commercial	$130.90
Rate for Payer: Amerigroup CHIP/Medicaid	$21.42
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 PPO	$95.20
Rate for Payer: Cash Price	$209.44
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: Scott and White EPO/PPO	$119.00

GERIATRIC SURG PROC LEVEL II BCE

Facility

$285.00

Hospital Charge Code	3913001
Hospital Revenue Code	510
Rate for Payer: Cash Price	$250.80

GERIATRIC SURG PROC LEVEL II BCE

Facility

$285.00

Hospital Charge Code	3913001
Hospital Revenue Code	510
Min. Negotiated Rate	$25.65
Max. Negotiated Rate	$185.25
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Amerigroup CHIP/Medicaid	$25.65
Rate for Payer: BCBS of TX Blue Advantage	$85.50
Rate for Payer: BCBS of TX Blue Essentials	$102.60
Rate for Payer: BCBS of TX PPO	$114.00
Rate for Payer: Cash Price	$250.80
Rate for Payer: Multiplan Auto	$185.25
Rate for Payer: Multiplan Commercial	$185.25
Rate for Payer: Multiplan Workers Comp	$185.25
Rate for Payer: Scott and White EPO/PPO	$142.50

GERIATRIC SURG PROC LEVEL III BCE

Facility

$360.00

Hospital Charge Code	3913002
Hospital Revenue Code	510
Rate for Payer: Cash Price	$316.80

GERIATRIC SURG PROC LEVEL III BCE

Facility

$360.00

Hospital Charge Code	3913002
Hospital Revenue Code	510
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna Commercial	$198.00
Rate for Payer: Amerigroup CHIP/Medicaid	$32.40
Rate for Payer: BCBS of TX Blue Advantage	$108.00
Rate for Payer: BCBS of TX Blue Essentials	$129.60
Rate for Payer: BCBS of TX PPO	$144.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Multiplan Auto	$234.00
Rate for Payer: Multiplan Commercial	$234.00
Rate for Payer: Multiplan Workers Comp	$234.00
Rate for Payer: Scott and White EPO/PPO	$180.00

GHB Screen, S/P SO

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1743071
Hospital Revenue Code	300
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$206.05
Rate for Payer: Aetna Commercial	$65.24
Rate for Payer: Aetna Medicare	$93.21
Rate for Payer: Amerigroup CHIP/Medicaid	$24.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$62.14
Rate for Payer: Amerigroup Medicare	$62.14
Rate for Payer: BCBS of TX Blue Advantage	$102.53
Rate for Payer: BCBS of TX Blue Essentials	$123.04
Rate for Payer: BCBS of TX Medicare	$62.14
Rate for Payer: BCBS of TX PPO	$137.33
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cash Price	$278.96
Rate for Payer: Cigna Medicaid	$62.14
Rate for Payer: Cigna Medicare	$62.14
Rate for Payer: Employer Direct Commercial	$62.14
Rate for Payer: Humana Medicare/TRICARE	$62.14
Rate for Payer: Molina CHIP/Medicaid	$62.14
Rate for Payer: Molina Dual Medicare/Medicaid	$62.14
Rate for Payer: Molina Medicare	$62.14
Rate for Payer: Multiplan Auto	$206.05
Rate for Payer: Multiplan Commercial	$206.05
Rate for Payer: Multiplan Workers Comp	$206.05
Rate for Payer: Parkland Medicaid	$62.14
Rate for Payer: Scott and White EPO/PPO	$77.68
Rate for Payer: Scott and White Medicare	$62.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$62.14
Rate for Payer: Superior Health Plan EPO	$62.14
Rate for Payer: Superior Health Plan Medicare	$62.14
Rate for Payer: Universal American Dual Medicare/Medicaid	$62.14
Rate for Payer: Universal American Medicare	$62.14
Rate for Payer: Wellcare Medicare	$62.14
Rate for Payer: Wellmed Medicare	$62.14

GHB Screen, S/P SO

Facility

$317.00

Service Code	CPT 80307
Hospital Charge Code	1743071
Hospital Revenue Code	300
Rate for Payer: Cash Price	$278.96

GIARDIA AG DETEC BY ENZ IMMUNO ASSA

Facility

$144.00

Service Code	CPT 87329
Hospital Charge Code	1620110
Hospital Revenue Code	306
Rate for Payer: Cash Price	$126.72

GIARDIA AG DETEC BY ENZ IMMUNO ASSA

Facility

$144.00

Service Code	CPT 87329
Hospital Charge Code	1620110
Hospital Revenue Code	306
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna Commercial	$12.58
Rate for Payer: Aetna Medicare	$17.97
Rate for Payer: Amerigroup CHIP/Medicaid	$4.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.98
Rate for Payer: Amerigroup Medicare	$11.98
Rate for Payer: BCBS of TX Blue Advantage	$19.77
Rate for Payer: BCBS of TX Blue Essentials	$23.72
Rate for Payer: BCBS of TX Medicare	$11.98
Rate for Payer: BCBS of TX PPO	$26.48
Rate for Payer: Cash Price	$126.72
Rate for Payer: Cash Price	$126.72
Rate for Payer: Cigna Medicaid	$11.98
Rate for Payer: Cigna Medicare	$11.98
Rate for Payer: Employer Direct Commercial	$11.98
Rate for Payer: Humana Medicare/TRICARE	$11.98
Rate for Payer: Molina CHIP/Medicaid	$11.98
Rate for Payer: Molina Dual Medicare/Medicaid	$11.98
Rate for Payer: Molina Medicare	$11.98
Rate for Payer: Multiplan Auto	$93.60
Rate for Payer: Multiplan Commercial	$93.60
Rate for Payer: Multiplan Workers Comp	$93.60
Rate for Payer: Parkland Medicaid	$11.98
Rate for Payer: Scott and White EPO/PPO	$14.98
Rate for Payer: Scott and White Medicare	$11.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.98
Rate for Payer: Superior Health Plan EPO	$11.98
Rate for Payer: Superior Health Plan Medicare	$11.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.98
Rate for Payer: Universal American Medicare	$11.98
Rate for Payer: Wellcare Medicare	$11.98
Rate for Payer: Wellmed Medicare	$11.98

Know your out-of-pocket cost for care.

All Charges