White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DFW BARIATRIC BEHAVIOR COUNSEL OBESITY 15MIN BCE

Facility

$150.00

Hospital Charge Code	8994975
Hospital Revenue Code	510
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$108.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.50
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$75.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00

DFW BARIATRIC E&M-EST. PATIENT-LVL I BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	8996974
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

DFW BARIATRIC E&M-EST. PATIENT-LVL I BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	8996974
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

DFW BARIATRIC E&M-EST. PATIENT-LVL II BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	8994976
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

DFW BARIATRIC E&M-EST. PATIENT-LVL II BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	8994976
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

DFW BARIATRIC E&M-EST. PATIENT-LVL III BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8996975
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

DFW BARIATRIC E&M-EST. PATIENT-LVL III BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8996975
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

DFW BARIATRIC E&M-EST. PATIENT-LVL IV BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	8994977
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

DFW BARIATRIC E&M-EST. PATIENT-LVL IV BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	8994977
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

DFW BARIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	8996973
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

DFW BARIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	8996973
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

DFW BARIATRIC E&M-NEW. PATIENT-LVL III BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8994978
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

DFW BARIATRIC E&M-NEW. PATIENT-LVL III BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8994978
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

DFW BARIATRIC E&M-NEW PATIENT LVL IV BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	8994979
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

DFW BARIATRIC E&M-NEW PATIENT LVL IV BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	8994979
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

DFW BARIATRIC E&M- NEW PATIENT LVL V BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	8996976
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

DFW BARIATRIC E&M- NEW PATIENT LVL V BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	8996976
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

DFW BARIATRIC GROUP PSYCHOTHERAPY BCE

Facility

$456.00

Service Code	HCPCS 90853
Hospital Charge Code	8582490
Hospital Revenue Code	915
Min. Negotiated Rate	$29.68
Max. Negotiated Rate	$328.32
Rate for Payer: Amerigroup CHIP/Medicaid	$41.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$102.05
Rate for Payer: Amerigroup Medicare	$102.05
Rate for Payer: BCBS of TX Blue Advantage	$136.80
Rate for Payer: BCBS of TX Blue Essentials	$164.16
Rate for Payer: BCBS of TX Medicare	$102.05
Rate for Payer: BCBS of TX PPO	$182.40
Rate for Payer: Cash Price	$310.08
Rate for Payer: Cash Price	$310.08
Rate for Payer: Cash Price	$310.08
Rate for Payer: Cigna Commercial	$215.73
Rate for Payer: Cigna Medicaid	$328.32
Rate for Payer: Cigna Medicare	$102.05
Rate for Payer: Employer Direct Commercial	$102.05
Rate for Payer: Humana Medicare/TRICARE	$102.05
Rate for Payer: Molina CHIP/Medicaid	$328.32
Rate for Payer: Molina Dual Medicare/Medicaid	$102.05
Rate for Payer: Molina Medicare	$102.05
Rate for Payer: Multiplan Auto	$296.40
Rate for Payer: Multiplan Commercial	$296.40
Rate for Payer: Multiplan Workers Comp	$296.40
Rate for Payer: Parkland Medicaid	$328.32
Rate for Payer: Scott and White EPO/PPO	$29.68
Rate for Payer: Scott and White Medicare	$102.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.32
Rate for Payer: Superior Health Plan EPO	$102.05
Rate for Payer: Superior Health Plan Medicare	$102.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$102.05
Rate for Payer: Universal American Medicare	$102.05
Rate for Payer: Wellcare Medicare	$102.05
Rate for Payer: Wellmed Medicare	$102.05

DFW BARIATRIC GROUP PSYCHOTHERAPY BCE

Facility

$456.00

Service Code	HCPCS 90853
Hospital Charge Code	8582490
Hospital Revenue Code	915
Rate for Payer: Cash Price	$310.08

DFW BARIATRIC HLTH BHAV INTERV IND 1ST 30MIN BCE

Facility

$385.00

Service Code	HCPCS 96158
Hospital Charge Code	8994981
Hospital Revenue Code	914
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$376.90
Rate for Payer: Amerigroup CHIP/Medicaid	$34.65
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$178.30
Rate for Payer: Amerigroup Medicare	$178.30
Rate for Payer: BCBS of TX Blue Advantage	$115.50
Rate for Payer: BCBS of TX Blue Essentials	$138.60
Rate for Payer: BCBS of TX Medicare	$178.30
Rate for Payer: BCBS of TX PPO	$154.00
Rate for Payer: Cash Price	$261.80
Rate for Payer: Cash Price	$261.80
Rate for Payer: Cash Price	$261.80
Rate for Payer: Cigna Commercial	$376.90
Rate for Payer: Cigna Medicaid	$277.20
Rate for Payer: Cigna Medicare	$178.30
Rate for Payer: Employer Direct Commercial	$178.30
Rate for Payer: Humana Medicare/TRICARE	$178.30
Rate for Payer: Molina CHIP/Medicaid	$277.20
Rate for Payer: Molina Dual Medicare/Medicaid	$178.30
Rate for Payer: Molina Medicare	$178.30
Rate for Payer: Multiplan Auto	$250.25
Rate for Payer: Multiplan Commercial	$250.25
Rate for Payer: Multiplan Workers Comp	$250.25
Rate for Payer: Parkland Medicaid	$277.20
Rate for Payer: Scott and White EPO/PPO	$72.58
Rate for Payer: Scott and White Medicare	$178.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.20
Rate for Payer: Superior Health Plan EPO	$178.30
Rate for Payer: Superior Health Plan Medicare	$178.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$178.30
Rate for Payer: Universal American Medicare	$178.30
Rate for Payer: Wellcare Medicare	$178.30
Rate for Payer: Wellmed Medicare	$178.30

DFW BARIATRIC HLTH BHAV INTERV IND 1ST 30MIN BCE

Facility

$385.00

Service Code	HCPCS 96158
Hospital Charge Code	8994981
Hospital Revenue Code	914
Rate for Payer: Cash Price	$261.80

DFW BARIATRIC HLTH BHV ASSMT/REASSESSMENT BCE

Facility

$483.00

Service Code	HCPCS 96156
Hospital Charge Code	8996977
Hospital Revenue Code	914
Rate for Payer: Cash Price	$328.44

DFW BARIATRIC HLTH BHV ASSMT/REASSESSMENT BCE

Facility

$483.00

Service Code	HCPCS 96156
Hospital Charge Code	8996977
Hospital Revenue Code	914
Min. Negotiated Rate	$43.47
Max. Negotiated Rate	$347.76
Rate for Payer: Amerigroup CHIP/Medicaid	$43.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$102.05
Rate for Payer: Amerigroup Medicare	$102.05
Rate for Payer: BCBS of TX Blue Advantage	$144.90
Rate for Payer: BCBS of TX Blue Essentials	$173.88
Rate for Payer: BCBS of TX Medicare	$102.05
Rate for Payer: BCBS of TX PPO	$193.20
Rate for Payer: Cash Price	$328.44
Rate for Payer: Cash Price	$328.44
Rate for Payer: Cash Price	$328.44
Rate for Payer: Cigna Commercial	$215.73
Rate for Payer: Cigna Medicaid	$347.76
Rate for Payer: Cigna Medicare	$102.05
Rate for Payer: Employer Direct Commercial	$102.05
Rate for Payer: Humana Medicare/TRICARE	$102.05
Rate for Payer: Molina CHIP/Medicaid	$347.76
Rate for Payer: Molina Dual Medicare/Medicaid	$102.05
Rate for Payer: Molina Medicare	$102.05
Rate for Payer: Multiplan Auto	$313.95
Rate for Payer: Multiplan Commercial	$313.95
Rate for Payer: Multiplan Workers Comp	$313.95
Rate for Payer: Parkland Medicaid	$347.76
Rate for Payer: Scott and White EPO/PPO	$108.39
Rate for Payer: Scott and White Medicare	$102.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$347.76
Rate for Payer: Superior Health Plan EPO	$102.05
Rate for Payer: Superior Health Plan Medicare	$102.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$102.05
Rate for Payer: Universal American Medicare	$102.05
Rate for Payer: Wellcare Medicare	$102.05
Rate for Payer: Wellmed Medicare	$102.05

DFW BARIATRIC IV INF HYD EA ADD HR BCE

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	610010
Hospital Revenue Code	260
Min. Negotiated Rate	$15.21
Max. Negotiated Rate	$180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47.04
Rate for Payer: Amerigroup Medicare	$47.04
Rate for Payer: BCBS of TX Blue Advantage	$75.30
Rate for Payer: BCBS of TX Blue Essentials	$90.36
Rate for Payer: BCBS of TX Medicare	$47.04
Rate for Payer: BCBS of TX PPO	$100.40
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cash Price	$170.68
Rate for Payer: Cigna Commercial	$99.43
Rate for Payer: Cigna Medicaid	$180.72
Rate for Payer: Cigna Medicare	$47.04
Rate for Payer: Employer Direct Commercial	$47.04
Rate for Payer: Humana Medicare/TRICARE	$47.04
Rate for Payer: Molina CHIP/Medicaid	$180.72
Rate for Payer: Molina Dual Medicare/Medicaid	$47.04
Rate for Payer: Molina Medicare	$47.04
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Parkland Medicaid	$180.72
Rate for Payer: Scott and White EPO/PPO	$15.21
Rate for Payer: Scott and White Medicare	$47.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$180.72
Rate for Payer: Superior Health Plan EPO	$47.04
Rate for Payer: Superior Health Plan Medicare	$47.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$47.04
Rate for Payer: Universal American Medicare	$47.04
Rate for Payer: Wellcare Medicare	$47.04
Rate for Payer: Wellmed Medicare	$47.04

DFW BARIATRIC IV INF HYD EA ADD HR BCE

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	5202379
Hospital Revenue Code	260
Rate for Payer: Cash Price	$170.68

Know your out-of-pocket cost for care.

All Charges