White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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: 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	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.36

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: 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	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$429.12

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 GROUP PSYCHOTHERAPY BCE

Facility

$456.00

Service Code	HCPCS 90853
Hospital Charge Code	8582490
Hospital Revenue Code	915
Min. Negotiated Rate	$41.04
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	$228.00
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	$192.50
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
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	$241.50
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 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 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

DFW BARIATRIC IV INF HYD EA ADD HR BCE

Facility

$251.00

Service Code	HCPCS 96361
Hospital Charge Code	610010
Hospital Revenue Code	260
Rate for Payer: Cash Price	$170.68

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	$22.59
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	$125.50
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
Min. Negotiated Rate	$22.59
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	$125.50
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 MEDICAL NUTRITION GROUP BCE

Facility

$56.00

Service Code	HCPCS 97804
Hospital Charge Code	8584478
Hospital Revenue Code	942
Rate for Payer: Cash Price	$38.08

DFW BARIATRIC MEDICAL NUTRITION GROUP BCE

Facility

$56.00

Service Code	HCPCS 97804
Hospital Charge Code	8994983
Hospital Revenue Code	942
Rate for Payer: Cash Price	$38.08

DFW BARIATRIC MEDICAL NUTRITION GROUP BCE

Facility

$56.00

Service Code	HCPCS 97804
Hospital Charge Code	8584478
Hospital Revenue Code	942
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$40.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.04
Rate for Payer: BCBS of TX Blue Advantage	$16.80
Rate for Payer: BCBS of TX Blue Essentials	$20.16
Rate for Payer: BCBS of TX PPO	$22.40
Rate for Payer: Cash Price	$38.08
Rate for Payer: Cigna Medicaid	$40.32
Rate for Payer: Molina CHIP/Medicaid	$40.32
Rate for Payer: Multiplan Auto	$36.40
Rate for Payer: Multiplan Commercial	$36.40
Rate for Payer: Multiplan Workers Comp	$36.40
Rate for Payer: Parkland Medicaid	$40.32
Rate for Payer: Scott and White EPO/PPO	$28.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.32
Rate for Payer: Superior Health Plan EPO	$7.62

DFW BARIATRIC MEDICAL NUTRITION GROUP BCE

Facility

$56.00

Service Code	HCPCS 97804
Hospital Charge Code	8994983
Hospital Revenue Code	942
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$40.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.04
Rate for Payer: BCBS of TX Blue Advantage	$16.80
Rate for Payer: BCBS of TX Blue Essentials	$20.16
Rate for Payer: BCBS of TX PPO	$22.40
Rate for Payer: Cash Price	$38.08
Rate for Payer: Cigna Medicaid	$40.32
Rate for Payer: Molina CHIP/Medicaid	$40.32
Rate for Payer: Multiplan Auto	$36.40
Rate for Payer: Multiplan Commercial	$36.40
Rate for Payer: Multiplan Workers Comp	$36.40
Rate for Payer: Parkland Medicaid	$40.32
Rate for Payer: Scott and White EPO/PPO	$28.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.32
Rate for Payer: Superior Health Plan EPO	$7.62

DFW BARIATRIC MED NUTRTN TH INIT 15MIN BCE

Facility

$120.00

Service Code	HCPCS 97802
Hospital Charge Code	8996980
Hospital Revenue Code	942
Rate for Payer: Cash Price	$81.60

DFW BARIATRIC MED NUTRTN TH INIT 15MIN BCE

Facility

$120.00

Service Code	HCPCS 97802
Hospital Charge Code	6019905
Hospital Revenue Code	942
Rate for Payer: Cash Price	$81.60

DFW BARIATRIC MED NUTRTN TH INIT 15MIN BCE

Facility

$120.00

Service Code	HCPCS 97802
Hospital Charge Code	8996980
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$86.40
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$36.00
Rate for Payer: BCBS of TX Blue Essentials	$43.20
Rate for Payer: BCBS of TX PPO	$48.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna Medicaid	$86.40
Rate for Payer: Molina CHIP/Medicaid	$86.40
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Parkland Medicaid	$86.40
Rate for Payer: Scott and White EPO/PPO	$60.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.40
Rate for Payer: Superior Health Plan EPO	$16.32

DFW BARIATRIC MED NUTRTN TH INIT 15MIN BCE

Facility

$120.00

Service Code	HCPCS 97802
Hospital Charge Code	6019905
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$86.40
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$36.00
Rate for Payer: BCBS of TX Blue Essentials	$43.20
Rate for Payer: BCBS of TX PPO	$48.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna Medicaid	$86.40
Rate for Payer: Molina CHIP/Medicaid	$86.40
Rate for Payer: Multiplan Auto	$78.00
Rate for Payer: Multiplan Commercial	$78.00
Rate for Payer: Multiplan Workers Comp	$78.00
Rate for Payer: Parkland Medicaid	$86.40
Rate for Payer: Scott and White EPO/PPO	$60.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.40
Rate for Payer: Superior Health Plan EPO	$16.32

DFW BARIATRIC O2 UPTAKE REST INDRCT BCE

Facility

$546.00

Service Code	HCPCS 94690
Hospital Charge Code	8996981
Hospital Revenue Code	460
Min. Negotiated Rate	$49.14
Max. Negotiated Rate	$393.12
Rate for Payer: Amerigroup CHIP/Medicaid	$49.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$163.80
Rate for Payer: BCBS of TX Blue Essentials	$196.56
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$218.40
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$393.12
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$393.12
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
Rate for Payer: Multiplan Auto	$354.90
Rate for Payer: Multiplan Commercial	$354.90
Rate for Payer: Multiplan Workers Comp	$354.90
Rate for Payer: Parkland Medicaid	$393.12
Rate for Payer: Scott and White EPO/PPO	$273.00
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$393.12
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

DFW BARIATRIC O2 UPTAKE REST INDRCT BCE

Facility

$546.00

Service Code	HCPCS 94690
Hospital Charge Code	8996981
Hospital Revenue Code	460
Rate for Payer: Cash Price	$371.28

DFW BARIATRIC PREVENTIVE COUNSELING INDIV 15 MIN BCE

Facility

$124.00

Service Code	HCPCS 99401
Hospital Charge Code	8996984
Hospital Revenue Code	510
Rate for Payer: Cash Price	$84.32

Know your out-of-pocket cost for care.

All Charges