White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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: 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	$18.95
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: 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	$18.95
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	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 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: 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	$39.19
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	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
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: 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	$39.19
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
Rate for Payer: Cash Price	$371.28

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	$60.09
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 PREVENTIVE COUNSELING INDIV 15 MIN BCE

Facility

$124.00

Service Code	HCPCS 99401
Hospital Charge Code	8996984
Hospital Revenue Code	510
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$89.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Molina CHIP/Medicaid	$89.28
Rate for Payer: Multiplan Auto	$80.60
Rate for Payer: Multiplan Commercial	$80.60
Rate for Payer: Multiplan Workers Comp	$80.60
Rate for Payer: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$62.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28

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

DFW BARIATRIC PREVENTIVE COUNSELING INDIV 30 MIN BCE

Facility

$208.00

Service Code	HCPCS 99402
Hospital Charge Code	8994984
Hospital Revenue Code	510
Rate for Payer: Cash Price	$141.44

DFW BARIATRIC PREVENTIVE COUNSELING INDIV 30 MIN BCE

Facility

$208.00

Service Code	HCPCS 99402
Hospital Charge Code	8994984
Hospital Revenue Code	510
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$149.76
Rate for Payer: Amerigroup CHIP/Medicaid	$18.72
Rate for Payer: BCBS of TX Blue Advantage	$62.40
Rate for Payer: BCBS of TX Blue Essentials	$74.88
Rate for Payer: BCBS of TX PPO	$83.20
Rate for Payer: Cash Price	$141.44
Rate for Payer: Cigna Medicaid	$149.76
Rate for Payer: Molina CHIP/Medicaid	$149.76
Rate for Payer: Multiplan Auto	$135.20
Rate for Payer: Multiplan Commercial	$135.20
Rate for Payer: Multiplan Workers Comp	$135.20
Rate for Payer: Parkland Medicaid	$149.76
Rate for Payer: Scott and White EPO/PPO	$104.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$149.76

DFW BARIATRIC PSYCL/NRPSYC TST PHY/QHP 1ST BCE

Facility

$283.00

Service Code	HCPCS 96136
Hospital Charge Code	8996986
Hospital Revenue Code	918
Rate for Payer: Cash Price	$192.44

DFW BARIATRIC PSYCL/NRPSYC TST PHY/QHP 1ST BCE

Facility

$283.00

Service Code	HCPCS 96136
Hospital Charge Code	8996986
Hospital Revenue Code	918
Min. Negotiated Rate	$25.47
Max. Negotiated Rate	$282.53
Rate for Payer: Amerigroup CHIP/Medicaid	$25.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$84.90
Rate for Payer: BCBS of TX Blue Essentials	$101.88
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$113.20
Rate for Payer: Cash Price	$192.44
Rate for Payer: Cash Price	$192.44
Rate for Payer: Cash Price	$192.44
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$203.76
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$203.76
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$183.95
Rate for Payer: Multiplan Commercial	$183.95
Rate for Payer: Multiplan Workers Comp	$183.95
Rate for Payer: Parkland Medicaid	$203.76
Rate for Payer: Scott and White EPO/PPO	$28.43
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$203.76
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

DFW BARIATRIC PSYCL/NRPSYC TST PHY/QHP EA BCE

Facility

$275.00

Service Code	HCPCS 96137
Hospital Charge Code	8996983
Hospital Revenue Code	918
Rate for Payer: Cash Price	$187.00

DFW BARIATRIC PSYCL/NRPSYC TST PHY/QHP EA BCE

Facility

$275.00

Service Code	HCPCS 96137
Hospital Charge Code	8996983
Hospital Revenue Code	918
Min. Negotiated Rate	$21.86
Max. Negotiated Rate	$198.00
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
Rate for Payer: BCBS of TX Blue Advantage	$82.50
Rate for Payer: BCBS of TX Blue Essentials	$99.00
Rate for Payer: BCBS of TX PPO	$110.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cigna Medicaid	$198.00
Rate for Payer: Molina CHIP/Medicaid	$198.00
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Parkland Medicaid	$198.00
Rate for Payer: Scott and White EPO/PPO	$21.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.00
Rate for Payer: Superior Health Plan EPO	$37.40

DFW BARIATRIC PSYCL TST EVAL PHYS/QHP 1ST BCE

Facility

$527.00

Service Code	HCPCS 96130
Hospital Charge Code	8996982
Hospital Revenue Code	918
Rate for Payer: Cash Price	$358.36

DFW BARIATRIC PSYCL TST EVAL PHYS/QHP 1ST BCE

Facility

$527.00

Service Code	HCPCS 96130
Hospital Charge Code	8996982
Hospital Revenue Code	918
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$458.51
Rate for Payer: Amerigroup CHIP/Medicaid	$47.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$158.10
Rate for Payer: BCBS of TX Blue Essentials	$189.72
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$210.80
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$379.44
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$379.44
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$342.55
Rate for Payer: Multiplan Commercial	$342.55
Rate for Payer: Multiplan Workers Comp	$342.55
Rate for Payer: Parkland Medicaid	$379.44
Rate for Payer: Scott and White EPO/PPO	$133.74
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$379.44
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

DFW BARIATRIC PSYCL TST EVAL PHYS/QHP EA BCE

Facility

$350.00

Service Code	HCPCS 96131
Hospital Charge Code	8994985
Hospital Revenue Code	918
Rate for Payer: Cash Price	$238.00

DFW BARIATRIC PSYCL TST EVAL PHYS/QHP EA BCE

Facility

$350.00

Service Code	HCPCS 96131
Hospital Charge Code	8994985
Hospital Revenue Code	918
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$252.00
Rate for Payer: Amerigroup CHIP/Medicaid	$31.50
Rate for Payer: BCBS of TX Blue Advantage	$105.00
Rate for Payer: BCBS of TX Blue Essentials	$126.00
Rate for Payer: BCBS of TX PPO	$140.00
Rate for Payer: Cash Price	$238.00
Rate for Payer: Cash Price	$238.00
Rate for Payer: Cigna Medicaid	$252.00
Rate for Payer: Molina CHIP/Medicaid	$252.00
Rate for Payer: Multiplan Auto	$227.50
Rate for Payer: Multiplan Commercial	$227.50
Rate for Payer: Multiplan Workers Comp	$227.50
Rate for Payer: Parkland Medicaid	$252.00
Rate for Payer: Scott and White EPO/PPO	$92.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.00
Rate for Payer: Superior Health Plan EPO	$47.60

DFW BARIATRIC PSYTX W PT 30 MINUTES BCE

Facility

$281.00

Service Code	HCPCS 90832
Hospital Charge Code	8584479
Hospital Revenue Code	914
Min. Negotiated Rate	$25.29
Max. Negotiated Rate	$376.90
Rate for Payer: Amerigroup CHIP/Medicaid	$25.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$178.30
Rate for Payer: Amerigroup Medicare	$178.30
Rate for Payer: BCBS of TX Blue Advantage	$84.30
Rate for Payer: BCBS of TX Blue Essentials	$101.16
Rate for Payer: BCBS of TX Medicare	$178.30
Rate for Payer: BCBS of TX PPO	$112.40
Rate for Payer: Cash Price	$191.08
Rate for Payer: Cash Price	$191.08
Rate for Payer: Cash Price	$191.08
Rate for Payer: Cigna Commercial	$376.90
Rate for Payer: Cigna Medicaid	$202.32
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	$202.32
Rate for Payer: Molina Dual Medicare/Medicaid	$178.30
Rate for Payer: Molina Medicare	$178.30
Rate for Payer: Multiplan Auto	$182.65
Rate for Payer: Multiplan Commercial	$182.65
Rate for Payer: Multiplan Workers Comp	$182.65
Rate for Payer: Parkland Medicaid	$202.32
Rate for Payer: Scott and White EPO/PPO	$84.53
Rate for Payer: Scott and White Medicare	$178.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.32
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

Know your out-of-pocket cost for care.

All Charges