White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GAS, HELIUM I40L 2200PSI CYLINDER DISPOSABLE

Facility

$1,969.09

Hospital Charge Code	993803
Hospital Revenue Code	270
Min. Negotiated Rate	$177.22
Max. Negotiated Rate	$1,417.74
Rate for Payer: Amerigroup CHIP/Medicaid	$177.22
Rate for Payer: BCBS of TX Blue Advantage	$590.73
Rate for Payer: BCBS of TX Blue Essentials	$708.87
Rate for Payer: BCBS of TX PPO	$787.64
Rate for Payer: Cash Price	$1,338.98
Rate for Payer: Cigna Medicaid	$1,417.74
Rate for Payer: Molina CHIP/Medicaid	$1,417.74
Rate for Payer: Multiplan Auto	$1,279.91
Rate for Payer: Multiplan Commercial	$1,279.91
Rate for Payer: Multiplan Workers Comp	$1,279.91
Rate for Payer: Parkland Medicaid	$1,417.74
Rate for Payer: Scott and White EPO/PPO	$984.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,417.74
Rate for Payer: Superior Health Plan EPO	$267.80

GAS, HELIUM I40L 2200PSI CYLINDER DISPOSABLE

Facility

$1,969.09

Hospital Charge Code	993803
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,338.98

GASPAK EZ ANAEROBIC POUCH SYSTEM

Facility

$107.77

Hospital Charge Code	993102
Hospital Revenue Code	270
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$77.59
Rate for Payer: Amerigroup CHIP/Medicaid	$9.70
Rate for Payer: BCBS of TX Blue Advantage	$32.33
Rate for Payer: BCBS of TX Blue Essentials	$38.80
Rate for Payer: BCBS of TX PPO	$43.11
Rate for Payer: Cash Price	$73.28
Rate for Payer: Cigna Medicaid	$77.59
Rate for Payer: Molina CHIP/Medicaid	$77.59
Rate for Payer: Multiplan Auto	$70.05
Rate for Payer: Multiplan Commercial	$70.05
Rate for Payer: Multiplan Workers Comp	$70.05
Rate for Payer: Parkland Medicaid	$77.59
Rate for Payer: Scott and White EPO/PPO	$53.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.59
Rate for Payer: Superior Health Plan EPO	$14.66

GASPAK EZ ANAEROBIC POUCH SYSTEM

Facility

$107.77

Hospital Charge Code	993102
Hospital Revenue Code	270
Rate for Payer: Cash Price	$73.28

GASPAK EZ CONTAINER SYSTEM SACHET

Facility

$69.52

Hospital Charge Code	993101
Hospital Revenue Code	270
Min. Negotiated Rate	$6.26
Max. Negotiated Rate	$50.05
Rate for Payer: Amerigroup CHIP/Medicaid	$6.26
Rate for Payer: BCBS of TX Blue Advantage	$20.86
Rate for Payer: BCBS of TX Blue Essentials	$25.03
Rate for Payer: BCBS of TX PPO	$27.81
Rate for Payer: Cash Price	$47.27
Rate for Payer: Cigna Medicaid	$50.05
Rate for Payer: Molina CHIP/Medicaid	$50.05
Rate for Payer: Multiplan Auto	$45.19
Rate for Payer: Multiplan Commercial	$45.19
Rate for Payer: Multiplan Workers Comp	$45.19
Rate for Payer: Parkland Medicaid	$50.05
Rate for Payer: Scott and White EPO/PPO	$34.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.05
Rate for Payer: Superior Health Plan EPO	$9.45

GASPAK EZ CONTAINER SYSTEM SACHET

Facility

$69.52

Hospital Charge Code	993101
Hospital Revenue Code	270
Rate for Payer: Cash Price	$47.27

Gastrectomy, partial, distal; with gastroduodenostomy

Facility

$64,200.00

Service Code	HCPCS 43631
Hospital Charge Code	994044
Hospital Revenue Code	360
Rate for Payer: Cash Price	$43,656.00

Gastrectomy, partial, distal; with gastroduodenostomy

Facility

$64,200.00

Service Code	HCPCS 43631
Hospital Charge Code	994044
Hospital Revenue Code	360
Min. Negotiated Rate	$2,533.21
Max. Negotiated Rate	$46,224.00
Rate for Payer: Amerigroup CHIP/Medicaid	$5,778.00
Rate for Payer: BCBS of TX Blue Advantage	$2,533.21
Rate for Payer: BCBS of TX Blue Essentials	$3,033.78
Rate for Payer: BCBS of TX PPO	$3,822.56
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cash Price	$43,656.00
Rate for Payer: Cigna Medicaid	$46,224.00
Rate for Payer: Molina CHIP/Medicaid	$46,224.00
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$46,224.00
Rate for Payer: Scott and White EPO/PPO	$32,100.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,224.00
Rate for Payer: Superior Health Plan EPO	$8,731.20

Gastrectomy, partial, distal with gastrojejunostomy

Facility

$10,000.00

Service Code	CPT 43632
Hospital Charge Code	36043632
Hospital Revenue Code	360
Min. Negotiated Rate	$2,468.88
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$3,555.75
Rate for Payer: BCBS of TX Blue Essentials	$4,258.38
Rate for Payer: BCBS of TX PPO	$5,365.56
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$2,468.88

Gastrectomy, partial, distal with gastrojejunostomy

Facility

$27,228.91

Service Code	HCPCS 43632
Hospital Charge Code	9900684
Hospital Revenue Code	360
Rate for Payer: Cash Price	$18,515.66

Gastrectomy, partial, distal with gastrojejunostomy

Facility

$27,228.91

Service Code	HCPCS 43632
Hospital Charge Code	9900684
Hospital Revenue Code	360
Min. Negotiated Rate	$2,450.60
Max. Negotiated Rate	$19,604.82
Rate for Payer: Amerigroup CHIP/Medicaid	$2,450.60
Rate for Payer: BCBS of TX Blue Advantage	$3,555.75
Rate for Payer: BCBS of TX Blue Essentials	$4,258.38
Rate for Payer: BCBS of TX PPO	$5,365.56
Rate for Payer: Cash Price	$18,515.66
Rate for Payer: Cash Price	$18,515.66
Rate for Payer: Cash Price	$18,515.66
Rate for Payer: Cigna Medicaid	$19,604.82
Rate for Payer: Molina CHIP/Medicaid	$19,604.82
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$19,604.82
Rate for Payer: Scott and White EPO/PPO	$13,614.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,604.82
Rate for Payer: Superior Health Plan EPO	$3,703.13

Gastrectomy, partial, distal; with Roux-en-Y reconstruction

Facility

$8,045.36

Service Code	HCPCS 43633
Hospital Charge Code	9900685
Hospital Revenue Code	360
Min. Negotiated Rate	$724.08
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$724.08
Rate for Payer: BCBS of TX Blue Advantage	$3,358.94
Rate for Payer: BCBS of TX Blue Essentials	$4,022.68
Rate for Payer: BCBS of TX PPO	$5,068.58
Rate for Payer: Cash Price	$5,470.84
Rate for Payer: Cash Price	$5,470.84
Rate for Payer: Cash Price	$5,470.84
Rate for Payer: Cigna Medicaid	$5,792.66
Rate for Payer: Molina CHIP/Medicaid	$5,792.66
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,792.66
Rate for Payer: Scott and White EPO/PPO	$4,022.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,792.66
Rate for Payer: Superior Health Plan EPO	$1,094.17

Gastrectomy, partial, distal; with Roux-en-Y reconstruction

Facility

$10,000.00

Service Code	CPT 43633
Hospital Charge Code	36043633
Hospital Revenue Code	360
Min. Negotiated Rate	$2,336.11
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$3,358.94
Rate for Payer: BCBS of TX Blue Essentials	$4,022.68
Rate for Payer: BCBS of TX PPO	$5,068.58
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$2,336.11

Gastrectomy, partial, distal; with Roux-en-Y reconstruction

Facility

$8,045.36

Service Code	HCPCS 43633
Hospital Charge Code	9900685
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,470.84

GASTRIC FUNDOPLICATION

Facility

$5,298.00

Service Code	APR-DRG 2322
Min. Negotiated Rate	$4,995.14
Max. Negotiated Rate	$5,298.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,995.14
Rate for Payer: Cigna Medicaid	$4,995.14
Rate for Payer: Molina CHIP/Medicaid	$4,995.14
Rate for Payer: Parkland Medicaid	$4,995.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,298.00

GASTRIC FUNDOPLICATION

Facility

$3,862.04

Service Code	APR-DRG 2321
Min. Negotiated Rate	$3,641.26
Max. Negotiated Rate	$3,862.04
Rate for Payer: Amerigroup CHIP/Medicaid	$3,641.26
Rate for Payer: Cigna Medicaid	$3,641.26
Rate for Payer: Molina CHIP/Medicaid	$3,641.26
Rate for Payer: Parkland Medicaid	$3,641.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,862.04

GASTRIC FUNDOPLICATION

Facility

$15,606.95

Service Code	APR-DRG 2324
Min. Negotiated Rate	$14,714.78
Max. Negotiated Rate	$15,606.95
Rate for Payer: Amerigroup CHIP/Medicaid	$14,714.78
Rate for Payer: Cigna Medicaid	$14,714.78
Rate for Payer: Molina CHIP/Medicaid	$14,714.78
Rate for Payer: Parkland Medicaid	$14,714.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,606.95

GASTRIC FUNDOPLICATION

Facility

$7,681.83

Service Code	APR-DRG 2323
Min. Negotiated Rate	$7,242.70
Max. Negotiated Rate	$7,681.83
Rate for Payer: Amerigroup CHIP/Medicaid	$7,242.70
Rate for Payer: Cigna Medicaid	$7,242.70
Rate for Payer: Molina CHIP/Medicaid	$7,242.70
Rate for Payer: Parkland Medicaid	$7,242.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,681.83

Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only

Facility

$14,643.88

Service Code	HCPCS 43888
Hospital Charge Code	994168
Hospital Revenue Code	360
Min. Negotiated Rate	$1,457.62
Max. Negotiated Rate	$10,543.59
Rate for Payer: Amerigroup CHIP/Medicaid	$1,457.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$9,957.84
Rate for Payer: Cash Price	$9,957.84
Rate for Payer: Cash Price	$9,957.84
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicaid	$10,543.59
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina CHIP/Medicaid	$10,543.59
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$10,543.59
Rate for Payer: Scott and White EPO/PPO	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,543.59
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only

Facility

$14,643.88

Service Code	HCPCS 43888
Hospital Charge Code	994168
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,957.84

Gastric restrictive procedure, open removal of subcutaneous port component only

Facility

$1,911.64

Service Code	HCPCS 43887
Hospital Charge Code	9900692
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,299.92

Gastric restrictive procedure, open removal of subcutaneous port component only

Facility

$1,911.64

Service Code	HCPCS 43887
Hospital Charge Code	9900692
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$1,299.92
Rate for Payer: Cash Price	$1,299.92
Rate for Payer: Cash Price	$1,299.92
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$1,376.38
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$1,376.38
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,376.38
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,376.38
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Gastric restrictive procedure, open removal of subcutaneous port component only

Facility

$10,000.00

Service Code	CPT 43887
Hospital Charge Code	36043887
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG)

Facility

$3,750.24

Service Code	HCPCS 43889
Hospital Charge Code	994153
Hospital Revenue Code	360
Min. Negotiated Rate	$337.52
Max. Negotiated Rate	$22,571.94
Rate for Payer: Amerigroup CHIP/Medicaid	$337.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Amerigroup Medicare	$10,678.27
Rate for Payer: BCBS of TX Blue Advantage	$1,125.07
Rate for Payer: BCBS of TX Blue Essentials	$1,350.09
Rate for Payer: BCBS of TX Medicare	$10,678.27
Rate for Payer: BCBS of TX PPO	$1,500.10
Rate for Payer: Cash Price	$2,550.16
Rate for Payer: Cash Price	$2,550.16
Rate for Payer: Cash Price	$2,550.16
Rate for Payer: Cigna Commercial	$22,571.94
Rate for Payer: Cigna Medicaid	$2,700.17
Rate for Payer: Cigna Medicare	$10,678.27
Rate for Payer: Employer Direct Commercial	$10,678.27
Rate for Payer: Humana Medicare/TRICARE	$10,678.27
Rate for Payer: Molina CHIP/Medicaid	$2,700.17
Rate for Payer: Molina Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Molina Medicare	$10,678.27
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,700.17
Rate for Payer: Scott and White EPO/PPO	$1,875.12
Rate for Payer: Scott and White Medicare	$10,678.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,700.17
Rate for Payer: Superior Health Plan EPO	$10,678.27
Rate for Payer: Superior Health Plan Medicare	$10,678.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,678.27
Rate for Payer: Universal American Medicare	$10,678.27
Rate for Payer: Wellcare Medicare	$10,678.27
Rate for Payer: Wellmed Medicare	$10,678.27

Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG)

Facility

$3,750.24

Service Code	HCPCS 43889
Hospital Charge Code	994153
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,550.16

Know your out-of-pocket cost for care.

All Charges