White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	3914023
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$306.72
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$127.80
Rate for Payer: BCBS of TX Blue Essentials	$153.36
Rate for Payer: BCBS of TX PPO	$170.40
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cigna Medicaid	$306.72
Rate for Payer: Molina CHIP/Medicaid	$306.72
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	$306.72
Rate for Payer: Scott and White EPO/PPO	$213.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.72

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

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	3914023
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

GERIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	3910002
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: 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	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84

GERIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	3910002
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

GERIATRIC E&M-NEW PATIENT-LVL III BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	3910003
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: 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	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92

GERIATRIC E&M-NEW PATIENT-LVL III BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	3910003
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

GERIATRIC E&M-NEW PATIENT-LVL IV BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	3910007
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

GERIATRIC E&M-NEW PATIENT-LVL IV BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	3910007
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

GERIATRIC E&M-NEW PATIENT-LVL V BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	3910005
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

GERIATRIC E&M-NEW PATIENT-LVL V BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	3910005
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

GERIATRIC SURG PROC LEVEL I BCE

Facility

$238.00

Hospital Charge Code	3913000
Hospital Revenue Code	510
Rate for Payer: Cash Price	$161.84

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	$171.36
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	$161.84
Rate for Payer: Cigna Medicaid	$171.36
Rate for Payer: Molina CHIP/Medicaid	$171.36
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: Parkland Medicaid	$171.36
Rate for Payer: Scott and White EPO/PPO	$119.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$171.36

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	$205.20
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	$193.80
Rate for Payer: Cigna Medicaid	$205.20
Rate for Payer: Molina CHIP/Medicaid	$205.20
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: Parkland Medicaid	$205.20
Rate for Payer: Scott and White EPO/PPO	$142.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$205.20

GERIATRIC SURG PROC LEVEL II BCE

Facility

$285.00

Hospital Charge Code	3913001
Hospital Revenue Code	510
Rate for Payer: Cash Price	$193.80

GERIATRIC SURG PROC LEVEL III BCE

Facility

$360.00

Hospital Charge Code	3913002
Hospital Revenue Code	510
Rate for Payer: Cash Price	$244.80

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	$259.20
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	$244.80
Rate for Payer: Cigna Medicaid	$259.20
Rate for Payer: Molina CHIP/Medicaid	$259.20
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: Parkland Medicaid	$259.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$259.20

GHEEP BLOOD AGAR PLATE 19ML

Facility

$26.67

Hospital Charge Code	993649
Hospital Revenue Code	270
Rate for Payer: Cash Price	$18.14

GHEEP BLOOD AGAR PLATE 19ML

Facility

$26.67

Hospital Charge Code	993649
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$19.20
Rate for Payer: Amerigroup CHIP/Medicaid	$2.40
Rate for Payer: BCBS of TX Blue Advantage	$8.00
Rate for Payer: BCBS of TX Blue Essentials	$9.60
Rate for Payer: BCBS of TX PPO	$10.67
Rate for Payer: Cash Price	$18.14
Rate for Payer: Cigna Medicaid	$19.20
Rate for Payer: Molina CHIP/Medicaid	$19.20
Rate for Payer: Multiplan Auto	$17.34
Rate for Payer: Multiplan Commercial	$17.34
Rate for Payer: Multiplan Workers Comp	$17.34
Rate for Payer: Parkland Medicaid	$19.20
Rate for Payer: Scott and White EPO/PPO	$13.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.20
Rate for Payer: Superior Health Plan EPO	$3.63

Giardia Antigen, EIA

Facility

$96.36

Service Code	HCPCS 87329
Hospital Charge Code	9146992
Hospital Revenue Code	306
Rate for Payer: Cash Price	$65.52

Giardia Antigen, EIA

Facility

$96.36

Service Code	HCPCS 87329
Hospital Charge Code	1620110
Hospital Revenue Code	306
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$69.38
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	$28.91
Rate for Payer: BCBS of TX Blue Essentials	$34.69
Rate for Payer: BCBS of TX Medicare	$11.98
Rate for Payer: BCBS of TX PPO	$38.54
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cigna Medicaid	$69.38
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	$69.38
Rate for Payer: Molina Dual Medicare/Medicaid	$11.98
Rate for Payer: Molina Medicare	$11.98
Rate for Payer: Multiplan Auto	$62.63
Rate for Payer: Multiplan Commercial	$62.63
Rate for Payer: Multiplan Workers Comp	$62.63
Rate for Payer: Parkland Medicaid	$69.38
Rate for Payer: Scott and White EPO/PPO	$14.97
Rate for Payer: Scott and White Medicare	$11.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.38
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

Giardia Antigen, EIA

Facility

$96.36

Service Code	HCPCS 87329
Hospital Charge Code	9146992
Hospital Revenue Code	306
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$69.38
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	$28.91
Rate for Payer: BCBS of TX Blue Essentials	$34.69
Rate for Payer: BCBS of TX Medicare	$11.98
Rate for Payer: BCBS of TX PPO	$38.54
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cigna Medicaid	$69.38
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	$69.38
Rate for Payer: Molina Dual Medicare/Medicaid	$11.98
Rate for Payer: Molina Medicare	$11.98
Rate for Payer: Multiplan Auto	$62.63
Rate for Payer: Multiplan Commercial	$62.63
Rate for Payer: Multiplan Workers Comp	$62.63
Rate for Payer: Parkland Medicaid	$69.38
Rate for Payer: Scott and White EPO/PPO	$14.97
Rate for Payer: Scott and White Medicare	$11.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.38
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

Giardia Antigen, EIA

Facility

$96.36

Service Code	HCPCS 87329
Hospital Charge Code	1620110
Hospital Revenue Code	306
Rate for Payer: Cash Price	$65.52

GI cocktail 30 mL

Facility

$97.60

Service Code	HCPCS J3490
Hospital Charge Code	78921429
Hospital Revenue Code	250
Rate for Payer: Cash Price	$66.37

GI cocktail 30 mL

Facility

$97.60

Service Code	HCPCS J3490
Hospital Charge Code	78921429
Hospital Revenue Code	250
Min. Negotiated Rate	$8.78
Max. Negotiated Rate	$70.27
Rate for Payer: Amerigroup CHIP/Medicaid	$8.78
Rate for Payer: BCBS of TX Blue Advantage	$29.28
Rate for Payer: BCBS of TX Blue Essentials	$35.14
Rate for Payer: BCBS of TX PPO	$39.04
Rate for Payer: Cash Price	$66.37
Rate for Payer: Cigna Medicaid	$70.27
Rate for Payer: Molina CHIP/Medicaid	$70.27
Rate for Payer: Multiplan Auto	$63.44
Rate for Payer: Multiplan Commercial	$63.44
Rate for Payer: Multiplan Workers Comp	$63.44
Rate for Payer: Parkland Medicaid	$70.27
Rate for Payer: Scott and White EPO/PPO	$48.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.27
Rate for Payer: Superior Health Plan EPO	$13.27

G.I. HEMORRHAGE W CC

Facility

$18,633.30

Service Code	MSDRG 378
Min. Negotiated Rate	$8,516.58
Max. Negotiated Rate	$18,633.30
Rate for Payer: BCBS of TX Blue Advantage	$8,516.58
Rate for Payer: BCBS of TX Blue Essentials	$10,218.91
Rate for Payer: BCBS of TX PPO	$11,354.78

Know your out-of-pocket cost for care.

All Charges