White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	6809211
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$73.45
Rate for Payer: Aetna Commercial	$62.15
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$16.30
Rate for Payer: BCBS of TX Blue Essentials	$19.49
Rate for Payer: BCBS of TX PPO	$21.74
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cigna Medicaid	$12.41
Rate for Payer: Molina CHIP/Medicaid	$12.41
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	$12.41
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.41

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

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	6809212
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$113.10
Rate for Payer: Aetna Commercial	$95.70
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$45.15
Rate for Payer: BCBS of TX Blue Essentials	$53.98
Rate for Payer: BCBS of TX PPO	$60.20
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cigna Medicaid	$20.78
Rate for Payer: Molina CHIP/Medicaid	$20.78
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	$20.78
Rate for Payer: Scott and White EPO/PPO	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.78

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

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	6809212
Hospital Revenue Code	510
Rate for Payer: Cash Price	$153.12

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

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	8578472
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$137.15
Rate for Payer: Aetna Commercial	$116.05
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$90.31
Rate for Payer: BCBS of TX Blue Essentials	$107.95
Rate for Payer: BCBS of TX PPO	$120.41
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cigna Medicaid	$31.23
Rate for Payer: Molina CHIP/Medicaid	$31.23
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	$31.23
Rate for Payer: Scott and White EPO/PPO	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.23

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

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	8578472
Hospital Revenue Code	510
Rate for Payer: Cash Price	$185.68

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

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	6809214
Hospital Revenue Code	510
Rate for Payer: Cash Price	$343.20

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

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	6809214
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$253.50
Rate for Payer: Aetna Commercial	$214.50
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$139.22
Rate for Payer: BCBS of TX Blue Essentials	$166.42
Rate for Payer: BCBS of TX PPO	$185.62
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cigna Medicaid	$43.87
Rate for Payer: Molina CHIP/Medicaid	$43.87
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	$43.87
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.87

BARIATRIC E&M - EST PATIENT LVL V BCE

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	8580498
Hospital Revenue Code	510
Rate for Payer: Cash Price	$374.88

BARIATRIC E&M - EST PATIENT LVL V BCE

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	8580498
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$276.90
Rate for Payer: Aetna Commercial	$234.30
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$196.27
Rate for Payer: BCBS of TX Blue Essentials	$234.62
Rate for Payer: BCBS of TX PPO	$261.70
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cigna Medicaid	$67.53
Rate for Payer: Molina CHIP/Medicaid	$67.53
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	$67.53
Rate for Payer: Scott and White EPO/PPO	$213.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.53

BARIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	6809202
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna Commercial	$149.60
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cigna Medicaid	$37.80
Rate for Payer: Molina CHIP/Medicaid	$37.80
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	$37.80
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.80

BARIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	6809202
Hospital Revenue Code	510
Rate for Payer: Cash Price	$239.36

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

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	8568500
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$267.15
Rate for Payer: Aetna Commercial	$226.05
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$134.82
Rate for Payer: BCBS of TX Blue Essentials	$161.16
Rate for Payer: BCBS of TX PPO	$179.75
Rate for Payer: Cash Price	$361.68
Rate for Payer: Cash Price	$361.68
Rate for Payer: Cigna Medicaid	$51.08
Rate for Payer: Molina CHIP/Medicaid	$51.08
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	$51.08
Rate for Payer: Scott and White EPO/PPO	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.08

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

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	8568500
Hospital Revenue Code	510
Rate for Payer: Cash Price	$361.68

BARIATRIC E&M-NEW PATIENT LVL IV BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	8584477
Hospital Revenue Code	510
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$317.20
Rate for Payer: Aetna Commercial	$268.40
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: BCBS of TX Blue Advantage	$228.25
Rate for Payer: BCBS of TX Blue Essentials	$272.85
Rate for Payer: BCBS of TX PPO	$304.34
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cigna Medicaid	$74.74
Rate for Payer: Molina CHIP/Medicaid	$74.74
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	$74.74
Rate for Payer: Scott and White EPO/PPO	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.74

BARIATRIC E&M-NEW PATIENT LVL IV BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	8584477
Hospital Revenue Code	510
Rate for Payer: Cash Price	$429.44

BARIATRIC E&M- NEW PATIENT LVL V BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	8582482
Hospital Revenue Code	510
Rate for Payer: Cash Price	$524.48

BARIATRIC E&M- NEW PATIENT LVL V BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	8582482
Hospital Revenue Code	510
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$397.16
Rate for Payer: Aetna Commercial	$327.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$297.87
Rate for Payer: BCBS of TX Blue Essentials	$356.08
Rate for Payer: BCBS of TX PPO	$397.16
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cigna Medicaid	$92.92
Rate for Payer: Molina CHIP/Medicaid	$92.92
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	$92.92
Rate for Payer: Scott and White EPO/PPO	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.92

BARIATRIC GROUP PSYCHOTHERAPY BCE

Facility

$456.00

Service Code	CPT 90853
Hospital Charge Code	8582490
Hospital Revenue Code	915
Rate for Payer: Cash Price	$401.28

BARIATRIC GROUP PSYCHOTHERAPY BCE

Facility

$456.00

Service Code	CPT 90853
Hospital Charge Code	8582490
Hospital Revenue Code	915
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$296.40
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$122.28
Rate for Payer: Amerigroup CHIP/Medicaid	$41.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$81.52
Rate for Payer: Amerigroup Medicare	$81.52
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	$81.52
Rate for Payer: BCBS of TX PPO	$182.40
Rate for Payer: Cash Price	$401.28
Rate for Payer: Cash Price	$401.28
Rate for Payer: Cash Price	$401.28
Rate for Payer: Cigna Commercial	$184.66
Rate for Payer: Cigna Medicaid	$18.44
Rate for Payer: Cigna Medicare	$81.52
Rate for Payer: Employer Direct Commercial	$81.52
Rate for Payer: Humana Medicare/TRICARE	$81.52
Rate for Payer: Molina CHIP/Medicaid	$18.44
Rate for Payer: Molina Dual Medicare/Medicaid	$81.52
Rate for Payer: Molina Medicare	$81.52
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	$18.44
Rate for Payer: Scott and White EPO/PPO	$1.46
Rate for Payer: Scott and White Medicare	$81.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.44
Rate for Payer: Superior Health Plan EPO	$81.52
Rate for Payer: Superior Health Plan Medicare	$81.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$81.52
Rate for Payer: Universal American Medicare	$81.52
Rate for Payer: Wellcare Medicare	$81.52
Rate for Payer: Wellmed Medicare	$81.52

BARIATRIC HLTH BHAV INTERV IND 1ST 30MIN BCE

Facility

$385.00

Service Code	CPT 96158
Hospital Charge Code	6806158
Hospital Revenue Code	914
Rate for Payer: Cash Price	$338.80

BARIATRIC HLTH BHAV INTERV IND 1ST 30MIN BCE

Facility

$385.00

Service Code	CPT 96158
Hospital Charge Code	6806158
Hospital Revenue Code	914
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$330.32
Rate for Payer: Aetna Commercial	$211.75
Rate for Payer: Aetna Medicare	$218.72
Rate for Payer: Amerigroup CHIP/Medicaid	$34.65
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$145.81
Rate for Payer: Amerigroup Medicare	$145.81
Rate for Payer: BCBS of TX Blue Advantage	$136.66
Rate for Payer: BCBS of TX Blue Essentials	$163.36
Rate for Payer: BCBS of TX Medicare	$145.81
Rate for Payer: BCBS of TX PPO	$182.21
Rate for Payer: Cash Price	$338.80
Rate for Payer: Cash Price	$338.80
Rate for Payer: Cash Price	$338.80
Rate for Payer: Cigna Commercial	$330.32
Rate for Payer: Cigna Medicare	$145.81
Rate for Payer: Employer Direct Commercial	$145.81
Rate for Payer: Humana Medicare/TRICARE	$145.81
Rate for Payer: Molina Dual Medicare/Medicaid	$145.81
Rate for Payer: Molina Medicare	$145.81
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: Scott and White EPO/PPO	$2.61
Rate for Payer: Scott and White Medicare	$145.81
Rate for Payer: Superior Health Plan EPO	$145.81
Rate for Payer: Superior Health Plan Medicare	$145.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$145.81
Rate for Payer: Universal American Medicare	$145.81
Rate for Payer: Wellcare Medicare	$145.81
Rate for Payer: Wellmed Medicare	$145.81

BARIATRIC HLTH BHV ASSMT/REASSESSMENT BCE

Facility

$483.00

Service Code	CPT 96156
Hospital Charge Code	8582487
Hospital Revenue Code	914
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$313.95
Rate for Payer: Aetna Commercial	$265.65
Rate for Payer: Aetna Medicare	$122.28
Rate for Payer: Amerigroup CHIP/Medicaid	$43.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$81.52
Rate for Payer: Amerigroup Medicare	$81.52
Rate for Payer: BCBS of TX Blue Advantage	$136.66
Rate for Payer: BCBS of TX Blue Essentials	$163.36
Rate for Payer: BCBS of TX Medicare	$81.52
Rate for Payer: BCBS of TX PPO	$182.21
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cash Price	$425.04
Rate for Payer: Cigna Commercial	$184.66
Rate for Payer: Cigna Medicare	$81.52
Rate for Payer: Employer Direct Commercial	$81.52
Rate for Payer: Humana Medicare/TRICARE	$81.52
Rate for Payer: Molina Dual Medicare/Medicaid	$81.52
Rate for Payer: Molina Medicare	$81.52
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: Scott and White EPO/PPO	$1.46
Rate for Payer: Scott and White Medicare	$81.52
Rate for Payer: Superior Health Plan EPO	$81.52
Rate for Payer: Superior Health Plan Medicare	$81.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$81.52
Rate for Payer: Universal American Medicare	$81.52
Rate for Payer: Wellcare Medicare	$81.52
Rate for Payer: Wellmed Medicare	$81.52

BARIATRIC HLTH BHV ASSMT/REASSESSMENT BCE

Facility

$483.00

Service Code	CPT 96156
Hospital Charge Code	8582487
Hospital Revenue Code	914
Rate for Payer: Cash Price	$425.04

BARIATRIC IV INF HYD EA ADD HR BCE

Facility

$251.00

Service Code	CPT 96361
Hospital Charge Code	6806361
Hospital Revenue Code	260
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$163.15
Rate for Payer: Aetna Commercial	$138.05
Rate for Payer: Aetna Medicare	$65.16
Rate for Payer: Amerigroup CHIP/Medicaid	$22.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$43.44
Rate for Payer: Amerigroup Medicare	$43.44
Rate for Payer: BCBS of TX Blue Advantage	$23.82
Rate for Payer: BCBS of TX Blue Essentials	$28.48
Rate for Payer: BCBS of TX Medicare	$43.44
Rate for Payer: BCBS of TX PPO	$31.76
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cigna Commercial	$98.40
Rate for Payer: Cigna Medicare	$43.44
Rate for Payer: Employer Direct Commercial	$43.44
Rate for Payer: Humana Medicare/TRICARE	$43.44
Rate for Payer: Molina Dual Medicare/Medicaid	$43.44
Rate for Payer: Molina Medicare	$43.44
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: Scott and White EPO/PPO	$0.78
Rate for Payer: Scott and White Medicare	$43.44
Rate for Payer: Superior Health Plan EPO	$43.44
Rate for Payer: Superior Health Plan Medicare	$43.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$43.44
Rate for Payer: Universal American Medicare	$43.44
Rate for Payer: Wellcare Medicare	$43.44
Rate for Payer: Wellmed Medicare	$43.44

BARIATRIC IV INF HYD EA ADD HR BCE

Facility

$251.00

Service Code	CPT 96361
Hospital Charge Code	6806361
Hospital Revenue Code	260
Rate for Payer: Cash Price	$220.88

Know your out-of-pocket cost for care.

All Charges