White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BARIATRIC IV INF HYD INIT 31-60MIN BCE

Facility

$847.00

Service Code	CPT 96360
Hospital Charge Code	6806360
Hospital Revenue Code	260
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$550.55
Rate for Payer: Aetna Commercial	$465.85
Rate for Payer: Aetna Medicare	$294.03
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$196.02
Rate for Payer: Amerigroup Medicare	$196.02
Rate for Payer: BCBS of TX Blue Advantage	$67.09
Rate for Payer: BCBS of TX Blue Essentials	$80.20
Rate for Payer: BCBS of TX Medicare	$196.02
Rate for Payer: BCBS of TX PPO	$89.46
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cash Price	$745.36
Rate for Payer: Cigna Commercial	$444.05
Rate for Payer: Cigna Medicare	$196.02
Rate for Payer: Employer Direct Commercial	$196.02
Rate for Payer: Humana Medicare/TRICARE	$196.02
Rate for Payer: Molina Dual Medicare/Medicaid	$196.02
Rate for Payer: Molina Medicare	$196.02
Rate for Payer: Multiplan Auto	$550.55
Rate for Payer: Multiplan Commercial	$550.55
Rate for Payer: Multiplan Workers Comp	$550.55
Rate for Payer: Scott and White EPO/PPO	$3.51
Rate for Payer: Scott and White Medicare	$196.02
Rate for Payer: Superior Health Plan EPO	$196.02
Rate for Payer: Superior Health Plan Medicare	$196.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$196.02
Rate for Payer: Universal American Medicare	$196.02
Rate for Payer: Wellcare Medicare	$196.02
Rate for Payer: Wellmed Medicare	$196.02

BARIATRIC IV INF HYD INIT 31-60MIN BCE

Facility

$847.00

Service Code	CPT 96360
Hospital Charge Code	6806360
Hospital Revenue Code	260
Rate for Payer: Cash Price	$745.36

BARIATRIC MEDICAL NUTRITION GROUP BCE

Facility

$56.00

Service Code	CPT 97804
Hospital Charge Code	8584478
Hospital Revenue Code	942
Rate for Payer: Cash Price	$49.28

BARIATRIC MEDICAL NUTRITION GROUP BCE

Facility

$56.00

Service Code	CPT 97804
Hospital Charge Code	8584478
Hospital Revenue Code	942
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$37.63
Rate for Payer: Aetna Commercial	$30.80
Rate for Payer: Amerigroup CHIP/Medicaid	$5.04
Rate for Payer: BCBS of TX Blue Advantage	$28.22
Rate for Payer: BCBS of TX Blue Essentials	$33.74
Rate for Payer: BCBS of TX PPO	$37.63
Rate for Payer: Cash Price	$49.28
Rate for Payer: Cash Price	$49.28
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: Scott and White EPO/PPO	$28.00
Rate for Payer: Superior Health Plan EPO	$7.62

BARIATRIC MED NUTRITION INDIV SUBSEQ BCE

Facility

$102.00

Service Code	CPT 97803
Hospital Charge Code	8582486
Hospital Revenue Code	942
Rate for Payer: Cash Price	$89.76

BARIATRIC MED NUTRITION INDIV SUBSEQ BCE

Facility

$102.00

Service Code	CPT 97803
Hospital Charge Code	8582486
Hospital Revenue Code	942
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$68.56
Rate for Payer: Aetna Commercial	$56.10
Rate for Payer: Amerigroup CHIP/Medicaid	$9.18
Rate for Payer: BCBS of TX Blue Advantage	$51.42
Rate for Payer: BCBS of TX Blue Essentials	$61.46
Rate for Payer: BCBS of TX PPO	$68.56
Rate for Payer: Cash Price	$89.76
Rate for Payer: Cash Price	$89.76
Rate for Payer: Multiplan Auto	$66.30
Rate for Payer: Multiplan Commercial	$66.30
Rate for Payer: Multiplan Workers Comp	$66.30
Rate for Payer: Scott and White EPO/PPO	$51.00
Rate for Payer: Superior Health Plan EPO	$13.87

BARIATRIC MED NUTRTN TH INIT 15MIN BCE

Facility

$120.00

Service Code	CPT 97802
Hospital Charge Code	6807802
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$80.27
Rate for Payer: Aetna Commercial	$66.00
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$60.20
Rate for Payer: BCBS of TX Blue Essentials	$71.97
Rate for Payer: BCBS of TX PPO	$80.27
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
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: Scott and White EPO/PPO	$60.00
Rate for Payer: Superior Health Plan EPO	$16.32

BARIATRIC MED NUTRTN TH INIT 15MIN BCE

Facility

$120.00

Service Code	CPT 97802
Hospital Charge Code	6807802
Hospital Revenue Code	942
Rate for Payer: Cash Price	$105.60

Bariatric MNT subs tx for change dx BCE

Facility

$102.00

Service Code	HCPCS G0270
Hospital Charge Code	8614505
Hospital Revenue Code	942
Rate for Payer: Cash Price	$89.76

Bariatric MNT subs tx for change dx BCE

Facility

$102.00

Service Code	HCPCS G0270
Hospital Charge Code	8614505
Hospital Revenue Code	942
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$68.56
Rate for Payer: Aetna Commercial	$56.10
Rate for Payer: Amerigroup CHIP/Medicaid	$9.18
Rate for Payer: BCBS of TX Blue Advantage	$51.42
Rate for Payer: BCBS of TX Blue Essentials	$61.46
Rate for Payer: BCBS of TX PPO	$68.56
Rate for Payer: Cash Price	$89.76
Rate for Payer: Cash Price	$89.76
Rate for Payer: Multiplan Auto	$66.30
Rate for Payer: Multiplan Commercial	$66.30
Rate for Payer: Multiplan Workers Comp	$66.30
Rate for Payer: Scott and White EPO/PPO	$51.00
Rate for Payer: Superior Health Plan EPO	$13.87

BARIATRIC O2 UPTAKE REST INDRCT BCE

Facility

$546.00

Service Code	CPT 94690
Hospital Charge Code	6809901
Hospital Revenue Code	460
Rate for Payer: Cash Price	$480.48

BARIATRIC O2 UPTAKE REST INDRCT BCE

Facility

$546.00

Service Code	CPT 94690
Hospital Charge Code	6809901
Hospital Revenue Code	460
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$354.90
Rate for Payer: Aetna Commercial	$300.30
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$49.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$58.17
Rate for Payer: BCBS of TX Blue Essentials	$69.53
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$77.56
Rate for Payer: Cash Price	$480.48
Rate for Payer: Cash Price	$480.48
Rate for Payer: Cash Price	$480.48
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
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: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

BARIATRIC PREVENTIVE COUNSELING INDIV 15 MIN BCE

Facility

$124.00

Service Code	CPT 99401
Hospital Charge Code	8582483
Hospital Revenue Code	510
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$80.60
Rate for Payer: Aetna Commercial	$68.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: BCBS of TX Blue Advantage	$43.90
Rate for Payer: BCBS of TX Blue Essentials	$52.48
Rate for Payer: BCBS of TX PPO	$58.53
Rate for Payer: Cash Price	$109.12
Rate for Payer: Cash Price	$109.12
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: Scott and White EPO/PPO	$62.00

BARIATRIC PREVENTIVE COUNSELING INDIV 15 MIN BCE

Facility

$124.00

Service Code	CPT 99401
Hospital Charge Code	8582483
Hospital Revenue Code	510
Rate for Payer: Cash Price	$109.12

BARIATRIC PREVENTIVE COUNSELING INDIV 30 MIN BCE

Facility

$208.00

Service Code	CPT 99402
Hospital Charge Code	8580499
Hospital Revenue Code	510
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$135.20
Rate for Payer: Aetna Commercial	$114.40
Rate for Payer: Amerigroup CHIP/Medicaid	$18.72
Rate for Payer: BCBS of TX Blue Advantage	$89.05
Rate for Payer: BCBS of TX Blue Essentials	$106.45
Rate for Payer: BCBS of TX PPO	$118.74
Rate for Payer: Cash Price	$183.04
Rate for Payer: Cash Price	$183.04
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: Scott and White EPO/PPO	$104.00

BARIATRIC PREVENTIVE COUNSELING INDIV 30 MIN BCE

Facility

$208.00

Service Code	CPT 99402
Hospital Charge Code	8580499
Hospital Revenue Code	510
Rate for Payer: Cash Price	$183.04

BARIATRIC PSYCL/NRPSYC TST PHY/QHP 1ST BCE

Facility

$283.00

Service Code	CPT 96136
Hospital Charge Code	8582491
Hospital Revenue Code	918
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$264.63
Rate for Payer: Aetna Commercial	$155.65
Rate for Payer: Aetna Medicare	$175.23
Rate for Payer: Amerigroup CHIP/Medicaid	$25.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$116.82
Rate for Payer: Amerigroup Medicare	$116.82
Rate for Payer: BCBS of TX Blue Advantage	$40.00
Rate for Payer: BCBS of TX Blue Essentials	$47.82
Rate for Payer: BCBS of TX Medicare	$116.82
Rate for Payer: BCBS of TX PPO	$53.34
Rate for Payer: Cash Price	$249.04
Rate for Payer: Cash Price	$249.04
Rate for Payer: Cash Price	$249.04
Rate for Payer: Cigna Commercial	$264.63
Rate for Payer: Cigna Medicaid	$18.44
Rate for Payer: Cigna Medicare	$116.82
Rate for Payer: Employer Direct Commercial	$116.82
Rate for Payer: Humana Medicare/TRICARE	$116.82
Rate for Payer: Molina CHIP/Medicaid	$18.44
Rate for Payer: Molina Dual Medicare/Medicaid	$116.82
Rate for Payer: Molina Medicare	$116.82
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	$18.44
Rate for Payer: Scott and White EPO/PPO	$2.09
Rate for Payer: Scott and White Medicare	$116.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.44
Rate for Payer: Superior Health Plan EPO	$116.82
Rate for Payer: Superior Health Plan Medicare	$116.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$116.82
Rate for Payer: Universal American Medicare	$116.82
Rate for Payer: Wellcare Medicare	$116.82
Rate for Payer: Wellmed Medicare	$116.82

BARIATRIC PSYCL/NRPSYC TST PHY/QHP 1ST BCE

Facility

$283.00

Service Code	CPT 96136
Hospital Charge Code	8582491
Hospital Revenue Code	918
Rate for Payer: Cash Price	$249.04

BARIATRIC PSYCL/NRPSYC TST PHY/QHP EA BCE

Facility

$275.00

Service Code	CPT 96137
Hospital Charge Code	8580503
Hospital Revenue Code	918
Rate for Payer: Cash Price	$242.00

BARIATRIC PSYCL/NRPSYC TST PHY/QHP EA BCE

Facility

$275.00

Service Code	CPT 96137
Hospital Charge Code	8580503
Hospital Revenue Code	918
Min. Negotiated Rate	$14.17
Max. Negotiated Rate	$178.75
Rate for Payer: Aetna Commercial	$151.25
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
Rate for Payer: BCBS of TX Blue Advantage	$34.49
Rate for Payer: BCBS of TX Blue Essentials	$41.23
Rate for Payer: BCBS of TX PPO	$45.98
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cigna Medicaid	$14.17
Rate for Payer: Molina CHIP/Medicaid	$14.17
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	$14.17
Rate for Payer: Scott and White EPO/PPO	$137.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.17
Rate for Payer: Superior Health Plan EPO	$37.40

BARIATRIC PSYCL TST EVAL PHYS/QHP 1ST BCE

Facility

$527.00

Service Code	CPT 96130
Hospital Charge Code	8580502
Hospital Revenue Code	918
Rate for Payer: Cash Price	$463.76

BARIATRIC PSYCL TST EVAL PHYS/QHP 1ST BCE

Facility

$527.00

Service Code	CPT 96130
Hospital Charge Code	8580502
Hospital Revenue Code	918
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$650.28
Rate for Payer: Aetna Commercial	$289.85
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$47.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$240.73
Rate for Payer: BCBS of TX Blue Essentials	$287.77
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$320.97
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicaid	$84.52
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina CHIP/Medicaid	$84.52
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
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	$84.52
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.52
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

BARIATRIC PSYCL TST EVAL PHYS/QHP EA BCE

Facility

$350.00

Service Code	CPT 96131
Hospital Charge Code	8584480
Hospital Revenue Code	918
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$227.50
Rate for Payer: Aetna Commercial	$192.50
Rate for Payer: Amerigroup CHIP/Medicaid	$31.50
Rate for Payer: BCBS of TX Blue Advantage	$147.99
Rate for Payer: BCBS of TX Blue Essentials	$176.90
Rate for Payer: BCBS of TX PPO	$197.32
Rate for Payer: Cash Price	$308.00
Rate for Payer: Cash Price	$308.00
Rate for Payer: Cigna Medicaid	$84.52
Rate for Payer: Molina CHIP/Medicaid	$84.52
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	$84.52
Rate for Payer: Scott and White EPO/PPO	$175.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.52
Rate for Payer: Superior Health Plan EPO	$47.60

BARIATRIC PSYCL TST EVAL PHYS/QHP EA BCE

Facility

$350.00

Service Code	CPT 96131
Hospital Charge Code	8584480
Hospital Revenue Code	918
Rate for Payer: Cash Price	$308.00

BARIATRIC PSYTX W PT 30 MINUTES BCE

Facility

$281.00

Service Code	CPT 90832
Hospital Charge Code	8584479
Hospital Revenue Code	914
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$330.32
Rate for Payer: Aetna Commercial	$154.55
Rate for Payer: Aetna Medicare	$218.72
Rate for Payer: Amerigroup CHIP/Medicaid	$25.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$145.81
Rate for Payer: Amerigroup Medicare	$145.81
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	$145.81
Rate for Payer: BCBS of TX PPO	$112.40
Rate for Payer: Cash Price	$247.28
Rate for Payer: Cash Price	$247.28
Rate for Payer: Cash Price	$247.28
Rate for Payer: Cigna Commercial	$330.32
Rate for Payer: Cigna Medicaid	$52.66
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 CHIP/Medicaid	$52.66
Rate for Payer: Molina Dual Medicare/Medicaid	$145.81
Rate for Payer: Molina Medicare	$145.81
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	$52.66
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 CHIP/Medicaid	$52.66
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

Know your out-of-pocket cost for care.

All Charges