White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BARIATRIC PSYTX W PT 30 MINUTES BCE

Facility

$281.00

Service Code	CPT 90832
Hospital Charge Code	8584479
Hospital Revenue Code	914
Rate for Payer: Cash Price	$247.28

BARIATRIC PSYTX W PT 45 MINUTES BCE

Facility

$364.00

Service Code	CPT 90834
Hospital Charge Code	8582488
Hospital Revenue Code	914
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$330.32
Rate for Payer: Aetna Commercial	$200.20
Rate for Payer: Aetna Medicare	$218.72
Rate for Payer: Amerigroup CHIP/Medicaid	$32.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$145.81
Rate for Payer: Amerigroup Medicare	$145.81
Rate for Payer: BCBS of TX Blue Advantage	$109.20
Rate for Payer: BCBS of TX Blue Essentials	$131.04
Rate for Payer: BCBS of TX Medicare	$145.81
Rate for Payer: BCBS of TX PPO	$145.60
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cigna Commercial	$330.32
Rate for Payer: Cigna Medicaid	$69.77
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	$69.77
Rate for Payer: Molina Dual Medicare/Medicaid	$145.81
Rate for Payer: Molina Medicare	$145.81
Rate for Payer: Multiplan Auto	$236.60
Rate for Payer: Multiplan Commercial	$236.60
Rate for Payer: Multiplan Workers Comp	$236.60
Rate for Payer: Parkland Medicaid	$69.77
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	$69.77
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 PSYTX W PT 45 MINUTES BCE

Facility

$364.00

Service Code	CPT 90834
Hospital Charge Code	8582488
Hospital Revenue Code	914
Rate for Payer: Cash Price	$320.32

BARIATRIC PSYTX W PT 60 MINUTES BCE

Facility

$416.00

Service Code	CPT 90837
Hospital Charge Code	8582489
Hospital Revenue Code	914
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$330.32
Rate for Payer: Aetna Commercial	$228.80
Rate for Payer: Aetna Medicare	$218.72
Rate for Payer: Amerigroup CHIP/Medicaid	$37.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$145.81
Rate for Payer: Amerigroup Medicare	$145.81
Rate for Payer: BCBS of TX Blue Advantage	$124.80
Rate for Payer: BCBS of TX Blue Essentials	$149.76
Rate for Payer: BCBS of TX Medicare	$145.81
Rate for Payer: BCBS of TX PPO	$166.40
Rate for Payer: Cash Price	$366.08
Rate for Payer: Cash Price	$366.08
Rate for Payer: Cash Price	$366.08
Rate for Payer: Cigna Commercial	$330.32
Rate for Payer: Cigna Medicaid	$103.18
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	$103.18
Rate for Payer: Molina Dual Medicare/Medicaid	$145.81
Rate for Payer: Molina Medicare	$145.81
Rate for Payer: Multiplan Auto	$270.40
Rate for Payer: Multiplan Commercial	$270.40
Rate for Payer: Multiplan Workers Comp	$270.40
Rate for Payer: Parkland Medicaid	$103.18
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	$103.18
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 PSYTX W PT 60 MINUTES BCE

Facility

$416.00

Service Code	CPT 90837
Hospital Charge Code	8582489
Hospital Revenue Code	914
Rate for Payer: Cash Price	$366.08

BARIATRIC REM MNTR PHYSIOL PARAM DEV BCE

Facility

$183.00

Service Code	CPT 99454
Hospital Charge Code	8580500
Hospital Revenue Code	510
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$118.95
Rate for Payer: Aetna Commercial	$100.65
Rate for Payer: Aetna Medicare	$51.74
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$34.49
Rate for Payer: Amerigroup Medicare	$34.49
Rate for Payer: BCBS of TX Blue Advantage	$63.08
Rate for Payer: BCBS of TX Blue Essentials	$75.40
Rate for Payer: BCBS of TX Medicare	$34.49
Rate for Payer: BCBS of TX PPO	$84.10
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cigna Commercial	$78.13
Rate for Payer: Cigna Medicare	$34.49
Rate for Payer: Employer Direct Commercial	$34.49
Rate for Payer: Humana Medicare/TRICARE	$34.49
Rate for Payer: Molina Dual Medicare/Medicaid	$34.49
Rate for Payer: Molina Medicare	$34.49
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$0.62
Rate for Payer: Scott and White Medicare	$34.49
Rate for Payer: Superior Health Plan EPO	$34.49
Rate for Payer: Superior Health Plan Medicare	$34.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$34.49
Rate for Payer: Universal American Medicare	$34.49
Rate for Payer: Wellcare Medicare	$34.49
Rate for Payer: Wellmed Medicare	$34.49

BARIATRIC REM MNTR PHYSIOL PARAM DEV BCE

Facility

$183.00

Service Code	CPT 99454
Hospital Charge Code	8580500
Hospital Revenue Code	510
Rate for Payer: Cash Price	$161.04

BARIATRIC REM MNTR PHYSIOL PARAM SETUP

Facility

$570.00

Service Code	CPT 99453
Hospital Charge Code	8602505
Hospital Revenue Code	510
Rate for Payer: Cash Price	$501.60

BARIATRIC REM MNTR PHYSIOL PARAM SETUP

Facility

$570.00

Service Code	CPT 99453
Hospital Charge Code	8602505
Hospital Revenue Code	510
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$370.50
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$181.34
Rate for Payer: Amerigroup CHIP/Medicaid	$51.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$120.89
Rate for Payer: Amerigroup Medicare	$120.89
Rate for Payer: BCBS of TX Blue Advantage	$201.72
Rate for Payer: BCBS of TX Blue Essentials	$241.13
Rate for Payer: BCBS of TX Medicare	$120.89
Rate for Payer: BCBS of TX PPO	$268.96
Rate for Payer: Cash Price	$501.60
Rate for Payer: Cash Price	$501.60
Rate for Payer: Cash Price	$501.60
Rate for Payer: Cigna Commercial	$273.87
Rate for Payer: Cigna Medicare	$120.89
Rate for Payer: Employer Direct Commercial	$120.89
Rate for Payer: Humana Medicare/TRICARE	$120.89
Rate for Payer: Molina Dual Medicare/Medicaid	$120.89
Rate for Payer: Molina Medicare	$120.89
Rate for Payer: Multiplan Auto	$370.50
Rate for Payer: Multiplan Commercial	$370.50
Rate for Payer: Multiplan Workers Comp	$370.50
Rate for Payer: Scott and White EPO/PPO	$2.16
Rate for Payer: Scott and White Medicare	$120.89
Rate for Payer: Superior Health Plan EPO	$120.89
Rate for Payer: Superior Health Plan Medicare	$120.89
Rate for Payer: Universal American Dual Medicare/Medicaid	$120.89
Rate for Payer: Universal American Medicare	$120.89
Rate for Payer: Wellcare Medicare	$120.89
Rate for Payer: Wellmed Medicare	$120.89

BARIATRIC REM PHYSIOL MNTR 1ST 20 MIN BCE

Facility

$183.00

Service Code	CPT 99457
Hospital Charge Code	8580501
Hospital Revenue Code	510
Rate for Payer: Cash Price	$161.04

BARIATRIC REM PHYSIOL MNTR 1ST 20 MIN BCE

Facility

$183.00

Service Code	CPT 99457
Hospital Charge Code	8580501
Hospital Revenue Code	510
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$118.95
Rate for Payer: Aetna Commercial	$100.65
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$56.45
Rate for Payer: BCBS of TX Blue Essentials	$67.48
Rate for Payer: BCBS of TX PPO	$75.26
Rate for Payer: Cash Price	$161.04
Rate for Payer: Cash Price	$161.04
Rate for Payer: Multiplan Auto	$118.95
Rate for Payer: Multiplan Commercial	$118.95
Rate for Payer: Multiplan Workers Comp	$118.95
Rate for Payer: Scott and White EPO/PPO	$91.50

BARIATRIC VITAMIN B12 INJECTION BCE

Facility

$57.40

Service Code	HCPCS J3420
Hospital Charge Code	8582485
Hospital Revenue Code	636
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$37.31
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: BCBS of TX Blue Advantage	$5.00
Rate for Payer: BCBS of TX Blue Essentials	$6.00
Rate for Payer: BCBS of TX PPO	$6.66
Rate for Payer: Cash Price	$50.51
Rate for Payer: Cash Price	$50.51
Rate for Payer: Multiplan Auto	$37.31
Rate for Payer: Multiplan Commercial	$37.31
Rate for Payer: Multiplan Workers Comp	$37.31
Rate for Payer: Scott and White EPO/PPO	$28.70
Rate for Payer: Superior Health Plan EPO	$7.81

BARIATRIC VITAMIN B12 INJECTION BCE

Facility

$57.40

Service Code	HCPCS J3420
Hospital Charge Code	8582485
Hospital Revenue Code	636
Min. Negotiated Rate	$14.35
Max. Negotiated Rate	$28.70
Rate for Payer: Cash Price	$50.51
Rate for Payer: Cigna Commercial	$14.35
Rate for Payer: Scott and White EPO/PPO	$28.70

BARRIER SKIN SPRAY

Facility

$27.78

Hospital Charge Code	8570487
Hospital Revenue Code	272
Rate for Payer: Cash Price	$24.45

BARRIER SKIN SPRAY

Facility

$27.78

Hospital Charge Code	8570487
Hospital Revenue Code	272
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$18.06
Rate for Payer: Aetna Commercial	$15.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.50
Rate for Payer: BCBS of TX Blue Advantage	$8.33
Rate for Payer: BCBS of TX Blue Essentials	$10.00
Rate for Payer: BCBS of TX PPO	$11.11
Rate for Payer: Cash Price	$24.45
Rate for Payer: Multiplan Auto	$18.06
Rate for Payer: Multiplan Commercial	$18.06
Rate for Payer: Multiplan Workers Comp	$18.06
Rate for Payer: Scott and White EPO/PPO	$13.89
Rate for Payer: Superior Health Plan EPO	$3.78

Bartholin's Gland

Facility

$695.00

Service Code	CPT 56420
Hospital Charge Code	8680562
Hospital Revenue Code	450
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$451.75
Rate for Payer: Aetna Commercial	$382.25
Rate for Payer: Aetna Medicare	$273.36
Rate for Payer: Amerigroup CHIP/Medicaid	$62.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$182.24
Rate for Payer: Amerigroup Medicare	$182.24
Rate for Payer: BCBS of TX Blue Advantage	$140.11
Rate for Payer: BCBS of TX Blue Essentials	$167.80
Rate for Payer: BCBS of TX Medicare	$182.24
Rate for Payer: BCBS of TX PPO	$211.43
Rate for Payer: Cash Price	$611.60
Rate for Payer: Cash Price	$611.60
Rate for Payer: Cash Price	$611.60
Rate for Payer: Cigna Commercial	$412.83
Rate for Payer: Cigna Medicaid	$70.52
Rate for Payer: Cigna Medicare	$182.24
Rate for Payer: Employer Direct Commercial	$182.24
Rate for Payer: Humana Medicare/TRICARE	$182.24
Rate for Payer: Molina CHIP/Medicaid	$70.52
Rate for Payer: Molina Dual Medicare/Medicaid	$182.24
Rate for Payer: Molina Medicare	$182.24
Rate for Payer: Multiplan Auto	$451.75
Rate for Payer: Multiplan Commercial	$451.75
Rate for Payer: Multiplan Workers Comp	$451.75
Rate for Payer: Parkland Medicaid	$70.52
Rate for Payer: Scott and White EPO/PPO	$3.26
Rate for Payer: Scott and White Medicare	$182.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.52
Rate for Payer: Superior Health Plan EPO	$182.24
Rate for Payer: Superior Health Plan Medicare	$182.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$182.24
Rate for Payer: Universal American Medicare	$182.24
Rate for Payer: Wellcare Medicare	$182.24
Rate for Payer: Wellmed Medicare	$182.24

Bartholin's Gland

Facility

$695.00

Service Code	CPT 56420
Hospital Charge Code	8680562
Hospital Revenue Code	450
Rate for Payer: Cash Price	$611.60

Basic Metabolic Panel

Facility

$496.00

Service Code	CPT 80048
Hospital Charge Code	1603182
Hospital Revenue Code	301
Rate for Payer: Cash Price	$436.48

Basic Metabolic Panel

Facility

$496.00

Service Code	CPT 80048
Hospital Charge Code	1603182
Hospital Revenue Code	301
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$322.40
Rate for Payer: Aetna Commercial	$8.89
Rate for Payer: Aetna Medicare	$12.69
Rate for Payer: Amerigroup CHIP/Medicaid	$3.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.46
Rate for Payer: Amerigroup Medicare	$8.46
Rate for Payer: BCBS of TX Blue Advantage	$13.96
Rate for Payer: BCBS of TX Blue Essentials	$16.75
Rate for Payer: BCBS of TX Medicare	$8.46
Rate for Payer: BCBS of TX PPO	$18.70
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cigna Medicaid	$8.46
Rate for Payer: Cigna Medicare	$8.46
Rate for Payer: Employer Direct Commercial	$8.46
Rate for Payer: Humana Medicare/TRICARE	$8.46
Rate for Payer: Molina CHIP/Medicaid	$8.46
Rate for Payer: Molina Dual Medicare/Medicaid	$8.46
Rate for Payer: Molina Medicare	$8.46
Rate for Payer: Multiplan Auto	$322.40
Rate for Payer: Multiplan Commercial	$322.40
Rate for Payer: Multiplan Workers Comp	$322.40
Rate for Payer: Parkland Medicaid	$8.46
Rate for Payer: Scott and White EPO/PPO	$10.58
Rate for Payer: Scott and White Medicare	$8.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.46
Rate for Payer: Superior Health Plan EPO	$8.46
Rate for Payer: Superior Health Plan Medicare	$8.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.46
Rate for Payer: Universal American Medicare	$8.46
Rate for Payer: Wellcare Medicare	$8.46
Rate for Payer: Wellmed Medicare	$8.46

basket special ret 180x4x2cm

Facility

$1,157.70

Hospital Charge Code	116256
Hospital Revenue Code	272
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$752.50
Rate for Payer: Aetna Commercial	$636.74
Rate for Payer: Amerigroup CHIP/Medicaid	$104.19
Rate for Payer: BCBS of TX Blue Advantage	$347.31
Rate for Payer: BCBS of TX Blue Essentials	$416.77
Rate for Payer: BCBS of TX PPO	$463.08
Rate for Payer: Cash Price	$1,018.78
Rate for Payer: Multiplan Auto	$752.50
Rate for Payer: Multiplan Commercial	$752.50
Rate for Payer: Multiplan Workers Comp	$752.50
Rate for Payer: Scott and White EPO/PPO	$578.85
Rate for Payer: Superior Health Plan EPO	$157.45

basket special ret 180x4x2cm

Facility

$1,157.70

Hospital Charge Code	116256
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,018.78

basket special ret 180x6x3cm

Facility

$1,157.70

Hospital Charge Code	116257
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,018.78

basket special ret 180x6x3cm

Facility

$1,157.70

Hospital Charge Code	116257
Hospital Revenue Code	272
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$752.50
Rate for Payer: Aetna Commercial	$636.74
Rate for Payer: Amerigroup CHIP/Medicaid	$104.19
Rate for Payer: BCBS of TX Blue Advantage	$347.31
Rate for Payer: BCBS of TX Blue Essentials	$416.77
Rate for Payer: BCBS of TX PPO	$463.08
Rate for Payer: Cash Price	$1,018.78
Rate for Payer: Multiplan Auto	$752.50
Rate for Payer: Multiplan Commercial	$752.50
Rate for Payer: Multiplan Workers Comp	$752.50
Rate for Payer: Scott and White EPO/PPO	$578.85
Rate for Payer: Superior Health Plan EPO	$157.45

BB Bill Antigen Type Unit

Facility

$217.00

Service Code	CPT 86902
Hospital Charge Code	2408749
Hospital Revenue Code	302
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$744.67
Rate for Payer: Aetna Commercial	$6.67
Rate for Payer: Aetna Medicare	$493.10
Rate for Payer: Amerigroup CHIP/Medicaid	$2.48
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$328.73
Rate for Payer: Amerigroup Medicare	$328.73
Rate for Payer: BCBS of TX Blue Advantage	$467.63
Rate for Payer: BCBS of TX Blue Essentials	$561.15
Rate for Payer: BCBS of TX Medicare	$328.73
Rate for Payer: BCBS of TX PPO	$626.34
Rate for Payer: Cash Price	$190.96
Rate for Payer: Cash Price	$190.96
Rate for Payer: Cash Price	$190.96
Rate for Payer: Cigna Commercial	$744.67
Rate for Payer: Cigna Medicaid	$6.35
Rate for Payer: Cigna Medicare	$328.73
Rate for Payer: Employer Direct Commercial	$328.73
Rate for Payer: Humana Medicare/TRICARE	$328.73
Rate for Payer: Molina CHIP/Medicaid	$6.35
Rate for Payer: Molina Dual Medicare/Medicaid	$328.73
Rate for Payer: Molina Medicare	$328.73
Rate for Payer: Multiplan Auto	$141.05
Rate for Payer: Multiplan Commercial	$141.05
Rate for Payer: Multiplan Workers Comp	$141.05
Rate for Payer: Parkland Medicaid	$6.35
Rate for Payer: Scott and White EPO/PPO	$7.94
Rate for Payer: Scott and White Medicare	$328.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.35
Rate for Payer: Superior Health Plan EPO	$328.73
Rate for Payer: Superior Health Plan Medicare	$328.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$328.73
Rate for Payer: Universal American Medicare	$328.73
Rate for Payer: Wellcare Medicare	$328.73
Rate for Payer: Wellmed Medicare	$328.73

BB Bill Only Cold Agglutinin Titer

Facility

$68.00

Service Code	CPT 86157
Hospital Charge Code	2400513
Hospital Revenue Code	302
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$44.20
Rate for Payer: Aetna Commercial	$8.47
Rate for Payer: Aetna Medicare	$12.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.06
Rate for Payer: Amerigroup Medicare	$8.06
Rate for Payer: BCBS of TX Blue Advantage	$13.30
Rate for Payer: BCBS of TX Blue Essentials	$15.96
Rate for Payer: BCBS of TX Medicare	$8.06
Rate for Payer: BCBS of TX PPO	$17.81
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cash Price	$59.84
Rate for Payer: Cigna Medicaid	$8.06
Rate for Payer: Cigna Medicare	$8.06
Rate for Payer: Employer Direct Commercial	$8.06
Rate for Payer: Humana Medicare/TRICARE	$8.06
Rate for Payer: Molina CHIP/Medicaid	$8.06
Rate for Payer: Molina Dual Medicare/Medicaid	$8.06
Rate for Payer: Molina Medicare	$8.06
Rate for Payer: Multiplan Auto	$44.20
Rate for Payer: Multiplan Commercial	$44.20
Rate for Payer: Multiplan Workers Comp	$44.20
Rate for Payer: Parkland Medicaid	$8.06
Rate for Payer: Scott and White EPO/PPO	$10.08
Rate for Payer: Scott and White Medicare	$8.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.06
Rate for Payer: Superior Health Plan EPO	$8.06
Rate for Payer: Superior Health Plan Medicare	$8.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.06
Rate for Payer: Universal American Medicare	$8.06
Rate for Payer: Wellcare Medicare	$8.06
Rate for Payer: Wellmed Medicare	$8.06

Know your out-of-pocket cost for care.

All Charges