White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Banded bag with rubber band and tape, 30' x 36'

Facility

$7.97

Hospital Charge Code	992785
Hospital Revenue Code	272
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.74
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.39
Rate for Payer: BCBS of TX Blue Essentials	$2.87
Rate for Payer: BCBS of TX PPO	$3.19
Rate for Payer: Cash Price	$5.42
Rate for Payer: Cigna Medicaid	$5.74
Rate for Payer: Molina CHIP/Medicaid	$5.74
Rate for Payer: Multiplan Auto	$5.18
Rate for Payer: Multiplan Commercial	$5.18
Rate for Payer: Multiplan Workers Comp	$5.18
Rate for Payer: Parkland Medicaid	$5.74
Rate for Payer: Scott and White EPO/PPO	$3.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.74
Rate for Payer: Superior Health Plan EPO	$1.08

Banded bag with rubber band and tape, 30' x 36'

Facility

$7.97

Hospital Charge Code	992785
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.42

BANDGE, GAZE, KRLX, 6PLY, STRL, 4.5X4.1YD

Facility

$5.20

Hospital Charge Code	992876
Hospital Revenue Code	272
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$3.74
Rate for Payer: Amerigroup CHIP/Medicaid	$0.47
Rate for Payer: BCBS of TX Blue Advantage	$1.56
Rate for Payer: BCBS of TX Blue Essentials	$1.87
Rate for Payer: BCBS of TX PPO	$2.08
Rate for Payer: Cash Price	$3.54
Rate for Payer: Cigna Medicaid	$3.74
Rate for Payer: Molina CHIP/Medicaid	$3.74
Rate for Payer: Multiplan Auto	$3.38
Rate for Payer: Multiplan Commercial	$3.38
Rate for Payer: Multiplan Workers Comp	$3.38
Rate for Payer: Parkland Medicaid	$3.74
Rate for Payer: Scott and White EPO/PPO	$2.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.74
Rate for Payer: Superior Health Plan EPO	$0.71

BANDGE, GAZE, KRLX, 6PLY, STRL, 4.5X4.1YD

Facility

$5.20

Hospital Charge Code	992876
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.54

BANDGE, SLF ADHRNT, CBN, 4'X5YD, LF STRL

Facility

$9.78

Hospital Charge Code	993248
Hospital Revenue Code	270
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$7.04
Rate for Payer: Amerigroup CHIP/Medicaid	$0.88
Rate for Payer: BCBS of TX Blue Advantage	$2.93
Rate for Payer: BCBS of TX Blue Essentials	$3.52
Rate for Payer: BCBS of TX PPO	$3.91
Rate for Payer: Cash Price	$6.65
Rate for Payer: Cigna Medicaid	$7.04
Rate for Payer: Molina CHIP/Medicaid	$7.04
Rate for Payer: Multiplan Auto	$6.36
Rate for Payer: Multiplan Commercial	$6.36
Rate for Payer: Multiplan Workers Comp	$6.36
Rate for Payer: Parkland Medicaid	$7.04
Rate for Payer: Scott and White EPO/PPO	$4.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.04
Rate for Payer: Superior Health Plan EPO	$1.33

BANDGE, SLF ADHRNT, CBN, 4'X5YD, LF STRL

Facility

$9.78

Hospital Charge Code	993248
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.65

BAND TR 24CM REG 2 BLN AIR INJ PORT XXRF06

Facility

$177.06

Hospital Charge Code	80320096
Hospital Revenue Code	270
Rate for Payer: Cash Price	$120.40

BAND TR 24CM REG 2 BLN AIR INJ PORT XXRF06

Facility

$177.06

Hospital Charge Code	80320096
Hospital Revenue Code	270
Min. Negotiated Rate	$15.94
Max. Negotiated Rate	$127.48
Rate for Payer: Amerigroup CHIP/Medicaid	$15.94
Rate for Payer: BCBS of TX Blue Advantage	$53.12
Rate for Payer: BCBS of TX Blue Essentials	$63.74
Rate for Payer: BCBS of TX PPO	$70.82
Rate for Payer: Cash Price	$120.40
Rate for Payer: Cigna Medicaid	$127.48
Rate for Payer: Molina CHIP/Medicaid	$127.48
Rate for Payer: Multiplan Auto	$115.09
Rate for Payer: Multiplan Commercial	$115.09
Rate for Payer: Multiplan Workers Comp	$115.09
Rate for Payer: Parkland Medicaid	$127.48
Rate for Payer: Scott and White EPO/PPO	$88.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$127.48
Rate for Payer: Superior Health Plan EPO	$24.08

BAND TR 29CM LNG 2 BLN AIR INJ PORT XXRF06L

Facility

$476.70

Service Code	HCPCS C1726
Hospital Charge Code	992573
Hospital Revenue Code	272
Min. Negotiated Rate	$42.90
Max. Negotiated Rate	$343.22
Rate for Payer: Amerigroup CHIP/Medicaid	$42.90
Rate for Payer: BCBS of TX Blue Advantage	$143.01
Rate for Payer: BCBS of TX Blue Essentials	$171.61
Rate for Payer: BCBS of TX PPO	$190.68
Rate for Payer: Cash Price	$324.16
Rate for Payer: Cigna Medicaid	$343.22
Rate for Payer: Molina CHIP/Medicaid	$343.22
Rate for Payer: Multiplan Auto	$309.86
Rate for Payer: Multiplan Commercial	$309.86
Rate for Payer: Multiplan Workers Comp	$309.86
Rate for Payer: Parkland Medicaid	$343.22
Rate for Payer: Scott and White EPO/PPO	$238.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$343.22
Rate for Payer: Superior Health Plan EPO	$64.83

BAND TR 29CM LNG 2 BLN AIR INJ PORT XXRF06L

Facility

$476.70

Service Code	HCPCS C1726
Hospital Charge Code	992573
Hospital Revenue Code	272
Rate for Payer: Cash Price	$324.16

bard mesh perfix plug

Facility

$27.15

Service Code	HCPCS C1781
Hospital Charge Code	992677
Hospital Revenue Code	272
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$19.55
Rate for Payer: Amerigroup CHIP/Medicaid	$2.44
Rate for Payer: BCBS of TX Blue Advantage	$8.14
Rate for Payer: BCBS of TX Blue Essentials	$9.77
Rate for Payer: BCBS of TX PPO	$10.86
Rate for Payer: Cash Price	$18.46
Rate for Payer: Cigna Medicaid	$19.55
Rate for Payer: Molina CHIP/Medicaid	$19.55
Rate for Payer: Multiplan Auto	$17.65
Rate for Payer: Multiplan Commercial	$17.65
Rate for Payer: Multiplan Workers Comp	$17.65
Rate for Payer: Parkland Medicaid	$19.55
Rate for Payer: Scott and White EPO/PPO	$13.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.55
Rate for Payer: Superior Health Plan EPO	$3.69

bard mesh perfix plug

Facility

$27.15

Service Code	HCPCS C1781
Hospital Charge Code	992677
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.46

BARIATRIC BEHAVIOR COUNSEL OBESITY 15MIN BCE

Facility

$150.00

Hospital Charge Code	8582484
Hospital Revenue Code	510
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$108.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.50
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$75.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00

BARIATRIC BEHAVIOR COUNSEL OBESITY 15MIN BCE

Facility

$150.00

Hospital Charge Code	8582484
Hospital Revenue Code	510
Rate for Payer: Cash Price	$102.00

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

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	6809211
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Molina CHIP/Medicaid	$81.36
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	$81.36
Rate for Payer: Scott and White EPO/PPO	$10.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

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

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	6809211
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

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

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	6809212
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

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

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	6809212
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$125.28
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$52.20
Rate for Payer: BCBS of TX Blue Essentials	$62.64
Rate for Payer: BCBS of TX PPO	$69.60
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cigna Medicaid	$125.28
Rate for Payer: Molina CHIP/Medicaid	$125.28
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	$125.28
Rate for Payer: Scott and White EPO/PPO	$43.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28

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

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8578472
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

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

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8578472
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$151.92
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$63.30
Rate for Payer: BCBS of TX Blue Essentials	$75.96
Rate for Payer: BCBS of TX PPO	$84.40
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cigna Medicaid	$151.92
Rate for Payer: Molina CHIP/Medicaid	$151.92
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	$151.92
Rate for Payer: Scott and White EPO/PPO	$80.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.92

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

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	6809214
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$280.80
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$117.00
Rate for Payer: BCBS of TX Blue Essentials	$140.40
Rate for Payer: BCBS of TX PPO	$156.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cigna Medicaid	$280.80
Rate for Payer: Molina CHIP/Medicaid	$280.80
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	$280.80
Rate for Payer: Scott and White EPO/PPO	$118.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.80

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

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	6809214
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

BARIATRIC E&M - EST PATIENT LVL V BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	8580498
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: 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	$176.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.72

BARIATRIC E&M - EST PATIENT LVL V BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	8580498
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

BARIATRIC E&M-NEW PATIENT-LVL I BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	6809202
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

Know your out-of-pocket cost for care.

All Charges