White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8568500
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: 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	$99.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92

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

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8568500
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

BARIATRIC E&M-NEW PATIENT LVL IV BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	8584477
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: 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	$162.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.36

BARIATRIC E&M-NEW PATIENT LVL IV BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	8584477
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

BARIATRIC E&M- NEW PATIENT LVL V BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	8582482
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: 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	$221.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$429.12

BARIATRIC E&M- NEW PATIENT LVL V BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	8582482
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

BARIATRIC GROUP PSYCHOTHERAPY BCE

Facility

$456.00

Service Code	HCPCS 90853
Hospital Charge Code	8994980
Hospital Revenue Code	915
Rate for Payer: Cash Price	$310.08

BARIATRIC GROUP PSYCHOTHERAPY BCE

Facility

$456.00

Service Code	HCPCS 90853
Hospital Charge Code	8994980
Hospital Revenue Code	915
Min. Negotiated Rate	$29.68
Max. Negotiated Rate	$328.32
Rate for Payer: Amerigroup CHIP/Medicaid	$41.04
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$102.05
Rate for Payer: Amerigroup Medicare	$102.05
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	$102.05
Rate for Payer: BCBS of TX PPO	$182.40
Rate for Payer: Cash Price	$310.08
Rate for Payer: Cash Price	$310.08
Rate for Payer: Cash Price	$310.08
Rate for Payer: Cigna Commercial	$215.73
Rate for Payer: Cigna Medicaid	$328.32
Rate for Payer: Cigna Medicare	$102.05
Rate for Payer: Employer Direct Commercial	$102.05
Rate for Payer: Humana Medicare/TRICARE	$102.05
Rate for Payer: Molina CHIP/Medicaid	$328.32
Rate for Payer: Molina Dual Medicare/Medicaid	$102.05
Rate for Payer: Molina Medicare	$102.05
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	$328.32
Rate for Payer: Scott and White EPO/PPO	$29.68
Rate for Payer: Scott and White Medicare	$102.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.32
Rate for Payer: Superior Health Plan EPO	$102.05
Rate for Payer: Superior Health Plan Medicare	$102.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$102.05
Rate for Payer: Universal American Medicare	$102.05
Rate for Payer: Wellcare Medicare	$102.05
Rate for Payer: Wellmed Medicare	$102.05

BARIATRIC HLTH BHAV INTERV IND 1ST 30MIN BCE

Facility

$385.00

Service Code	HCPCS 96158
Hospital Charge Code	6806158
Hospital Revenue Code	914
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$376.90
Rate for Payer: Amerigroup CHIP/Medicaid	$34.65
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$178.30
Rate for Payer: Amerigroup Medicare	$178.30
Rate for Payer: BCBS of TX Blue Advantage	$115.50
Rate for Payer: BCBS of TX Blue Essentials	$138.60
Rate for Payer: BCBS of TX Medicare	$178.30
Rate for Payer: BCBS of TX PPO	$154.00
Rate for Payer: Cash Price	$261.80
Rate for Payer: Cash Price	$261.80
Rate for Payer: Cash Price	$261.80
Rate for Payer: Cigna Commercial	$376.90
Rate for Payer: Cigna Medicaid	$277.20
Rate for Payer: Cigna Medicare	$178.30
Rate for Payer: Employer Direct Commercial	$178.30
Rate for Payer: Humana Medicare/TRICARE	$178.30
Rate for Payer: Molina CHIP/Medicaid	$277.20
Rate for Payer: Molina Dual Medicare/Medicaid	$178.30
Rate for Payer: Molina Medicare	$178.30
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: Parkland Medicaid	$277.20
Rate for Payer: Scott and White EPO/PPO	$72.58
Rate for Payer: Scott and White Medicare	$178.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$277.20
Rate for Payer: Superior Health Plan EPO	$178.30
Rate for Payer: Superior Health Plan Medicare	$178.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$178.30
Rate for Payer: Universal American Medicare	$178.30
Rate for Payer: Wellcare Medicare	$178.30
Rate for Payer: Wellmed Medicare	$178.30

BARIATRIC HLTH BHAV INTERV IND 1ST 30MIN BCE

Facility

$385.00

Service Code	HCPCS 96158
Hospital Charge Code	6806158
Hospital Revenue Code	914
Rate for Payer: Cash Price	$261.80

BARIATRIC HLTH BHV ASSMT/REASSESSMENT BCE

Facility

$483.00

Service Code	HCPCS 96156
Hospital Charge Code	8582487
Hospital Revenue Code	914
Min. Negotiated Rate	$43.47
Max. Negotiated Rate	$347.76
Rate for Payer: Amerigroup CHIP/Medicaid	$43.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$102.05
Rate for Payer: Amerigroup Medicare	$102.05
Rate for Payer: BCBS of TX Blue Advantage	$144.90
Rate for Payer: BCBS of TX Blue Essentials	$173.88
Rate for Payer: BCBS of TX Medicare	$102.05
Rate for Payer: BCBS of TX PPO	$193.20
Rate for Payer: Cash Price	$328.44
Rate for Payer: Cash Price	$328.44
Rate for Payer: Cash Price	$328.44
Rate for Payer: Cigna Commercial	$215.73
Rate for Payer: Cigna Medicaid	$347.76
Rate for Payer: Cigna Medicare	$102.05
Rate for Payer: Employer Direct Commercial	$102.05
Rate for Payer: Humana Medicare/TRICARE	$102.05
Rate for Payer: Molina CHIP/Medicaid	$347.76
Rate for Payer: Molina Dual Medicare/Medicaid	$102.05
Rate for Payer: Molina Medicare	$102.05
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: Parkland Medicaid	$347.76
Rate for Payer: Scott and White EPO/PPO	$108.39
Rate for Payer: Scott and White Medicare	$102.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$347.76
Rate for Payer: Superior Health Plan EPO	$102.05
Rate for Payer: Superior Health Plan Medicare	$102.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$102.05
Rate for Payer: Universal American Medicare	$102.05
Rate for Payer: Wellcare Medicare	$102.05
Rate for Payer: Wellmed Medicare	$102.05

BARIATRIC HLTH BHV ASSMT/REASSESSMENT BCE

Facility

$483.00

Service Code	HCPCS 96156
Hospital Charge Code	8582487
Hospital Revenue Code	914
Rate for Payer: Cash Price	$328.44

BARIATRIC IV INF HYD INIT 31-60MIN BCE

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	6806360
Hospital Revenue Code	260
Rate for Payer: Cash Price	$575.96

BARIATRIC IV INF HYD INIT 31-60MIN BCE

Facility

$847.00

Service Code	HCPCS 96360
Hospital Charge Code	6806360
Hospital Revenue Code	260
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$609.84
Rate for Payer: Amerigroup CHIP/Medicaid	$76.23
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$254.10
Rate for Payer: BCBS of TX Blue Essentials	$304.92
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$338.80
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cash Price	$575.96
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$609.84
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$609.84
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
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: Parkland Medicaid	$609.84
Rate for Payer: Scott and White EPO/PPO	$39.95
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$609.84
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

BARIATRIC MED NUTRITION INDIV SUBSEQ BCE

Facility

$102.00

Service Code	HCPCS 97803
Hospital Charge Code	8500191
Hospital Revenue Code	942
Rate for Payer: Cash Price	$69.36

BARIATRIC MED NUTRITION INDIV SUBSEQ BCE

Facility

$102.00

Service Code	HCPCS 97803
Hospital Charge Code	8500191
Hospital Revenue Code	942
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$73.44
Rate for Payer: Amerigroup CHIP/Medicaid	$9.18
Rate for Payer: BCBS of TX Blue Advantage	$30.60
Rate for Payer: BCBS of TX Blue Essentials	$36.72
Rate for Payer: BCBS of TX PPO	$40.80
Rate for Payer: Cash Price	$69.36
Rate for Payer: Cash Price	$69.36
Rate for Payer: Cigna Medicaid	$73.44
Rate for Payer: Molina CHIP/Medicaid	$73.44
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: Parkland Medicaid	$73.44
Rate for Payer: Scott and White EPO/PPO	$33.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$73.44
Rate for Payer: Superior Health Plan EPO	$13.87

BARIATRIC MED NUTRTN TH INIT 15MIN BCE

Facility

$120.00

Service Code	HCPCS 97802
Hospital Charge Code	6807802
Hospital Revenue Code	942
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$86.40
Rate for Payer: Amerigroup CHIP/Medicaid	$10.80
Rate for Payer: BCBS of TX Blue Advantage	$36.00
Rate for Payer: BCBS of TX Blue Essentials	$43.20
Rate for Payer: BCBS of TX PPO	$48.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna Medicaid	$86.40
Rate for Payer: Molina CHIP/Medicaid	$86.40
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: Parkland Medicaid	$86.40
Rate for Payer: Scott and White EPO/PPO	$39.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$86.40
Rate for Payer: Superior Health Plan EPO	$16.32

BARIATRIC MED NUTRTN TH INIT 15MIN BCE

Facility

$120.00

Service Code	HCPCS 97802
Hospital Charge Code	6807802
Hospital Revenue Code	942
Rate for Payer: Cash Price	$81.60

BARIATRIC O2 UPTAKE REST INDRCT BCE

Facility

$546.00

Service Code	HCPCS 94690
Hospital Charge Code	6809901
Hospital Revenue Code	460
Min. Negotiated Rate	$49.14
Max. Negotiated Rate	$393.12
Rate for Payer: Amerigroup CHIP/Medicaid	$49.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$163.80
Rate for Payer: BCBS of TX Blue Essentials	$196.56
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$218.40
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cash Price	$371.28
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$393.12
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$393.12
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
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: Parkland Medicaid	$393.12
Rate for Payer: Scott and White EPO/PPO	$60.09
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$393.12
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

BARIATRIC O2 UPTAKE REST INDRCT BCE

Facility

$546.00

Service Code	HCPCS 94690
Hospital Charge Code	6809901
Hospital Revenue Code	460
Rate for Payer: Cash Price	$371.28

BARIATRIC PREVENTIVE COUNSELING INDIV 15 MIN BCE

Facility

$124.00

Service Code	HCPCS 99401
Hospital Charge Code	8582483
Hospital Revenue Code	510
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$89.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.16
Rate for Payer: BCBS of TX Blue Advantage	$37.20
Rate for Payer: BCBS of TX Blue Essentials	$44.64
Rate for Payer: BCBS of TX PPO	$49.60
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cigna Medicaid	$89.28
Rate for Payer: Molina CHIP/Medicaid	$89.28
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: Parkland Medicaid	$89.28
Rate for Payer: Scott and White EPO/PPO	$62.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$89.28

BARIATRIC PREVENTIVE COUNSELING INDIV 15 MIN BCE

Facility

$124.00

Service Code	HCPCS 99401
Hospital Charge Code	8582483
Hospital Revenue Code	510
Rate for Payer: Cash Price	$84.32

BARIATRIC PREVENTIVE COUNSELING INDIV 30 MIN BCE

Facility

$208.00

Service Code	HCPCS 99402
Hospital Charge Code	8580499
Hospital Revenue Code	510
Rate for Payer: Cash Price	$141.44

BARIATRIC PREVENTIVE COUNSELING INDIV 30 MIN BCE

Facility

$208.00

Service Code	HCPCS 99402
Hospital Charge Code	8580499
Hospital Revenue Code	510
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$149.76
Rate for Payer: Amerigroup CHIP/Medicaid	$18.72
Rate for Payer: BCBS of TX Blue Advantage	$62.40
Rate for Payer: BCBS of TX Blue Essentials	$74.88
Rate for Payer: BCBS of TX PPO	$83.20
Rate for Payer: Cash Price	$141.44
Rate for Payer: Cigna Medicaid	$149.76
Rate for Payer: Molina CHIP/Medicaid	$149.76
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: Parkland Medicaid	$149.76
Rate for Payer: Scott and White EPO/PPO	$104.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$149.76

Know your out-of-pocket cost for care.

All Charges