White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

BARIATRIC PSYCL/NRPSYC TST PHY/QHP 1ST BCE

Facility

$283.00

Service Code	HCPCS 96136
Hospital Charge Code	8582491
Hospital Revenue Code	918
Rate for Payer: Cash Price	$192.44

BARIATRIC PSYCL/NRPSYC TST PHY/QHP 1ST BCE

Facility

$283.00

Service Code	HCPCS 96136
Hospital Charge Code	8582491
Hospital Revenue Code	918
Min. Negotiated Rate	$25.47
Max. Negotiated Rate	$282.53
Rate for Payer: Amerigroup CHIP/Medicaid	$25.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$84.90
Rate for Payer: BCBS of TX Blue Essentials	$101.88
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$113.20
Rate for Payer: Cash Price	$192.44
Rate for Payer: Cash Price	$192.44
Rate for Payer: Cash Price	$192.44
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$203.76
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$203.76
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
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	$203.76
Rate for Payer: Scott and White EPO/PPO	$141.50
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$203.76
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

BARIATRIC PSYCL/NRPSYC TST PHY/QHP EA BCE

Facility

$275.00

Service Code	HCPCS 96137
Hospital Charge Code	8580503
Hospital Revenue Code	918
Rate for Payer: Cash Price	$187.00

BARIATRIC PSYCL/NRPSYC TST PHY/QHP EA BCE

Facility

$275.00

Service Code	HCPCS 96137
Hospital Charge Code	8580503
Hospital Revenue Code	918
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$198.00
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
Rate for Payer: BCBS of TX Blue Advantage	$82.50
Rate for Payer: BCBS of TX Blue Essentials	$99.00
Rate for Payer: BCBS of TX PPO	$110.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cigna Medicaid	$198.00
Rate for Payer: Molina CHIP/Medicaid	$198.00
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	$198.00
Rate for Payer: Scott and White EPO/PPO	$137.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.00
Rate for Payer: Superior Health Plan EPO	$37.40

BARIATRIC PSYCL TST EVAL PHYS/QHP 1ST BCE

Facility

$527.00

Service Code	HCPCS 96130
Hospital Charge Code	8580502
Hospital Revenue Code	918
Rate for Payer: Cash Price	$358.36

BARIATRIC PSYCL TST EVAL PHYS/QHP 1ST BCE

Facility

$527.00

Service Code	HCPCS 96130
Hospital Charge Code	8580502
Hospital Revenue Code	918
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$458.51
Rate for Payer: Amerigroup CHIP/Medicaid	$47.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$158.10
Rate for Payer: BCBS of TX Blue Essentials	$189.72
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$210.80
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$379.44
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$379.44
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
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	$379.44
Rate for Payer: Scott and White EPO/PPO	$263.50
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$379.44
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

BARIATRIC PSYCL TST EVAL PHYS/QHP EA BCE

Facility

$350.00

Service Code	HCPCS 96131
Hospital Charge Code	8584480
Hospital Revenue Code	918
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$252.00
Rate for Payer: Amerigroup CHIP/Medicaid	$31.50
Rate for Payer: BCBS of TX Blue Advantage	$105.00
Rate for Payer: BCBS of TX Blue Essentials	$126.00
Rate for Payer: BCBS of TX PPO	$140.00
Rate for Payer: Cash Price	$238.00
Rate for Payer: Cigna Medicaid	$252.00
Rate for Payer: Molina CHIP/Medicaid	$252.00
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	$252.00
Rate for Payer: Scott and White EPO/PPO	$175.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.00
Rate for Payer: Superior Health Plan EPO	$47.60

BARIATRIC PSYCL TST EVAL PHYS/QHP EA BCE

Facility

$350.00

Service Code	HCPCS 96131
Hospital Charge Code	8584480
Hospital Revenue Code	918
Rate for Payer: Cash Price	$238.00

BARIATRIC PSYTX W PT 30 MINUTES BCE

Facility

$281.00

Service Code	HCPCS 90832
Hospital Charge Code	8996987
Hospital Revenue Code	914
Rate for Payer: Cash Price	$191.08

BARIATRIC PSYTX W PT 30 MINUTES BCE

Facility

$281.00

Service Code	HCPCS 90832
Hospital Charge Code	8996987
Hospital Revenue Code	914
Min. Negotiated Rate	$25.29
Max. Negotiated Rate	$376.90
Rate for Payer: Amerigroup CHIP/Medicaid	$25.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$178.30
Rate for Payer: Amerigroup Medicare	$178.30
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	$178.30
Rate for Payer: BCBS of TX PPO	$112.40
Rate for Payer: Cash Price	$191.08
Rate for Payer: Cash Price	$191.08
Rate for Payer: Cash Price	$191.08
Rate for Payer: Cigna Commercial	$376.90
Rate for Payer: Cigna Medicaid	$202.32
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	$202.32
Rate for Payer: Molina Dual Medicare/Medicaid	$178.30
Rate for Payer: Molina Medicare	$178.30
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	$202.32
Rate for Payer: Scott and White EPO/PPO	$140.50
Rate for Payer: Scott and White Medicare	$178.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.32
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 PSYTX W PT 45 MINUTES BCE

Facility

$364.00

Service Code	HCPCS 90834
Hospital Charge Code	8996985
Hospital Revenue Code	914
Rate for Payer: Cash Price	$247.52

BARIATRIC PSYTX W PT 45 MINUTES BCE

Facility

$364.00

Service Code	HCPCS 90834
Hospital Charge Code	8996985
Hospital Revenue Code	914
Min. Negotiated Rate	$32.76
Max. Negotiated Rate	$376.90
Rate for Payer: Amerigroup CHIP/Medicaid	$32.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$178.30
Rate for Payer: Amerigroup Medicare	$178.30
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	$178.30
Rate for Payer: BCBS of TX PPO	$145.60
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cigna Commercial	$376.90
Rate for Payer: Cigna Medicaid	$262.08
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	$262.08
Rate for Payer: Molina Dual Medicare/Medicaid	$178.30
Rate for Payer: Molina Medicare	$178.30
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	$262.08
Rate for Payer: Scott and White EPO/PPO	$182.00
Rate for Payer: Scott and White Medicare	$178.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.08
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 PSYTX W PT 60 MINUTES BCE

Facility

$416.00

Service Code	HCPCS 90837
Hospital Charge Code	8992975
Hospital Revenue Code	914
Rate for Payer: Cash Price	$282.88

BARIATRIC PSYTX W PT 60 MINUTES BCE

Facility

$416.00

Service Code	HCPCS 90837
Hospital Charge Code	8992975
Hospital Revenue Code	914
Min. Negotiated Rate	$37.44
Max. Negotiated Rate	$376.90
Rate for Payer: Amerigroup CHIP/Medicaid	$37.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$178.30
Rate for Payer: Amerigroup Medicare	$178.30
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	$178.30
Rate for Payer: BCBS of TX PPO	$166.40
Rate for Payer: Cash Price	$282.88
Rate for Payer: Cash Price	$282.88
Rate for Payer: Cash Price	$282.88
Rate for Payer: Cigna Commercial	$376.90
Rate for Payer: Cigna Medicaid	$299.52
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	$299.52
Rate for Payer: Molina Dual Medicare/Medicaid	$178.30
Rate for Payer: Molina Medicare	$178.30
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	$299.52
Rate for Payer: Scott and White EPO/PPO	$208.00
Rate for Payer: Scott and White Medicare	$178.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$299.52
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 REM MNTR PHYSIOL PARAM DEV BCE

Facility

$183.00

Service Code	HCPCS 99454
Hospital Charge Code	8994986
Hospital Revenue Code	510
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$131.76
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.49
Rate for Payer: Amerigroup Medicare	$37.49
Rate for Payer: BCBS of TX Blue Advantage	$54.90
Rate for Payer: BCBS of TX Blue Essentials	$65.88
Rate for Payer: BCBS of TX Medicare	$37.49
Rate for Payer: BCBS of TX PPO	$73.20
Rate for Payer: Cash Price	$124.44
Rate for Payer: Cash Price	$124.44
Rate for Payer: Cash Price	$124.44
Rate for Payer: Cigna Commercial	$79.25
Rate for Payer: Cigna Medicaid	$131.76
Rate for Payer: Cigna Medicare	$37.49
Rate for Payer: Employer Direct Commercial	$37.49
Rate for Payer: Humana Medicare/TRICARE	$37.49
Rate for Payer: Molina CHIP/Medicaid	$131.76
Rate for Payer: Molina Dual Medicare/Medicaid	$37.49
Rate for Payer: Molina Medicare	$37.49
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: Parkland Medicaid	$131.76
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Scott and White Medicare	$37.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.76
Rate for Payer: Superior Health Plan EPO	$37.49
Rate for Payer: Superior Health Plan Medicare	$37.49
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.49
Rate for Payer: Universal American Medicare	$37.49
Rate for Payer: Wellcare Medicare	$37.49
Rate for Payer: Wellmed Medicare	$37.49

BARIATRIC REM MNTR PHYSIOL PARAM DEV BCE

Facility

$183.00

Service Code	HCPCS 99454
Hospital Charge Code	8994986
Hospital Revenue Code	510
Rate for Payer: Cash Price	$124.44

BARIATRIC REM MNTR PHYSIOL PARAM SETUP

Facility

$570.00

Service Code	HCPCS 99453
Hospital Charge Code	8602505
Hospital Revenue Code	510
Rate for Payer: Cash Price	$387.60

BARIATRIC REM MNTR PHYSIOL PARAM SETUP

Facility

$570.00

Service Code	HCPCS 99453
Hospital Charge Code	8602505
Hospital Revenue Code	510
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$410.40
Rate for Payer: Amerigroup CHIP/Medicaid	$51.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.74
Rate for Payer: Amerigroup Medicare	$133.74
Rate for Payer: BCBS of TX Blue Advantage	$171.00
Rate for Payer: BCBS of TX Blue Essentials	$205.20
Rate for Payer: BCBS of TX Medicare	$133.74
Rate for Payer: BCBS of TX PPO	$228.00
Rate for Payer: Cash Price	$387.60
Rate for Payer: Cash Price	$387.60
Rate for Payer: Cash Price	$387.60
Rate for Payer: Cigna Commercial	$282.70
Rate for Payer: Cigna Medicaid	$410.40
Rate for Payer: Cigna Medicare	$133.74
Rate for Payer: Employer Direct Commercial	$133.74
Rate for Payer: Humana Medicare/TRICARE	$133.74
Rate for Payer: Molina CHIP/Medicaid	$410.40
Rate for Payer: Molina Dual Medicare/Medicaid	$133.74
Rate for Payer: Molina Medicare	$133.74
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: Parkland Medicaid	$410.40
Rate for Payer: Scott and White EPO/PPO	$285.00
Rate for Payer: Scott and White Medicare	$133.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$410.40
Rate for Payer: Superior Health Plan EPO	$133.74
Rate for Payer: Superior Health Plan Medicare	$133.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.74
Rate for Payer: Universal American Medicare	$133.74
Rate for Payer: Wellcare Medicare	$133.74
Rate for Payer: Wellmed Medicare	$133.74

BARIATRIC REM PHYSIOL MNTR 1ST 20 MIN BCE

Facility

$183.00

Service Code	HCPCS 99457
Hospital Charge Code	8580501
Hospital Revenue Code	510
Rate for Payer: Cash Price	$124.44

BARIATRIC REM PHYSIOL MNTR 1ST 20 MIN BCE

Facility

$183.00

Service Code	HCPCS 99457
Hospital Charge Code	8580501
Hospital Revenue Code	510
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$131.76
Rate for Payer: Amerigroup CHIP/Medicaid	$16.47
Rate for Payer: BCBS of TX Blue Advantage	$54.90
Rate for Payer: BCBS of TX Blue Essentials	$65.88
Rate for Payer: BCBS of TX PPO	$73.20
Rate for Payer: Cash Price	$124.44
Rate for Payer: Cigna Medicaid	$131.76
Rate for Payer: Molina CHIP/Medicaid	$131.76
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: Parkland Medicaid	$131.76
Rate for Payer: Scott and White EPO/PPO	$91.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.76

BARRIER SKIN SPRAY

Facility

$27.78

Hospital Charge Code	8570487
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.89

BARRIER SKIN SPRAY

Facility

$27.78

Hospital Charge Code	8570487
Hospital Revenue Code	272
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$20.00
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	$18.89
Rate for Payer: Cigna Medicaid	$20.00
Rate for Payer: Molina CHIP/Medicaid	$20.00
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: Parkland Medicaid	$20.00
Rate for Payer: Scott and White EPO/PPO	$13.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.00
Rate for Payer: Superior Health Plan EPO	$3.78

Bartonella DNA PCR SO

Facility

$964.60

Service Code	HCPCS 87471
Hospital Charge Code	1741002
Hospital Revenue Code	306
Rate for Payer: Cash Price	$655.93

Know your out-of-pocket cost for care.

All Charges