White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DFW SPINE OFC/OUTPT E&M ESTAB FOCUSED BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	8996992
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

DFW SPINE OFC/OUTPT E&M ESTAB FOCUSED BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	8996992
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: 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	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28

DFW SPINE OFC/OUTPT E&M ESTAB MINIMAL BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	8994987
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

DFW SPINE OFC/OUTPT E&M ESTAB MINIMAL BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	8994987
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: 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	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

DFW SPINE OFC/OUTPT E&M EST HIGH COMPLEXITY BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	8996993
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

DFW SPINE OFC/OUTPT E&M EST HIGH COMPLEXITY BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	8996993
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: 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	$213.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.72

DFW SPINE OFC/OUTPT E&M EST LOW COMPLEXITY BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8994988
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: 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	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.92

DFW SPINE OFC/OUTPT E&M EST LOW COMPLEXITY BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8994988
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

DFW SPINE OFC/OUTPT E&M EST MOD COMPLEXITY BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	8994989
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: 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	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.80

DFW SPINE OFC/OUTPT E&M EST MOD COMPLEXITY BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	8994989
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

DFW SPINE OFC/OUTPT E&M NEW DETAILED VISIT BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8996991
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

DFW SPINE OFC/OUTPT E&M NEW DETAILED VISIT BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8996991
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: 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	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92

DFW SPINE OFC/OUTPT E&M NEW EXP PROB FOCUSED BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	8996990
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

DFW SPINE OFC/OUTPT E&M NEW EXP PROB FOCUSED BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	8996990
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$195.84
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$81.60
Rate for Payer: BCBS of TX Blue Essentials	$97.92
Rate for Payer: BCBS of TX PPO	$108.80
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cigna Medicaid	$195.84
Rate for Payer: Molina CHIP/Medicaid	$195.84
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$195.84
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84

DFW SPINE OFC/OUTPT E&M NEW HI COMPLEXITY BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	8996995
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

DFW SPINE OFC/OUTPT E&M NEW HI COMPLEXITY BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	8996995
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: 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	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$429.12

DFW SPINE OFC/OUTPT E&M NEW MOD COMPLEXITY BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	8996994
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: 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	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.36

DFW SPINE OFC/OUTPT E&M NEW MOD COMPLEXITY BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	8996994
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

DHEA, Serum SO

Facility

$186.00

Service Code	HCPCS 82626
Hospital Charge Code	1701911
Hospital Revenue Code	301
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$133.92
Rate for Payer: Amerigroup CHIP/Medicaid	$9.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25.27
Rate for Payer: Amerigroup Medicare	$25.27
Rate for Payer: BCBS of TX Blue Advantage	$55.80
Rate for Payer: BCBS of TX Blue Essentials	$66.96
Rate for Payer: BCBS of TX Medicare	$25.27
Rate for Payer: BCBS of TX PPO	$74.40
Rate for Payer: Cash Price	$126.48
Rate for Payer: Cash Price	$126.48
Rate for Payer: Cigna Medicaid	$133.92
Rate for Payer: Cigna Medicare	$25.27
Rate for Payer: Employer Direct Commercial	$25.27
Rate for Payer: Humana Medicare/TRICARE	$25.27
Rate for Payer: Molina CHIP/Medicaid	$133.92
Rate for Payer: Molina Dual Medicare/Medicaid	$25.27
Rate for Payer: Molina Medicare	$25.27
Rate for Payer: Multiplan Auto	$120.90
Rate for Payer: Multiplan Commercial	$120.90
Rate for Payer: Multiplan Workers Comp	$120.90
Rate for Payer: Parkland Medicaid	$133.92
Rate for Payer: Scott and White EPO/PPO	$31.59
Rate for Payer: Scott and White Medicare	$25.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.92
Rate for Payer: Superior Health Plan EPO	$25.27
Rate for Payer: Superior Health Plan Medicare	$25.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$25.27
Rate for Payer: Universal American Medicare	$25.27
Rate for Payer: Wellcare Medicare	$25.27
Rate for Payer: Wellmed Medicare	$25.27

DHEA, Serum SO

Facility

$186.00

Service Code	HCPCS 82626
Hospital Charge Code	1701911
Hospital Revenue Code	301
Rate for Payer: Cash Price	$126.48

DHEA-Sulfate SO

Facility

$213.72

Service Code	HCPCS 82627
Hospital Charge Code	1701929
Hospital Revenue Code	300
Rate for Payer: Cash Price	$145.33

DHEA-Sulfate SO

Facility

$213.72

Service Code	HCPCS 82627
Hospital Charge Code	1701929
Hospital Revenue Code	300
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$153.88
Rate for Payer: Amerigroup CHIP/Medicaid	$8.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.23
Rate for Payer: Amerigroup Medicare	$22.23
Rate for Payer: BCBS of TX Blue Advantage	$64.12
Rate for Payer: BCBS of TX Blue Essentials	$76.94
Rate for Payer: BCBS of TX Medicare	$22.23
Rate for Payer: BCBS of TX PPO	$85.49
Rate for Payer: Cash Price	$145.33
Rate for Payer: Cash Price	$145.33
Rate for Payer: Cigna Medicaid	$153.88
Rate for Payer: Cigna Medicare	$22.23
Rate for Payer: Employer Direct Commercial	$22.23
Rate for Payer: Humana Medicare/TRICARE	$22.23
Rate for Payer: Molina CHIP/Medicaid	$153.88
Rate for Payer: Molina Dual Medicare/Medicaid	$22.23
Rate for Payer: Molina Medicare	$22.23
Rate for Payer: Multiplan Auto	$138.92
Rate for Payer: Multiplan Commercial	$138.92
Rate for Payer: Multiplan Workers Comp	$138.92
Rate for Payer: Parkland Medicaid	$153.88
Rate for Payer: Scott and White EPO/PPO	$27.79
Rate for Payer: Scott and White Medicare	$22.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$153.88
Rate for Payer: Superior Health Plan EPO	$22.23
Rate for Payer: Superior Health Plan Medicare	$22.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.23
Rate for Payer: Universal American Medicare	$22.23
Rate for Payer: Wellcare Medicare	$22.23
Rate for Payer: Wellmed Medicare	$22.23

DIA1,4MM GUIDE WIRE

Facility

$81.72

Service Code	HCPCS C1769
Hospital Charge Code	993556
Hospital Revenue Code	272
Rate for Payer: Cash Price	$55.57

DIA1,4MM GUIDE WIRE

Facility

$81.72

Service Code	HCPCS C1769
Hospital Charge Code	993556
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$58.84
Rate for Payer: Amerigroup CHIP/Medicaid	$7.35
Rate for Payer: BCBS of TX Blue Advantage	$24.52
Rate for Payer: BCBS of TX Blue Essentials	$29.42
Rate for Payer: BCBS of TX PPO	$32.69
Rate for Payer: Cash Price	$55.57
Rate for Payer: Cigna Medicaid	$58.84
Rate for Payer: Molina CHIP/Medicaid	$58.84
Rate for Payer: Multiplan Auto	$53.12
Rate for Payer: Multiplan Commercial	$53.12
Rate for Payer: Multiplan Workers Comp	$53.12
Rate for Payer: Parkland Medicaid	$58.84
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.84
Rate for Payer: Superior Health Plan EPO	$11.11

DIABETES

Facility

$8,794.54

Service Code	APR-DRG 4204
Min. Negotiated Rate	$8,291.80
Max. Negotiated Rate	$8,794.54
Rate for Payer: Amerigroup CHIP/Medicaid	$8,291.80
Rate for Payer: Cigna Medicaid	$8,291.80
Rate for Payer: Molina CHIP/Medicaid	$8,291.80
Rate for Payer: Parkland Medicaid	$8,291.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,794.54

Know your out-of-pocket cost for care.

All Charges