White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DFW BARIATRIC PSYTX W PT 30 MINUTES BCE

Facility

$281.00

Service Code	HCPCS 90832
Hospital Charge Code	8584479
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	$84.53
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

DFW BARIATRIC PSYTX W PT 45 MINUTES BCE

Facility

$364.00

Service Code	HCPCS 90834
Hospital Charge Code	8582488
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	$111.76
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

DFW BARIATRIC PSYTX W PT 45 MINUTES BCE

Facility

$364.00

Service Code	HCPCS 90834
Hospital Charge Code	8582488
Hospital Revenue Code	914
Rate for Payer: Cash Price	$247.52

DFW BARIATRIC PSYTX W PT 60 MINUTES BCE

Facility

$416.00

Service Code	HCPCS 90837
Hospital Charge Code	8582489
Hospital Revenue Code	914
Rate for Payer: Cash Price	$282.88

DFW BARIATRIC PSYTX W PT 60 MINUTES BCE

Facility

$416.00

Service Code	HCPCS 90837
Hospital Charge Code	8582489
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	$164.96
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

DFW BARIATRIC REM MNTR PHYSIOL PARAM DEV BCE

Facility

$183.00

Service Code	HCPCS 99454
Hospital Charge Code	8580500
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	$58.48
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

DFW BARIATRIC REM MNTR PHYSIOL PARAM DEV BCE

Facility

$183.00

Service Code	HCPCS 99454
Hospital Charge Code	8580500
Hospital Revenue Code	510
Rate for Payer: Cash Price	$124.44

DFW BARIATRIC REM MNTR PHYSIOL PARAM DEV BCE

Facility

$183.00

Service Code	HCPCS 99454
Hospital Charge Code	6019907
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	$58.48
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

DFW BARIATRIC REM MNTR PHYSIOL PARAM DEV BCE

Facility

$183.00

Service Code	HCPCS 99454
Hospital Charge Code	6019907
Hospital Revenue Code	510
Rate for Payer: Cash Price	$124.44

DFW BARIATRIC REM MNTR PHYSIOL PARAM SETUP

Facility

$570.00

Service Code	HCPCS 99453
Hospital Charge Code	8992976
Hospital Revenue Code	510
Min. Negotiated Rate	$24.62
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	$24.62
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

DFW BARIATRIC REM MNTR PHYSIOL PARAM SETUP

Facility

$570.00

Service Code	HCPCS 99453
Hospital Charge Code	8992976
Hospital Revenue Code	510
Rate for Payer: Cash Price	$387.60

DFW BARIATRIC REM PHYSIOL MNTR 1ST 20 MIN BCE

Facility

$183.00

Service Code	HCPCS 99457
Hospital Charge Code	8996988
Hospital Revenue Code	510
Rate for Payer: Cash Price	$124.44

DFW BARIATRIC REM PHYSIOL MNTR 1ST 20 MIN BCE

Facility

$183.00

Service Code	HCPCS 99457
Hospital Charge Code	8996988
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: 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	$36.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.76

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: 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

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 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: 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

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: 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

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 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 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: 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

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: 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

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: 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

Know your out-of-pocket cost for care.

All Charges