White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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: 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	$57.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84

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 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: 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

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 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

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: 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

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, 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-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

$2,156.39

Service Code	APR-DRG 4201
Min. Negotiated Rate	$2,033.12
Max. Negotiated Rate	$2,156.39
Rate for Payer: Amerigroup CHIP/Medicaid	$2,033.12
Rate for Payer: Cigna Medicaid	$2,033.12
Rate for Payer: Molina CHIP/Medicaid	$2,033.12
Rate for Payer: Parkland Medicaid	$2,033.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,156.39

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

DIABETES

Facility

$4,226.03

Service Code	APR-DRG 4203
Min. Negotiated Rate	$3,984.44
Max. Negotiated Rate	$4,226.03
Rate for Payer: Amerigroup CHIP/Medicaid	$3,984.44
Rate for Payer: Cigna Medicaid	$3,984.44
Rate for Payer: Molina CHIP/Medicaid	$3,984.44
Rate for Payer: Parkland Medicaid	$3,984.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,226.03

DIABETES

Facility

$2,725.19

Service Code	APR-DRG 4202
Min. Negotiated Rate	$2,569.41
Max. Negotiated Rate	$2,725.19
Rate for Payer: Amerigroup CHIP/Medicaid	$2,569.41
Rate for Payer: Cigna Medicaid	$2,569.41
Rate for Payer: Molina CHIP/Medicaid	$2,569.41
Rate for Payer: Parkland Medicaid	$2,569.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,725.19

Diabetes Self Mgmnt Group per 30 Min

Facility

$109.00

Hospital Charge Code	8590002
Hospital Revenue Code	510
Rate for Payer: Cash Price	$74.12

Diabetes Self Mgmnt Group per 30 Min

Facility

$109.00

Hospital Charge Code	8590002
Hospital Revenue Code	510
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$78.48
Rate for Payer: Amerigroup CHIP/Medicaid	$9.81
Rate for Payer: BCBS of TX Blue Advantage	$32.70
Rate for Payer: BCBS of TX Blue Essentials	$39.24
Rate for Payer: BCBS of TX PPO	$43.60
Rate for Payer: Cash Price	$74.12
Rate for Payer: Cigna Medicaid	$78.48
Rate for Payer: Molina CHIP/Medicaid	$78.48
Rate for Payer: Multiplan Auto	$70.85
Rate for Payer: Multiplan Commercial	$70.85
Rate for Payer: Multiplan Workers Comp	$70.85
Rate for Payer: Parkland Medicaid	$78.48
Rate for Payer: Scott and White EPO/PPO	$54.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$78.48

Diabetes Self Mgmnt Individual 30 Min

Facility

$194.00

Hospital Charge Code	8590001
Hospital Revenue Code	510
Min. Negotiated Rate	$17.46
Max. Negotiated Rate	$139.68
Rate for Payer: Amerigroup CHIP/Medicaid	$17.46
Rate for Payer: BCBS of TX Blue Advantage	$58.20
Rate for Payer: BCBS of TX Blue Essentials	$69.84
Rate for Payer: BCBS of TX PPO	$77.60
Rate for Payer: Cash Price	$131.92
Rate for Payer: Cigna Medicaid	$139.68
Rate for Payer: Molina CHIP/Medicaid	$139.68
Rate for Payer: Multiplan Auto	$126.10
Rate for Payer: Multiplan Commercial	$126.10
Rate for Payer: Multiplan Workers Comp	$126.10
Rate for Payer: Parkland Medicaid	$139.68
Rate for Payer: Scott and White EPO/PPO	$97.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$139.68

Diabetes Self Mgmnt Individual 30 Min

Facility

$194.00

Hospital Charge Code	8590001
Hospital Revenue Code	510
Rate for Payer: Cash Price	$131.92

DIABETES W CC

Facility

$16,644.00

Service Code	MSDRG 638
Min. Negotiated Rate	$7,500.92
Max. Negotiated Rate	$16,644.00
Rate for Payer: BCBS of TX Blue Advantage	$7,500.92
Rate for Payer: BCBS of TX Blue Essentials	$9,000.23
Rate for Payer: BCBS of TX PPO	$10,000.65

DIABETES WITH CC

Facility

$16,644.00

Service Code	MSDRG 638
Min. Negotiated Rate	$7,500.92
Max. Negotiated Rate	$16,644.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,328.35
Rate for Payer: Amerigroup Medicare	$11,328.35
Rate for Payer: BCBS of TX Medicare	$11,328.35
Rate for Payer: Cigna Commercial	$11,543.06
Rate for Payer: Cigna Medicare	$11,328.35
Rate for Payer: Employer Direct Commercial	$11,328.35
Rate for Payer: Humana Medicare/TRICARE	$11,328.35
Rate for Payer: Molina Dual Medicare/Medicaid	$11,328.35
Rate for Payer: Molina Medicare	$11,328.35
Rate for Payer: Multiplan Auto	$16,644.00
Rate for Payer: Multiplan Commercial	$16,644.00
Rate for Payer: Multiplan Workers Comp	$16,644.00
Rate for Payer: Scott and White EPO/PPO	$7,665.00
Rate for Payer: Scott and White Medicare	$11,328.35
Rate for Payer: Superior Health Plan EPO	$11,328.35
Rate for Payer: Superior Health Plan Medicare	$11,328.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,328.35
Rate for Payer: Universal American Medicare	$11,328.35
Rate for Payer: Wellcare Medicare	$11,328.35
Rate for Payer: Wellmed Medicare	$11,328.35

DIABETES WITH MCC

Facility

$26,518.30

Service Code	MSDRG 637
Min. Negotiated Rate	$11,879.18
Max. Negotiated Rate	$26,518.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,289.69
Rate for Payer: Amerigroup Medicare	$15,289.69
Rate for Payer: BCBS of TX Medicare	$15,289.69
Rate for Payer: Cigna Commercial	$18,504.70
Rate for Payer: Cigna Medicare	$15,289.69
Rate for Payer: Employer Direct Commercial	$15,289.69
Rate for Payer: Humana Medicare/TRICARE	$15,289.69
Rate for Payer: Molina Dual Medicare/Medicaid	$15,289.69
Rate for Payer: Molina Medicare	$15,289.69
Rate for Payer: Multiplan Auto	$26,518.30
Rate for Payer: Multiplan Commercial	$26,518.30
Rate for Payer: Multiplan Workers Comp	$26,518.30
Rate for Payer: Scott and White EPO/PPO	$12,212.38
Rate for Payer: Scott and White Medicare	$15,289.69
Rate for Payer: Superior Health Plan EPO	$15,289.69
Rate for Payer: Superior Health Plan Medicare	$15,289.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,289.69
Rate for Payer: Universal American Medicare	$15,289.69
Rate for Payer: Wellcare Medicare	$15,289.69
Rate for Payer: Wellmed Medicare	$15,289.69

DIABETES WITHOUT CC/MCC

Facility

$11,415.20

Service Code	MSDRG 639
Min. Negotiated Rate	$5,257.00
Max. Negotiated Rate	$11,415.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,312.86
Rate for Payer: Amerigroup Medicare	$9,312.86
Rate for Payer: BCBS of TX Medicare	$9,312.86
Rate for Payer: Cigna Commercial	$8,001.06
Rate for Payer: Cigna Medicare	$9,312.86
Rate for Payer: Employer Direct Commercial	$9,312.86
Rate for Payer: Humana Medicare/TRICARE	$9,312.86
Rate for Payer: Molina Dual Medicare/Medicaid	$9,312.86
Rate for Payer: Molina Medicare	$9,312.86
Rate for Payer: Multiplan Auto	$11,415.20
Rate for Payer: Multiplan Commercial	$11,415.20
Rate for Payer: Multiplan Workers Comp	$11,415.20
Rate for Payer: Scott and White EPO/PPO	$5,257.00
Rate for Payer: Scott and White Medicare	$9,312.86
Rate for Payer: Superior Health Plan EPO	$9,312.86
Rate for Payer: Superior Health Plan Medicare	$9,312.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,312.86
Rate for Payer: Universal American Medicare	$9,312.86
Rate for Payer: Wellcare Medicare	$9,312.86
Rate for Payer: Wellmed Medicare	$9,312.86

DIABETES W MCC

Facility

$26,518.30

Service Code	MSDRG 637
Min. Negotiated Rate	$11,879.18
Max. Negotiated Rate	$26,518.30
Rate for Payer: BCBS of TX Blue Advantage	$11,879.18
Rate for Payer: BCBS of TX Blue Essentials	$14,253.63
Rate for Payer: BCBS of TX PPO	$15,837.99

Know your out-of-pocket cost for care.

All Charges