White Rock Medical Center

All Charges

Charge

Type

Setting

Price

F3D Straight Ti Interbody 30mm x 10mm x 0deg x 12mm

Facility

$21,084.34

Service Code	HCPCS C1831
Hospital Charge Code	992224
Hospital Revenue Code	278
Min. Negotiated Rate	$1,897.59
Max. Negotiated Rate	$15,180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,897.59
Rate for Payer: Cash Price	$14,337.35
Rate for Payer: Cigna Medicaid	$15,180.72
Rate for Payer: Molina CHIP/Medicaid	$15,180.72
Rate for Payer: Multiplan Auto	$10,542.17
Rate for Payer: Multiplan Commercial	$10,542.17
Rate for Payer: Multiplan Workers Comp	$10,542.17
Rate for Payer: Parkland Medicaid	$15,180.72
Rate for Payer: Scott and White EPO/PPO	$10,542.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,180.72
Rate for Payer: Superior Health Plan EPO	$2,867.47

F3D Straight Ti Interbody 30mm x 10mm x 0deg x 12mm

Facility

$21,084.34

Service Code	HCPCS C1831
Hospital Charge Code	992224
Hospital Revenue Code	278
Min. Negotiated Rate	$5,271.09
Max. Negotiated Rate	$10,542.17
Rate for Payer: Cash Price	$14,337.35
Rate for Payer: Cigna Commercial	$5,271.09
Rate for Payer: Multiplan Auto	$10,542.17
Rate for Payer: Multiplan Commercial	$10,542.17
Rate for Payer: Multiplan Workers Comp	$10,542.17
Rate for Payer: Scott and White EPO/PPO	$10,542.17

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$7,670.52

Service Code	APR-DRG 0921
Min. Negotiated Rate	$7,232.03
Max. Negotiated Rate	$7,670.52
Rate for Payer: Amerigroup CHIP/Medicaid	$7,232.03
Rate for Payer: Cigna Medicaid	$7,232.03
Rate for Payer: Molina CHIP/Medicaid	$7,232.03
Rate for Payer: Parkland Medicaid	$7,232.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,670.52

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$28,776.50

Service Code	APR-DRG 0924
Min. Negotiated Rate	$27,131.50
Max. Negotiated Rate	$28,776.50
Rate for Payer: Amerigroup CHIP/Medicaid	$27,131.50
Rate for Payer: Cigna Medicaid	$27,131.50
Rate for Payer: Molina CHIP/Medicaid	$27,131.50
Rate for Payer: Parkland Medicaid	$27,131.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28,776.50

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$27,755.83

Service Code	APR-DRG 0923
Min. Negotiated Rate	$26,169.17
Max. Negotiated Rate	$27,755.83
Rate for Payer: Amerigroup CHIP/Medicaid	$26,169.17
Rate for Payer: Cigna Medicaid	$26,169.17
Rate for Payer: Molina CHIP/Medicaid	$26,169.17
Rate for Payer: Parkland Medicaid	$26,169.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,755.83

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$9,005.01

Service Code	APR-DRG 0922
Min. Negotiated Rate	$8,490.24
Max. Negotiated Rate	$9,005.01
Rate for Payer: Amerigroup CHIP/Medicaid	$8,490.24
Rate for Payer: Cigna Medicaid	$8,490.24
Rate for Payer: Molina CHIP/Medicaid	$8,490.24
Rate for Payer: Parkland Medicaid	$8,490.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,005.01

Facility Eval and Management Level 2 99212

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	7000078
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

Facility Eval and Management Level 2 99212

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	7000078
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

Facility Eval and Management Level 3 99213

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	7000086
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

Facility Eval and Management Level 3 99213

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	7000086
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

Facility Eval and Management Level 4 99214

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	7000094
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

Facility Eval and Management Level 4 99214

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	7000094
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

Facility Eval and Management Level 5 99215

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	7000102
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

Facility Eval and Management Level 5 99215

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	7000102
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

Facility Eval, New Patient Level 2 99202

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	7003106
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

Facility Eval, New Patient Level 2 99202

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	7003106
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

Facility Eval, New Patient Level 4 99204

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	7003114
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

Facility Eval, New Patient Level 4 99204

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	7003114
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

Facility Eval, New Patient Level 5 99205

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	7000029
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

Facility Eval, New Patient Level 5 99205

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	7000029
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

FACILTY EST PATIENT E/M LEVEL 2 Units

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	6039212
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

FACILTY EST PATIENT E/M LEVEL 2 Units

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	6039212
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

FACILTY EST PATIENT E/M LEVEL 3 Units

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	6039213
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

FACILTY EST PATIENT E/M LEVEL 3 Units

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	6039213
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

FACILTY EST PATIENT E/M LEVEL 4 Units

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	6039214
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

Know your out-of-pocket cost for care.

All Charges