White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Pulmonary Facilty Est Patient E/M Level 2 Units BCE

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	6039212
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$113.10
Rate for Payer: Aetna Commercial	$95.70
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$45.15
Rate for Payer: BCBS of TX Blue Essentials	$53.98
Rate for Payer: BCBS of TX PPO	$60.20
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cash Price	$153.12
Rate for Payer: Cigna Medicaid	$20.78
Rate for Payer: Molina CHIP/Medicaid	$20.78
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	$20.78
Rate for Payer: Scott and White EPO/PPO	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.78

Pulmonary Facilty Est Patient E/M Level 2 Units BCE

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	6039212
Hospital Revenue Code	510
Rate for Payer: Cash Price	$153.12

Pulmonary Facilty Est Patient E/M Level 3 Units BCE

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	6039213
Hospital Revenue Code	510
Rate for Payer: Cash Price	$185.68

Pulmonary Facilty Est Patient E/M Level 3 Units BCE

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	6039213
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$137.15
Rate for Payer: Aetna Commercial	$116.05
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$90.31
Rate for Payer: BCBS of TX Blue Essentials	$107.95
Rate for Payer: BCBS of TX PPO	$120.41
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cash Price	$185.68
Rate for Payer: Cigna Medicaid	$31.23
Rate for Payer: Molina CHIP/Medicaid	$31.23
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	$31.23
Rate for Payer: Scott and White EPO/PPO	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$31.23

Pulmonary Facilty Est Patient E/M Level 4 Units BCE

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	6039214
Hospital Revenue Code	510
Rate for Payer: Cash Price	$343.20

Pulmonary Facilty Est Patient E/M Level 4 Units BCE

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	6039214
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$253.50
Rate for Payer: Aetna Commercial	$214.50
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$139.22
Rate for Payer: BCBS of TX Blue Essentials	$166.42
Rate for Payer: BCBS of TX PPO	$185.62
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cigna Medicaid	$43.87
Rate for Payer: Molina CHIP/Medicaid	$43.87
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	$43.87
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.87

Pulmonary Facilty Est Patient E/M Level 5 Units BCE

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	6039215
Hospital Revenue Code	510
Rate for Payer: Cash Price	$374.88

Pulmonary Facilty Est Patient E/M Level 5 Units BCE

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	6039215
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$276.90
Rate for Payer: Aetna Commercial	$234.30
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$196.27
Rate for Payer: BCBS of TX Blue Essentials	$234.62
Rate for Payer: BCBS of TX PPO	$261.70
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cash Price	$374.88
Rate for Payer: Cigna Medicaid	$67.53
Rate for Payer: Molina CHIP/Medicaid	$67.53
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	$67.53
Rate for Payer: Scott and White EPO/PPO	$213.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$67.53

Pulmonary Facilty New Patient E/M Level 4 Units BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	6039204
Hospital Revenue Code	510
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$317.20
Rate for Payer: Aetna Commercial	$268.40
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: BCBS of TX Blue Advantage	$228.25
Rate for Payer: BCBS of TX Blue Essentials	$272.85
Rate for Payer: BCBS of TX PPO	$304.34
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cash Price	$429.44
Rate for Payer: Cigna Medicaid	$74.74
Rate for Payer: Molina CHIP/Medicaid	$74.74
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	$74.74
Rate for Payer: Scott and White EPO/PPO	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.74

Pulmonary Facilty New Patient E/M Level 4 Units BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	6039204
Hospital Revenue Code	510
Rate for Payer: Cash Price	$429.44

Pulmonary Facilty New Patient E/M Level 5 Units BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	6039205
Hospital Revenue Code	510
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$397.16
Rate for Payer: Aetna Commercial	$327.80
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$297.87
Rate for Payer: BCBS of TX Blue Essentials	$356.08
Rate for Payer: BCBS of TX PPO	$397.16
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cash Price	$524.48
Rate for Payer: Cigna Medicaid	$92.92
Rate for Payer: Molina CHIP/Medicaid	$92.92
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	$92.92
Rate for Payer: Scott and White EPO/PPO	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.92

Pulmonary Facilty New Patient E/M Level 5 Units BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	6039205
Hospital Revenue Code	510
Rate for Payer: Cash Price	$524.48

Pulmonary Oxygen Per Hour Units BCE

Facility

$29.68

Hospital Charge Code	6034600
Hospital Revenue Code	270
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$19.29
Rate for Payer: Aetna Commercial	$16.32
Rate for Payer: Amerigroup CHIP/Medicaid	$2.67
Rate for Payer: BCBS of TX Blue Advantage	$8.90
Rate for Payer: BCBS of TX Blue Essentials	$10.68
Rate for Payer: BCBS of TX PPO	$11.87
Rate for Payer: Cash Price	$26.12
Rate for Payer: Multiplan Auto	$19.29
Rate for Payer: Multiplan Commercial	$19.29
Rate for Payer: Multiplan Workers Comp	$19.29
Rate for Payer: Scott and White EPO/PPO	$14.84
Rate for Payer: Superior Health Plan EPO	$4.04

Pulmonary Oxygen Per Hour Units BCE

Facility

$29.68

Hospital Charge Code	6034600
Hospital Revenue Code	270
Rate for Payer: Cash Price	$26.12

PULMONARY REHAB - 1 HOUR SESS Units

Facility

$293.00

Service Code	HCPCS G0424
Hospital Charge Code	6030237
Hospital Revenue Code	410
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$190.45
Rate for Payer: Aetna Commercial	$161.15
Rate for Payer: Amerigroup CHIP/Medicaid	$26.37
Rate for Payer: BCBS of TX Blue Advantage	$87.90
Rate for Payer: BCBS of TX Blue Essentials	$105.48
Rate for Payer: BCBS of TX PPO	$117.20
Rate for Payer: Cash Price	$257.84
Rate for Payer: Cash Price	$257.84
Rate for Payer: Multiplan Auto	$190.45
Rate for Payer: Multiplan Commercial	$190.45
Rate for Payer: Multiplan Workers Comp	$190.45
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$39.85

PULMONARY REHAB - 1 HOUR SESS Units

Facility

$293.00

Service Code	HCPCS G0424
Hospital Charge Code	6030237
Hospital Revenue Code	410
Rate for Payer: Cash Price	$257.84

Pulmonary Rehab - 1 Hour Sess Units BCE

Facility

$54.00

Service Code	HCPCS G0237
Hospital Charge Code	6030237
Hospital Revenue Code	410
Rate for Payer: Cash Price	$47.52

Pulmonary Rehab - 1 Hour Sess Units BCE

Facility

$54.00

Service Code	HCPCS G0237
Hospital Charge Code	6030237
Hospital Revenue Code	410
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$61.69
Rate for Payer: Aetna Commercial	$29.70
Rate for Payer: Aetna Medicare	$40.84
Rate for Payer: Amerigroup CHIP/Medicaid	$4.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.23
Rate for Payer: Amerigroup Medicare	$27.23
Rate for Payer: BCBS of TX Blue Advantage	$16.93
Rate for Payer: BCBS of TX Blue Essentials	$20.24
Rate for Payer: BCBS of TX Medicare	$27.23
Rate for Payer: BCBS of TX PPO	$22.57
Rate for Payer: Cash Price	$47.52
Rate for Payer: Cash Price	$47.52
Rate for Payer: Cash Price	$47.52
Rate for Payer: Cigna Commercial	$61.69
Rate for Payer: Cigna Medicare	$27.23
Rate for Payer: Employer Direct Commercial	$27.23
Rate for Payer: Humana Medicare/TRICARE	$27.23
Rate for Payer: Molina Dual Medicare/Medicaid	$27.23
Rate for Payer: Molina Medicare	$27.23
Rate for Payer: Multiplan Auto	$35.10
Rate for Payer: Multiplan Commercial	$35.10
Rate for Payer: Multiplan Workers Comp	$35.10
Rate for Payer: Scott and White EPO/PPO	$0.49
Rate for Payer: Scott and White Medicare	$27.23
Rate for Payer: Superior Health Plan EPO	$27.23
Rate for Payer: Superior Health Plan Medicare	$27.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.23
Rate for Payer: Universal American Medicare	$27.23
Rate for Payer: Wellcare Medicare	$27.23
Rate for Payer: Wellmed Medicare	$27.23

PULMONARY REHAB - GROUP SESS Units

Facility

$293.00

Service Code	HCPCS G0424
Hospital Charge Code	6030424
Hospital Revenue Code	948
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$190.45
Rate for Payer: Aetna Commercial	$161.15
Rate for Payer: Amerigroup CHIP/Medicaid	$26.37
Rate for Payer: BCBS of TX Blue Advantage	$87.90
Rate for Payer: BCBS of TX Blue Essentials	$105.48
Rate for Payer: BCBS of TX PPO	$117.20
Rate for Payer: Cash Price	$257.84
Rate for Payer: Multiplan Auto	$190.45
Rate for Payer: Multiplan Commercial	$190.45
Rate for Payer: Multiplan Workers Comp	$190.45
Rate for Payer: Scott and White EPO/PPO	$146.50
Rate for Payer: Superior Health Plan EPO	$39.85

Pulmonary Rehab - Group Sess Units BCE

Facility

$293.00

Service Code	HCPCS G0424
Hospital Charge Code	6030424
Hospital Revenue Code	948
Rate for Payer: Cash Price	$257.84

Pulmonary Rehab - Group Sess Units BCE

Facility

$293.00

Service Code	HCPCS G0424
Hospital Charge Code	6030424
Hospital Revenue Code	948
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$190.45
Rate for Payer: Aetna Commercial	$161.15
Rate for Payer: Amerigroup CHIP/Medicaid	$26.37
Rate for Payer: BCBS of TX Blue Advantage	$87.90
Rate for Payer: BCBS of TX Blue Essentials	$105.48
Rate for Payer: BCBS of TX PPO	$117.20
Rate for Payer: Cash Price	$257.84
Rate for Payer: Multiplan Auto	$190.45
Rate for Payer: Multiplan Commercial	$190.45
Rate for Payer: Multiplan Workers Comp	$190.45
Rate for Payer: Scott and White EPO/PPO	$146.50
Rate for Payer: Superior Health Plan EPO	$39.85

Pulmonary Rehab with Conti Oximetry Monitoring BCE

Facility

$56.85

Service Code	CPT 94626
Hospital Charge Code	8844559
Hospital Revenue Code	948
Rate for Payer: Cash Price	$50.03

Pulmonary Rehab with Conti Oximetry Monitoring BCE

Facility

$56.85

Service Code	CPT 94626
Hospital Charge Code	8844559
Hospital Revenue Code	948
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$31.27
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$5.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$50.03
Rate for Payer: Cash Price	$50.03
Rate for Payer: Cash Price	$50.03
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$36.95
Rate for Payer: Multiplan Commercial	$36.95
Rate for Payer: Multiplan Workers Comp	$36.95
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

Pulmonary Rehab w/o Cont Oximetry Monitoring BCE

Facility

$56.25

Service Code	CPT 94625
Hospital Charge Code	8846559
Hospital Revenue Code	948
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$30.94
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$34.49
Rate for Payer: BCBS of TX Blue Essentials	$41.23
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$45.98
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
Rate for Payer: Multiplan Auto	$36.56
Rate for Payer: Multiplan Commercial	$36.56
Rate for Payer: Multiplan Workers Comp	$36.56
Rate for Payer: Scott and White EPO/PPO	$1.00
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

Pulmonary Rehab w/o Cont Oximetry Monitoring BCE

Facility

$56.25

Service Code	CPT 94625
Hospital Charge Code	8846559
Hospital Revenue Code	948
Rate for Payer: Cash Price	$49.50

Know your out-of-pocket cost for care.

All Charges