White Rock Medical Center

All Charges

Charge

Type

Setting

Price

O.R. PROCEDURES FOR OBESITY W/O CC/MCC

Facility

$28,659.60

Service Code	MSDRG 621
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$28,659.60
Rate for Payer: BCBS of TX Blue Advantage	$13,573.38
Rate for Payer: BCBS of TX Blue Essentials	$16,286.48
Rate for Payer: BCBS of TX PPO	$18,096.79

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$44,401.10

Service Code	MSDRG 940
Min. Negotiated Rate	$18,700.70
Max. Negotiated Rate	$44,401.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,887.28
Rate for Payer: Amerigroup Medicare	$21,887.28
Rate for Payer: BCBS of TX Medicare	$21,887.28
Rate for Payer: Cigna Commercial	$30,099.27
Rate for Payer: Cigna Medicare	$21,887.28
Rate for Payer: Employer Direct Commercial	$21,887.28
Rate for Payer: Humana Medicare/TRICARE	$21,887.28
Rate for Payer: Molina Dual Medicare/Medicaid	$21,887.28
Rate for Payer: Molina Medicare	$21,887.28
Rate for Payer: Multiplan Auto	$44,401.10
Rate for Payer: Multiplan Commercial	$44,401.10
Rate for Payer: Multiplan Workers Comp	$44,401.10
Rate for Payer: Scott and White EPO/PPO	$20,447.88
Rate for Payer: Scott and White Medicare	$21,887.28
Rate for Payer: Superior Health Plan EPO	$21,887.28
Rate for Payer: Superior Health Plan Medicare	$21,887.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,887.28
Rate for Payer: Universal American Medicare	$21,887.28
Rate for Payer: Wellcare Medicare	$21,887.28
Rate for Payer: Wellmed Medicare	$21,887.28

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$68,941.50

Service Code	MSDRG 939
Min. Negotiated Rate	$28,196.82
Max. Negotiated Rate	$68,941.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$31,353.46
Rate for Payer: Amerigroup Medicare	$31,353.46
Rate for Payer: BCBS of TX Medicare	$31,353.46
Rate for Payer: Cigna Commercial	$46,735.08
Rate for Payer: Cigna Medicare	$31,353.46
Rate for Payer: Employer Direct Commercial	$31,353.46
Rate for Payer: Humana Medicare/TRICARE	$31,353.46
Rate for Payer: Molina Dual Medicare/Medicaid	$31,353.46
Rate for Payer: Molina Medicare	$31,353.46
Rate for Payer: Multiplan Auto	$68,941.50
Rate for Payer: Multiplan Commercial	$68,941.50
Rate for Payer: Multiplan Workers Comp	$68,941.50
Rate for Payer: Scott and White EPO/PPO	$31,749.38
Rate for Payer: Scott and White Medicare	$31,353.46
Rate for Payer: Superior Health Plan EPO	$31,353.46
Rate for Payer: Superior Health Plan Medicare	$31,353.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$31,353.46
Rate for Payer: Universal American Medicare	$31,353.46
Rate for Payer: Wellcare Medicare	$31,353.46
Rate for Payer: Wellmed Medicare	$31,353.46

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$38,526.30

Service Code	MSDRG 941
Min. Negotiated Rate	$15,922.04
Max. Negotiated Rate	$38,526.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19,621.15
Rate for Payer: Amerigroup Medicare	$19,621.15
Rate for Payer: BCBS of TX Medicare	$19,621.15
Rate for Payer: Cigna Commercial	$26,116.78
Rate for Payer: Cigna Medicare	$19,621.15
Rate for Payer: Employer Direct Commercial	$19,621.15
Rate for Payer: Humana Medicare/TRICARE	$19,621.15
Rate for Payer: Molina Dual Medicare/Medicaid	$19,621.15
Rate for Payer: Molina Medicare	$19,621.15
Rate for Payer: Multiplan Auto	$38,526.30
Rate for Payer: Multiplan Commercial	$38,526.30
Rate for Payer: Multiplan Workers Comp	$38,526.30
Rate for Payer: Scott and White EPO/PPO	$17,742.38
Rate for Payer: Scott and White Medicare	$19,621.15
Rate for Payer: Superior Health Plan EPO	$19,621.15
Rate for Payer: Superior Health Plan Medicare	$19,621.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$19,621.15
Rate for Payer: Universal American Medicare	$19,621.15
Rate for Payer: Wellcare Medicare	$19,621.15
Rate for Payer: Wellmed Medicare	$19,621.15

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$73,433.10

Service Code	MSDRG 876
Min. Negotiated Rate	$28,392.04
Max. Negotiated Rate	$73,433.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$33,086.04
Rate for Payer: Amerigroup Medicare	$33,086.04
Rate for Payer: BCBS of TX Medicare	$33,086.04
Rate for Payer: Cigna Commercial	$49,779.91
Rate for Payer: Cigna Medicare	$33,086.04
Rate for Payer: Employer Direct Commercial	$33,086.04
Rate for Payer: Molina Dual Medicare/Medicaid	$33,086.04
Rate for Payer: Molina Medicare	$33,086.04
Rate for Payer: Multiplan Auto	$73,433.10
Rate for Payer: Multiplan Commercial	$73,433.10
Rate for Payer: Multiplan Workers Comp	$73,433.10
Rate for Payer: Scott and White EPO/PPO	$33,817.88
Rate for Payer: Scott and White Medicare	$33,086.04
Rate for Payer: Superior Health Plan EPO	$33,086.04
Rate for Payer: Superior Health Plan Medicare	$33,086.04
Rate for Payer: Universal American Dual Medicare/Medicaid	$33,086.04
Rate for Payer: Universal American Medicare	$33,086.04
Rate for Payer: Wellcare Medicare	$33,086.04
Rate for Payer: Wellmed Medicare	$33,086.04

O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS

Facility

$73,433.10

Service Code	MSDRG 876
Min. Negotiated Rate	$28,392.04
Max. Negotiated Rate	$73,433.10
Rate for Payer: BCBS of TX Blue Advantage	$28,392.04
Rate for Payer: BCBS of TX Blue Essentials	$34,067.15
Rate for Payer: BCBS of TX PPO	$37,853.85

O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC

Facility

$44,401.10

Service Code	MSDRG 940
Min. Negotiated Rate	$18,700.70
Max. Negotiated Rate	$44,401.10
Rate for Payer: BCBS of TX Blue Advantage	$18,700.70
Rate for Payer: BCBS of TX Blue Essentials	$22,438.67
Rate for Payer: BCBS of TX PPO	$24,932.82

O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W MCC

Facility

$68,941.50

Service Code	MSDRG 939
Min. Negotiated Rate	$28,196.82
Max. Negotiated Rate	$68,941.50
Rate for Payer: BCBS of TX Blue Advantage	$28,196.82
Rate for Payer: BCBS of TX Blue Essentials	$33,832.91
Rate for Payer: BCBS of TX PPO	$37,593.57

O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC

Facility

$38,526.30

Service Code	MSDRG 941
Min. Negotiated Rate	$15,922.04
Max. Negotiated Rate	$38,526.30
Rate for Payer: BCBS of TX Blue Advantage	$15,922.04
Rate for Payer: BCBS of TX Blue Essentials	$19,104.60
Rate for Payer: BCBS of TX PPO	$21,228.15

ORTHO OFC/OUTPT E&M ESTAB FOCUSED BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	9220088
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

ORTHO OFC/OUTPT E&M ESTAB FOCUSED BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	9220088
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

ORTHO OFC/OUTPT E&M ESTAB MINIMAL BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	9220070
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

ORTHO OFC/OUTPT E&M ESTAB MINIMAL BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	9220070
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

ORTHO OFC/OUTPT E&M EST HIGH COMPLEXITY BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	9220112
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

ORTHO OFC/OUTPT E&M EST HIGH COMPLEXITY BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	9220112
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

ORTHO OFC/OUTPT E&M EST LOW COMPLEXITY BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	9220096
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

ORTHO OFC/OUTPT E&M EST LOW COMPLEXITY BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	9220096
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

ORTHO OFC/OUTPT E&M EST MOD COMPLEXITY BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	9220104
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

ORTHO OFC/OUTPT E&M EST MOD COMPLEXITY BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	9220104
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

ORTHO OFC/OUTPT E&M NEW DETAILED VISIT BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	9220062
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

ORTHO OFC/OUTPT E&M NEW DETAILED VISIT BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	9220062
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

ORTHO OFC/OUTPT E&M NEW EXP PROB FOCUSED BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	9220054
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

ORTHO OFC/OUTPT E&M NEW EXP PROB FOCUSED BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	9220054
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

ORTHO OFC/OUTPT E&M NEW HI COMPLEXITY BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	9220245
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

ORTHO OFC/OUTPT E&M NEW HI COMPLEXITY BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	9220245
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

Know your out-of-pocket cost for care.

All Charges