White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC Epidermal Autograft,T/A/L BCE

Facility

$5,206.00

Service Code	CPT 15110
Hospital Charge Code	8910552
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,581.28

OPWC Epidermal Autograft,T/A/L BCE

Facility

$5,206.00

Service Code	CPT 15110
Hospital Charge Code	8910552
Hospital Revenue Code	361
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Amerigroup Medicare	$1,667.79
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$1,667.79
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,581.28
Rate for Payer: Cash Price	$4,581.28
Rate for Payer: Cigna Commercial	$3,778.02
Rate for Payer: Cigna Medicaid	$709.01
Rate for Payer: Cigna Medicare	$1,667.79
Rate for Payer: Employer Direct Commercial	$1,667.79
Rate for Payer: Humana Medicare/TRICARE	$1,667.79
Rate for Payer: Molina CHIP/Medicaid	$709.01
Rate for Payer: Molina Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$709.01
Rate for Payer: Scott and White EPO/PPO	$36.79
Rate for Payer: Scott and White Medicare	$1,667.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$709.01
Rate for Payer: Superior Health Plan EPO	$1,667.79
Rate for Payer: Superior Health Plan Medicare	$1,667.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Universal American Medicare	$1,667.79
Rate for Payer: Wellcare Medicare	$1,667.79
Rate for Payer: Wellmed Medicare	$1,667.79

OPWC EST PT Visit Level 1 (0-15 Min) BCE

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	8912546
Hospital Revenue Code	510
Rate for Payer: Cash Price	$99.44

OPWC EST PT Visit Level 1 (0-15 Min) BCE

Facility

$113.00

Service Code	CPT 99211
Hospital Charge Code	8912546
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$73.45
Rate for Payer: Aetna Commercial	$62.15
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$16.30
Rate for Payer: BCBS of TX Blue Essentials	$19.49
Rate for Payer: BCBS of TX PPO	$21.74
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cash Price	$99.44
Rate for Payer: Cigna Medicaid	$12.41
Rate for Payer: Molina CHIP/Medicaid	$12.41
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	$12.41
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.41

OPWC EST PT Visit Level 2 (16-30 Min) BCE

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	8910549
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

OPWC EST PT Visit Level 2 (16-30 Min) BCE

Facility

$174.00

Service Code	CPT 99212
Hospital Charge Code	8910549
Hospital Revenue Code	510
Rate for Payer: Cash Price	$153.12

OPWC EST PT Visit Level 3 (31-45 Min) BCE

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	8910550
Hospital Revenue Code	510
Rate for Payer: Cash Price	$185.68

OPWC EST PT Visit Level 3 (31-45 Min) BCE

Facility

$211.00

Service Code	CPT 99213
Hospital Charge Code	8910550
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

OPWC EST PT Visit Level 4 (46-60 Min) BCE

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	8910551
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

OPWC EST PT Visit Level 4 (46-60 Min) BCE

Facility

$390.00

Service Code	CPT 99214
Hospital Charge Code	8910551
Hospital Revenue Code	510
Rate for Payer: Cash Price	$343.20

OPWC EST PT Visit Level 5 (60+ Min) BCE

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	8914542
Hospital Revenue Code	510
Rate for Payer: Cash Price	$374.88

OPWC EST PT Visit Level 5 (60+ Min) BCE

Facility

$426.00

Service Code	CPT 99215
Hospital Charge Code	8914542
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

OPWC Extremity Study Bilateral 1-2 Levels BCE

Facility

$720.00

Service Code	CPT 93922
Hospital Charge Code	8910553
Hospital Revenue Code	921
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$468.00
Rate for Payer: Aetna Commercial	$141.36
Rate for Payer: Aetna Medicare	$175.23
Rate for Payer: Amerigroup CHIP/Medicaid	$64.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$116.82
Rate for Payer: Amerigroup Medicare	$116.82
Rate for Payer: BCBS of TX Blue Advantage	$189.71
Rate for Payer: BCBS of TX Blue Essentials	$226.78
Rate for Payer: BCBS of TX Medicare	$116.82
Rate for Payer: BCBS of TX PPO	$252.95
Rate for Payer: Cash Price	$633.60
Rate for Payer: Cash Price	$633.60
Rate for Payer: Cash Price	$633.60
Rate for Payer: Cigna Commercial	$264.63
Rate for Payer: Cigna Medicare	$116.82
Rate for Payer: Employer Direct Commercial	$116.82
Rate for Payer: Humana Medicare/TRICARE	$116.82
Rate for Payer: Molina Dual Medicare/Medicaid	$116.82
Rate for Payer: Molina Medicare	$116.82
Rate for Payer: Multiplan Auto	$468.00
Rate for Payer: Multiplan Commercial	$468.00
Rate for Payer: Multiplan Workers Comp	$468.00
Rate for Payer: Scott and White EPO/PPO	$2.09
Rate for Payer: Scott and White Medicare	$116.82
Rate for Payer: Superior Health Plan EPO	$116.82
Rate for Payer: Superior Health Plan Medicare	$116.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$116.82
Rate for Payer: Universal American Medicare	$116.82
Rate for Payer: Wellcare Medicare	$116.82
Rate for Payer: Wellmed Medicare	$116.82

OPWC Extremity Study Bilateral 1-2 Levels BCE

Facility

$720.00

Service Code	CPT 93922
Hospital Charge Code	8910553
Hospital Revenue Code	921
Rate for Payer: Cash Price	$633.60

OPWC Extremity Study Bilateral 3+ Levels BCE

Facility

$1,579.00

Service Code	CPT 93923
Hospital Charge Code	8910554
Hospital Revenue Code	921
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$1,026.35
Rate for Payer: Aetna Commercial	$215.61
Rate for Payer: Aetna Medicare	$214.29
Rate for Payer: Amerigroup CHIP/Medicaid	$142.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$142.86
Rate for Payer: Amerigroup Medicare	$142.86
Rate for Payer: BCBS of TX Blue Advantage	$197.52
Rate for Payer: BCBS of TX Blue Essentials	$236.12
Rate for Payer: BCBS of TX Medicare	$142.86
Rate for Payer: BCBS of TX PPO	$263.37
Rate for Payer: Cash Price	$1,389.52
Rate for Payer: Cash Price	$1,389.52
Rate for Payer: Cash Price	$1,389.52
Rate for Payer: Cigna Commercial	$323.61
Rate for Payer: Cigna Medicaid	$128.31
Rate for Payer: Cigna Medicare	$142.86
Rate for Payer: Employer Direct Commercial	$142.86
Rate for Payer: Humana Medicare/TRICARE	$142.86
Rate for Payer: Molina CHIP/Medicaid	$128.31
Rate for Payer: Molina Dual Medicare/Medicaid	$142.86
Rate for Payer: Molina Medicare	$142.86
Rate for Payer: Multiplan Auto	$1,026.35
Rate for Payer: Multiplan Commercial	$1,026.35
Rate for Payer: Multiplan Workers Comp	$1,026.35
Rate for Payer: Parkland Medicaid	$128.31
Rate for Payer: Scott and White EPO/PPO	$2.55
Rate for Payer: Scott and White Medicare	$142.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$128.31
Rate for Payer: Superior Health Plan EPO	$142.86
Rate for Payer: Superior Health Plan Medicare	$142.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$142.86
Rate for Payer: Universal American Medicare	$142.86
Rate for Payer: Wellcare Medicare	$142.86
Rate for Payer: Wellmed Medicare	$142.86

OPWC Extremity Study Bilateral 3+ Levels BCE

Facility

$1,579.00

Service Code	CPT 93923
Hospital Charge Code	8910554
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,389.52

OPWC Glucose Blood Test BCE

Facility

$43.00

Service Code	CPT 82962
Hospital Charge Code	8910555
Hospital Revenue Code	301
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$27.95
Rate for Payer: Aetna Commercial	$3.45
Rate for Payer: Aetna Medicare	$4.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.28
Rate for Payer: Amerigroup Medicare	$3.28
Rate for Payer: BCBS of TX Blue Advantage	$5.41
Rate for Payer: BCBS of TX Blue Essentials	$6.49
Rate for Payer: BCBS of TX Medicare	$3.28
Rate for Payer: BCBS of TX PPO	$7.25
Rate for Payer: Cash Price	$37.84
Rate for Payer: Cash Price	$37.84
Rate for Payer: Cigna Medicare	$3.28
Rate for Payer: Employer Direct Commercial	$3.28
Rate for Payer: Humana Medicare/TRICARE	$3.28
Rate for Payer: Molina Dual Medicare/Medicaid	$3.28
Rate for Payer: Molina Medicare	$3.28
Rate for Payer: Multiplan Auto	$27.95
Rate for Payer: Multiplan Commercial	$27.95
Rate for Payer: Multiplan Workers Comp	$27.95
Rate for Payer: Scott and White EPO/PPO	$4.10
Rate for Payer: Scott and White Medicare	$3.28
Rate for Payer: Superior Health Plan EPO	$3.28
Rate for Payer: Superior Health Plan Medicare	$3.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.28
Rate for Payer: Universal American Medicare	$3.28
Rate for Payer: Wellcare Medicare	$3.28
Rate for Payer: Wellmed Medicare	$3.28

OPWC Glucose Blood Test BCE

Facility

$43.00

Service Code	CPT 82962
Hospital Charge Code	8910555
Hospital Revenue Code	301
Rate for Payer: Cash Price	$37.84

OPWC Hyperbaric O2 Full Body Chmbr/30Min BCE

Facility

$582.00

Service Code	HCPCS G0277
Hospital Charge Code	8910556
Hospital Revenue Code	413
Rate for Payer: Cash Price	$512.16

OPWC Hyperbaric O2 Full Body Chmbr/30Min BCE

Facility

$582.00

Service Code	HCPCS G0277
Hospital Charge Code	8910556
Hospital Revenue Code	413
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$378.30
Rate for Payer: Aetna Commercial	$320.10
Rate for Payer: Aetna Medicare	$190.35
Rate for Payer: Amerigroup CHIP/Medicaid	$52.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$126.90
Rate for Payer: Amerigroup Medicare	$126.90
Rate for Payer: BCBS of TX Blue Advantage	$200.20
Rate for Payer: BCBS of TX Blue Essentials	$239.32
Rate for Payer: BCBS of TX Medicare	$126.90
Rate for Payer: BCBS of TX PPO	$266.94
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cash Price	$512.16
Rate for Payer: Cigna Commercial	$287.47
Rate for Payer: Cigna Medicare	$126.90
Rate for Payer: Employer Direct Commercial	$126.90
Rate for Payer: Humana Medicare/TRICARE	$126.90
Rate for Payer: Molina Dual Medicare/Medicaid	$126.90
Rate for Payer: Molina Medicare	$126.90
Rate for Payer: Multiplan Auto	$378.30
Rate for Payer: Multiplan Commercial	$378.30
Rate for Payer: Multiplan Workers Comp	$378.30
Rate for Payer: Scott and White EPO/PPO	$2.27
Rate for Payer: Scott and White Medicare	$126.90
Rate for Payer: Superior Health Plan EPO	$126.90
Rate for Payer: Superior Health Plan Medicare	$126.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$126.90
Rate for Payer: Universal American Medicare	$126.90
Rate for Payer: Wellcare Medicare	$126.90
Rate for Payer: Wellmed Medicare	$126.90

OPWC I&D Abscess, Comp Or Mult BCE

Facility

$1,574.00

Service Code	CPT 10061
Hospital Charge Code	8914545
Hospital Revenue Code	761
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$1,023.10
Rate for Payer: Aetna Commercial	$865.70
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$141.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$192.87
Rate for Payer: BCBS of TX Blue Essentials	$230.98
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$291.03
Rate for Payer: Cash Price	$1,385.12
Rate for Payer: Cash Price	$1,385.12
Rate for Payer: Cash Price	$1,385.12
Rate for Payer: Cigna Commercial	$826.08
Rate for Payer: Cigna Medicaid	$98.28
Rate for Payer: Cigna Medicare	$364.67
Rate for Payer: Employer Direct Commercial	$364.67
Rate for Payer: Humana Medicare/TRICARE	$364.67
Rate for Payer: Molina CHIP/Medicaid	$98.28
Rate for Payer: Molina Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$1,023.10
Rate for Payer: Multiplan Commercial	$1,023.10
Rate for Payer: Multiplan Workers Comp	$1,023.10
Rate for Payer: Parkland Medicaid	$98.28
Rate for Payer: Scott and White EPO/PPO	$6.52
Rate for Payer: Scott and White Medicare	$364.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.28
Rate for Payer: Superior Health Plan EPO	$364.67
Rate for Payer: Superior Health Plan Medicare	$364.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$364.67
Rate for Payer: Universal American Medicare	$364.67
Rate for Payer: Wellcare Medicare	$364.67
Rate for Payer: Wellmed Medicare	$364.67

OPWC I&D Abscess, Comp Or Mult BCE

Facility

$1,574.00

Service Code	CPT 10061
Hospital Charge Code	8914545
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,385.12

OPWC I&D Abscess, Simple BCE

Facility

$821.00

Service Code	CPT 10060
Hospital Charge Code	8914544
Hospital Revenue Code	761
Rate for Payer: Cash Price	$722.48

OPWC I&D Abscess, Simple BCE

Facility

$821.00

Service Code	CPT 10060
Hospital Charge Code	8914544
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$533.65
Rate for Payer: Aetna Commercial	$451.55
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$73.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$125.97
Rate for Payer: BCBS of TX Blue Essentials	$150.86
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$190.08
Rate for Payer: Cash Price	$722.48
Rate for Payer: Cash Price	$722.48
Rate for Payer: Cash Price	$722.48
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$65.06
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$65.06
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$533.65
Rate for Payer: Multiplan Commercial	$533.65
Rate for Payer: Multiplan Workers Comp	$533.65
Rate for Payer: Parkland Medicaid	$65.06
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.06
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

OPWC I&D Hematoma/Seroma BCE

Facility

$3,948.00

Service Code	CPT 10140
Hospital Charge Code	8912548
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,474.24

Know your out-of-pocket cost for care.

All Charges