White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC Multilayer Compression Wrap Below the Knee RT BCE

Facility

$282.00

Service Code	CPT 29581 RT
Hospital Charge Code	8912553
Hospital Revenue Code	761
Rate for Payer: Cash Price	$248.16

OPWC Multilayer Compression Wrap Below the Knee RT BCE

Facility

$282.00

Service Code	CPT 29581 RT
Hospital Charge Code	8912553
Hospital Revenue Code	761
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$326.44
Rate for Payer: Aetna Commercial	$155.10
Rate for Payer: Aetna Medicare	$216.15
Rate for Payer: Amerigroup CHIP/Medicaid	$25.38
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$144.10
Rate for Payer: Amerigroup Medicare	$144.10
Rate for Payer: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
Rate for Payer: BCBS of TX Medicare	$144.10
Rate for Payer: BCBS of TX PPO	$170.30
Rate for Payer: Cash Price	$248.16
Rate for Payer: Cash Price	$248.16
Rate for Payer: Cash Price	$248.16
Rate for Payer: Cigna Commercial	$326.44
Rate for Payer: Cigna Medicaid	$56.48
Rate for Payer: Cigna Medicare	$144.10
Rate for Payer: Employer Direct Commercial	$144.10
Rate for Payer: Humana Medicare/TRICARE	$144.10
Rate for Payer: Molina CHIP/Medicaid	$56.48
Rate for Payer: Molina Dual Medicare/Medicaid	$144.10
Rate for Payer: Molina Medicare	$144.10
Rate for Payer: Multiplan Auto	$183.30
Rate for Payer: Multiplan Commercial	$183.30
Rate for Payer: Multiplan Workers Comp	$183.30
Rate for Payer: Parkland Medicaid	$56.48
Rate for Payer: Scott and White EPO/PPO	$2.58
Rate for Payer: Scott and White Medicare	$144.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.48
Rate for Payer: Superior Health Plan EPO	$144.10
Rate for Payer: Superior Health Plan Medicare	$144.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$144.10
Rate for Payer: Universal American Medicare	$144.10
Rate for Payer: Wellcare Medicare	$144.10
Rate for Payer: Wellmed Medicare	$144.10

OPWC Nail Debride 1-5 BCE

Facility

$203.00

Service Code	CPT 11720
Hospital Charge Code	8910558
Hospital Revenue Code	761
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$138.63
Rate for Payer: Aetna Commercial	$111.65
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$18.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cash Price	$178.64
Rate for Payer: Cash Price	$178.64
Rate for Payer: Cash Price	$178.64
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	$131.95
Rate for Payer: Multiplan Commercial	$131.95
Rate for Payer: Multiplan Workers Comp	$131.95
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

OPWC Nail Debride 1-5 BCE

Facility

$203.00

Service Code	CPT 11720
Hospital Charge Code	8910558
Hospital Revenue Code	761
Rate for Payer: Cash Price	$178.64

OPWC Nail Debridement 6 or more BCE

Facility

$415.00

Service Code	CPT 11721
Hospital Charge Code	8914553
Hospital Revenue Code	761
Rate for Payer: Cash Price	$365.20

OPWC Nail Debridement 6 or more BCE

Facility

$415.00

Service Code	CPT 11721
Hospital Charge Code	8914553
Hospital Revenue Code	761
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$269.75
Rate for Payer: Aetna Commercial	$228.25
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$37.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cash Price	$365.20
Rate for Payer: Cash Price	$365.20
Rate for Payer: Cash Price	$365.20
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	$269.75
Rate for Payer: Multiplan Commercial	$269.75
Rate for Payer: Multiplan Workers Comp	$269.75
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

OPWC New PT Visit Level 2 BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	8910559
Hospital Revenue Code	510
Rate for Payer: Cash Price	$239.36

OPWC New PT Visit Level 2 BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	8910559
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna Commercial	$149.60
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cigna Medicaid	$37.80
Rate for Payer: Molina CHIP/Medicaid	$37.80
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	$37.80
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.80

OPWC New PT Visit Level 3 BCE

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	8914554
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$267.15
Rate for Payer: Aetna Commercial	$226.05
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$134.82
Rate for Payer: BCBS of TX Blue Essentials	$161.16
Rate for Payer: BCBS of TX PPO	$179.75
Rate for Payer: Cash Price	$361.68
Rate for Payer: Cash Price	$361.68
Rate for Payer: Cigna Medicaid	$51.08
Rate for Payer: Molina CHIP/Medicaid	$51.08
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	$51.08
Rate for Payer: Scott and White EPO/PPO	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.08

OPWC New PT Visit Level 3 BCE

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	8914554
Hospital Revenue Code	510
Rate for Payer: Cash Price	$361.68

OPWC New PT Visit Level 4 BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	8914555
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

OPWC New PT Visit Level 4 BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	8914555
Hospital Revenue Code	510
Rate for Payer: Cash Price	$429.44

OPWC New PT Visit Level 5 BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	8910560
Hospital Revenue Code	510
Rate for Payer: Cash Price	$524.48

OPWC New PT Visit Level 5 BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	8910560
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

OPWC Non-Selective Debridement BCE

Facility

$358.00

Service Code	CPT 97602
Hospital Charge Code	8910561
Hospital Revenue Code	761
Rate for Payer: Cash Price	$315.04

OPWC Non-Selective Debridement BCE

Facility

$358.00

Service Code	CPT 97602
Hospital Charge Code	8910561
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$414.75
Rate for Payer: Aetna Commercial	$196.90
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$27.68
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	$27.68
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$232.70
Rate for Payer: Multiplan Commercial	$232.70
Rate for Payer: Multiplan Workers Comp	$232.70
Rate for Payer: Parkland Medicaid	$27.68
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	$27.68
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 Npwt Dme <= 50 Sq cm BCE

Facility

$304.00

Service Code	CPT 97605
Hospital Charge Code	8914556
Hospital Revenue Code	761
Rate for Payer: Cash Price	$267.52

OPWC Npwt Dme <= 50 Sq cm BCE

Facility

$304.00

Service Code	CPT 97605
Hospital Charge Code	8914556
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$414.75
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$27.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Commercial	$414.75
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
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 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 Npwt Dme >50 Sq cm BCE

Facility

$400.00

Service Code	CPT 97606
Hospital Charge Code	8910562
Hospital Revenue Code	761
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$220.00
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cigna Commercial	$826.08
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 Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
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 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 Npwt Dme >50 Sq cm BCE

Facility

$400.00

Service Code	CPT 97606
Hospital Charge Code	8910562
Hospital Revenue Code	761
Rate for Payer: Cash Price	$352.00

OPWC Npwt Nondme <= 50 Sq cm BCE

Facility

$688.00

Service Code	CPT 97607
Hospital Charge Code	8910563
Hospital Revenue Code	761
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$826.08
Rate for Payer: Aetna Commercial	$378.40
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$61.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$364.67
Rate for Payer: Amerigroup Medicare	$364.67
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX Medicare	$364.67
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$605.44
Rate for Payer: Cash Price	$605.44
Rate for Payer: Cash Price	$605.44
Rate for Payer: Cigna Commercial	$826.08
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 Dual Medicare/Medicaid	$364.67
Rate for Payer: Molina Medicare	$364.67
Rate for Payer: Multiplan Auto	$447.20
Rate for Payer: Multiplan Commercial	$447.20
Rate for Payer: Multiplan Workers Comp	$447.20
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 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 Npwt Nondme <= 50 Sq cm BCE

Facility

$688.00

Service Code	CPT 97607
Hospital Charge Code	8910563
Hospital Revenue Code	761
Rate for Payer: Cash Price	$605.44

OPWC Paring/Cutting Benign Lesion 2-4 BCE

Facility

$403.00

Service Code	CPT 11056
Hospital Charge Code	8914557
Hospital Revenue Code	761
Rate for Payer: Cash Price	$354.64

OPWC Paring/Cutting Benign Lesion 2-4 BCE

Facility

$403.00

Service Code	CPT 11056
Hospital Charge Code	8914557
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$221.65
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$36.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$354.64
Rate for Payer: Cash Price	$354.64
Rate for Payer: Cash Price	$354.64
Rate for Payer: Cigna Commercial	$414.75
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$261.95
Rate for Payer: Multiplan Commercial	$261.95
Rate for Payer: Multiplan Workers Comp	$261.95
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 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 Paring/Cutting Benign Lesion Over 4 BCE

Facility

$521.00

Service Code	CPT 11057
Hospital Charge Code	8914558
Hospital Revenue Code	761
Rate for Payer: Cash Price	$458.48

Know your out-of-pocket cost for care.

All Charges