White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC Skin Sub Grft Trk/Arm/Leg Ch 1st 100sqcm BCE

Facility

$6,927.00

Service Code	CPT 15273
Hospital Charge Code	8910573
Hospital Revenue Code	761
Min. Negotiated Rate	$236.22
Max. Negotiated Rate	$7,502.77
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,921.57
Rate for Payer: Amerigroup CHIP/Medicaid	$623.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Amerigroup Medicare	$3,281.05
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,281.05
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$6,095.76
Rate for Payer: Cash Price	$6,095.76
Rate for Payer: Cash Price	$6,095.76
Rate for Payer: Cigna Commercial	$7,432.53
Rate for Payer: Cigna Medicaid	$1,457.62
Rate for Payer: Cigna Medicare	$3,281.05
Rate for Payer: Employer Direct Commercial	$3,281.05
Rate for Payer: Humana Medicare/TRICARE	$3,281.05
Rate for Payer: Molina CHIP/Medicaid	$1,457.62
Rate for Payer: Molina Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Molina Medicare	$3,281.05
Rate for Payer: Multiplan Auto	$4,502.55
Rate for Payer: Multiplan Commercial	$4,502.55
Rate for Payer: Multiplan Workers Comp	$4,502.55
Rate for Payer: Parkland Medicaid	$1,457.62
Rate for Payer: Scott and White EPO/PPO	$236.22
Rate for Payer: Scott and White Medicare	$3,281.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,457.62
Rate for Payer: Superior Health Plan EPO	$3,281.05
Rate for Payer: Superior Health Plan Medicare	$3,281.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,281.05
Rate for Payer: Universal American Medicare	$3,281.05
Rate for Payer: Wellcare Medicare	$3,281.05
Rate for Payer: Wellmed Medicare	$3,281.05

OPWC Skin Sub Grft Trk/Arm/Leg Ch 1st 100sqcm BCE

Facility

$6,927.00

Service Code	CPT 15273
Hospital Charge Code	8910573
Hospital Revenue Code	761
Rate for Payer: Cash Price	$6,095.76

OPWC Skin Sub Grft Trk/Arm/Leg Ch 1st 25 sqcm BCE

Facility

$3,398.00

Service Code	CPT 15271
Hospital Charge Code	8912556
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,990.24

OPWC Skin Sub Grft Trk/Arm/Leg Ch 1st 25 sqcm BCE

Facility

$3,398.00

Service Code	CPT 15271
Hospital Charge Code	8912556
Hospital Revenue Code	761
Min. Negotiated Rate	$102.11
Max. Negotiated Rate	$4,089.30
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,501.68
Rate for Payer: Amerigroup CHIP/Medicaid	$305.82
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	$2,990.24
Rate for Payer: Cash Price	$2,990.24
Rate for Payer: Cash Price	$2,990.24
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	$2,208.70
Rate for Payer: Multiplan Commercial	$2,208.70
Rate for Payer: Multiplan Workers Comp	$2,208.70
Rate for Payer: Parkland Medicaid	$709.01
Rate for Payer: Scott and White EPO/PPO	$102.11
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 Skin Sub Grft Trk/Arm/Leg Ch ad 25 sqcm BCE

Facility

$977.00

Service Code	CPT 15272
Hospital Charge Code	8910572
Hospital Revenue Code	761
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$635.05
Rate for Payer: Aetna Commercial	$537.35
Rate for Payer: Amerigroup CHIP/Medicaid	$87.93
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 PPO	$50.00
Rate for Payer: Cash Price	$859.76
Rate for Payer: Cash Price	$859.76
Rate for Payer: Multiplan Auto	$635.05
Rate for Payer: Multiplan Commercial	$635.05
Rate for Payer: Multiplan Workers Comp	$635.05
Rate for Payer: Scott and White EPO/PPO	$20.40
Rate for Payer: Superior Health Plan EPO	$132.87

OPWC Skin Sub Grft Trk/Arm/Leg Ch ad 25 sqcm BCE

Facility

$977.00

Service Code	CPT 15272
Hospital Charge Code	8910572
Hospital Revenue Code	761
Rate for Payer: Cash Price	$859.76

OPWC Skin Sub Grft Trnk/Arm/Leg Ch ad 100sqcm BCE

Facility

$3,438.00

Service Code	CPT 15274
Hospital Charge Code	8910574
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,234.70
Rate for Payer: Aetna Commercial	$1,890.90
Rate for Payer: Amerigroup CHIP/Medicaid	$309.42
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 PPO	$50.00
Rate for Payer: Cash Price	$3,025.44
Rate for Payer: Cash Price	$3,025.44
Rate for Payer: Multiplan Auto	$2,234.70
Rate for Payer: Multiplan Commercial	$2,234.70
Rate for Payer: Multiplan Workers Comp	$2,234.70
Rate for Payer: Scott and White EPO/PPO	$53.64
Rate for Payer: Superior Health Plan EPO	$467.57

OPWC Skin Sub Grft Trnk/Arm/Leg Ch ad 100sqcm BCE

Facility

$3,438.00

Service Code	CPT 15274
Hospital Charge Code	8910574
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,025.44

OPWC Strapping Una Boot Lt BCE

Facility

$353.00

Service Code	CPT 29580 LT
Hospital Charge Code	8910576
Hospital Revenue Code	761
Rate for Payer: Cash Price	$310.64

OPWC Strapping Una Boot Lt BCE

Facility

$353.00

Service Code	CPT 29580 LT
Hospital Charge Code	8910576
Hospital Revenue Code	761
Min. Negotiated Rate	$31.77
Max. Negotiated Rate	$326.44
Rate for Payer: Aetna Commercial	$194.15
Rate for Payer: Aetna Medicare	$216.15
Rate for Payer: Amerigroup CHIP/Medicaid	$31.77
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cash Price	$310.64
Rate for Payer: Cash Price	$310.64
Rate for Payer: Cash Price	$310.64
Rate for Payer: Cigna Commercial	$326.44
Rate for Payer: Cigna Medicaid	$35.16
Rate for Payer: Molina CHIP/Medicaid	$35.16
Rate for Payer: Multiplan Auto	$229.45
Rate for Payer: Multiplan Commercial	$229.45
Rate for Payer: Multiplan Workers Comp	$229.45
Rate for Payer: Parkland Medicaid	$35.16
Rate for Payer: Scott and White EPO/PPO	$176.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.16
Rate for Payer: Superior Health Plan EPO	$48.01

OPWC Strapping Una Boot Rt BCE

Facility

$353.00

Service Code	CPT 29580 RT
Hospital Charge Code	8912558
Hospital Revenue Code	761
Min. Negotiated Rate	$31.77
Max. Negotiated Rate	$326.44
Rate for Payer: Aetna Commercial	$194.15
Rate for Payer: Aetna Medicare	$216.15
Rate for Payer: Amerigroup CHIP/Medicaid	$31.77
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cash Price	$310.64
Rate for Payer: Cash Price	$310.64
Rate for Payer: Cash Price	$310.64
Rate for Payer: Cigna Commercial	$326.44
Rate for Payer: Cigna Medicaid	$35.16
Rate for Payer: Molina CHIP/Medicaid	$35.16
Rate for Payer: Multiplan Auto	$229.45
Rate for Payer: Multiplan Commercial	$229.45
Rate for Payer: Multiplan Workers Comp	$229.45
Rate for Payer: Parkland Medicaid	$35.16
Rate for Payer: Scott and White EPO/PPO	$176.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.16
Rate for Payer: Superior Health Plan EPO	$48.01

OPWC Strapping Una Boot Rt BCE

Facility

$353.00

Service Code	CPT 29580 RT
Hospital Charge Code	8912558
Hospital Revenue Code	761
Rate for Payer: Cash Price	$310.64

OPWC Tangntl Bx Skin Ea Sep/Addl BCE

Facility

$399.00

Service Code	CPT 11103
Hospital Charge Code	8914561
Hospital Revenue Code	761
Min. Negotiated Rate	$26.64
Max. Negotiated Rate	$259.35
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Amerigroup CHIP/Medicaid	$35.91
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 PPO	$50.00
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Multiplan Auto	$259.35
Rate for Payer: Multiplan Commercial	$259.35
Rate for Payer: Multiplan Workers Comp	$259.35
Rate for Payer: Scott and White EPO/PPO	$26.64
Rate for Payer: Superior Health Plan EPO	$54.26

OPWC Tangntl Bx Skin Ea Sep/Addl BCE

Facility

$399.00

Service Code	CPT 11103
Hospital Charge Code	8914561
Hospital Revenue Code	761
Rate for Payer: Cash Price	$351.12

OPWC Tangntl Bx Skin Single Les BCE

Facility

$715.00

Service Code	CPT 11102
Hospital Charge Code	8912559
Hospital Revenue Code	761
Rate for Payer: Cash Price	$629.20

OPWC Tangntl Bx Skin Single Les BCE

Facility

$715.00

Service Code	CPT 11102
Hospital Charge Code	8912559
Hospital Revenue Code	761
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$464.75
Rate for Payer: Aetna Commercial	$393.25
Rate for Payer: Aetna Medicare	$274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$64.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$126.57
Rate for Payer: BCBS of TX Blue Essentials	$151.58
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$190.99
Rate for Payer: Cash Price	$629.20
Rate for Payer: Cash Price	$629.20
Rate for Payer: Cash Price	$629.20
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$64.23
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	$64.23
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$464.75
Rate for Payer: Multiplan Commercial	$464.75
Rate for Payer: Multiplan Workers Comp	$464.75
Rate for Payer: Parkland Medicaid	$64.23
Rate for Payer: Scott and White EPO/PPO	$45.90
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$64.23
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 Tobacco Counsel >10Min Symtomatic BCE

Facility

$97.00

Service Code	CPT 99407
Hospital Charge Code	8910577
Hospital Revenue Code	761
Min. Negotiated Rate	$8.73
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$53.35
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$8.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
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	$26.24
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$20.07
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$20.07
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$20.07
Rate for Payer: Scott and White EPO/PPO	$30.38
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.07
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

OPWC Tobacco Counsel >10Min Symtomatic BCE

Facility

$97.00

Service Code	CPT 99407
Hospital Charge Code	8910577
Hospital Revenue Code	761
Rate for Payer: Cash Price	$85.36

OPWC Trim Nails Any Number BCE

Facility

$191.00

Service Code	CPT 11719
Hospital Charge Code	8910578
Hospital Revenue Code	761
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$138.63
Rate for Payer: Aetna Commercial	$105.05
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$17.19
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	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
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	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Scott and White EPO/PPO	$9.04
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 Trim Nails Any Number BCE

Facility

$191.00

Service Code	CPT 11719
Hospital Charge Code	8910578
Hospital Revenue Code	761
Rate for Payer: Cash Price	$168.08

OPWC Unna Boot Bilateral BCE

Facility

$530.00

Service Code	CPT 29580 50
Hospital Charge Code	8910579
Hospital Revenue Code	761
Rate for Payer: Cash Price	$466.40

OPWC Unna Boot Bilateral BCE

Facility

$530.00

Service Code	CPT 29580 50
Hospital Charge Code	8910579
Hospital Revenue Code	761
Min. Negotiated Rate	$35.16
Max. Negotiated Rate	$344.50
Rate for Payer: Aetna Commercial	$291.50
Rate for Payer: Aetna Medicare	$216.15
Rate for Payer: Amerigroup CHIP/Medicaid	$47.70
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX PPO	$106.39
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cash Price	$466.40
Rate for Payer: Cigna Commercial	$326.44
Rate for Payer: Cigna Medicaid	$35.16
Rate for Payer: Molina CHIP/Medicaid	$35.16
Rate for Payer: Multiplan Auto	$344.50
Rate for Payer: Multiplan Commercial	$344.50
Rate for Payer: Multiplan Workers Comp	$344.50
Rate for Payer: Parkland Medicaid	$35.16
Rate for Payer: Scott and White EPO/PPO	$265.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.16
Rate for Payer: Superior Health Plan EPO	$72.08

ORBITAL PROCEDURES WITH CC/MCC

Facility

$32,294.02

Service Code	MSDRG 113
Min. Negotiated Rate	$18,035.92
Max. Negotiated Rate	$32,294.02
Rate for Payer: Aetna Commercial	$28,207.12
Rate for Payer: Aetna Medicare	$31,120.53
Rate for Payer: BCBS of TX Blue Advantage	$18,035.92
Rate for Payer: BCBS of TX Blue Essentials	$23,761.56
Rate for Payer: BCBS of TX PPO	$26,402.76
Rate for Payer: Cigna Commercial	$32,294.02

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$17,467.47

Service Code	MSDRG 114
Min. Negotiated Rate	$10,279.58
Max. Negotiated Rate	$17,467.47
Rate for Payer: Aetna Commercial	$13,857.75
Rate for Payer: Aetna Medicare	$17,467.47
Rate for Payer: BCBS of TX Blue Advantage	$10,279.58
Rate for Payer: BCBS of TX Blue Essentials	$12,951.38
Rate for Payer: BCBS of TX PPO	$14,390.98
Rate for Payer: Cigna Commercial	$15,865.58

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$23,088.19

Service Code	MSDRG 884
Min. Negotiated Rate	$10,107.58
Max. Negotiated Rate	$23,088.19
Rate for Payer: Aetna Commercial	$19,765.12
Rate for Payer: Aetna Medicare	$23,088.19
Rate for Payer: BCBS of TX Blue Advantage	$10,107.58
Rate for Payer: BCBS of TX Blue Essentials	$13,908.98
Rate for Payer: BCBS of TX PPO	$15,455.02
Rate for Payer: Cigna Commercial	$22,628.87

Know your out-of-pocket cost for care.

All Charges