White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$80,089.13

Service Code	MSDRG 573
Min. Negotiated Rate	$31,709.92
Max. Negotiated Rate	$80,089.13
Rate for Payer: Aetna Commercial	$69,953.62
Rate for Payer: Aetna Medicare	$70,841.26
Rate for Payer: BCBS of TX Blue Advantage	$31,709.92
Rate for Payer: BCBS of TX Blue Essentials	$54,190.23
Rate for Payer: BCBS of TX PPO	$60,213.70
Rate for Payer: Cigna Commercial	$80,089.13

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$26,352.48

Service Code	MSDRG 575
Min. Negotiated Rate	$12,721.12
Max. Negotiated Rate	$26,352.48
Rate for Payer: Aetna Commercial	$23,017.50
Rate for Payer: Aetna Medicare	$26,182.74
Rate for Payer: BCBS of TX Blue Advantage	$12,721.12
Rate for Payer: BCBS of TX Blue Essentials	$18,146.99
Rate for Payer: BCBS of TX PPO	$20,164.11
Rate for Payer: Cigna Commercial	$26,352.48

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$24,206.76

Service Code	MSDRG 623
Min. Negotiated Rate	$16,297.00
Max. Negotiated Rate	$24,206.76
Rate for Payer: Aetna Commercial	$20,940.75
Rate for Payer: Aetna Medicare	$24,206.76
Rate for Payer: BCBS of TX Blue Advantage	$16,297.00
Rate for Payer: BCBS of TX Blue Essentials	$19,845.50
Rate for Payer: BCBS of TX PPO	$22,051.41
Rate for Payer: Cigna Commercial	$23,974.83

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$49,273.73

Service Code	MSDRG 622
Min. Negotiated Rate	$31,658.32
Max. Negotiated Rate	$49,273.73
Rate for Payer: Aetna Commercial	$43,038.00
Rate for Payer: Aetna Medicare	$45,231.74
Rate for Payer: BCBS of TX Blue Advantage	$31,658.32
Rate for Payer: BCBS of TX Blue Essentials	$39,191.56
Rate for Payer: BCBS of TX PPO	$43,547.87
Rate for Payer: Cigna Commercial	$49,273.73

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$16,211.88

Service Code	MSDRG 624
Min. Negotiated Rate	$9,220.92
Max. Negotiated Rate	$16,211.88
Rate for Payer: Aetna Commercial	$12,538.12
Rate for Payer: Aetna Medicare	$16,211.88
Rate for Payer: BCBS of TX Blue Advantage	$9,220.92
Rate for Payer: BCBS of TX Blue Essentials	$13,373.42
Rate for Payer: BCBS of TX PPO	$14,859.94
Rate for Payer: Cigna Commercial	$14,354.76

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$41,939.86

Service Code	MSDRG 904
Min. Negotiated Rate	$28,057.50
Max. Negotiated Rate	$41,939.86
Rate for Payer: Aetna Commercial	$36,632.25
Rate for Payer: Aetna Medicare	$39,136.82
Rate for Payer: BCBS of TX Blue Advantage	$28,057.50
Rate for Payer: BCBS of TX Blue Essentials	$33,289.09
Rate for Payer: BCBS of TX PPO	$36,989.32
Rate for Payer: Cigna Commercial	$41,939.86

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$21,234.24

Service Code	MSDRG 905
Min. Negotiated Rate	$11,866.28
Max. Negotiated Rate	$21,234.24
Rate for Payer: Aetna Commercial	$17,816.62
Rate for Payer: Aetna Medicare	$21,234.24
Rate for Payer: BCBS of TX Blue Advantage	$11,866.28
Rate for Payer: BCBS of TX Blue Essentials	$18,256.37
Rate for Payer: BCBS of TX PPO	$20,285.65
Rate for Payer: Cigna Commercial	$20,398.06

Skin Sub Graft Face/Neck/Nk/Fh/G First 25 Sq cm

Facility

$3,398.00

Service Code	CPT 15275
Hospital Charge Code	7150814
Hospital Revenue Code	761
Min. Negotiated Rate	$113.46
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	$113.46
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

Skin Sub Grft Fce/Nck/FH/G Ch ad 20sqcm

Facility

$1,476.00

Service Code	CPT 15276
Hospital Charge Code	7150815
Hospital Revenue Code	761
Min. Negotiated Rate	$30.21
Max. Negotiated Rate	$959.40
Rate for Payer: Aetna Commercial	$811.80
Rate for Payer: Amerigroup CHIP/Medicaid	$132.84
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	$1,298.88
Rate for Payer: Cash Price	$1,298.88
Rate for Payer: Multiplan Auto	$959.40
Rate for Payer: Multiplan Commercial	$959.40
Rate for Payer: Multiplan Workers Comp	$959.40
Rate for Payer: Scott and White EPO/PPO	$30.21
Rate for Payer: Superior Health Plan EPO	$200.74

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

Facility

$6,927.00

Service Code	CPT 15273
Hospital Charge Code	7150812
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

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

Facility

$3,398.00

Service Code	CPT 15271
Hospital Charge Code	7150810
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

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

Facility

$977.00

Service Code	CPT 15272
Hospital Charge Code	7150811
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

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

Facility

$3,438.00

Service Code	CPT 15274
Hospital Charge Code	7150813
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

SKIN ULCERS WITH CC

Facility

$17,233.05

Service Code	MSDRG 593
Min. Negotiated Rate	$8,585.38
Max. Negotiated Rate	$17,233.05
Rate for Payer: Aetna Commercial	$13,611.38
Rate for Payer: Aetna Medicare	$17,233.05
Rate for Payer: BCBS of TX Blue Advantage	$8,585.38
Rate for Payer: BCBS of TX Blue Essentials	$11,654.28
Rate for Payer: BCBS of TX PPO	$12,949.70
Rate for Payer: Cigna Commercial	$15,583.51

SKIN ULCERS WITH MCC

Facility

$26,920.49

Service Code	MSDRG 592
Min. Negotiated Rate	$12,113.96
Max. Negotiated Rate	$26,920.49
Rate for Payer: Aetna Commercial	$23,513.62
Rate for Payer: Aetna Medicare	$26,654.81
Rate for Payer: BCBS of TX Blue Advantage	$12,113.96
Rate for Payer: BCBS of TX Blue Essentials	$17,626.92
Rate for Payer: BCBS of TX PPO	$19,586.22
Rate for Payer: Cigna Commercial	$26,920.49

SKIN ULCERS WITHOUT CC/MCC

Facility

$12,710.58

Service Code	MSDRG 594
Min. Negotiated Rate	$6,321.86
Max. Negotiated Rate	$12,710.58
Rate for Payer: Aetna Commercial	$8,858.25
Rate for Payer: Aetna Medicare	$12,710.58
Rate for Payer: BCBS of TX Blue Advantage	$6,321.86
Rate for Payer: BCBS of TX Blue Essentials	$8,360.45
Rate for Payer: BCBS of TX PPO	$9,289.75
Rate for Payer: Cigna Commercial	$10,141.71

SLEEVE, ENDOPATH BLADELESS 5MM X 100MM L -- DHF

Facility

$624.98

Hospital Charge Code	80828155
Hospital Revenue Code	272
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$406.24
Rate for Payer: Aetna Commercial	$343.74
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.49
Rate for Payer: BCBS of TX Blue Essentials	$224.99
Rate for Payer: BCBS of TX PPO	$249.99
Rate for Payer: Cash Price	$549.98
Rate for Payer: Multiplan Auto	$406.24
Rate for Payer: Multiplan Commercial	$406.24
Rate for Payer: Multiplan Workers Comp	$406.24
Rate for Payer: Scott and White EPO/PPO	$312.49
Rate for Payer: Superior Health Plan EPO	$85.00

SLEEVE, ENDOPATH BLADELESS W/OPTIVIEW 12MMX100MM -- DHF

Facility

$624.98

Hospital Charge Code	80828155
Hospital Revenue Code	272
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$406.24
Rate for Payer: Aetna Commercial	$343.74
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.49
Rate for Payer: BCBS of TX Blue Essentials	$224.99
Rate for Payer: BCBS of TX PPO	$249.99
Rate for Payer: Cash Price	$549.98
Rate for Payer: Multiplan Auto	$406.24
Rate for Payer: Multiplan Commercial	$406.24
Rate for Payer: Multiplan Workers Comp	$406.24
Rate for Payer: Scott and White EPO/PPO	$312.49
Rate for Payer: Superior Health Plan EPO	$85.00

SLEEVE GLIDESCOPE -- DHF

Facility

$85.81

Hospital Charge Code	82067596
Hospital Revenue Code	272
Min. Negotiated Rate	$7.72
Max. Negotiated Rate	$55.78
Rate for Payer: Aetna Commercial	$47.20
Rate for Payer: Amerigroup CHIP/Medicaid	$7.72
Rate for Payer: BCBS of TX Blue Advantage	$25.74
Rate for Payer: BCBS of TX Blue Essentials	$30.89
Rate for Payer: BCBS of TX PPO	$34.32
Rate for Payer: Cash Price	$75.51
Rate for Payer: Multiplan Auto	$55.78
Rate for Payer: Multiplan Commercial	$55.78
Rate for Payer: Multiplan Workers Comp	$55.78
Rate for Payer: Scott and White EPO/PPO	$42.91
Rate for Payer: Superior Health Plan EPO	$11.67

SLEEVE GLIDESCOPE -- DHF

Facility

$85.81

Hospital Charge Code	82067596
Hospital Revenue Code	272
Rate for Payer: Cash Price	$75.51

SLEEVE Kii 5X100 CFF02

Facility

$408.60

Hospital Charge Code	80810344
Hospital Revenue Code	272
Rate for Payer: Cash Price	$359.57

SLEEVE Kii 5X100 CFF02

Facility

$408.60

Hospital Charge Code	80810344
Hospital Revenue Code	272
Min. Negotiated Rate	$36.77
Max. Negotiated Rate	$265.59
Rate for Payer: Aetna Commercial	$224.73
Rate for Payer: Amerigroup CHIP/Medicaid	$36.77
Rate for Payer: BCBS of TX Blue Advantage	$122.58
Rate for Payer: BCBS of TX Blue Essentials	$147.10
Rate for Payer: BCBS of TX PPO	$163.44
Rate for Payer: Cash Price	$359.57
Rate for Payer: Multiplan Auto	$265.59
Rate for Payer: Multiplan Commercial	$265.59
Rate for Payer: Multiplan Workers Comp	$265.59
Rate for Payer: Scott and White EPO/PPO	$204.30
Rate for Payer: Superior Health Plan EPO	$55.57

SLEEVE, SHOULDER TRACTN/ROTATN FOAM W/VELCRO STRLE -- DHF

Facility

$583.71

Hospital Charge Code	81771446
Hospital Revenue Code	272
Min. Negotiated Rate	$52.53
Max. Negotiated Rate	$379.41
Rate for Payer: Aetna Commercial	$321.04
Rate for Payer: Amerigroup CHIP/Medicaid	$52.53
Rate for Payer: BCBS of TX Blue Advantage	$175.11
Rate for Payer: BCBS of TX Blue Essentials	$210.14
Rate for Payer: BCBS of TX PPO	$233.48
Rate for Payer: Cash Price	$513.66
Rate for Payer: Multiplan Auto	$379.41
Rate for Payer: Multiplan Commercial	$379.41
Rate for Payer: Multiplan Workers Comp	$379.41
Rate for Payer: Scott and White EPO/PPO	$291.86
Rate for Payer: Superior Health Plan EPO	$79.38

SLEEVE, SHOULDER TRACTN/ROTATN FOAM W/VELCRO STRLE -- DHF

Facility

$583.71

Hospital Charge Code	81771446
Hospital Revenue Code	272
Rate for Payer: Cash Price	$513.66

SLEEVE SKIN ARM REGULAR

Facility

$16.34

Hospital Charge Code	8576467
Hospital Revenue Code	272
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$10.62
Rate for Payer: Aetna Commercial	$8.99
Rate for Payer: Amerigroup CHIP/Medicaid	$1.47
Rate for Payer: BCBS of TX Blue Advantage	$4.90
Rate for Payer: BCBS of TX Blue Essentials	$5.88
Rate for Payer: BCBS of TX PPO	$6.54
Rate for Payer: Cash Price	$14.38
Rate for Payer: Multiplan Auto	$10.62
Rate for Payer: Multiplan Commercial	$10.62
Rate for Payer: Multiplan Workers Comp	$10.62
Rate for Payer: Scott and White EPO/PPO	$8.17
Rate for Payer: Superior Health Plan EPO	$2.22

Know your out-of-pocket cost for care.

All Charges