White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WC LC Skin Sub App Trnk/Arm/Leg to 25 sqcm BCE

Facility

$1,845.00

Service Code	HCPCS C5271
Hospital Charge Code	7150901
Hospital Revenue Code	761
Min. Negotiated Rate	$166.05
Max. Negotiated Rate	$1,301.14
Rate for Payer: Aetna Commercial	$1,014.75
Rate for Payer: Aetna Medicare	$861.57
Rate for Payer: Amerigroup CHIP/Medicaid	$166.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$574.38
Rate for Payer: Amerigroup Medicare	$574.38
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$574.38
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$1,623.60
Rate for Payer: Cash Price	$1,623.60
Rate for Payer: Cash Price	$1,623.60
Rate for Payer: Cigna Commercial	$1,301.14
Rate for Payer: Cigna Medicare	$574.38
Rate for Payer: Employer Direct Commercial	$574.38
Rate for Payer: Humana Medicare/TRICARE	$574.38
Rate for Payer: Molina Dual Medicare/Medicaid	$574.38
Rate for Payer: Molina Medicare	$574.38
Rate for Payer: Multiplan Auto	$1,199.25
Rate for Payer: Multiplan Commercial	$1,199.25
Rate for Payer: Multiplan Workers Comp	$1,199.25
Rate for Payer: Scott and White EPO/PPO	$922.50
Rate for Payer: Scott and White Medicare	$574.38
Rate for Payer: Superior Health Plan EPO	$574.38
Rate for Payer: Superior Health Plan Medicare	$574.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$574.38
Rate for Payer: Universal American Medicare	$574.38
Rate for Payer: Wellcare Medicare	$574.38
Rate for Payer: Wellmed Medicare	$574.38

WC LC Skin Sub App Trnk/Arm/Leg up 100sqcm BCE

Facility

$3,676.00

Service Code	HCPCS C5273
Hospital Charge Code	7150903
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,234.88

WC LC Skin Sub App Trnk/Arm/Leg up 100sqcm BCE

Facility

$3,676.00

Service Code	HCPCS C5273
Hospital Charge Code	7150903
Hospital Revenue Code	761
Min. Negotiated Rate	$330.84
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	$330.84
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	$3,234.88
Rate for Payer: Cash Price	$3,234.88
Rate for Payer: Cash Price	$3,234.88
Rate for Payer: Cigna Commercial	$3,778.02
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 Dual Medicare/Medicaid	$1,667.79
Rate for Payer: Molina Medicare	$1,667.79
Rate for Payer: Multiplan Auto	$2,389.40
Rate for Payer: Multiplan Commercial	$2,389.40
Rate for Payer: Multiplan Workers Comp	$2,389.40
Rate for Payer: Scott and White EPO/PPO	$1,838.00
Rate for Payer: Scott and White Medicare	$1,667.79
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

WC Multilayer Compression Wrap Below the Knee Bilat BCE

Facility

$423.00

Service Code	CPT 29581 50
Hospital Charge Code	7150774
Hospital Revenue Code	761
Rate for Payer: Cash Price	$372.24

WC Multilayer Compression Wrap Below the Knee Bilat BCE

Facility

$423.00

Service Code	CPT 29581 50
Hospital Charge Code	7150774
Hospital Revenue Code	761
Min. Negotiated Rate	$38.07
Max. Negotiated Rate	$326.44
Rate for Payer: Aetna Commercial	$232.65
Rate for Payer: Aetna Medicare	$216.15
Rate for Payer: Amerigroup CHIP/Medicaid	$38.07
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 PPO	$170.30
Rate for Payer: Cash Price	$372.24
Rate for Payer: Cash Price	$372.24
Rate for Payer: Cash Price	$372.24
Rate for Payer: Cigna Commercial	$326.44
Rate for Payer: Cigna Medicaid	$56.48
Rate for Payer: Molina CHIP/Medicaid	$56.48
Rate for Payer: Multiplan Auto	$274.95
Rate for Payer: Multiplan Commercial	$274.95
Rate for Payer: Multiplan Workers Comp	$274.95
Rate for Payer: Parkland Medicaid	$56.48
Rate for Payer: Scott and White EPO/PPO	$211.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.48
Rate for Payer: Superior Health Plan EPO	$57.53

WC Multilayer Compression Wrap Below the Knee LT BCE

Facility

$282.00

Service Code	CPT 29581 LT
Hospital Charge Code	7150830
Hospital Revenue Code	761
Rate for Payer: Cash Price	$248.16

WC Multilayer Compression Wrap Below the Knee LT BCE

Facility

$282.00

Service Code	CPT 29581 LT
Hospital Charge Code	7150830
Hospital Revenue Code	761
Min. Negotiated Rate	$25.38
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: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
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: Molina CHIP/Medicaid	$56.48
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	$141.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.48
Rate for Payer: Superior Health Plan EPO	$38.35

WC Multilayer Compression Wrap Below the Knee RT BCE

Facility

$282.00

Service Code	CPT 29581 RT
Hospital Charge Code	7150829
Hospital Revenue Code	761
Rate for Payer: Cash Price	$248.16

WC Multilayer Compression Wrap Below the Knee RT BCE

Facility

$282.00

Service Code	CPT 29581 RT
Hospital Charge Code	7150829
Hospital Revenue Code	761
Min. Negotiated Rate	$25.38
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: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
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: Molina CHIP/Medicaid	$56.48
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	$141.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.48
Rate for Payer: Superior Health Plan EPO	$38.35

WC Nail Debride 1-5 BCE

Facility

$203.00

Service Code	CPT 11720
Hospital Charge Code	7150246
Hospital Revenue Code	761
Min. Negotiated Rate	$17.20
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	$17.20
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

WC Nail Debride 1-5 BCE

Facility

$203.00

Service Code	CPT 11720
Hospital Charge Code	7150246
Hospital Revenue Code	761
Rate for Payer: Cash Price	$178.64

WC Nail Debridement 6 or more BCE

Facility

$415.00

Service Code	CPT 11721
Hospital Charge Code	7150253
Hospital Revenue Code	761
Rate for Payer: Cash Price	$365.20

WC Nail Debridement 6 or more BCE

Facility

$415.00

Service Code	CPT 11721
Hospital Charge Code	7150253
Hospital Revenue Code	761
Min. Negotiated Rate	$28.73
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	$28.73
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

WC New PT Visit Level 2 BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	7150451
Hospital Revenue Code	510
Rate for Payer: Cash Price	$239.36

WC New PT Visit Level 2 BCE

Facility

$272.00

Service Code	CPT 99202
Hospital Charge Code	7150451
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	$57.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.80

WC New PT Visit Level 3 BCE

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	7150469
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	$99.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51.08

WC New PT Visit Level 3 BCE

Facility

$411.00

Service Code	CPT 99203
Hospital Charge Code	7150469
Hospital Revenue Code	510
Rate for Payer: Cash Price	$361.68

WC New PT Visit Level 4 BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	7150477
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	$162.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.74

WC New PT Visit Level 4 BCE

Facility

$488.00

Service Code	CPT 99204
Hospital Charge Code	7150477
Hospital Revenue Code	510
Rate for Payer: Cash Price	$429.44

WC New PT Visit Level 5 BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	7150485
Hospital Revenue Code	510
Rate for Payer: Cash Price	$524.48

WC New PT Visit Level 5 BCE

Facility

$596.00

Service Code	CPT 99205
Hospital Charge Code	7150485
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	$221.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.92

WC Non-Selective Debridement BCE

Facility

$358.00

Service Code	CPT 97602
Hospital Charge Code	7150055
Hospital Revenue Code	761
Rate for Payer: Cash Price	$315.04

WC Non-Selective Debridement BCE

Facility

$358.00

Service Code	CPT 97602
Hospital Charge Code	7150055
Hospital Revenue Code	761
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$414.75
Rate for Payer: Aetna Commercial	$196.90
Rate for Payer: Aetna Medicare	$274.63
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	$179.00
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

WC Npwt Dme <= 50 Sq cm BCE

Facility

$304.00

Service Code	CPT 97605
Hospital Charge Code	7150618
Hospital Revenue Code	761
Rate for Payer: Cash Price	$267.52

WC Npwt Dme <= 50 Sq cm BCE

Facility

$304.00

Service Code	CPT 97605
Hospital Charge Code	7150618
Hospital Revenue Code	761
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$414.75
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$274.63
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	$29.71
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

Know your out-of-pocket cost for care.

All Charges