White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC Chemical Cauterization of Wound BCE

Facility

$993.50

Service Code	HCPCS 17250
Hospital Charge Code	8910543
Hospital Revenue Code	361
Min. Negotiated Rate	$89.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
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	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cash Price	$675.58
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
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	$715.32
Rate for Payer: Scott and White EPO/PPO	$338.72
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

OPWC Chemical Cauterization of Wound BCE

Facility

$993.50

Service Code	HCPCS 17250
Hospital Charge Code	8910543
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Counsel Smoking Cessatn 3-10Min BCE

Facility

$53.00

Service Code	HCPCS 99406
Hospital Charge Code	8910544
Hospital Revenue Code	510
Rate for Payer: Cash Price	$36.04

OPWC Counsel Smoking Cessatn 3-10Min BCE

Facility

$53.00

Service Code	HCPCS 99406
Hospital Charge Code	8910544
Hospital Revenue Code	510
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$79.55
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37.64
Rate for Payer: Amerigroup Medicare	$37.64
Rate for Payer: BCBS of TX Blue Advantage	$15.90
Rate for Payer: BCBS of TX Blue Essentials	$19.08
Rate for Payer: BCBS of TX Medicare	$37.64
Rate for Payer: BCBS of TX PPO	$21.20
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cash Price	$36.04
Rate for Payer: Cigna Commercial	$79.55
Rate for Payer: Cigna Medicaid	$38.16
Rate for Payer: Cigna Medicare	$37.64
Rate for Payer: Employer Direct Commercial	$37.64
Rate for Payer: Humana Medicare/TRICARE	$37.64
Rate for Payer: Molina CHIP/Medicaid	$38.16
Rate for Payer: Molina Dual Medicare/Medicaid	$37.64
Rate for Payer: Molina Medicare	$37.64
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$38.16
Rate for Payer: Scott and White EPO/PPO	$14.36
Rate for Payer: Scott and White Medicare	$37.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$38.16
Rate for Payer: Superior Health Plan EPO	$37.64
Rate for Payer: Superior Health Plan Medicare	$37.64
Rate for Payer: Universal American Dual Medicare/Medicaid	$37.64
Rate for Payer: Universal American Medicare	$37.64
Rate for Payer: Wellcare Medicare	$37.64
Rate for Payer: Wellmed Medicare	$37.64

OPWC Debrid Bone <=20 BCE

Facility

$6,480.96

Service Code	HCPCS 11044
Hospital Charge Code	7150188
Hospital Revenue Code	360
Min. Negotiated Rate	$566.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$566.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$4,407.05
Rate for Payer: Cash Price	$4,407.05
Rate for Payer: Cash Price	$4,407.05
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,666.29
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$4,666.29
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$4,666.29
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,666.29
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

OPWC Debrid Bone <=20 BCE

Facility

$6,480.96

Service Code	HCPCS 11044
Hospital Charge Code	7150188
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,407.05

OPWC Debrid Bone Ad 20 Sqcm BCE

Facility

$4,412.00

Service Code	HCPCS 11047
Hospital Charge Code	8912544
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,000.16

OPWC Debrid Bone Ad 20 Sqcm BCE

Facility

$4,412.00

Service Code	HCPCS 11047
Hospital Charge Code	8912544
Hospital Revenue Code	361
Min. Negotiated Rate	$397.08
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$397.08
Rate for Payer: BCBS of TX Blue Advantage	$1,323.60
Rate for Payer: BCBS of TX Blue Essentials	$1,588.32
Rate for Payer: BCBS of TX PPO	$1,764.80
Rate for Payer: Cash Price	$3,000.16
Rate for Payer: Cash Price	$3,000.16
Rate for Payer: Cigna Medicaid	$3,176.64
Rate for Payer: Molina CHIP/Medicaid	$3,176.64
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	$3,176.64
Rate for Payer: Scott and White EPO/PPO	$2,206.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,176.64
Rate for Payer: Superior Health Plan EPO	$600.03

OPWC Debrid Mus/Fsc Ad 20 Sqcm BCE

Facility

$2,026.00

Service Code	HCPCS 11046
Hospital Charge Code	8914540
Hospital Revenue Code	361
Min. Negotiated Rate	$182.34
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$182.34
Rate for Payer: BCBS of TX Blue Advantage	$607.80
Rate for Payer: BCBS of TX Blue Essentials	$729.36
Rate for Payer: BCBS of TX PPO	$810.40
Rate for Payer: Cash Price	$1,377.68
Rate for Payer: Cash Price	$1,377.68
Rate for Payer: Cigna Medicaid	$1,458.72
Rate for Payer: Molina CHIP/Medicaid	$1,458.72
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	$1,458.72
Rate for Payer: Scott and White EPO/PPO	$1,013.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,458.72
Rate for Payer: Superior Health Plan EPO	$275.54

OPWC Debrid Mus/Fsc Ad 20 Sqcm BCE

Facility

$2,026.00

Service Code	HCPCS 11046
Hospital Charge Code	8914540
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,377.68

OPWC Debrid Mus/Fsc Tiss <=20 BCE

Facility

$4,383.94

Service Code	HCPCS 11043
Hospital Charge Code	8910546
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,981.08

OPWC Debrid Mus/Fsc Tiss <=20 BCE

Facility

$4,383.94

Service Code	HCPCS 11043
Hospital Charge Code	8910546
Hospital Revenue Code	361
Min. Negotiated Rate	$262.63
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
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	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cash Price	$2,981.08
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$3,156.44
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$3,156.44
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
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	$3,156.44
Rate for Payer: Scott and White EPO/PPO	$1,062.60
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,156.44
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

OPWC Debrid Skin/Sq Tiss <=20 BCE

Facility

$1,546.00

Service Code	HCPCS 11042
Hospital Charge Code	8914541
Hospital Revenue Code	360
Min. Negotiated Rate	$171.51
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$171.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cash Price	$1,051.28
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,113.12
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,113.12
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$1,113.12
Rate for Payer: Scott and White EPO/PPO	$674.64
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,113.12
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

OPWC Debrid Skin/Sq Tiss <=20 BCE

Facility

$1,546.00

Service Code	HCPCS 11042
Hospital Charge Code	8914541
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,051.28

OPWC Debrid Sq Tiss Ad 20 Sqcm BCE

Facility

$1,020.00

Service Code	HCPCS 11045
Hospital Charge Code	8910547
Hospital Revenue Code	360
Rate for Payer: Cash Price	$693.60

OPWC Debrid Sq Tiss Ad 20 Sqcm BCE

Facility

$1,020.00

Service Code	HCPCS 11045
Hospital Charge Code	8910547
Hospital Revenue Code	360
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$91.80
Rate for Payer: BCBS of TX Blue Advantage	$306.00
Rate for Payer: BCBS of TX Blue Essentials	$367.20
Rate for Payer: BCBS of TX PPO	$408.00
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cigna Medicaid	$734.40
Rate for Payer: Molina CHIP/Medicaid	$734.40
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	$734.40
Rate for Payer: Scott and White EPO/PPO	$510.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$734.40
Rate for Payer: Superior Health Plan EPO	$138.72

OPWC Dressing/Debridement Burns, Small BCE

Facility

$413.00

Service Code	HCPCS 16020
Hospital Charge Code	8912545
Hospital Revenue Code	761
Rate for Payer: Cash Price	$280.84

OPWC Dressing/Debridement Burns, Small BCE

Facility

$413.00

Service Code	HCPCS 16020
Hospital Charge Code	8912545
Hospital Revenue Code	761
Min. Negotiated Rate	$37.17
Max. Negotiated Rate	$440.32
Rate for Payer: Amerigroup CHIP/Medicaid	$37.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
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	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$280.84
Rate for Payer: Cash Price	$280.84
Rate for Payer: Cash Price	$280.84
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$297.36
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$297.36
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$268.45
Rate for Payer: Multiplan Commercial	$268.45
Rate for Payer: Multiplan Workers Comp	$268.45
Rate for Payer: Parkland Medicaid	$297.36
Rate for Payer: Scott and White EPO/PPO	$68.72
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$297.36
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

OPWC Duplex Scan Extremity Veins Complete Bilateral BCE

Facility

$2,850.00

Service Code	HCPCS 93970
Hospital Charge Code	8910548
Hospital Revenue Code	921
Min. Negotiated Rate	$230.86
Max. Negotiated Rate	$2,052.00
Rate for Payer: Amerigroup CHIP/Medicaid	$256.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$855.00
Rate for Payer: BCBS of TX Blue Essentials	$1,026.00
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$1,140.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cash Price	$1,938.00
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,052.00
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$2,052.00
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$1,852.50
Rate for Payer: Multiplan Commercial	$1,852.50
Rate for Payer: Multiplan Workers Comp	$1,852.50
Rate for Payer: Parkland Medicaid	$2,052.00
Rate for Payer: Scott and White EPO/PPO	$230.86
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,052.00
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

OPWC Duplex Scan Extremity Veins Complete Bilateral BCE

Facility

$2,850.00

Service Code	HCPCS 93970
Hospital Charge Code	8910548
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,938.00

OPWC Epdrml Atgrft,Face/Nk/Hf BCE

Facility

$5,070.00

Service Code	HCPCS 15115
Hospital Charge Code	8912547
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,447.60

OPWC Epdrml Atgrft,Face/Nk/Hf BCE

Facility

$5,070.00

Service Code	HCPCS 15115
Hospital Charge Code	8912547
Hospital Revenue Code	361
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
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	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cash Price	$3,447.60
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,650.40
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,650.40
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,650.40
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,650.40
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

OPWC Epi Auto Trnk/Arms/Legs ea/add 100 sqcm BCE

Facility

$5,206.00

Service Code	HCPCS 15111
Hospital Charge Code	8914543
Hospital Revenue Code	361
Min. Negotiated Rate	$468.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$468.54
Rate for Payer: BCBS of TX Blue Advantage	$1,561.80
Rate for Payer: BCBS of TX Blue Essentials	$1,874.16
Rate for Payer: BCBS of TX PPO	$2,082.40
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cigna Medicaid	$3,748.32
Rate for Payer: Molina CHIP/Medicaid	$3,748.32
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	$3,748.32
Rate for Payer: Scott and White EPO/PPO	$2,603.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,748.32
Rate for Payer: Superior Health Plan EPO	$708.02

OPWC Epi Auto Trnk/Arms/Legs ea/add 100 sqcm BCE

Facility

$5,206.00

Service Code	HCPCS 15111
Hospital Charge Code	8914543
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,540.08

OPWC Epi Auto Trnk/Arms/Legs ea/add 100 sqcm BCE

Facility

$5,206.00

Service Code	HCPCS 15111
Hospital Charge Code	7150913
Hospital Revenue Code	361
Min. Negotiated Rate	$468.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$468.54
Rate for Payer: BCBS of TX Blue Advantage	$1,561.80
Rate for Payer: BCBS of TX Blue Essentials	$1,874.16
Rate for Payer: BCBS of TX PPO	$2,082.40
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cigna Medicaid	$3,748.32
Rate for Payer: Molina CHIP/Medicaid	$3,748.32
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	$3,748.32
Rate for Payer: Scott and White EPO/PPO	$2,603.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,748.32
Rate for Payer: Superior Health Plan EPO	$708.02

Know your out-of-pocket cost for care.

All Charges