White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$1,373.51
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 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 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 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	$206.50
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	$239.69
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	$1,425.00
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
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	$3,834.46
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 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 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	7150913
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	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

OPWC Epidermal Autograft,T/A/L BCE

Facility

$5,206.00

Service Code	HCPCS 15110
Hospital Charge Code	8910552
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	$3,540.08
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cash Price	$3,540.08
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,748.32
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	$3,748.32
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	$3,748.32
Rate for Payer: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,748.32
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 Epidermal Autograft,T/A/L BCE

Facility

$5,206.00

Service Code	HCPCS 15110
Hospital Charge Code	8910552
Hospital Revenue Code	361
Rate for Payer: Cash Price	$3,540.08

OPWC EST PT Visit Level 1 (0-15 Min) BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	8912546
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

OPWC EST PT Visit Level 1 (0-15 Min) BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	8912546
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Molina CHIP/Medicaid	$81.36
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$81.36
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

OPWC EST PT Visit Level 2 (16-30 Min) BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	8910549
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$125.28
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$52.20
Rate for Payer: BCBS of TX Blue Essentials	$62.64
Rate for Payer: BCBS of TX PPO	$69.60
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cigna Medicaid	$125.28
Rate for Payer: Molina CHIP/Medicaid	$125.28
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$125.28
Rate for Payer: Scott and White EPO/PPO	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28

OPWC EST PT Visit Level 2 (16-30 Min) BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	8910549
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

OPWC EST PT Visit Level 3 (31-45 Min) BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8910550
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

OPWC EST PT Visit Level 3 (31-45 Min) BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8910550
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$151.92
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$63.30
Rate for Payer: BCBS of TX Blue Essentials	$75.96
Rate for Payer: BCBS of TX PPO	$84.40
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cigna Medicaid	$151.92
Rate for Payer: Molina CHIP/Medicaid	$151.92
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$151.92
Rate for Payer: Scott and White EPO/PPO	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.92

OPWC EST PT Visit Level 4 (46-60 Min) BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	8910551
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

Know your out-of-pocket cost for care.

All Charges