White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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	$3,085.41
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: 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	$10.69
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
Rate for Payer: Cash Price	$118.32

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: 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	$43.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28

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: 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	$80.46
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
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$280.80
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$117.00
Rate for Payer: BCBS of TX Blue Essentials	$140.40
Rate for Payer: BCBS of TX PPO	$156.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cigna Medicaid	$280.80
Rate for Payer: Molina CHIP/Medicaid	$280.80
Rate for Payer: Multiplan Auto	$253.50
Rate for Payer: Multiplan Commercial	$253.50
Rate for Payer: Multiplan Workers Comp	$253.50
Rate for Payer: Parkland Medicaid	$280.80
Rate for Payer: Scott and White EPO/PPO	$118.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.80

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

OPWC EST PT Visit Level 5 (60+ Min) BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	8914542
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

OPWC EST PT Visit Level 5 (60+ Min) BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	8914542
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$306.72
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$127.80
Rate for Payer: BCBS of TX Blue Essentials	$153.36
Rate for Payer: BCBS of TX PPO	$170.40
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cigna Medicaid	$306.72
Rate for Payer: Molina CHIP/Medicaid	$306.72
Rate for Payer: Multiplan Auto	$276.90
Rate for Payer: Multiplan Commercial	$276.90
Rate for Payer: Multiplan Workers Comp	$276.90
Rate for Payer: Parkland Medicaid	$306.72
Rate for Payer: Scott and White EPO/PPO	$176.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.72

OPWC Extremity Study Bilateral 1-2 Levels BCE

Facility

$720.00

Service Code	HCPCS 93922
Hospital Charge Code	8910553
Hospital Revenue Code	921
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$518.40
Rate for Payer: Amerigroup CHIP/Medicaid	$64.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$216.00
Rate for Payer: BCBS of TX Blue Essentials	$259.20
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$288.00
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cash Price	$489.60
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$518.40
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$518.40
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$468.00
Rate for Payer: Multiplan Commercial	$468.00
Rate for Payer: Multiplan Workers Comp	$468.00
Rate for Payer: Parkland Medicaid	$518.40
Rate for Payer: Scott and White EPO/PPO	$101.58
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$518.40
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

OPWC Extremity Study Bilateral 1-2 Levels BCE

Facility

$720.00

Service Code	HCPCS 93922
Hospital Charge Code	8910553
Hospital Revenue Code	921
Rate for Payer: Cash Price	$489.60

OPWC Extremity Study Bilateral 3+ Levels BCE

Facility

$1,579.00

Service Code	HCPCS 93923
Hospital Charge Code	8910554
Hospital Revenue Code	921
Rate for Payer: Cash Price	$1,073.72

OPWC Extremity Study Bilateral 3+ Levels BCE

Facility

$1,579.00

Service Code	HCPCS 93923
Hospital Charge Code	8910554
Hospital Revenue Code	921
Min. Negotiated Rate	$142.11
Max. Negotiated Rate	$1,136.88
Rate for Payer: Amerigroup CHIP/Medicaid	$142.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$473.70
Rate for Payer: BCBS of TX Blue Essentials	$568.44
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$631.60
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cash Price	$1,073.72
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$1,136.88
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$1,136.88
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$1,026.35
Rate for Payer: Multiplan Commercial	$1,026.35
Rate for Payer: Multiplan Workers Comp	$1,026.35
Rate for Payer: Parkland Medicaid	$1,136.88
Rate for Payer: Scott and White EPO/PPO	$160.75
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,136.88
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

OPWC Glucose Blood Test BCE

Facility

$43.00

Service Code	HCPCS 82962
Hospital Charge Code	1690014
Hospital Revenue Code	301
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$30.96
Rate for Payer: Amerigroup CHIP/Medicaid	$1.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.28
Rate for Payer: Amerigroup Medicare	$3.28
Rate for Payer: BCBS of TX Blue Advantage	$12.90
Rate for Payer: BCBS of TX Blue Essentials	$15.48
Rate for Payer: BCBS of TX Medicare	$3.28
Rate for Payer: BCBS of TX PPO	$17.20
Rate for Payer: Cash Price	$29.24
Rate for Payer: Cash Price	$29.24
Rate for Payer: Cigna Medicaid	$30.96
Rate for Payer: Cigna Medicare	$3.28
Rate for Payer: Employer Direct Commercial	$3.28
Rate for Payer: Humana Medicare/TRICARE	$3.28
Rate for Payer: Molina CHIP/Medicaid	$30.96
Rate for Payer: Molina Dual Medicare/Medicaid	$3.28
Rate for Payer: Molina Medicare	$3.28
Rate for Payer: Multiplan Auto	$27.95
Rate for Payer: Multiplan Commercial	$27.95
Rate for Payer: Multiplan Workers Comp	$27.95
Rate for Payer: Parkland Medicaid	$30.96
Rate for Payer: Scott and White EPO/PPO	$4.10
Rate for Payer: Scott and White Medicare	$3.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.96
Rate for Payer: Superior Health Plan EPO	$3.28
Rate for Payer: Superior Health Plan Medicare	$3.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.28
Rate for Payer: Universal American Medicare	$3.28
Rate for Payer: Wellcare Medicare	$3.28
Rate for Payer: Wellmed Medicare	$3.28

OPWC Glucose Blood Test BCE

Facility

$43.00

Service Code	HCPCS 82962
Hospital Charge Code	1690014
Hospital Revenue Code	301
Rate for Payer: Cash Price	$29.24

OPWC Hyperbaric O2 Full Body Chmbr/30Min BCE

Facility

$582.00

Hospital Charge Code	8910556
Hospital Revenue Code	413
Rate for Payer: Cash Price	$395.76

OPWC Hyperbaric O2 Full Body Chmbr/30Min BCE

Facility

$582.00

Hospital Charge Code	8910556
Hospital Revenue Code	413
Min. Negotiated Rate	$52.38
Max. Negotiated Rate	$419.04
Rate for Payer: Amerigroup CHIP/Medicaid	$52.38
Rate for Payer: BCBS of TX Blue Advantage	$174.60
Rate for Payer: BCBS of TX Blue Essentials	$209.52
Rate for Payer: BCBS of TX PPO	$232.80
Rate for Payer: Cash Price	$395.76
Rate for Payer: Cash Price	$395.76
Rate for Payer: Cigna Medicaid	$419.04
Rate for Payer: Molina CHIP/Medicaid	$419.04
Rate for Payer: Multiplan Auto	$378.30
Rate for Payer: Multiplan Commercial	$378.30
Rate for Payer: Multiplan Workers Comp	$378.30
Rate for Payer: Parkland Medicaid	$419.04
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$419.04
Rate for Payer: Superior Health Plan EPO	$79.15

OPWC I&D Abscess, Comp Or Mult BCE

Facility

$2,238.42

Service Code	HCPCS 10061
Hospital Charge Code	8914545
Hospital Revenue Code	361
Min. Negotiated Rate	$98.28
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$98.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$192.87
Rate for Payer: BCBS of TX Blue Essentials	$230.98
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$291.03
Rate for Payer: Cash Price	$1,522.13
Rate for Payer: Cash Price	$1,522.13
Rate for Payer: Cash Price	$1,522.13
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,611.66
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	$1,611.66
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	$1,611.66
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	$1,611.66
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 I&D Abscess, Comp Or Mult BCE

Facility

$2,238.42

Service Code	HCPCS 10061
Hospital Charge Code	8914545
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,522.13

OPWC I&D Abscess, Simple BCE

Facility

$993.50

Service Code	HCPCS 10060
Hospital Charge Code	8914544
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC I&D Abscess, Simple BCE

Facility

$993.50

Service Code	HCPCS 10060
Hospital Charge Code	8914544
Hospital Revenue Code	361
Min. Negotiated Rate	$65.06
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$65.06
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$125.97
Rate for Payer: BCBS of TX Blue Essentials	$150.86
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$190.08
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

Know your out-of-pocket cost for care.

All Charges