White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC I&D Hematoma/Seroma BCE

Facility

$6,773.30

Service Code	HCPCS 10140
Hospital Charge Code	7150105
Hospital Revenue Code	361
Min. Negotiated Rate	$90.81
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$90.81
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	$183.82
Rate for Payer: BCBS of TX Blue Essentials	$220.14
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$277.38
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cash Price	$4,605.84
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$4,876.78
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	$4,876.78
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	$4,876.78
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	$4,876.78
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 I&D Hematoma/Seroma BCE

Facility

$6,773.30

Service Code	HCPCS 10140
Hospital Charge Code	7150105
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,605.84

OPWC Incisional Bx Skin Sep/Addl BCE

Facility

$1,014.00

Service Code	HCPCS 11107
Hospital Charge Code	8914546
Hospital Revenue Code	761
Rate for Payer: Cash Price	$689.52

OPWC Incisional Bx Skin Sep/Addl BCE

Facility

$1,014.00

Service Code	HCPCS 11107
Hospital Charge Code	8914546
Hospital Revenue Code	761
Min. Negotiated Rate	$37.23
Max. Negotiated Rate	$730.08
Rate for Payer: Amerigroup CHIP/Medicaid	$91.26
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	$689.52
Rate for Payer: Cash Price	$689.52
Rate for Payer: Cigna Medicaid	$730.08
Rate for Payer: Molina CHIP/Medicaid	$730.08
Rate for Payer: Multiplan Auto	$659.10
Rate for Payer: Multiplan Commercial	$659.10
Rate for Payer: Multiplan Workers Comp	$659.10
Rate for Payer: Parkland Medicaid	$730.08
Rate for Payer: Scott and White EPO/PPO	$37.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$730.08
Rate for Payer: Superior Health Plan EPO	$137.90

OPWC Incisional Bx Skin Sgl Les BCE

Facility

$1,538.00

Service Code	HCPCS 11106
Hospital Charge Code	7150052
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,045.84

OPWC Incisional Bx Skin Sgl Les BCE

Facility

$1,538.00

Service Code	HCPCS 11106
Hospital Charge Code	8912549
Hospital Revenue Code	361
Min. Negotiated Rate	$98.83
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$98.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$194.07
Rate for Payer: BCBS of TX Blue Essentials	$232.42
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$292.85
Rate for Payer: Cash Price	$1,045.84
Rate for Payer: Cash Price	$1,045.84
Rate for Payer: Cash Price	$1,045.84
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,107.36
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	$1,107.36
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	$1,107.36
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	$1,107.36
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 Incisional Bx Skin Sgl Les BCE

Facility

$1,538.00

Service Code	HCPCS 11106
Hospital Charge Code	7150052
Hospital Revenue Code	361
Min. Negotiated Rate	$98.83
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$98.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$194.07
Rate for Payer: BCBS of TX Blue Essentials	$232.42
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$292.85
Rate for Payer: Cash Price	$1,045.84
Rate for Payer: Cash Price	$1,045.84
Rate for Payer: Cash Price	$1,045.84
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,107.36
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	$1,107.36
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	$1,107.36
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	$1,107.36
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 Incisional Bx Skin Sgl Les BCE

Facility

$1,538.00

Service Code	HCPCS 11106
Hospital Charge Code	8912549
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,045.84

OPWC LC Skin Sub App Face/Nck/HF ad 100sqcm BCE

Facility

$4,073.00

Hospital Charge Code	8914552
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,932.56
Rate for Payer: Amerigroup CHIP/Medicaid	$366.57
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	$2,769.64
Rate for Payer: Cash Price	$2,769.64
Rate for Payer: Cigna Medicaid	$2,932.56
Rate for Payer: Molina CHIP/Medicaid	$2,932.56
Rate for Payer: Multiplan Auto	$2,647.45
Rate for Payer: Multiplan Commercial	$2,647.45
Rate for Payer: Multiplan Workers Comp	$2,647.45
Rate for Payer: Parkland Medicaid	$2,932.56
Rate for Payer: Scott and White EPO/PPO	$2,036.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,932.56
Rate for Payer: Superior Health Plan EPO	$553.93

OPWC LC Skin Sub App Face/Nck/HF ad 100sqcm BCE

Facility

$4,073.00

Hospital Charge Code	8914552
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,769.64

OPWC LC Skin Sub App Face/Nck/HF ad 25 sqcm BCE

Facility

$1,267.00

Hospital Charge Code	8914551
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$912.24
Rate for Payer: Amerigroup CHIP/Medicaid	$114.03
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	$861.56
Rate for Payer: Cash Price	$861.56
Rate for Payer: Cigna Medicaid	$912.24
Rate for Payer: Molina CHIP/Medicaid	$912.24
Rate for Payer: Multiplan Auto	$823.55
Rate for Payer: Multiplan Commercial	$823.55
Rate for Payer: Multiplan Workers Comp	$823.55
Rate for Payer: Parkland Medicaid	$912.24
Rate for Payer: Scott and White EPO/PPO	$633.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$912.24
Rate for Payer: Superior Health Plan EPO	$172.31

OPWC LC Skin Sub App Face/Nck/HF ad 25 sqcm BCE

Facility

$1,267.00

Hospital Charge Code	8914551
Hospital Revenue Code	761
Rate for Payer: Cash Price	$861.56

OPWC LC Skin Sub App Face/Nck/HF to100sqcm BCE

Facility

$5,030.00

Hospital Charge Code	8912550
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$3,621.60
Rate for Payer: Amerigroup CHIP/Medicaid	$452.70
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	$3,420.40
Rate for Payer: Cash Price	$3,420.40
Rate for Payer: Cigna Medicaid	$3,621.60
Rate for Payer: Molina CHIP/Medicaid	$3,621.60
Rate for Payer: Multiplan Auto	$3,269.50
Rate for Payer: Multiplan Commercial	$3,269.50
Rate for Payer: Multiplan Workers Comp	$3,269.50
Rate for Payer: Parkland Medicaid	$3,621.60
Rate for Payer: Scott and White EPO/PPO	$2,515.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,621.60
Rate for Payer: Superior Health Plan EPO	$684.08

OPWC LC Skin Sub App Face/Nck/HF to100sqcm BCE

Facility

$5,030.00

Hospital Charge Code	8912550
Hospital Revenue Code	761
Rate for Payer: Cash Price	$3,420.40

OPWC LC Skin Sub App Face/Nck/HF to 25 sqcm BCE

Facility

$2,804.00

Hospital Charge Code	8910557
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,906.72

OPWC LC Skin Sub App Face/Nck/HF to 25 sqcm BCE

Facility

$2,804.00

Hospital Charge Code	8910557
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,018.88
Rate for Payer: Amerigroup CHIP/Medicaid	$252.36
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	$1,906.72
Rate for Payer: Cash Price	$1,906.72
Rate for Payer: Cigna Medicaid	$2,018.88
Rate for Payer: Molina CHIP/Medicaid	$2,018.88
Rate for Payer: Multiplan Auto	$1,822.60
Rate for Payer: Multiplan Commercial	$1,822.60
Rate for Payer: Multiplan Workers Comp	$1,822.60
Rate for Payer: Parkland Medicaid	$2,018.88
Rate for Payer: Scott and White EPO/PPO	$1,402.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,018.88
Rate for Payer: Superior Health Plan EPO	$381.34

OPWC LC Skin Sub App Trnk/Arm/Leg ad 100sqcm BCE

Facility

$1,623.00

Hospital Charge Code	8914550
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$1,168.56
Rate for Payer: Amerigroup CHIP/Medicaid	$146.07
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	$1,103.64
Rate for Payer: Cash Price	$1,103.64
Rate for Payer: Cigna Medicaid	$1,168.56
Rate for Payer: Molina CHIP/Medicaid	$1,168.56
Rate for Payer: Multiplan Auto	$1,054.95
Rate for Payer: Multiplan Commercial	$1,054.95
Rate for Payer: Multiplan Workers Comp	$1,054.95
Rate for Payer: Parkland Medicaid	$1,168.56
Rate for Payer: Scott and White EPO/PPO	$811.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,168.56
Rate for Payer: Superior Health Plan EPO	$220.73

OPWC LC Skin Sub App Trnk/Arm/Leg ad 100sqcm BCE

Facility

$1,623.00

Hospital Charge Code	8914550
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,103.64

OPWC LC Skin Sub App Trnk/Arm/Leg ad 25 sqcm BCE

Facility

$1,037.00

Hospital Charge Code	8914548
Hospital Revenue Code	761
Rate for Payer: Cash Price	$705.16

OPWC LC Skin Sub App Trnk/Arm/Leg ad 25 sqcm BCE

Facility

$1,037.00

Hospital Charge Code	8914548
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$746.64
Rate for Payer: Amerigroup CHIP/Medicaid	$93.33
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	$705.16
Rate for Payer: Cash Price	$705.16
Rate for Payer: Cigna Medicaid	$746.64
Rate for Payer: Molina CHIP/Medicaid	$746.64
Rate for Payer: Multiplan Auto	$674.05
Rate for Payer: Multiplan Commercial	$674.05
Rate for Payer: Multiplan Workers Comp	$674.05
Rate for Payer: Parkland Medicaid	$746.64
Rate for Payer: Scott and White EPO/PPO	$518.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$746.64
Rate for Payer: Superior Health Plan EPO	$141.03

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

Facility

$1,845.00

Hospital Charge Code	8914547
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$1,328.40
Rate for Payer: Amerigroup CHIP/Medicaid	$166.05
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	$1,254.60
Rate for Payer: Cash Price	$1,254.60
Rate for Payer: Cigna Medicaid	$1,328.40
Rate for Payer: Molina CHIP/Medicaid	$1,328.40
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: Parkland Medicaid	$1,328.40
Rate for Payer: Scott and White EPO/PPO	$922.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,328.40
Rate for Payer: Superior Health Plan EPO	$250.92

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

Facility

$1,845.00

Hospital Charge Code	8914547
Hospital Revenue Code	761
Rate for Payer: Cash Price	$1,254.60

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

Facility

$3,676.00

Hospital Charge Code	8914549
Hospital Revenue Code	761
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$2,646.72
Rate for Payer: Amerigroup CHIP/Medicaid	$330.84
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	$2,499.68
Rate for Payer: Cash Price	$2,499.68
Rate for Payer: Cigna Medicaid	$2,646.72
Rate for Payer: Molina CHIP/Medicaid	$2,646.72
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: Parkland Medicaid	$2,646.72
Rate for Payer: Scott and White EPO/PPO	$1,838.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,646.72
Rate for Payer: Superior Health Plan EPO	$499.94

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

Facility

$3,676.00

Hospital Charge Code	8914549
Hospital Revenue Code	761
Rate for Payer: Cash Price	$2,499.68

OPWC Multilayer Compression Wrap Below the Knee Bilat BCE

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	8912551
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

Know your out-of-pocket cost for care.

All Charges