White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$38,658.03

Service Code	MSDRG 464
Min. Negotiated Rate	$26,223.12
Max. Negotiated Rate	$38,658.03
Rate for Payer: Aetna Commercial	$33,765.75
Rate for Payer: Aetna Medicare	$36,409.44
Rate for Payer: BCBS of TX Blue Advantage	$26,223.12
Rate for Payer: BCBS of TX Blue Essentials	$30,379.14
Rate for Payer: BCBS of TX PPO	$33,755.90
Rate for Payer: Cigna Commercial	$38,658.03

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$72,948.46

Service Code	MSDRG 463
Min. Negotiated Rate	$46,278.32
Max. Negotiated Rate	$72,948.46
Rate for Payer: Aetna Commercial	$63,716.62
Rate for Payer: Aetna Medicare	$64,906.93
Rate for Payer: BCBS of TX Blue Advantage	$46,278.32
Rate for Payer: BCBS of TX Blue Essentials	$52,956.08
Rate for Payer: BCBS of TX PPO	$58,842.37
Rate for Payer: Cigna Commercial	$72,948.46

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$24,307.37

Service Code	MSDRG 465
Min. Negotiated Rate	$17,575.82
Max. Negotiated Rate	$24,307.37
Rate for Payer: Aetna Commercial	$21,046.50
Rate for Payer: Aetna Medicare	$24,307.37
Rate for Payer: BCBS of TX Blue Advantage	$17,575.82
Rate for Payer: BCBS of TX Blue Essentials	$18,960.13
Rate for Payer: BCBS of TX PPO	$21,067.63
Rate for Payer: Cigna Commercial	$24,095.90

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$24,456.17

Service Code	MSDRG 902
Min. Negotiated Rate	$16,267.76
Max. Negotiated Rate	$24,456.17
Rate for Payer: Aetna Commercial	$21,202.88
Rate for Payer: Aetna Medicare	$24,456.17
Rate for Payer: BCBS of TX Blue Advantage	$16,267.76
Rate for Payer: BCBS of TX Blue Essentials	$19,816.61
Rate for Payer: BCBS of TX PPO	$22,019.31
Rate for Payer: Cigna Commercial	$24,274.94

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$55,742.06

Service Code	MSDRG 901
Min. Negotiated Rate	$37,207.04
Max. Negotiated Rate	$55,742.06
Rate for Payer: Aetna Commercial	$48,687.75
Rate for Payer: Aetna Medicare	$50,607.33
Rate for Payer: BCBS of TX Blue Advantage	$37,207.04
Rate for Payer: BCBS of TX Blue Essentials	$46,073.30
Rate for Payer: BCBS of TX PPO	$51,194.54
Rate for Payer: Cigna Commercial	$55,742.06

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$17,571.30

Service Code	MSDRG 903
Min. Negotiated Rate	$9,558.04
Max. Negotiated Rate	$17,571.30
Rate for Payer: Aetna Commercial	$13,966.88
Rate for Payer: Aetna Medicare	$17,571.30
Rate for Payer: BCBS of TX Blue Advantage	$9,558.04
Rate for Payer: BCBS of TX Blue Essentials	$12,010.28
Rate for Payer: BCBS of TX PPO	$13,345.28
Rate for Payer: Cigna Commercial	$15,990.52

WRENCH KIT TORQUE 5873W

Facility

$163.44

Hospital Charge Code	114630
Hospital Revenue Code	272
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$106.24
Rate for Payer: Aetna Commercial	$89.89
Rate for Payer: Amerigroup CHIP/Medicaid	$14.71
Rate for Payer: BCBS of TX Blue Advantage	$49.03
Rate for Payer: BCBS of TX Blue Essentials	$58.84
Rate for Payer: BCBS of TX PPO	$65.38
Rate for Payer: Cash Price	$143.83
Rate for Payer: Multiplan Auto	$106.24
Rate for Payer: Multiplan Commercial	$106.24
Rate for Payer: Multiplan Workers Comp	$106.24
Rate for Payer: Scott and White EPO/PPO	$81.72
Rate for Payer: Superior Health Plan EPO	$22.23

WRENCH KIT TORQUE 5873W

Facility

$163.44

Hospital Charge Code	114630
Hospital Revenue Code	272
Rate for Payer: Cash Price	$143.83

WRENCH TW TOOL CARD

Facility

$202.71

Hospital Charge Code	114623
Hospital Revenue Code	272
Min. Negotiated Rate	$18.24
Max. Negotiated Rate	$131.76
Rate for Payer: Aetna Commercial	$111.49
Rate for Payer: Amerigroup CHIP/Medicaid	$18.24
Rate for Payer: BCBS of TX Blue Advantage	$60.81
Rate for Payer: BCBS of TX Blue Essentials	$72.98
Rate for Payer: BCBS of TX PPO	$81.08
Rate for Payer: Cash Price	$178.38
Rate for Payer: Multiplan Auto	$131.76
Rate for Payer: Multiplan Commercial	$131.76
Rate for Payer: Multiplan Workers Comp	$131.76
Rate for Payer: Scott and White EPO/PPO	$101.36
Rate for Payer: Superior Health Plan EPO	$27.57

WRENCH TW TOOL CARD

Facility

$202.71

Hospital Charge Code	114623
Hospital Revenue Code	272
Rate for Payer: Cash Price	$178.38

WSTNT B ENDPR UNISTEP+DS -- DHF

Facility

$5,544.00

Service Code	HCPCS C1876
Hospital Charge Code	82404229
Hospital Revenue Code	278
Min. Negotiated Rate	$1,386.00
Max. Negotiated Rate	$2,772.00
Rate for Payer: Aetna Commercial	$1,663.20
Rate for Payer: Cash Price	$4,878.72
Rate for Payer: Cigna Commercial	$1,386.00
Rate for Payer: Multiplan Auto	$2,772.00
Rate for Payer: Multiplan Commercial	$2,772.00
Rate for Payer: Multiplan Workers Comp	$2,772.00
Rate for Payer: Scott and White EPO/PPO	$2,772.00

WSTNT B ENDPR UNISTEP+DS -- DHF

Facility

$5,544.00

Service Code	HCPCS C1876
Hospital Charge Code	82404229
Hospital Revenue Code	278
Min. Negotiated Rate	$498.96
Max. Negotiated Rate	$2,772.00
Rate for Payer: Aetna Commercial	$1,663.20
Rate for Payer: Amerigroup CHIP/Medicaid	$498.96
Rate for Payer: BCBS of TX Blue Advantage	$1,663.20
Rate for Payer: BCBS of TX Blue Essentials	$1,995.84
Rate for Payer: BCBS of TX PPO	$2,217.60
Rate for Payer: Cash Price	$4,878.72
Rate for Payer: Multiplan Auto	$2,772.00
Rate for Payer: Multiplan Commercial	$2,772.00
Rate for Payer: Multiplan Workers Comp	$2,772.00
Rate for Payer: Scott and White EPO/PPO	$2,772.00
Rate for Payer: Superior Health Plan EPO	$753.98

XR Abdomen 2 Views

Facility

$808.00

Service Code	CPT 74019 FY
Hospital Charge Code	3181558
Hospital Revenue Code	320
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$525.20
Rate for Payer: Aetna Commercial	$29.49
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$711.04
Rate for Payer: Cash Price	$711.04
Rate for Payer: Cash Price	$711.04
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$20.85
Rate for Payer: Molina CHIP/Medicaid	$20.85
Rate for Payer: Multiplan Auto	$525.20
Rate for Payer: Multiplan Commercial	$525.20
Rate for Payer: Multiplan Workers Comp	$525.20
Rate for Payer: Parkland Medicaid	$20.85
Rate for Payer: Scott and White EPO/PPO	$404.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.85
Rate for Payer: Superior Health Plan EPO	$109.89

XR Abdomen 2 Views

Facility

$808.00

Service Code	CPT 74019 FY
Hospital Charge Code	3181558
Hospital Revenue Code	320
Rate for Payer: Cash Price	$711.04

XR Abdomen 2 Views BCE

Facility

$808.00

Service Code	CPT 74019 FY
Hospital Charge Code	3181558
Hospital Revenue Code	320
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$525.20
Rate for Payer: Aetna Commercial	$29.49
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$37.09
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$711.04
Rate for Payer: Cash Price	$711.04
Rate for Payer: Cash Price	$711.04
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$20.85
Rate for Payer: Molina CHIP/Medicaid	$20.85
Rate for Payer: Multiplan Auto	$525.20
Rate for Payer: Multiplan Commercial	$525.20
Rate for Payer: Multiplan Workers Comp	$525.20
Rate for Payer: Parkland Medicaid	$20.85
Rate for Payer: Scott and White EPO/PPO	$404.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.85
Rate for Payer: Superior Health Plan EPO	$109.89

XR Abdomen Complete 3 Views

Facility

$819.00

Service Code	CPT 74021 FY
Hospital Charge Code	3181560
Hospital Revenue Code	320
Min. Negotiated Rate	$34.88
Max. Negotiated Rate	$532.35
Rate for Payer: Aetna Commercial	$34.88
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$43.10
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$43.10
Rate for Payer: Molina CHIP/Medicaid	$43.10
Rate for Payer: Multiplan Auto	$532.35
Rate for Payer: Multiplan Commercial	$532.35
Rate for Payer: Multiplan Workers Comp	$532.35
Rate for Payer: Parkland Medicaid	$43.10
Rate for Payer: Scott and White EPO/PPO	$409.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.10
Rate for Payer: Superior Health Plan EPO	$111.38

XR Abdomen Complete 3 Views BCE

Facility

$819.00

Service Code	CPT 74021 FY
Hospital Charge Code	3181560
Hospital Revenue Code	320
Rate for Payer: Cash Price	$720.72

XR Abdomen Complete 3 Views BCE

Facility

$819.00

Service Code	CPT 74021 FY
Hospital Charge Code	3181560
Hospital Revenue Code	320
Min. Negotiated Rate	$34.88
Max. Negotiated Rate	$532.35
Rate for Payer: Aetna Commercial	$34.88
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$43.10
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cash Price	$720.72
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$43.10
Rate for Payer: Molina CHIP/Medicaid	$43.10
Rate for Payer: Multiplan Auto	$532.35
Rate for Payer: Multiplan Commercial	$532.35
Rate for Payer: Multiplan Workers Comp	$532.35
Rate for Payer: Parkland Medicaid	$43.10
Rate for Payer: Scott and White EPO/PPO	$409.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.10
Rate for Payer: Superior Health Plan EPO	$111.38

XR Abdomen KUB 1 View

Facility

$739.00

Service Code	CPT 74018 FY
Hospital Charge Code	3181556
Hospital Revenue Code	320
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$480.35
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$30.08
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$650.32
Rate for Payer: Cash Price	$650.32
Rate for Payer: Cash Price	$650.32
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$17.11
Rate for Payer: Molina CHIP/Medicaid	$17.11
Rate for Payer: Multiplan Auto	$480.35
Rate for Payer: Multiplan Commercial	$480.35
Rate for Payer: Multiplan Workers Comp	$480.35
Rate for Payer: Parkland Medicaid	$17.11
Rate for Payer: Scott and White EPO/PPO	$369.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.11
Rate for Payer: Superior Health Plan EPO	$100.50

XR Abdomen KUB 1 View BCE

Facility

$739.00

Service Code	CPT 74018 FY
Hospital Charge Code	3181556
Hospital Revenue Code	320
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$480.35
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$30.08
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$650.32
Rate for Payer: Cash Price	$650.32
Rate for Payer: Cash Price	$650.32
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$17.11
Rate for Payer: Molina CHIP/Medicaid	$17.11
Rate for Payer: Multiplan Auto	$480.35
Rate for Payer: Multiplan Commercial	$480.35
Rate for Payer: Multiplan Workers Comp	$480.35
Rate for Payer: Parkland Medicaid	$17.11
Rate for Payer: Scott and White EPO/PPO	$369.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.11
Rate for Payer: Superior Health Plan EPO	$100.50

XR Abdomen KUB 1 View BCE

Facility

$739.00

Service Code	CPT 74018 FY
Hospital Charge Code	3181556
Hospital Revenue Code	320
Rate for Payer: Cash Price	$650.32

XR Abdomen Series + Chest 1 View

Facility

$827.00

Service Code	CPT 74022 FY
Hospital Charge Code	3160314
Hospital Revenue Code	320
Min. Negotiated Rate	$39.88
Max. Negotiated Rate	$537.55
Rate for Payer: Aetna Commercial	$39.88
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$50.13
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$727.76
Rate for Payer: Cash Price	$727.76
Rate for Payer: Cash Price	$727.76
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$50.13
Rate for Payer: Molina CHIP/Medicaid	$50.13
Rate for Payer: Multiplan Auto	$537.55
Rate for Payer: Multiplan Commercial	$537.55
Rate for Payer: Multiplan Workers Comp	$537.55
Rate for Payer: Parkland Medicaid	$50.13
Rate for Payer: Scott and White EPO/PPO	$413.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.13
Rate for Payer: Superior Health Plan EPO	$112.47

XR Abdomen Series + Chest 1 View BCE

Facility

$827.00

Service Code	CPT 74022 FY
Hospital Charge Code	3160314
Hospital Revenue Code	320
Rate for Payer: Cash Price	$727.76

XR Abdomen Series + Chest 1 View BCE

Facility

$827.00

Service Code	CPT 74022 FY
Hospital Charge Code	3160314
Hospital Revenue Code	320
Min. Negotiated Rate	$39.88
Max. Negotiated Rate	$537.55
Rate for Payer: Aetna Commercial	$39.88
Rate for Payer: Aetna Medicare	$150.82
Rate for Payer: Amerigroup CHIP/Medicaid	$50.13
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$727.76
Rate for Payer: Cash Price	$727.76
Rate for Payer: Cash Price	$727.76
Rate for Payer: Cigna Commercial	$227.77
Rate for Payer: Cigna Medicaid	$50.13
Rate for Payer: Molina CHIP/Medicaid	$50.13
Rate for Payer: Multiplan Auto	$537.55
Rate for Payer: Multiplan Commercial	$537.55
Rate for Payer: Multiplan Workers Comp	$537.55
Rate for Payer: Parkland Medicaid	$50.13
Rate for Payer: Scott and White EPO/PPO	$413.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.13
Rate for Payer: Superior Health Plan EPO	$112.47

XR AC Joints Bilateral

Facility

$701.00

Service Code	CPT 73050 FY
Hospital Charge Code	3100617
Hospital Revenue Code	320
Min. Negotiated Rate	$22.16
Max. Negotiated Rate	$455.65
Rate for Payer: Aetna Commercial	$22.16
Rate for Payer: Aetna Medicare	$124.65
Rate for Payer: Amerigroup CHIP/Medicaid	$28.74
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$616.88
Rate for Payer: Cash Price	$616.88
Rate for Payer: Cash Price	$616.88
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Cigna Medicaid	$28.74
Rate for Payer: Molina CHIP/Medicaid	$28.74
Rate for Payer: Multiplan Auto	$455.65
Rate for Payer: Multiplan Commercial	$455.65
Rate for Payer: Multiplan Workers Comp	$455.65
Rate for Payer: Parkland Medicaid	$28.74
Rate for Payer: Scott and White EPO/PPO	$350.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.74
Rate for Payer: Superior Health Plan EPO	$95.34

Know your out-of-pocket cost for care.

All Charges