White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$1,103.64

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 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 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 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 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 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: BCBS of TX Blue Essentials	$45.00
Rate for Payer: Amerigroup CHIP/Medicaid	$330.84
Rate for Payer: BCBS of TX Blue Advantage	$38.00
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
Min. Negotiated Rate	$51.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$51.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$170.30
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	$345.06
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$301.99
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

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

OPWC Multilayer Compression Wrap Below the Knee LT BCE

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	8912553
Hospital Revenue Code	361
Min. Negotiated Rate	$51.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$51.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$170.30
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	$345.06
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$301.99
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

OPWC Multilayer Compression Wrap Below the Knee LT BCE

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	8912552
Hospital Revenue Code	361
Min. Negotiated Rate	$51.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$51.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$112.86
Rate for Payer: BCBS of TX Blue Essentials	$135.16
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$170.30
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	$345.06
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$163.24
Rate for Payer: Employer Direct Commercial	$163.24
Rate for Payer: Humana Medicare/TRICARE	$163.24
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$163.24
Rate for Payer: Molina Medicare	$163.24
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	$301.99
Rate for Payer: Scott and White Medicare	$163.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$163.24
Rate for Payer: Superior Health Plan Medicare	$163.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$163.24
Rate for Payer: Universal American Medicare	$163.24
Rate for Payer: Wellcare Medicare	$163.24
Rate for Payer: Wellmed Medicare	$163.24

OPWC Multilayer Compression Wrap Below the Knee LT BCE

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	8912552
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Multilayer Compression Wrap Below the Knee LT BCE

Facility

$993.50

Service Code	HCPCS 29581
Hospital Charge Code	8912553
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Nail Debride 1-5 BCE

Facility

$993.50

Service Code	HCPCS 11720
Hospital Charge Code	8910558
Hospital Revenue Code	361
Min. Negotiated Rate	$59.26
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$138.63
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	$125.27
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
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	$109.63
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

OPWC Nail Debride 1-5 BCE

Facility

$993.50

Service Code	HCPCS 11720
Hospital Charge Code	8910558
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Nail Debridement 6 or more BCE

Facility

$993.50

Service Code	HCPCS 11721
Hospital Charge Code	8914553
Hospital Revenue Code	361
Min. Negotiated Rate	$59.26
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$138.63
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	$125.27
Rate for Payer: Cigna Medicaid	$715.32
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$715.32
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
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	$109.63
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$715.32
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

OPWC Nail Debridement 6 or more BCE

Facility

$993.50

Service Code	HCPCS 11721
Hospital Charge Code	8914553
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC New PT Visit Level 2 BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	8910559
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$195.84
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$81.60
Rate for Payer: BCBS of TX Blue Essentials	$97.92
Rate for Payer: BCBS of TX PPO	$108.80
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cigna Medicaid	$195.84
Rate for Payer: Molina CHIP/Medicaid	$195.84
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$195.84
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84

Know your out-of-pocket cost for care.

All Charges