White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC New PT Visit Level 2 BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	8910559
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

OPWC New PT Visit Level 3 BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8914554
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

OPWC New PT Visit Level 3 BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8914554
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$295.92
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$123.30
Rate for Payer: BCBS of TX Blue Essentials	$147.96
Rate for Payer: BCBS of TX PPO	$164.40
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cigna Medicaid	$295.92
Rate for Payer: Molina CHIP/Medicaid	$295.92
Rate for Payer: Multiplan Auto	$267.15
Rate for Payer: Multiplan Commercial	$267.15
Rate for Payer: Multiplan Workers Comp	$267.15
Rate for Payer: Parkland Medicaid	$295.92
Rate for Payer: Scott and White EPO/PPO	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92

OPWC New PT Visit Level 4 BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	8914555
Hospital Revenue Code	510
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$351.36
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: BCBS of TX Blue Advantage	$146.40
Rate for Payer: BCBS of TX Blue Essentials	$175.68
Rate for Payer: BCBS of TX PPO	$195.20
Rate for Payer: Cash Price	$331.84
Rate for Payer: Cigna Medicaid	$351.36
Rate for Payer: Molina CHIP/Medicaid	$351.36
Rate for Payer: Multiplan Auto	$317.20
Rate for Payer: Multiplan Commercial	$317.20
Rate for Payer: Multiplan Workers Comp	$317.20
Rate for Payer: Parkland Medicaid	$351.36
Rate for Payer: Scott and White EPO/PPO	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.36

OPWC New PT Visit Level 4 BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	8914555
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

OPWC New PT Visit Level 5 BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	8910560
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

OPWC New PT Visit Level 5 BCE

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	8910560
Hospital Revenue Code	510
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$429.12
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$178.80
Rate for Payer: BCBS of TX Blue Essentials	$214.56
Rate for Payer: BCBS of TX PPO	$238.40
Rate for Payer: Cash Price	$405.28
Rate for Payer: Cigna Medicaid	$429.12
Rate for Payer: Molina CHIP/Medicaid	$429.12
Rate for Payer: Multiplan Auto	$387.40
Rate for Payer: Multiplan Commercial	$387.40
Rate for Payer: Multiplan Workers Comp	$387.40
Rate for Payer: Parkland Medicaid	$429.12
Rate for Payer: Scott and White EPO/PPO	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$429.12

OPWC Non-Selective Debridement BCE

Facility

$358.00

Service Code	HCPCS 97602
Hospital Charge Code	8910561
Hospital Revenue Code	361
Rate for Payer: Cash Price	$243.44

OPWC Non-Selective Debridement BCE

Facility

$358.00

Service Code	HCPCS 97602
Hospital Charge Code	8910561
Hospital Revenue Code	361
Min. Negotiated Rate	$32.22
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$107.40
Rate for Payer: BCBS of TX Blue Essentials	$128.88
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$143.20
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$257.76
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	$257.76
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	$257.76
Rate for Payer: Scott and White EPO/PPO	$179.00
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$257.76
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 Npwt Dme <= 50 Sq cm BCE

Facility

$794.80

Service Code	HCPCS 97605
Hospital Charge Code	8914556
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

OPWC Npwt Dme <= 50 Sq cm BCE

Facility

$794.80

Service Code	HCPCS 97605
Hospital Charge Code	8914556
Hospital Revenue Code	361
Min. Negotiated Rate	$71.53
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$238.44
Rate for Payer: BCBS of TX Blue Essentials	$286.13
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$317.92
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$572.26
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	$572.26
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	$572.26
Rate for Payer: Scott and White EPO/PPO	$397.40
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.26
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 Npwt Dme >50 Sq cm BCE

Facility

$400.00

Service Code	HCPCS 97606
Hospital Charge Code	8910562
Hospital Revenue Code	361
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$120.00
Rate for Payer: BCBS of TX Blue Essentials	$144.00
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$160.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$288.00
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	$288.00
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	$288.00
Rate for Payer: Scott and White EPO/PPO	$200.00
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$288.00
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 Npwt Dme >50 Sq cm BCE

Facility

$400.00

Service Code	HCPCS 97606
Hospital Charge Code	8910562
Hospital Revenue Code	361
Rate for Payer: Cash Price	$272.00

OPWC Npwt Nondme <= 50 Sq cm BCE

Facility

$688.00

Service Code	HCPCS 97607
Hospital Charge Code	8910563
Hospital Revenue Code	361
Min. Negotiated Rate	$61.92
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$61.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$206.40
Rate for Payer: BCBS of TX Blue Essentials	$247.68
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$275.20
Rate for Payer: Cash Price	$467.84
Rate for Payer: Cash Price	$467.84
Rate for Payer: Cash Price	$467.84
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$495.36
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	$495.36
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	$495.36
Rate for Payer: Scott and White EPO/PPO	$344.00
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$495.36
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 Npwt Nondme <= 50 Sq cm BCE

Facility

$688.00

Service Code	HCPCS 97607
Hospital Charge Code	8910563
Hospital Revenue Code	361
Rate for Payer: Cash Price	$467.84

OPWC Paring/Cutting Benign Lesion 2-4 BCE

Facility

$403.00

Service Code	HCPCS 11056
Hospital Charge Code	8914557
Hospital Revenue Code	361
Rate for Payer: Cash Price	$274.04

OPWC Paring/Cutting Benign Lesion 2-4 BCE

Facility

$403.00

Service Code	HCPCS 11056
Hospital Charge Code	8914557
Hospital Revenue Code	361
Min. Negotiated Rate	$36.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.27
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	$274.04
Rate for Payer: Cash Price	$274.04
Rate for Payer: Cash Price	$274.04
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$290.16
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	$290.16
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	$290.16
Rate for Payer: Scott and White EPO/PPO	$372.87
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$290.16
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 Paring/Cutting Benign Lesion Over 4 BCE

Facility

$521.00

Service Code	HCPCS 11057
Hospital Charge Code	8914558
Hospital Revenue Code	361
Rate for Payer: Cash Price	$354.28

OPWC Paring/Cutting Benign Lesion Over 4 BCE

Facility

$521.00

Service Code	HCPCS 11057
Hospital Charge Code	8914558
Hospital Revenue Code	361
Min. Negotiated Rate	$55.65
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$55.65
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$97.03
Rate for Payer: BCBS of TX Blue Essentials	$116.20
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$146.41
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$375.12
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	$375.12
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	$375.12
Rate for Payer: Scott and White EPO/PPO	$372.87
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.12
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 Paring Of Single Callus BCE

Facility

$993.50

Service Code	HCPCS 11055
Hospital Charge Code	8910564
Hospital Revenue Code	361
Min. Negotiated Rate	$89.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$89.42
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	$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	$372.87
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

OPWC Paring Of Single Callus BCE

Facility

$993.50

Service Code	HCPCS 11055
Hospital Charge Code	8910564
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OPWC Punch Biopsy Skin, Ea Add BCE

Facility

$346.00

Service Code	HCPCS 11105
Hospital Charge Code	7150054
Hospital Revenue Code	361
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$31.14
Rate for Payer: BCBS of TX Blue Advantage	$103.80
Rate for Payer: BCBS of TX Blue Essentials	$124.56
Rate for Payer: BCBS of TX PPO	$138.40
Rate for Payer: Cash Price	$235.28
Rate for Payer: Cash Price	$235.28
Rate for Payer: Cigna Medicaid	$249.12
Rate for Payer: Molina CHIP/Medicaid	$249.12
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	$249.12
Rate for Payer: Scott and White EPO/PPO	$173.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$249.12
Rate for Payer: Superior Health Plan EPO	$47.06

OPWC Punch Biopsy Skin, Ea Add BCE

Facility

$346.00

Service Code	HCPCS 11105
Hospital Charge Code	7150054
Hospital Revenue Code	361
Rate for Payer: Cash Price	$235.28

OPWC Punch Biopsy Skn, One Lsn BCE

Facility

$688.00

Service Code	HCPCS 11104
Hospital Charge Code	8910565
Hospital Revenue Code	361
Min. Negotiated Rate	$79.46
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$79.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$147.44
Rate for Payer: BCBS of TX Blue Essentials	$176.58
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$222.49
Rate for Payer: Cash Price	$467.84
Rate for Payer: Cash Price	$467.84
Rate for Payer: Cash Price	$467.84
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$495.36
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	$495.36
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	$495.36
Rate for Payer: Scott and White EPO/PPO	$755.48
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$495.36
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 Punch Biopsy Skn, One Lsn BCE

Facility

$688.00

Service Code	HCPCS 11104
Hospital Charge Code	8910565
Hospital Revenue Code	361
Rate for Payer: Cash Price	$467.84

Know your out-of-pocket cost for care.

All Charges