White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OPWC Unna Boot Bilateral BCE

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	8910579
Hospital Revenue Code	361
Min. Negotiated Rate	$33.12
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$33.12
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$163.24
Rate for Payer: Amerigroup Medicare	$163.24
Rate for Payer: BCBS of TX Blue Advantage	$70.51
Rate for Payer: BCBS of TX Blue Essentials	$84.44
Rate for Payer: BCBS of TX Medicare	$163.24
Rate for Payer: BCBS of TX PPO	$106.39
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	$266.58
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 Unna Boot Bilateral BCE

Facility

$993.50

Service Code	HCPCS 29580
Hospital Charge Code	8910579
Hospital Revenue Code	361
Rate for Payer: Cash Price	$675.58

OR01293

Facility

$24,909.63

Service Code	HCPCS C1734
Hospital Charge Code	991126
Hospital Revenue Code	278
Min. Negotiated Rate	$6,227.41
Max. Negotiated Rate	$12,454.82
Rate for Payer: Cash Price	$16,938.55
Rate for Payer: Cigna Commercial	$6,227.41
Rate for Payer: Multiplan Auto	$12,454.82
Rate for Payer: Multiplan Commercial	$12,454.82
Rate for Payer: Multiplan Workers Comp	$12,454.82
Rate for Payer: Scott and White EPO/PPO	$12,454.82

OR01293

Facility

$24,909.63

Service Code	HCPCS C1734
Hospital Charge Code	991126
Hospital Revenue Code	278
Min. Negotiated Rate	$2,241.87
Max. Negotiated Rate	$17,934.93
Rate for Payer: Amerigroup CHIP/Medicaid	$2,241.87
Rate for Payer: BCBS of TX Blue Advantage	$7,472.89
Rate for Payer: BCBS of TX Blue Essentials	$8,967.47
Rate for Payer: BCBS of TX PPO	$9,963.85
Rate for Payer: Cash Price	$16,938.55
Rate for Payer: Cigna Medicaid	$17,934.93
Rate for Payer: Molina CHIP/Medicaid	$17,934.93
Rate for Payer: Multiplan Auto	$12,454.82
Rate for Payer: Multiplan Commercial	$12,454.82
Rate for Payer: Multiplan Workers Comp	$12,454.82
Rate for Payer: Parkland Medicaid	$17,934.93
Rate for Payer: Scott and White EPO/PPO	$12,454.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,934.93
Rate for Payer: Superior Health Plan EPO	$3,387.71

OR01529

Facility

$5,180.72

Service Code	HCPCS C1734
Hospital Charge Code	991124
Hospital Revenue Code	278
Min. Negotiated Rate	$1,295.18
Max. Negotiated Rate	$2,590.36
Rate for Payer: Cash Price	$3,522.89
Rate for Payer: Cigna Commercial	$1,295.18
Rate for Payer: Multiplan Auto	$2,590.36
Rate for Payer: Multiplan Commercial	$2,590.36
Rate for Payer: Multiplan Workers Comp	$2,590.36
Rate for Payer: Scott and White EPO/PPO	$2,590.36

OR01529

Facility

$5,180.72

Service Code	HCPCS C1734
Hospital Charge Code	991124
Hospital Revenue Code	278
Min. Negotiated Rate	$466.26
Max. Negotiated Rate	$3,730.12
Rate for Payer: Amerigroup CHIP/Medicaid	$466.26
Rate for Payer: BCBS of TX Blue Advantage	$1,554.22
Rate for Payer: BCBS of TX Blue Essentials	$1,865.06
Rate for Payer: BCBS of TX PPO	$2,072.29
Rate for Payer: Cash Price	$3,522.89
Rate for Payer: Cigna Medicaid	$3,730.12
Rate for Payer: Molina CHIP/Medicaid	$3,730.12
Rate for Payer: Multiplan Auto	$2,590.36
Rate for Payer: Multiplan Commercial	$2,590.36
Rate for Payer: Multiplan Workers Comp	$2,590.36
Rate for Payer: Parkland Medicaid	$3,730.12
Rate for Payer: Scott and White EPO/PPO	$2,590.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,730.12
Rate for Payer: Superior Health Plan EPO	$704.58

OR01677

Facility

$34,910.64

Service Code	HCPCS C1734
Hospital Charge Code	991125
Hospital Revenue Code	278
Min. Negotiated Rate	$8,727.66
Max. Negotiated Rate	$17,455.32
Rate for Payer: Cash Price	$23,739.24
Rate for Payer: Cigna Commercial	$8,727.66
Rate for Payer: Multiplan Auto	$17,455.32
Rate for Payer: Multiplan Commercial	$17,455.32
Rate for Payer: Multiplan Workers Comp	$17,455.32
Rate for Payer: Scott and White EPO/PPO	$17,455.32

OR01677

Facility

$34,910.64

Service Code	HCPCS C1734
Hospital Charge Code	991125
Hospital Revenue Code	278
Min. Negotiated Rate	$3,141.96
Max. Negotiated Rate	$25,135.66
Rate for Payer: Amerigroup CHIP/Medicaid	$3,141.96
Rate for Payer: BCBS of TX Blue Advantage	$10,473.19
Rate for Payer: BCBS of TX Blue Essentials	$12,567.83
Rate for Payer: BCBS of TX PPO	$13,964.26
Rate for Payer: Cash Price	$23,739.24
Rate for Payer: Cigna Medicaid	$25,135.66
Rate for Payer: Molina CHIP/Medicaid	$25,135.66
Rate for Payer: Multiplan Auto	$17,455.32
Rate for Payer: Multiplan Commercial	$17,455.32
Rate for Payer: Multiplan Workers Comp	$17,455.32
Rate for Payer: Parkland Medicaid	$25,135.66
Rate for Payer: Scott and White EPO/PPO	$17,455.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,135.66
Rate for Payer: Superior Health Plan EPO	$4,747.85

ORBITAL PROCEDURES W CC/MCC

Facility

$42,660.70

Service Code	MSDRG 113
Min. Negotiated Rate	$19,646.38
Max. Negotiated Rate	$42,660.70
Rate for Payer: BCBS of TX Blue Advantage	$19,803.22
Rate for Payer: BCBS of TX Blue Essentials	$23,761.56
Rate for Payer: BCBS of TX PPO	$26,402.76

ORBITAL PROCEDURES WITH CC/MCC

Facility

$42,660.70

Service Code	MSDRG 113
Min. Negotiated Rate	$19,646.38
Max. Negotiated Rate	$42,660.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,991.36
Rate for Payer: Amerigroup Medicare	$21,991.36
Rate for Payer: BCBS of TX Medicare	$21,991.36
Rate for Payer: Cigna Commercial	$30,282.17
Rate for Payer: Cigna Medicare	$21,991.36
Rate for Payer: Employer Direct Commercial	$21,991.36
Rate for Payer: Humana Medicare/TRICARE	$21,991.36
Rate for Payer: Molina Dual Medicare/Medicaid	$21,991.36
Rate for Payer: Molina Medicare	$21,991.36
Rate for Payer: Multiplan Auto	$42,660.70
Rate for Payer: Multiplan Commercial	$42,660.70
Rate for Payer: Multiplan Workers Comp	$42,660.70
Rate for Payer: Scott and White EPO/PPO	$19,646.38
Rate for Payer: Scott and White Medicare	$21,991.36
Rate for Payer: Superior Health Plan EPO	$21,991.36
Rate for Payer: Superior Health Plan Medicare	$21,991.36
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,991.36
Rate for Payer: Universal American Medicare	$21,991.36
Rate for Payer: Wellcare Medicare	$21,991.36
Rate for Payer: Wellmed Medicare	$21,991.36

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$24,753.20

Service Code	MSDRG 114
Min. Negotiated Rate	$10,793.86
Max. Negotiated Rate	$24,753.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,676.25
Rate for Payer: Amerigroup Medicare	$14,676.25
Rate for Payer: BCBS of TX Medicare	$14,676.25
Rate for Payer: Cigna Commercial	$17,426.64
Rate for Payer: Cigna Medicare	$14,676.25
Rate for Payer: Employer Direct Commercial	$14,676.25
Rate for Payer: Humana Medicare/TRICARE	$14,676.25
Rate for Payer: Molina Dual Medicare/Medicaid	$14,676.25
Rate for Payer: Molina Medicare	$14,676.25
Rate for Payer: Multiplan Auto	$24,753.20
Rate for Payer: Multiplan Commercial	$24,753.20
Rate for Payer: Multiplan Workers Comp	$24,753.20
Rate for Payer: Scott and White EPO/PPO	$11,399.50
Rate for Payer: Scott and White Medicare	$14,676.25
Rate for Payer: Superior Health Plan EPO	$14,676.25
Rate for Payer: Superior Health Plan Medicare	$14,676.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,676.25
Rate for Payer: Universal American Medicare	$14,676.25
Rate for Payer: Wellcare Medicare	$14,676.25
Rate for Payer: Wellmed Medicare	$14,676.25

ORBITAL PROCEDURES W/O CC/MCC

Facility

$24,753.20

Service Code	MSDRG 114
Min. Negotiated Rate	$10,793.86
Max. Negotiated Rate	$24,753.20
Rate for Payer: BCBS of TX Blue Advantage	$10,793.86
Rate for Payer: BCBS of TX Blue Essentials	$12,951.38
Rate for Payer: BCBS of TX PPO	$14,390.98

ORBIT AND EYE PROCEDURES

Facility

$6,804.87

Service Code	APR-DRG 0732
Min. Negotiated Rate	$6,415.87
Max. Negotiated Rate	$6,804.87
Rate for Payer: Amerigroup CHIP/Medicaid	$6,415.87
Rate for Payer: Cigna Medicaid	$6,415.87
Rate for Payer: Molina CHIP/Medicaid	$6,415.87
Rate for Payer: Parkland Medicaid	$6,415.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,804.87

ORBIT AND EYE PROCEDURES

Facility

$9,748.45

Service Code	APR-DRG 0733
Min. Negotiated Rate	$9,191.18
Max. Negotiated Rate	$9,748.45
Rate for Payer: Amerigroup CHIP/Medicaid	$9,191.18
Rate for Payer: Cigna Medicaid	$9,191.18
Rate for Payer: Molina CHIP/Medicaid	$9,191.18
Rate for Payer: Parkland Medicaid	$9,191.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,748.45

ORBIT AND EYE PROCEDURES

Facility

$24,974.06

Service Code	APR-DRG 0734
Min. Negotiated Rate	$23,546.42
Max. Negotiated Rate	$24,974.06
Rate for Payer: Amerigroup CHIP/Medicaid	$23,546.42
Rate for Payer: Cigna Medicaid	$23,546.42
Rate for Payer: Molina CHIP/Medicaid	$23,546.42
Rate for Payer: Parkland Medicaid	$23,546.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,974.06

ORBIT AND EYE PROCEDURES

Facility

$4,995.87

Service Code	APR-DRG 0731
Min. Negotiated Rate	$4,710.28
Max. Negotiated Rate	$4,995.87
Rate for Payer: Amerigroup CHIP/Medicaid	$4,710.28
Rate for Payer: Cigna Medicaid	$4,710.28
Rate for Payer: Molina CHIP/Medicaid	$4,710.28
Rate for Payer: Parkland Medicaid	$4,710.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,995.87

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$29,830.00

Service Code	MSDRG 884
Min. Negotiated Rate	$11,591.94
Max. Negotiated Rate	$29,830.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,551.76
Rate for Payer: Amerigroup Medicare	$16,551.76
Rate for Payer: BCBS of TX Medicare	$16,551.76
Rate for Payer: Cigna Commercial	$20,722.63
Rate for Payer: Cigna Medicare	$16,551.76
Rate for Payer: Employer Direct Commercial	$16,551.76
Rate for Payer: Molina Dual Medicare/Medicaid	$16,551.76
Rate for Payer: Molina Medicare	$16,551.76
Rate for Payer: Multiplan Auto	$29,830.00
Rate for Payer: Multiplan Commercial	$29,830.00
Rate for Payer: Multiplan Workers Comp	$29,830.00
Rate for Payer: Scott and White EPO/PPO	$13,737.50
Rate for Payer: Scott and White Medicare	$16,551.76
Rate for Payer: Superior Health Plan EPO	$16,551.76
Rate for Payer: Superior Health Plan Medicare	$16,551.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,551.76
Rate for Payer: Universal American Medicare	$16,551.76
Rate for Payer: Wellcare Medicare	$16,551.76
Rate for Payer: Wellmed Medicare	$16,551.76

ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY

Facility

$29,830.00

Service Code	MSDRG 884
Min. Negotiated Rate	$11,591.94
Max. Negotiated Rate	$29,830.00
Rate for Payer: BCBS of TX Blue Advantage	$11,591.94
Rate for Payer: BCBS of TX Blue Essentials	$13,908.98
Rate for Payer: BCBS of TX PPO	$15,455.02

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$1,653.97

Service Code	APR-DRG 7571
Min. Negotiated Rate	$1,559.42
Max. Negotiated Rate	$1,653.97
Rate for Payer: Amerigroup CHIP/Medicaid	$1,559.42
Rate for Payer: Cigna Medicaid	$1,559.42
Rate for Payer: Molina CHIP/Medicaid	$1,559.42
Rate for Payer: Parkland Medicaid	$1,559.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,653.97

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$15,495.30

Service Code	APR-DRG 7574
Min. Negotiated Rate	$14,609.51
Max. Negotiated Rate	$15,495.30
Rate for Payer: Amerigroup CHIP/Medicaid	$14,609.51
Rate for Payer: Cigna Medicaid	$14,609.51
Rate for Payer: Molina CHIP/Medicaid	$14,609.51
Rate for Payer: Parkland Medicaid	$14,609.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,495.30

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$6,871.63

Service Code	APR-DRG 7573
Min. Negotiated Rate	$6,478.81
Max. Negotiated Rate	$6,871.63
Rate for Payer: Amerigroup CHIP/Medicaid	$6,478.81
Rate for Payer: Cigna Medicaid	$6,478.81
Rate for Payer: Molina CHIP/Medicaid	$6,478.81
Rate for Payer: Parkland Medicaid	$6,478.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,871.63

ORGANIC MENTAL HEALTH DISTURBANCES

Facility

$4,848.39

Service Code	APR-DRG 7572
Min. Negotiated Rate	$4,571.23
Max. Negotiated Rate	$4,848.39
Rate for Payer: Amerigroup CHIP/Medicaid	$4,571.23
Rate for Payer: Cigna Medicaid	$4,571.23
Rate for Payer: Molina CHIP/Medicaid	$4,571.23
Rate for Payer: Parkland Medicaid	$4,571.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,848.39

Organism ID, Bacteria SO

Facility

$238.00

Service Code	HCPCS 87077
Hospital Charge Code	1603646
Hospital Revenue Code	306
Rate for Payer: Cash Price	$161.84

Organism ID, Bacteria SO

Facility

$238.00

Service Code	HCPCS 87077
Hospital Charge Code	1603646
Hospital Revenue Code	306
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$171.36
Rate for Payer: Amerigroup CHIP/Medicaid	$3.15
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.08
Rate for Payer: Amerigroup Medicare	$8.08
Rate for Payer: BCBS of TX Blue Advantage	$71.40
Rate for Payer: BCBS of TX Blue Essentials	$85.68
Rate for Payer: BCBS of TX Medicare	$8.08
Rate for Payer: BCBS of TX PPO	$95.20
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cash Price	$161.84
Rate for Payer: Cigna Medicaid	$171.36
Rate for Payer: Cigna Medicare	$8.08
Rate for Payer: Employer Direct Commercial	$8.08
Rate for Payer: Humana Medicare/TRICARE	$8.08
Rate for Payer: Molina CHIP/Medicaid	$171.36
Rate for Payer: Molina Dual Medicare/Medicaid	$8.08
Rate for Payer: Molina Medicare	$8.08
Rate for Payer: Multiplan Auto	$154.70
Rate for Payer: Multiplan Commercial	$154.70
Rate for Payer: Multiplan Workers Comp	$154.70
Rate for Payer: Parkland Medicaid	$171.36
Rate for Payer: Scott and White EPO/PPO	$10.10
Rate for Payer: Scott and White Medicare	$8.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$171.36
Rate for Payer: Superior Health Plan EPO	$8.08
Rate for Payer: Superior Health Plan Medicare	$8.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.08
Rate for Payer: Universal American Medicare	$8.08
Rate for Payer: Wellcare Medicare	$8.08
Rate for Payer: Wellmed Medicare	$8.08

Organism Identification, Yeast SO

Facility

$191.00

Service Code	HCPCS 87106
Hospital Charge Code	1603679
Hospital Revenue Code	306
Min. Negotiated Rate	$4.02
Max. Negotiated Rate	$137.52
Rate for Payer: Amerigroup CHIP/Medicaid	$4.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10.32
Rate for Payer: Amerigroup Medicare	$10.32
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX Medicare	$10.32
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Cigna Medicare	$10.32
Rate for Payer: Employer Direct Commercial	$10.32
Rate for Payer: Humana Medicare/TRICARE	$10.32
Rate for Payer: Molina CHIP/Medicaid	$137.52
Rate for Payer: Molina Dual Medicare/Medicaid	$10.32
Rate for Payer: Molina Medicare	$10.32
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$12.90
Rate for Payer: Scott and White Medicare	$10.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$10.32
Rate for Payer: Superior Health Plan Medicare	$10.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$10.32
Rate for Payer: Universal American Medicare	$10.32
Rate for Payer: Wellcare Medicare	$10.32
Rate for Payer: Wellmed Medicare	$10.32

Know your out-of-pocket cost for care.

All Charges