White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Application of short leg splint (calf to foot)

Facility

$635.31

Service Code	HCPCS 29515
Hospital Charge Code	9900541
Hospital Revenue Code	360
Rate for Payer: Cash Price	$432.01

Application of short leg splint (calf to foot)

Facility

$635.31

Service Code	HCPCS 29515
Hospital Charge Code	9900541
Hospital Revenue Code	360
Min. Negotiated Rate	$34.33
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$34.33
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	$432.01
Rate for Payer: Cash Price	$432.01
Rate for Payer: Cash Price	$432.01
Rate for Payer: Cigna Commercial	$345.06
Rate for Payer: Cigna Medicaid	$457.42
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	$457.42
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	$457.42
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	$457.42
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

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$10,292.16

Service Code	HCPCS 15276
Hospital Charge Code	9900128
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,998.67

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$7,316.92

Service Code	HCPCS 15275
Hospital Charge Code	9900127
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,975.51

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$10,000.00

Service Code	CPT 15275
Hospital Charge Code	36015275
Hospital Revenue Code	360
Min. Negotiated Rate	$71.16
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$1,569.38
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 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: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$742.44
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

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$10,292.16

Service Code	HCPCS 15276
Hospital Charge Code	9900128
Hospital Revenue Code	360
Min. Negotiated Rate	$926.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$926.29
Rate for Payer: BCBS of TX Blue Advantage	$3,087.65
Rate for Payer: BCBS of TX Blue Essentials	$3,705.18
Rate for Payer: BCBS of TX PPO	$4,116.86
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cigna Medicaid	$7,410.36
Rate for Payer: Molina CHIP/Medicaid	$7,410.36
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	$7,410.36
Rate for Payer: Scott and White EPO/PPO	$5,146.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,410.36
Rate for Payer: Superior Health Plan EPO	$1,399.73

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$7,316.92

Service Code	HCPCS 15275
Hospital Charge Code	9900127
Hospital Revenue Code	360
Min. Negotiated Rate	$71.16
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$5,268.18
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	$5,268.18
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	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
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

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$10,000.00

Service Code	CPT 15276
Hospital Charge Code	36015276
Hospital Revenue Code	360
Min. Negotiated Rate	$30.21
Max. Negotiated Rate	$10,000.00
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: Scott and White EPO/PPO	$30.21

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$10,292.16

Service Code	HCPCS 15276
Hospital Charge Code	7150815
Hospital Revenue Code	360
Min. Negotiated Rate	$926.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$926.29
Rate for Payer: BCBS of TX Blue Advantage	$3,087.65
Rate for Payer: BCBS of TX Blue Essentials	$3,705.18
Rate for Payer: BCBS of TX PPO	$4,116.86
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cigna Medicaid	$7,410.36
Rate for Payer: Molina CHIP/Medicaid	$7,410.36
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	$7,410.36
Rate for Payer: Scott and White EPO/PPO	$5,146.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,410.36
Rate for Payer: Superior Health Plan EPO	$1,399.73

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,

Facility

$10,292.16

Service Code	HCPCS 15276
Hospital Charge Code	7150815
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,998.67

Application of skin substitute graft to face, scalp, neck, ears, genitalia, hands, feet, and/or multiple digits, total wound surface area > than or = to 100 sq cm; 1st 100 sq cm wound surface area

Facility

$7,316.92

Service Code	HCPCS 15277
Hospital Charge Code	994055
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

Application of skin substitute graft to face, scalp, neck, ears, genitalia, hands, feet, and/or multiple digits, total wound surface area > than or = to 100 sq cm; 1st 100 sq cm wound surface area

Facility

$7,316.92

Service Code	HCPCS 15277
Hospital Charge Code	994055
Hospital Revenue Code	361
Min. Negotiated Rate	$784.87
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$784.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cash Price	$4,975.51
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$5,268.18
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$5,268.18
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$5,268.18
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,268.18
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm

Facility

$10,292.16

Service Code	HCPCS 15271
Hospital Charge Code	9900126
Hospital Revenue Code	360
Min. Negotiated Rate	$742.44
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$784.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cash Price	$6,998.67
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$7,410.36
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	$7,410.36
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	$7,410.36
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,410.36
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

Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm

Facility

$10,000.00

Service Code	CPT 15271
Hospital Charge Code	36015271
Hospital Revenue Code	360
Min. Negotiated Rate	$742.44
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$784.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$1,569.38
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 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: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$742.44
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

Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm

Facility

$10,292.16

Service Code	HCPCS 15271
Hospital Charge Code	9900126
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,998.67

APPLICATOR, REG FOAM, PS, STD, 6', ST, 1000/CS

Facility

$1.51

Hospital Charge Code	993350
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.03

APPLICATOR, REG FOAM, PS, STD, 6', ST, 1000/CS

Facility

$1.51

Hospital Charge Code	993350
Hospital Revenue Code	270
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$1.09
Rate for Payer: Amerigroup CHIP/Medicaid	$0.14
Rate for Payer: BCBS of TX Blue Advantage	$0.45
Rate for Payer: BCBS of TX Blue Essentials	$0.54
Rate for Payer: BCBS of TX PPO	$0.60
Rate for Payer: Cash Price	$1.03
Rate for Payer: Cigna Medicaid	$1.09
Rate for Payer: Molina CHIP/Medicaid	$1.09
Rate for Payer: Multiplan Auto	$0.98
Rate for Payer: Multiplan Commercial	$0.98
Rate for Payer: Multiplan Workers Comp	$0.98
Rate for Payer: Parkland Medicaid	$1.09
Rate for Payer: Scott and White EPO/PPO	$0.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.09
Rate for Payer: Superior Health Plan EPO	$0.21

APPLICATOR TISSUE GLUE DUPLOTIP 5MM 40CM RIGID SNAP-LOCK

Facility

$58.81

Hospital Charge Code	992623
Hospital Revenue Code	272
Rate for Payer: Cash Price	$39.99

APPLICATOR TISSUE GLUE DUPLOTIP 5MM 40CM RIGID SNAP-LOCK

Facility

$58.81

Hospital Charge Code	992623
Hospital Revenue Code	272
Min. Negotiated Rate	$5.29
Max. Negotiated Rate	$42.34
Rate for Payer: Amerigroup CHIP/Medicaid	$5.29
Rate for Payer: BCBS of TX Blue Advantage	$17.64
Rate for Payer: BCBS of TX Blue Essentials	$21.17
Rate for Payer: BCBS of TX PPO	$23.52
Rate for Payer: Cash Price	$39.99
Rate for Payer: Cigna Medicaid	$42.34
Rate for Payer: Molina CHIP/Medicaid	$42.34
Rate for Payer: Multiplan Auto	$38.23
Rate for Payer: Multiplan Commercial	$38.23
Rate for Payer: Multiplan Workers Comp	$38.23
Rate for Payer: Parkland Medicaid	$42.34
Rate for Payer: Scott and White EPO/PPO	$29.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.34
Rate for Payer: Superior Health Plan EPO	$8.00

APPLIED SLEEVE 5MM

Facility

$55.39

Hospital Charge Code	992696
Hospital Revenue Code	272
Min. Negotiated Rate	$4.99
Max. Negotiated Rate	$39.88
Rate for Payer: Amerigroup CHIP/Medicaid	$4.99
Rate for Payer: BCBS of TX Blue Advantage	$16.62
Rate for Payer: BCBS of TX Blue Essentials	$19.94
Rate for Payer: BCBS of TX PPO	$22.16
Rate for Payer: Cash Price	$37.67
Rate for Payer: Cigna Medicaid	$39.88
Rate for Payer: Molina CHIP/Medicaid	$39.88
Rate for Payer: Multiplan Auto	$36.00
Rate for Payer: Multiplan Commercial	$36.00
Rate for Payer: Multiplan Workers Comp	$36.00
Rate for Payer: Parkland Medicaid	$39.88
Rate for Payer: Scott and White EPO/PPO	$27.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.88
Rate for Payer: Superior Health Plan EPO	$7.53

APPLIED SLEEVE 5MM

Facility

$55.39

Hospital Charge Code	992696
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.67

APPLIER, CLIP, LIGACLIP, 20 SMALL, 9 3/8'

Facility

$173.64

Hospital Charge Code	992818
Hospital Revenue Code	272
Rate for Payer: Cash Price	$118.08

APPLIER, CLIP, LIGACLIP, 20 SMALL, 9 3/8'

Facility

$173.64

Hospital Charge Code	992818
Hospital Revenue Code	272
Min. Negotiated Rate	$15.63
Max. Negotiated Rate	$125.02
Rate for Payer: Amerigroup CHIP/Medicaid	$15.63
Rate for Payer: BCBS of TX Blue Advantage	$52.09
Rate for Payer: BCBS of TX Blue Essentials	$62.51
Rate for Payer: BCBS of TX PPO	$69.46
Rate for Payer: Cash Price	$118.08
Rate for Payer: Cigna Medicaid	$125.02
Rate for Payer: Molina CHIP/Medicaid	$125.02
Rate for Payer: Multiplan Auto	$112.87
Rate for Payer: Multiplan Commercial	$112.87
Rate for Payer: Multiplan Workers Comp	$112.87
Rate for Payer: Parkland Medicaid	$125.02
Rate for Payer: Scott and White EPO/PPO	$86.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.02
Rate for Payer: Superior Health Plan EPO	$23.62

APPLIER, ENDO MULTI CLIP MED/LG 5MM SHFT STRL DISP -- DHF

Facility

$1,735.94

Hospital Charge Code	81941056
Hospital Revenue Code	272
Min. Negotiated Rate	$156.23
Max. Negotiated Rate	$1,249.88
Rate for Payer: Amerigroup CHIP/Medicaid	$156.23
Rate for Payer: BCBS of TX Blue Advantage	$520.78
Rate for Payer: BCBS of TX Blue Essentials	$624.94
Rate for Payer: BCBS of TX PPO	$694.38
Rate for Payer: Cash Price	$1,180.44
Rate for Payer: Cigna Medicaid	$1,249.88
Rate for Payer: Molina CHIP/Medicaid	$1,249.88
Rate for Payer: Multiplan Auto	$1,128.36
Rate for Payer: Multiplan Commercial	$1,128.36
Rate for Payer: Multiplan Workers Comp	$1,128.36
Rate for Payer: Parkland Medicaid	$1,249.88
Rate for Payer: Scott and White EPO/PPO	$867.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,249.88
Rate for Payer: Superior Health Plan EPO	$236.09

APPLIER, ENDO MULTI CLIP MED/LG 5MM SHFT STRL DISP -- DHF

Facility

$1,735.94

Hospital Charge Code	81941056
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,180.44

Know your out-of-pocket cost for care.

All Charges