White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SIZER BREAST IMPLANT

Facility

$1,265.00

Service Code	HCPCS C1789
Hospital Charge Code	82402025
Hospital Revenue Code	278
Min. Negotiated Rate	$316.25
Max. Negotiated Rate	$632.50
Rate for Payer: Cash Price	$860.20
Rate for Payer: Cigna Commercial	$316.25
Rate for Payer: Multiplan Auto	$632.50
Rate for Payer: Multiplan Commercial	$632.50
Rate for Payer: Multiplan Workers Comp	$632.50
Rate for Payer: Scott and White EPO/PPO	$632.50

SIZER BREAST IMPLANT

Facility

$1,265.00

Service Code	HCPCS C1789
Hospital Charge Code	82402025
Hospital Revenue Code	278
Min. Negotiated Rate	$113.85
Max. Negotiated Rate	$910.80
Rate for Payer: Amerigroup CHIP/Medicaid	$113.85
Rate for Payer: BCBS of TX Blue Advantage	$379.50
Rate for Payer: BCBS of TX Blue Essentials	$455.40
Rate for Payer: BCBS of TX PPO	$506.00
Rate for Payer: Cash Price	$860.20
Rate for Payer: Cigna Medicaid	$910.80
Rate for Payer: Molina CHIP/Medicaid	$910.80
Rate for Payer: Multiplan Auto	$632.50
Rate for Payer: Multiplan Commercial	$632.50
Rate for Payer: Multiplan Workers Comp	$632.50
Rate for Payer: Parkland Medicaid	$910.80
Rate for Payer: Scott and White EPO/PPO	$632.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$910.80
Rate for Payer: Superior Health Plan EPO	$172.04

SKIN CLOS 1/4 -- DHF

Facility

$55.15

Hospital Charge Code	81850653
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.50

SKIN CLOS 1/4 -- DHF

Facility

$55.15

Hospital Charge Code	81850653
Hospital Revenue Code	272
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$39.71
Rate for Payer: Amerigroup CHIP/Medicaid	$4.96
Rate for Payer: BCBS of TX Blue Advantage	$16.55
Rate for Payer: BCBS of TX Blue Essentials	$19.85
Rate for Payer: BCBS of TX PPO	$22.06
Rate for Payer: Cash Price	$37.50
Rate for Payer: Cigna Medicaid	$39.71
Rate for Payer: Molina CHIP/Medicaid	$39.71
Rate for Payer: Multiplan Auto	$35.85
Rate for Payer: Multiplan Commercial	$35.85
Rate for Payer: Multiplan Workers Comp	$35.85
Rate for Payer: Parkland Medicaid	$39.71
Rate for Payer: Scott and White EPO/PPO	$27.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.71
Rate for Payer: Superior Health Plan EPO	$7.50

SKIN DEBRIDEMENT W CC

Facility

$31,323.40

Service Code	MSDRG 571
Min. Negotiated Rate	$14,425.25
Max. Negotiated Rate	$31,323.40
Rate for Payer: BCBS of TX Blue Advantage	$14,644.94
Rate for Payer: BCBS of TX Blue Essentials	$17,572.23
Rate for Payer: BCBS of TX PPO	$19,525.45

SKIN DEBRIDEMENT WITH CC

Facility

$31,323.40

Service Code	MSDRG 571
Min. Negotiated Rate	$14,425.25
Max. Negotiated Rate	$31,323.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,142.48
Rate for Payer: Amerigroup Medicare	$17,142.48
Rate for Payer: BCBS of TX Medicare	$17,142.48
Rate for Payer: Cigna Commercial	$21,760.76
Rate for Payer: Cigna Medicare	$17,142.48
Rate for Payer: Employer Direct Commercial	$17,142.48
Rate for Payer: Humana Medicare/TRICARE	$17,142.48
Rate for Payer: Molina Dual Medicare/Medicaid	$17,142.48
Rate for Payer: Molina Medicare	$17,142.48
Rate for Payer: Multiplan Auto	$31,323.40
Rate for Payer: Multiplan Commercial	$31,323.40
Rate for Payer: Multiplan Workers Comp	$31,323.40
Rate for Payer: Scott and White EPO/PPO	$14,425.25
Rate for Payer: Scott and White Medicare	$17,142.48
Rate for Payer: Superior Health Plan EPO	$17,142.48
Rate for Payer: Superior Health Plan Medicare	$17,142.48
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,142.48
Rate for Payer: Universal American Medicare	$17,142.48
Rate for Payer: Wellcare Medicare	$17,142.48
Rate for Payer: Wellmed Medicare	$17,142.48

SKIN DEBRIDEMENT WITH MCC

Facility

$55,424.90

Service Code	MSDRG 570
Min. Negotiated Rate	$25,524.62
Max. Negotiated Rate	$55,424.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26,315.48
Rate for Payer: Amerigroup Medicare	$26,315.48
Rate for Payer: BCBS of TX Medicare	$26,315.48
Rate for Payer: Cigna Commercial	$37,881.37
Rate for Payer: Cigna Medicare	$26,315.48
Rate for Payer: Employer Direct Commercial	$26,315.48
Rate for Payer: Humana Medicare/TRICARE	$26,315.48
Rate for Payer: Molina Dual Medicare/Medicaid	$26,315.48
Rate for Payer: Molina Medicare	$26,315.48
Rate for Payer: Multiplan Auto	$55,424.90
Rate for Payer: Multiplan Commercial	$55,424.90
Rate for Payer: Multiplan Workers Comp	$55,424.90
Rate for Payer: Scott and White EPO/PPO	$25,524.62
Rate for Payer: Scott and White Medicare	$26,315.48
Rate for Payer: Superior Health Plan EPO	$26,315.48
Rate for Payer: Superior Health Plan Medicare	$26,315.48
Rate for Payer: Universal American Dual Medicare/Medicaid	$26,315.48
Rate for Payer: Universal American Medicare	$26,315.48
Rate for Payer: Wellcare Medicare	$26,315.48
Rate for Payer: Wellmed Medicare	$26,315.48

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$22,868.40

Service Code	MSDRG 572
Min. Negotiated Rate	$10,135.96
Max. Negotiated Rate	$22,868.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,161.34
Rate for Payer: Amerigroup Medicare	$13,161.34
Rate for Payer: BCBS of TX Medicare	$13,161.34
Rate for Payer: Cigna Commercial	$14,764.34
Rate for Payer: Cigna Medicare	$13,161.34
Rate for Payer: Employer Direct Commercial	$13,161.34
Rate for Payer: Humana Medicare/TRICARE	$13,161.34
Rate for Payer: Molina Dual Medicare/Medicaid	$13,161.34
Rate for Payer: Molina Medicare	$13,161.34
Rate for Payer: Multiplan Auto	$22,868.40
Rate for Payer: Multiplan Commercial	$22,868.40
Rate for Payer: Multiplan Workers Comp	$22,868.40
Rate for Payer: Scott and White EPO/PPO	$10,531.50
Rate for Payer: Scott and White Medicare	$13,161.34
Rate for Payer: Superior Health Plan EPO	$13,161.34
Rate for Payer: Superior Health Plan Medicare	$13,161.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,161.34
Rate for Payer: Universal American Medicare	$13,161.34
Rate for Payer: Wellcare Medicare	$13,161.34
Rate for Payer: Wellmed Medicare	$13,161.34

SKIN DEBRIDEMENT W MCC

Facility

$55,424.90

Service Code	MSDRG 570
Min. Negotiated Rate	$25,524.62
Max. Negotiated Rate	$55,424.90
Rate for Payer: BCBS of TX Blue Advantage	$26,098.42
Rate for Payer: BCBS of TX Blue Essentials	$31,315.07
Rate for Payer: BCBS of TX PPO	$34,795.87

SKIN DEBRIDEMENT W/O CC/MCC

Facility

$22,868.40

Service Code	MSDRG 572
Min. Negotiated Rate	$10,135.96
Max. Negotiated Rate	$22,868.40
Rate for Payer: BCBS of TX Blue Advantage	$10,135.96
Rate for Payer: BCBS of TX Blue Essentials	$12,161.97
Rate for Payer: BCBS of TX PPO	$13,513.83

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$49,755.30

Service Code	MSDRG 577
Min. Negotiated Rate	$21,579.12
Max. Negotiated Rate	$49,755.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,187.13
Rate for Payer: Amerigroup Medicare	$24,187.13
Rate for Payer: BCBS of TX Medicare	$24,187.13
Rate for Payer: Cigna Commercial	$34,141.02
Rate for Payer: Cigna Medicare	$24,187.13
Rate for Payer: Employer Direct Commercial	$24,187.13
Rate for Payer: Humana Medicare/TRICARE	$24,187.13
Rate for Payer: Molina Dual Medicare/Medicaid	$24,187.13
Rate for Payer: Molina Medicare	$24,187.13
Rate for Payer: Multiplan Auto	$49,755.30
Rate for Payer: Multiplan Commercial	$49,755.30
Rate for Payer: Multiplan Workers Comp	$49,755.30
Rate for Payer: Scott and White EPO/PPO	$22,913.62
Rate for Payer: Scott and White Medicare	$24,187.13
Rate for Payer: Superior Health Plan EPO	$24,187.13
Rate for Payer: Superior Health Plan Medicare	$24,187.13
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,187.13
Rate for Payer: Universal American Medicare	$24,187.13
Rate for Payer: Wellcare Medicare	$24,187.13
Rate for Payer: Wellmed Medicare	$24,187.13

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$107,331.00

Service Code	MSDRG 576
Min. Negotiated Rate	$40,681.11
Max. Negotiated Rate	$107,331.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$40,681.11
Rate for Payer: Amerigroup Medicare	$40,681.11
Rate for Payer: BCBS of TX Medicare	$40,681.11
Rate for Payer: Cigna Commercial	$63,127.46
Rate for Payer: Cigna Medicare	$40,681.11
Rate for Payer: Employer Direct Commercial	$40,681.11
Rate for Payer: Humana Medicare/TRICARE	$40,681.11
Rate for Payer: Molina Dual Medicare/Medicaid	$40,681.11
Rate for Payer: Molina Medicare	$40,681.11
Rate for Payer: Multiplan Auto	$107,331.00
Rate for Payer: Multiplan Commercial	$107,331.00
Rate for Payer: Multiplan Workers Comp	$107,331.00
Rate for Payer: Scott and White EPO/PPO	$49,428.75
Rate for Payer: Scott and White Medicare	$40,681.11
Rate for Payer: Superior Health Plan EPO	$40,681.11
Rate for Payer: Superior Health Plan Medicare	$40,681.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$40,681.11
Rate for Payer: Universal American Medicare	$40,681.11
Rate for Payer: Wellcare Medicare	$40,681.11
Rate for Payer: Wellmed Medicare	$40,681.11

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$32,537.50

Service Code	MSDRG 578
Min. Negotiated Rate	$13,155.42
Max. Negotiated Rate	$32,537.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,533.43
Rate for Payer: Amerigroup Medicare	$16,533.43
Rate for Payer: BCBS of TX Medicare	$16,533.43
Rate for Payer: Cigna Commercial	$20,690.43
Rate for Payer: Cigna Medicare	$16,533.43
Rate for Payer: Employer Direct Commercial	$16,533.43
Rate for Payer: Humana Medicare/TRICARE	$16,533.43
Rate for Payer: Molina Dual Medicare/Medicaid	$16,533.43
Rate for Payer: Molina Medicare	$16,533.43
Rate for Payer: Multiplan Auto	$32,537.50
Rate for Payer: Multiplan Commercial	$32,537.50
Rate for Payer: Multiplan Workers Comp	$32,537.50
Rate for Payer: Scott and White EPO/PPO	$14,984.38
Rate for Payer: Scott and White Medicare	$16,533.43
Rate for Payer: Superior Health Plan EPO	$16,533.43
Rate for Payer: Superior Health Plan Medicare	$16,533.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,533.43
Rate for Payer: Universal American Medicare	$16,533.43
Rate for Payer: Wellcare Medicare	$16,533.43
Rate for Payer: Wellmed Medicare	$16,533.43

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$9,349.01

Service Code	APR-DRG 3122
Min. Negotiated Rate	$8,814.57
Max. Negotiated Rate	$9,349.01
Rate for Payer: Amerigroup CHIP/Medicaid	$8,814.57
Rate for Payer: Cigna Medicaid	$8,814.57
Rate for Payer: Molina CHIP/Medicaid	$8,814.57
Rate for Payer: Parkland Medicaid	$8,814.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,349.01

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$14,475.76

Service Code	APR-DRG 3123
Min. Negotiated Rate	$13,648.25
Max. Negotiated Rate	$14,475.76
Rate for Payer: Amerigroup CHIP/Medicaid	$13,648.25
Rate for Payer: Cigna Medicaid	$13,648.25
Rate for Payer: Molina CHIP/Medicaid	$13,648.25
Rate for Payer: Parkland Medicaid	$13,648.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,475.76

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$6,201.36

Service Code	APR-DRG 3121
Min. Negotiated Rate	$5,846.86
Max. Negotiated Rate	$6,201.36
Rate for Payer: Amerigroup CHIP/Medicaid	$5,846.86
Rate for Payer: Cigna Medicaid	$5,846.86
Rate for Payer: Molina CHIP/Medicaid	$5,846.86
Rate for Payer: Parkland Medicaid	$5,846.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,201.36

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$27,147.42

Service Code	APR-DRG 3124
Min. Negotiated Rate	$25,595.54
Max. Negotiated Rate	$27,147.42
Rate for Payer: Amerigroup CHIP/Medicaid	$25,595.54
Rate for Payer: Cigna Medicaid	$25,595.54
Rate for Payer: Molina CHIP/Medicaid	$25,595.54
Rate for Payer: Parkland Medicaid	$25,595.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,147.42

SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W CC

Facility

$49,755.30

Service Code	MSDRG 577
Min. Negotiated Rate	$21,579.12
Max. Negotiated Rate	$49,755.30
Rate for Payer: BCBS of TX Blue Advantage	$21,579.12
Rate for Payer: BCBS of TX Blue Essentials	$25,892.43
Rate for Payer: BCBS of TX PPO	$28,770.49

SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W MCC

Facility

$107,331.00

Service Code	MSDRG 576
Min. Negotiated Rate	$40,681.11
Max. Negotiated Rate	$107,331.00
Rate for Payer: BCBS of TX Blue Advantage	$41,974.02
Rate for Payer: BCBS of TX Blue Essentials	$50,363.94
Rate for Payer: BCBS of TX PPO	$55,962.11

SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC

Facility

$32,537.50

Service Code	MSDRG 578
Min. Negotiated Rate	$13,155.42
Max. Negotiated Rate	$32,537.50
Rate for Payer: BCBS of TX Blue Advantage	$13,155.42
Rate for Payer: BCBS of TX Blue Essentials	$15,784.97
Rate for Payer: BCBS of TX PPO	$17,539.54

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$13,269.51

Service Code	APR-DRG 3612
Min. Negotiated Rate	$12,510.96
Max. Negotiated Rate	$13,269.51
Rate for Payer: Amerigroup CHIP/Medicaid	$12,510.96
Rate for Payer: Cigna Medicaid	$12,510.96
Rate for Payer: Molina CHIP/Medicaid	$12,510.96
Rate for Payer: Parkland Medicaid	$12,510.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,269.51

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$14,793.35

Service Code	APR-DRG 3613
Min. Negotiated Rate	$13,947.69
Max. Negotiated Rate	$14,793.35
Rate for Payer: Amerigroup CHIP/Medicaid	$13,947.69
Rate for Payer: Cigna Medicaid	$13,947.69
Rate for Payer: Molina CHIP/Medicaid	$13,947.69
Rate for Payer: Parkland Medicaid	$13,947.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,793.35

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$34,148.05

Service Code	APR-DRG 3614
Min. Negotiated Rate	$32,195.98
Max. Negotiated Rate	$34,148.05
Rate for Payer: Amerigroup CHIP/Medicaid	$32,195.98
Rate for Payer: Cigna Medicaid	$32,195.98
Rate for Payer: Molina CHIP/Medicaid	$32,195.98
Rate for Payer: Parkland Medicaid	$32,195.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34,148.05

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$7,094.93

Service Code	APR-DRG 3611
Min. Negotiated Rate	$6,689.34
Max. Negotiated Rate	$7,094.93
Rate for Payer: Amerigroup CHIP/Medicaid	$6,689.34
Rate for Payer: Cigna Medicaid	$6,689.34
Rate for Payer: Molina CHIP/Medicaid	$6,689.34
Rate for Payer: Parkland Medicaid	$6,689.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,094.93

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC

Facility

$68,487.40

Service Code	MSDRG 574
Min. Negotiated Rate	$26,194.74
Max. Negotiated Rate	$68,487.40
Rate for Payer: BCBS of TX Blue Advantage	$26,194.74
Rate for Payer: BCBS of TX Blue Essentials	$31,430.64
Rate for Payer: BCBS of TX PPO	$34,924.29

Know your out-of-pocket cost for care.

All Charges