White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC

Facility

$67,624.80

Service Code	MSDRG 622
Min. Negotiated Rate	$30,845.56
Max. Negotiated Rate	$67,624.80
Rate for Payer: BCBS of TX Blue Advantage	$32,662.80
Rate for Payer: BCBS of TX Blue Essentials	$39,191.56
Rate for Payer: BCBS of TX PPO	$43,547.87

SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W/O CC/MCC

Facility

$23,786.10

Service Code	MSDRG 624
Min. Negotiated Rate	$10,954.12
Max. Negotiated Rate	$23,786.10
Rate for Payer: BCBS of TX Blue Advantage	$11,145.60
Rate for Payer: BCBS of TX Blue Essentials	$13,373.42
Rate for Payer: BCBS of TX PPO	$14,859.94

Skin Sub Graft Face/Neck/Nk/Fh/G First 25 Sq cm

Facility

$7,316.92

Service Code	HCPCS 15275
Hospital Charge Code	7150814
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,975.51

Skin Sub Graft Face/Neck/Nk/Fh/G First 25 Sq cm

Facility

$7,316.92

Service Code	HCPCS 15275
Hospital Charge Code	7150814
Hospital Revenue Code	361
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	$1,373.51
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

Skin Sub Grft Trk/Arm/Leg Ch 1st 100sqcm

Facility

$6,927.00

Service Code	HCPCS 15273
Hospital Charge Code	7150812
Hospital Revenue Code	361
Rate for Payer: Cash Price	$4,710.36

Skin Sub Grft Trk/Arm/Leg Ch 1st 100sqcm

Facility

$6,927.00

Service Code	HCPCS 15273
Hospital Charge Code	7150812
Hospital Revenue Code	361
Min. Negotiated Rate	$1,565.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,565.86
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	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$4,710.36
Rate for Payer: Cash Price	$4,710.36
Rate for Payer: Cash Price	$4,710.36
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$4,987.44
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	$4,987.44
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	$4,987.44
Rate for Payer: Scott and White EPO/PPO	$3,834.46
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,987.44
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

Skin Sub Grft Trk/Arm/Leg Ch 1st 25 sqcm

Facility

$10,292.16

Service Code	HCPCS 15271
Hospital Charge Code	7150810
Hospital Revenue Code	361
Rate for Payer: Cash Price	$6,998.67

Skin Sub Grft Trk/Arm/Leg Ch 1st 25 sqcm

Facility

$10,292.16

Service Code	HCPCS 15271
Hospital Charge Code	7150810
Hospital Revenue Code	361
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	$1,373.51
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

Skin Sub Grft Trk/Arm/Leg Ch ad 25 sqcm

Facility

$977.00

Service Code	HCPCS 15272
Hospital Charge Code	7150811
Hospital Revenue Code	361
Rate for Payer: Cash Price	$664.36

Skin Sub Grft Trk/Arm/Leg Ch ad 25 sqcm

Facility

$977.00

Service Code	HCPCS 15272
Hospital Charge Code	7150811
Hospital Revenue Code	361
Min. Negotiated Rate	$87.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$87.93
Rate for Payer: BCBS of TX Blue Advantage	$293.10
Rate for Payer: BCBS of TX Blue Essentials	$351.72
Rate for Payer: BCBS of TX PPO	$390.80
Rate for Payer: Cash Price	$664.36
Rate for Payer: Cash Price	$664.36
Rate for Payer: Cigna Medicaid	$703.44
Rate for Payer: Molina CHIP/Medicaid	$703.44
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	$703.44
Rate for Payer: Scott and White EPO/PPO	$488.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$703.44
Rate for Payer: Superior Health Plan EPO	$132.87

Skin Sub Grft Trnk/Arm/Leg Ch ad 100sqcm

Facility

$3,438.00

Service Code	HCPCS 15274
Hospital Charge Code	7150813
Hospital Revenue Code	361
Min. Negotiated Rate	$309.42
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$309.42
Rate for Payer: BCBS of TX Blue Advantage	$1,031.40
Rate for Payer: BCBS of TX Blue Essentials	$1,237.68
Rate for Payer: BCBS of TX PPO	$1,375.20
Rate for Payer: Cash Price	$2,337.84
Rate for Payer: Cash Price	$2,337.84
Rate for Payer: Cigna Medicaid	$2,475.36
Rate for Payer: Molina CHIP/Medicaid	$2,475.36
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	$2,475.36
Rate for Payer: Scott and White EPO/PPO	$1,719.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,475.36
Rate for Payer: Superior Health Plan EPO	$467.57

Skin Sub Grft Trnk/Arm/Leg Ch ad 100sqcm

Facility

$3,438.00

Service Code	HCPCS 15274
Hospital Charge Code	7150813
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,337.84

Skin test; tuberculosis, intradermal

Facility

$97.96

Service Code	HCPCS 86580
Hospital Charge Code	994061
Hospital Revenue Code	305
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$70.53
Rate for Payer: Amerigroup CHIP/Medicaid	$3.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.06
Rate for Payer: Amerigroup Medicare	$29.06
Rate for Payer: BCBS of TX Blue Advantage	$29.39
Rate for Payer: BCBS of TX Blue Essentials	$35.27
Rate for Payer: BCBS of TX Medicare	$29.06
Rate for Payer: BCBS of TX PPO	$39.18
Rate for Payer: Cash Price	$66.61
Rate for Payer: Cash Price	$66.61
Rate for Payer: Cash Price	$66.61
Rate for Payer: Cigna Commercial	$61.41
Rate for Payer: Cigna Medicaid	$70.53
Rate for Payer: Cigna Medicare	$29.06
Rate for Payer: Employer Direct Commercial	$29.06
Rate for Payer: Humana Medicare/TRICARE	$29.06
Rate for Payer: Molina CHIP/Medicaid	$70.53
Rate for Payer: Molina Dual Medicare/Medicaid	$29.06
Rate for Payer: Molina Medicare	$29.06
Rate for Payer: Multiplan Auto	$63.67
Rate for Payer: Multiplan Commercial	$63.67
Rate for Payer: Multiplan Workers Comp	$63.67
Rate for Payer: Parkland Medicaid	$70.53
Rate for Payer: Scott and White EPO/PPO	$13.66
Rate for Payer: Scott and White Medicare	$29.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.53
Rate for Payer: Superior Health Plan EPO	$29.06
Rate for Payer: Superior Health Plan Medicare	$29.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.06
Rate for Payer: Universal American Medicare	$29.06
Rate for Payer: Wellcare Medicare	$29.06
Rate for Payer: Wellmed Medicare	$29.06

Skin test; tuberculosis, intradermal

Facility

$97.96

Service Code	HCPCS 86580
Hospital Charge Code	994061
Hospital Revenue Code	305
Rate for Payer: Cash Price	$66.61

SKIN ULCERS

Facility

$2,603.74

Service Code	APR-DRG 3801
Min. Negotiated Rate	$2,454.89
Max. Negotiated Rate	$2,603.74
Rate for Payer: Amerigroup CHIP/Medicaid	$2,454.89
Rate for Payer: Cigna Medicaid	$2,454.89
Rate for Payer: Molina CHIP/Medicaid	$2,454.89
Rate for Payer: Parkland Medicaid	$2,454.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,603.74

SKIN ULCERS

Facility

$14,605.89

Service Code	APR-DRG 3804
Min. Negotiated Rate	$13,770.94
Max. Negotiated Rate	$14,605.89
Rate for Payer: Amerigroup CHIP/Medicaid	$13,770.94
Rate for Payer: Cigna Medicaid	$13,770.94
Rate for Payer: Molina CHIP/Medicaid	$13,770.94
Rate for Payer: Parkland Medicaid	$13,770.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,605.89

SKIN ULCERS

Facility

$3,376.60

Service Code	APR-DRG 3802
Min. Negotiated Rate	$3,183.57
Max. Negotiated Rate	$3,376.60
Rate for Payer: Amerigroup CHIP/Medicaid	$3,183.57
Rate for Payer: Cigna Medicaid	$3,183.57
Rate for Payer: Molina CHIP/Medicaid	$3,183.57
Rate for Payer: Parkland Medicaid	$3,183.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,376.60

SKIN ULCERS

Facility

$4,861.59

Service Code	APR-DRG 3803
Min. Negotiated Rate	$4,583.68
Max. Negotiated Rate	$4,861.59
Rate for Payer: Amerigroup CHIP/Medicaid	$4,583.68
Rate for Payer: Cigna Medicaid	$4,583.68
Rate for Payer: Molina CHIP/Medicaid	$4,583.68
Rate for Payer: Parkland Medicaid	$4,583.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,861.59

SKIN ULCERS W CC

Facility

$22,539.70

Service Code	MSDRG 593
Min. Negotiated Rate	$9,712.84
Max. Negotiated Rate	$22,539.70
Rate for Payer: BCBS of TX Blue Advantage	$9,712.84
Rate for Payer: BCBS of TX Blue Essentials	$11,654.28
Rate for Payer: BCBS of TX PPO	$12,949.70

SKIN ULCERS WITH CC

Facility

$22,539.70

Service Code	MSDRG 593
Min. Negotiated Rate	$9,712.84
Max. Negotiated Rate	$22,539.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,454.50
Rate for Payer: Amerigroup Medicare	$13,454.50
Rate for Payer: BCBS of TX Medicare	$13,454.50
Rate for Payer: Cigna Commercial	$15,279.54
Rate for Payer: Cigna Medicare	$13,454.50
Rate for Payer: Employer Direct Commercial	$13,454.50
Rate for Payer: Humana Medicare/TRICARE	$13,454.50
Rate for Payer: Molina Dual Medicare/Medicaid	$13,454.50
Rate for Payer: Molina Medicare	$13,454.50
Rate for Payer: Multiplan Auto	$22,539.70
Rate for Payer: Multiplan Commercial	$22,539.70
Rate for Payer: Multiplan Workers Comp	$22,539.70
Rate for Payer: Scott and White EPO/PPO	$10,380.12
Rate for Payer: Scott and White Medicare	$13,454.50
Rate for Payer: Superior Health Plan EPO	$13,454.50
Rate for Payer: Superior Health Plan Medicare	$13,454.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,454.50
Rate for Payer: Universal American Medicare	$13,454.50
Rate for Payer: Wellcare Medicare	$13,454.50
Rate for Payer: Wellmed Medicare	$13,454.50

SKIN ULCERS WITH MCC

Facility

$36,770.70

Service Code	MSDRG 592
Min. Negotiated Rate	$14,690.52
Max. Negotiated Rate	$36,770.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,943.95
Rate for Payer: Amerigroup Medicare	$18,943.95
Rate for Payer: BCBS of TX Medicare	$18,943.95
Rate for Payer: Cigna Commercial	$24,926.66
Rate for Payer: Cigna Medicare	$18,943.95
Rate for Payer: Employer Direct Commercial	$18,943.95
Rate for Payer: Humana Medicare/TRICARE	$18,943.95
Rate for Payer: Molina Dual Medicare/Medicaid	$18,943.95
Rate for Payer: Molina Medicare	$18,943.95
Rate for Payer: Multiplan Auto	$36,770.70
Rate for Payer: Multiplan Commercial	$36,770.70
Rate for Payer: Multiplan Workers Comp	$36,770.70
Rate for Payer: Scott and White EPO/PPO	$16,933.88
Rate for Payer: Scott and White Medicare	$18,943.95
Rate for Payer: Superior Health Plan EPO	$18,943.95
Rate for Payer: Superior Health Plan Medicare	$18,943.95
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,943.95
Rate for Payer: Universal American Medicare	$18,943.95
Rate for Payer: Wellcare Medicare	$18,943.95
Rate for Payer: Wellmed Medicare	$18,943.95

SKIN ULCERS WITHOUT CC/MCC

Facility

$16,469.20

Service Code	MSDRG 594
Min. Negotiated Rate	$6,967.72
Max. Negotiated Rate	$16,469.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,112.88
Rate for Payer: Amerigroup Medicare	$11,112.88
Rate for Payer: BCBS of TX Medicare	$11,112.88
Rate for Payer: Cigna Commercial	$11,164.38
Rate for Payer: Cigna Medicare	$11,112.88
Rate for Payer: Employer Direct Commercial	$11,112.88
Rate for Payer: Humana Medicare/TRICARE	$11,112.88
Rate for Payer: Molina Dual Medicare/Medicaid	$11,112.88
Rate for Payer: Molina Medicare	$11,112.88
Rate for Payer: Multiplan Auto	$16,469.20
Rate for Payer: Multiplan Commercial	$16,469.20
Rate for Payer: Multiplan Workers Comp	$16,469.20
Rate for Payer: Scott and White EPO/PPO	$7,584.50
Rate for Payer: Scott and White Medicare	$11,112.88
Rate for Payer: Superior Health Plan EPO	$11,112.88
Rate for Payer: Superior Health Plan Medicare	$11,112.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,112.88
Rate for Payer: Universal American Medicare	$11,112.88
Rate for Payer: Wellcare Medicare	$11,112.88
Rate for Payer: Wellmed Medicare	$11,112.88

SKIN ULCERS W MCC

Facility

$36,770.70

Service Code	MSDRG 592
Min. Negotiated Rate	$14,690.52
Max. Negotiated Rate	$36,770.70
Rate for Payer: BCBS of TX Blue Advantage	$14,690.52
Rate for Payer: BCBS of TX Blue Essentials	$17,626.92
Rate for Payer: BCBS of TX PPO	$19,586.22

SKIN ULCERS W/O CC/MCC

Facility

$16,469.20

Service Code	MSDRG 594
Min. Negotiated Rate	$6,967.72
Max. Negotiated Rate	$16,469.20
Rate for Payer: BCBS of TX Blue Advantage	$6,967.72
Rate for Payer: BCBS of TX Blue Essentials	$8,360.45
Rate for Payer: BCBS of TX PPO	$9,289.75

SLEEK OTW 2.0X4 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992490
Hospital Revenue Code	272
Rate for Payer: Cash Price	$696.93

Know your out-of-pocket cost for care.

All Charges