White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$12.72
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

$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

$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

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

$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 W CC

Facility

$21,886.10

Service Code	MSDRG 593
Min. Negotiated Rate	$9,712.84
Max. Negotiated Rate	$21,886.10
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

$21,886.10

Service Code	MSDRG 593
Min. Negotiated Rate	$9,712.84
Max. Negotiated Rate	$21,886.10
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	$21,886.10
Rate for Payer: Multiplan Commercial	$21,886.10
Rate for Payer: Multiplan Workers Comp	$21,886.10
Rate for Payer: Scott and White EPO/PPO	$10,079.12
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

$33,896.00

Service Code	MSDRG 592
Min. Negotiated Rate	$14,690.52
Max. Negotiated Rate	$33,896.00
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	$33,896.00
Rate for Payer: Multiplan Commercial	$33,896.00
Rate for Payer: Multiplan Workers Comp	$33,896.00
Rate for Payer: Scott and White EPO/PPO	$15,610.00
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

$14,704.10

Service Code	MSDRG 594
Min. Negotiated Rate	$6,771.62
Max. Negotiated Rate	$14,704.10
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	$14,704.10
Rate for Payer: Multiplan Commercial	$14,704.10
Rate for Payer: Multiplan Workers Comp	$14,704.10
Rate for Payer: Scott and White EPO/PPO	$6,771.62
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

$33,896.00

Service Code	MSDRG 592
Min. Negotiated Rate	$14,690.52
Max. Negotiated Rate	$33,896.00
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

$14,704.10

Service Code	MSDRG 594
Min. Negotiated Rate	$6,771.62
Max. Negotiated Rate	$14,704.10
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
Min. Negotiated Rate	$92.24
Max. Negotiated Rate	$737.93
Rate for Payer: Amerigroup CHIP/Medicaid	$92.24
Rate for Payer: BCBS of TX Blue Advantage	$307.47
Rate for Payer: BCBS of TX Blue Essentials	$368.96
Rate for Payer: BCBS of TX PPO	$409.96
Rate for Payer: Cash Price	$696.93
Rate for Payer: Cigna Medicaid	$737.93
Rate for Payer: Molina CHIP/Medicaid	$737.93
Rate for Payer: Multiplan Auto	$666.18
Rate for Payer: Multiplan Commercial	$666.18
Rate for Payer: Multiplan Workers Comp	$666.18
Rate for Payer: Parkland Medicaid	$737.93
Rate for Payer: Scott and White EPO/PPO	$512.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$737.93
Rate for Payer: Superior Health Plan EPO	$139.39

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

SLEEK OTW 2.0X8 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992491
Hospital Revenue Code	272
Rate for Payer: Cash Price	$696.93

SLEEK OTW 2.0X8 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992491
Hospital Revenue Code	272
Min. Negotiated Rate	$92.24
Max. Negotiated Rate	$737.93
Rate for Payer: Amerigroup CHIP/Medicaid	$92.24
Rate for Payer: BCBS of TX Blue Advantage	$307.47
Rate for Payer: BCBS of TX Blue Essentials	$368.96
Rate for Payer: BCBS of TX PPO	$409.96
Rate for Payer: Cash Price	$696.93
Rate for Payer: Cigna Medicaid	$737.93
Rate for Payer: Molina CHIP/Medicaid	$737.93
Rate for Payer: Multiplan Auto	$666.18
Rate for Payer: Multiplan Commercial	$666.18
Rate for Payer: Multiplan Workers Comp	$666.18
Rate for Payer: Parkland Medicaid	$737.93
Rate for Payer: Scott and White EPO/PPO	$512.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$737.93
Rate for Payer: Superior Health Plan EPO	$139.39

SLEEK OTW 2.5X10 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992494
Hospital Revenue Code	272
Rate for Payer: Cash Price	$696.93

SLEEK OTW 2.5X10 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992494
Hospital Revenue Code	272
Min. Negotiated Rate	$92.24
Max. Negotiated Rate	$737.93
Rate for Payer: Amerigroup CHIP/Medicaid	$92.24
Rate for Payer: BCBS of TX Blue Advantage	$307.47
Rate for Payer: BCBS of TX Blue Essentials	$368.96
Rate for Payer: BCBS of TX PPO	$409.96
Rate for Payer: Cash Price	$696.93
Rate for Payer: Cigna Medicaid	$737.93
Rate for Payer: Molina CHIP/Medicaid	$737.93
Rate for Payer: Multiplan Auto	$666.18
Rate for Payer: Multiplan Commercial	$666.18
Rate for Payer: Multiplan Workers Comp	$666.18
Rate for Payer: Parkland Medicaid	$737.93
Rate for Payer: Scott and White EPO/PPO	$512.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$737.93
Rate for Payer: Superior Health Plan EPO	$139.39

SLEEK OTW 2.5X4 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992492
Hospital Revenue Code	272
Rate for Payer: Cash Price	$696.93

SLEEK OTW 2.5X4 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992492
Hospital Revenue Code	272
Min. Negotiated Rate	$92.24
Max. Negotiated Rate	$737.93
Rate for Payer: Amerigroup CHIP/Medicaid	$92.24
Rate for Payer: BCBS of TX Blue Advantage	$307.47
Rate for Payer: BCBS of TX Blue Essentials	$368.96
Rate for Payer: BCBS of TX PPO	$409.96
Rate for Payer: Cash Price	$696.93
Rate for Payer: Cigna Medicaid	$737.93
Rate for Payer: Molina CHIP/Medicaid	$737.93
Rate for Payer: Multiplan Auto	$666.18
Rate for Payer: Multiplan Commercial	$666.18
Rate for Payer: Multiplan Workers Comp	$666.18
Rate for Payer: Parkland Medicaid	$737.93
Rate for Payer: Scott and White EPO/PPO	$512.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$737.93
Rate for Payer: Superior Health Plan EPO	$139.39

SLEEK OTW 2.5X8 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992493
Hospital Revenue Code	272
Rate for Payer: Cash Price	$696.93

SLEEK OTW 2.5X8 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992493
Hospital Revenue Code	272
Min. Negotiated Rate	$92.24
Max. Negotiated Rate	$737.93
Rate for Payer: Amerigroup CHIP/Medicaid	$92.24
Rate for Payer: BCBS of TX Blue Advantage	$307.47
Rate for Payer: BCBS of TX Blue Essentials	$368.96
Rate for Payer: BCBS of TX PPO	$409.96
Rate for Payer: Cash Price	$696.93
Rate for Payer: Cigna Medicaid	$737.93
Rate for Payer: Molina CHIP/Medicaid	$737.93
Rate for Payer: Multiplan Auto	$666.18
Rate for Payer: Multiplan Commercial	$666.18
Rate for Payer: Multiplan Workers Comp	$666.18
Rate for Payer: Parkland Medicaid	$737.93
Rate for Payer: Scott and White EPO/PPO	$512.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$737.93
Rate for Payer: Superior Health Plan EPO	$139.39

SLEEK OTW 3.0X8 X

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992496
Hospital Revenue Code	272
Min. Negotiated Rate	$92.24
Max. Negotiated Rate	$737.93
Rate for Payer: Amerigroup CHIP/Medicaid	$92.24
Rate for Payer: BCBS of TX Blue Advantage	$307.47
Rate for Payer: BCBS of TX Blue Essentials	$368.96
Rate for Payer: BCBS of TX PPO	$409.96
Rate for Payer: Cash Price	$696.93
Rate for Payer: Cigna Medicaid	$737.93
Rate for Payer: Molina CHIP/Medicaid	$737.93
Rate for Payer: Multiplan Auto	$666.18
Rate for Payer: Multiplan Commercial	$666.18
Rate for Payer: Multiplan Workers Comp	$666.18
Rate for Payer: Parkland Medicaid	$737.93
Rate for Payer: Scott and White EPO/PPO	$512.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$737.93
Rate for Payer: Superior Health Plan EPO	$139.39

SLEEK OTW 3.0X8 X

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992496
Hospital Revenue Code	272
Rate for Payer: Cash Price	$696.93

SLEEK OTW 4.0X 10 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992497
Hospital Revenue Code	272
Rate for Payer: Cash Price	$696.93

Know your out-of-pocket cost for care.

All Charges