White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC

Facility

$59,179.30

Service Code	MSDRG 464
Min. Negotiated Rate	$25,318.40
Max. Negotiated Rate	$59,179.30
Rate for Payer: BCBS of TX Blue Advantage	$25,318.40
Rate for Payer: BCBS of TX Blue Essentials	$30,379.14
Rate for Payer: BCBS of TX PPO	$33,755.90

WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC

Facility

$108,290.50

Service Code	MSDRG 463
Min. Negotiated Rate	$44,134.34
Max. Negotiated Rate	$108,290.50
Rate for Payer: BCBS of TX Blue Advantage	$44,134.34
Rate for Payer: BCBS of TX Blue Essentials	$52,956.08
Rate for Payer: BCBS of TX PPO	$58,842.37

WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC

Facility

$34,650.30

Service Code	MSDRG 465
Min. Negotiated Rate	$15,801.64
Max. Negotiated Rate	$34,650.30
Rate for Payer: BCBS of TX Blue Advantage	$15,801.64
Rate for Payer: BCBS of TX Blue Essentials	$18,960.13
Rate for Payer: BCBS of TX PPO	$21,067.63

Work hardening/conditioning; initial 2 hours

Facility

$254.10

Service Code	HCPCS 97545 GP
Hospital Charge Code	9381003
Hospital Revenue Code	420
Min. Negotiated Rate	$22.87
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$22.87
Rate for Payer: BCBS of TX Blue Advantage	$76.23
Rate for Payer: BCBS of TX Blue Essentials	$91.48
Rate for Payer: BCBS of TX PPO	$101.64
Rate for Payer: Cash Price	$172.79
Rate for Payer: Cash Price	$172.79
Rate for Payer: Cash Price	$172.79
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$182.95
Rate for Payer: Molina CHIP/Medicaid	$182.95
Rate for Payer: Multiplan Auto	$165.16
Rate for Payer: Multiplan Commercial	$165.16
Rate for Payer: Multiplan Workers Comp	$165.16
Rate for Payer: Parkland Medicaid	$182.95
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$182.95
Rate for Payer: Superior Health Plan EPO	$34.56

Work hardening/conditioning; initial 2 hours

Facility

$254.10

Service Code	HCPCS 97545 GP
Hospital Charge Code	9381003
Hospital Revenue Code	420
Rate for Payer: Cash Price	$172.79

WOUND CLOSURE

Facility

$6,480.00

Service Code	HCPCS 13160
Hospital Charge Code	9900116
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
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	$3,559.87
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$4,406.40
Rate for Payer: Cash Price	$4,406.40
Rate for Payer: Cash Price	$4,406.40
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicaid	$4,665.60
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina CHIP/Medicaid	$4,665.60
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$4,665.60
Rate for Payer: Scott and White EPO/PPO	$6,585.76
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,665.60
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

WOUND CLOSURE

Facility

$10,000.00

Service Code	CPT 13160
Hospital Charge Code	36013160
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
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	$3,559.87
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$6,585.76
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

WOUND CLOSURE

Facility

$6,480.00

Service Code	HCPCS 13160
Hospital Charge Code	9900116
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,406.40

Wound Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107133
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Wound Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107133
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$59,179.30

Service Code	MSDRG 464
Min. Negotiated Rate	$25,318.40
Max. Negotiated Rate	$59,179.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,587.81
Rate for Payer: Amerigroup Medicare	$27,587.81
Rate for Payer: BCBS of TX Medicare	$27,587.81
Rate for Payer: Cigna Commercial	$40,117.34
Rate for Payer: Cigna Medicare	$27,587.81
Rate for Payer: Employer Direct Commercial	$27,587.81
Rate for Payer: Humana Medicare/TRICARE	$27,587.81
Rate for Payer: Molina Dual Medicare/Medicaid	$27,587.81
Rate for Payer: Molina Medicare	$27,587.81
Rate for Payer: Multiplan Auto	$59,179.30
Rate for Payer: Multiplan Commercial	$59,179.30
Rate for Payer: Multiplan Workers Comp	$59,179.30
Rate for Payer: Scott and White EPO/PPO	$27,253.62
Rate for Payer: Scott and White Medicare	$27,587.81
Rate for Payer: Superior Health Plan EPO	$27,587.81
Rate for Payer: Superior Health Plan Medicare	$27,587.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,587.81
Rate for Payer: Universal American Medicare	$27,587.81
Rate for Payer: Wellcare Medicare	$27,587.81
Rate for Payer: Wellmed Medicare	$27,587.81

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$108,290.50

Service Code	MSDRG 463
Min. Negotiated Rate	$44,134.34
Max. Negotiated Rate	$108,290.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$46,531.87
Rate for Payer: Amerigroup Medicare	$46,531.87
Rate for Payer: BCBS of TX Medicare	$46,531.87
Rate for Payer: Cigna Commercial	$73,409.56
Rate for Payer: Cigna Medicare	$46,531.87
Rate for Payer: Employer Direct Commercial	$46,531.87
Rate for Payer: Humana Medicare/TRICARE	$46,531.87
Rate for Payer: Molina Dual Medicare/Medicaid	$46,531.87
Rate for Payer: Molina Medicare	$46,531.87
Rate for Payer: Multiplan Auto	$108,290.50
Rate for Payer: Multiplan Commercial	$108,290.50
Rate for Payer: Multiplan Workers Comp	$108,290.50
Rate for Payer: Scott and White EPO/PPO	$49,870.62
Rate for Payer: Scott and White Medicare	$46,531.87
Rate for Payer: Superior Health Plan EPO	$46,531.87
Rate for Payer: Superior Health Plan Medicare	$46,531.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$46,531.87
Rate for Payer: Universal American Medicare	$46,531.87
Rate for Payer: Wellcare Medicare	$46,531.87
Rate for Payer: Wellmed Medicare	$46,531.87

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$34,650.30

Service Code	MSDRG 465
Min. Negotiated Rate	$15,801.64
Max. Negotiated Rate	$34,650.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,126.02
Rate for Payer: Amerigroup Medicare	$18,126.02
Rate for Payer: BCBS of TX Medicare	$18,126.02
Rate for Payer: Cigna Commercial	$23,489.26
Rate for Payer: Cigna Medicare	$18,126.02
Rate for Payer: Employer Direct Commercial	$18,126.02
Rate for Payer: Humana Medicare/TRICARE	$18,126.02
Rate for Payer: Molina Dual Medicare/Medicaid	$18,126.02
Rate for Payer: Molina Medicare	$18,126.02
Rate for Payer: Multiplan Auto	$34,650.30
Rate for Payer: Multiplan Commercial	$34,650.30
Rate for Payer: Multiplan Workers Comp	$34,650.30
Rate for Payer: Scott and White EPO/PPO	$15,957.38
Rate for Payer: Scott and White Medicare	$18,126.02
Rate for Payer: Superior Health Plan EPO	$18,126.02
Rate for Payer: Superior Health Plan Medicare	$18,126.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,126.02
Rate for Payer: Universal American Medicare	$18,126.02
Rate for Payer: Wellcare Medicare	$18,126.02
Rate for Payer: Wellmed Medicare	$18,126.02

WOUND DEBRIDEMENTS FOR INJURIES W CC

Facility

$36,375.50

Service Code	MSDRG 902
Min. Negotiated Rate	$16,515.44
Max. Negotiated Rate	$36,375.50
Rate for Payer: BCBS of TX Blue Advantage	$16,515.44
Rate for Payer: BCBS of TX Blue Essentials	$19,816.61
Rate for Payer: BCBS of TX PPO	$22,019.31

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$36,375.50

Service Code	MSDRG 902
Min. Negotiated Rate	$16,515.44
Max. Negotiated Rate	$36,375.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,791.51
Rate for Payer: Amerigroup Medicare	$18,791.51
Rate for Payer: BCBS of TX Medicare	$18,791.51
Rate for Payer: Cigna Commercial	$24,658.76
Rate for Payer: Cigna Medicare	$18,791.51
Rate for Payer: Employer Direct Commercial	$18,791.51
Rate for Payer: Humana Medicare/TRICARE	$18,791.51
Rate for Payer: Molina Dual Medicare/Medicaid	$18,791.51
Rate for Payer: Molina Medicare	$18,791.51
Rate for Payer: Multiplan Auto	$36,375.50
Rate for Payer: Multiplan Commercial	$36,375.50
Rate for Payer: Multiplan Workers Comp	$36,375.50
Rate for Payer: Scott and White EPO/PPO	$16,751.88
Rate for Payer: Scott and White Medicare	$18,791.51
Rate for Payer: Superior Health Plan EPO	$18,791.51
Rate for Payer: Superior Health Plan Medicare	$18,791.51
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,791.51
Rate for Payer: Universal American Medicare	$18,791.51
Rate for Payer: Wellcare Medicare	$18,791.51
Rate for Payer: Wellmed Medicare	$18,791.51

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$79,735.40

Service Code	MSDRG 901
Min. Negotiated Rate	$35,517.08
Max. Negotiated Rate	$79,735.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,517.08
Rate for Payer: Amerigroup Medicare	$35,517.08
Rate for Payer: BCBS of TX Medicare	$35,517.08
Rate for Payer: Cigna Commercial	$54,052.21
Rate for Payer: Cigna Medicare	$35,517.08
Rate for Payer: Employer Direct Commercial	$35,517.08
Rate for Payer: Humana Medicare/TRICARE	$35,517.08
Rate for Payer: Molina Dual Medicare/Medicaid	$35,517.08
Rate for Payer: Molina Medicare	$35,517.08
Rate for Payer: Multiplan Auto	$79,735.40
Rate for Payer: Multiplan Commercial	$79,735.40
Rate for Payer: Multiplan Workers Comp	$79,735.40
Rate for Payer: Scott and White EPO/PPO	$36,720.25
Rate for Payer: Scott and White Medicare	$35,517.08
Rate for Payer: Superior Health Plan EPO	$35,517.08
Rate for Payer: Superior Health Plan Medicare	$35,517.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,517.08
Rate for Payer: Universal American Medicare	$35,517.08
Rate for Payer: Wellcare Medicare	$35,517.08
Rate for Payer: Wellmed Medicare	$35,517.08

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$22,222.40

Service Code	MSDRG 903
Min. Negotiated Rate	$10,009.54
Max. Negotiated Rate	$22,222.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,332.11
Rate for Payer: Amerigroup Medicare	$13,332.11
Rate for Payer: BCBS of TX Medicare	$13,332.11
Rate for Payer: Cigna Commercial	$15,064.45
Rate for Payer: Cigna Medicare	$13,332.11
Rate for Payer: Employer Direct Commercial	$13,332.11
Rate for Payer: Humana Medicare/TRICARE	$13,332.11
Rate for Payer: Molina Dual Medicare/Medicaid	$13,332.11
Rate for Payer: Molina Medicare	$13,332.11
Rate for Payer: Multiplan Auto	$22,222.40
Rate for Payer: Multiplan Commercial	$22,222.40
Rate for Payer: Multiplan Workers Comp	$22,222.40
Rate for Payer: Scott and White EPO/PPO	$10,234.00
Rate for Payer: Scott and White Medicare	$13,332.11
Rate for Payer: Superior Health Plan EPO	$13,332.11
Rate for Payer: Superior Health Plan Medicare	$13,332.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,332.11
Rate for Payer: Universal American Medicare	$13,332.11
Rate for Payer: Wellcare Medicare	$13,332.11
Rate for Payer: Wellmed Medicare	$13,332.11

WOUND DEBRIDEMENTS FOR INJURIES W MCC

Facility

$79,735.40

Service Code	MSDRG 901
Min. Negotiated Rate	$35,517.08
Max. Negotiated Rate	$79,735.40
Rate for Payer: BCBS of TX Blue Advantage	$38,398.14
Rate for Payer: BCBS of TX Blue Essentials	$46,073.30
Rate for Payer: BCBS of TX PPO	$51,194.54

WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC

Facility

$22,222.40

Service Code	MSDRG 903
Min. Negotiated Rate	$10,009.54
Max. Negotiated Rate	$22,222.40
Rate for Payer: BCBS of TX Blue Advantage	$10,009.54
Rate for Payer: BCBS of TX Blue Essentials	$12,010.28
Rate for Payer: BCBS of TX PPO	$13,345.28

*Wound Visit Levels -> EST PT Wound Visit Level 1 (0-15 Min)

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	7150493
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Molina CHIP/Medicaid	$81.36
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$81.36
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

*Wound Visit Levels -> EST PT Wound Visit Level 1 (0-15 Min)

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	7150493
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

*Wound Visit Levels -> EST PT Wound Visit Level 2 (16-30 Min)

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	7150501
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$125.28
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$52.20
Rate for Payer: BCBS of TX Blue Essentials	$62.64
Rate for Payer: BCBS of TX PPO	$69.60
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cigna Medicaid	$125.28
Rate for Payer: Molina CHIP/Medicaid	$125.28
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$125.28
Rate for Payer: Scott and White EPO/PPO	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28

*Wound Visit Levels -> EST PT Wound Visit Level 2 (16-30 Min)

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	7150501
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

*Wound Visit Levels -> EST PT Wound Visit Level 3 (31-45 Min)

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	7150519
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

*Wound Visit Levels -> EST PT Wound Visit Level 3 (31-45 Min)

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	7150519
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$151.92
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$63.30
Rate for Payer: BCBS of TX Blue Essentials	$75.96
Rate for Payer: BCBS of TX PPO	$84.40
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cigna Medicaid	$151.92
Rate for Payer: Molina CHIP/Medicaid	$151.92
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$151.92
Rate for Payer: Scott and White EPO/PPO	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.92

Know your out-of-pocket cost for care.

All Charges