White Rock Medical Center

All Charges

Charge

Type

Setting

Price

*Wound Visit Levels -> EST PT Wound Visit Level 4 (46-60 Min)

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	7150527
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$280.80
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$117.00
Rate for Payer: BCBS of TX Blue Essentials	$140.40
Rate for Payer: BCBS of TX PPO	$156.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cigna Medicaid	$280.80
Rate for Payer: Molina CHIP/Medicaid	$280.80
Rate for Payer: Multiplan Auto	$253.50
Rate for Payer: Multiplan Commercial	$253.50
Rate for Payer: Multiplan Workers Comp	$253.50
Rate for Payer: Parkland Medicaid	$280.80
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.80

*Wound Visit Levels -> EST PT Wound Visit Level 4 (46-60 Min)

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	7150527
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

*Wound Visit Levels -> EST PT Wound Visit Level 5 (60+ Min)

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	7150535
Hospital Revenue Code	510
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$306.72
Rate for Payer: Amerigroup CHIP/Medicaid	$38.34
Rate for Payer: BCBS of TX Blue Advantage	$127.80
Rate for Payer: BCBS of TX Blue Essentials	$153.36
Rate for Payer: BCBS of TX PPO	$170.40
Rate for Payer: Cash Price	$289.68
Rate for Payer: Cigna Medicaid	$306.72
Rate for Payer: Molina CHIP/Medicaid	$306.72
Rate for Payer: Multiplan Auto	$276.90
Rate for Payer: Multiplan Commercial	$276.90
Rate for Payer: Multiplan Workers Comp	$276.90
Rate for Payer: Parkland Medicaid	$306.72
Rate for Payer: Scott and White EPO/PPO	$213.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$306.72

*Wound Visit Levels -> EST PT Wound Visit Level 5 (60+ Min)

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	7150535
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

*Wound Visit Levels -> New PT Wound Visit Level 2

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	7150451
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

*Wound Visit Levels -> New PT Wound Visit Level 2

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	7150451
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$195.84
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$81.60
Rate for Payer: BCBS of TX Blue Essentials	$97.92
Rate for Payer: BCBS of TX PPO	$108.80
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cigna Medicaid	$195.84
Rate for Payer: Molina CHIP/Medicaid	$195.84
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$195.84
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84

*Wound Visit Levels -> New PT Wound Visit Level 3

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	7150469
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$295.92
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$123.30
Rate for Payer: BCBS of TX Blue Essentials	$147.96
Rate for Payer: BCBS of TX PPO	$164.40
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cigna Medicaid	$295.92
Rate for Payer: Molina CHIP/Medicaid	$295.92
Rate for Payer: Multiplan Auto	$267.15
Rate for Payer: Multiplan Commercial	$267.15
Rate for Payer: Multiplan Workers Comp	$267.15
Rate for Payer: Parkland Medicaid	$295.92
Rate for Payer: Scott and White EPO/PPO	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92

*Wound Visit Levels -> New PT Wound Visit Level 3

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	7150469
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

*Wound Visit Levels -> New PT Wound Visit Level 4

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	7150477
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

*Wound Visit Levels -> New PT Wound Visit Level 4

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	7150477
Hospital Revenue Code	510
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$351.36
Rate for Payer: Amerigroup CHIP/Medicaid	$43.92
Rate for Payer: BCBS of TX Blue Advantage	$146.40
Rate for Payer: BCBS of TX Blue Essentials	$175.68
Rate for Payer: BCBS of TX PPO	$195.20
Rate for Payer: Cash Price	$331.84
Rate for Payer: Cigna Medicaid	$351.36
Rate for Payer: Molina CHIP/Medicaid	$351.36
Rate for Payer: Multiplan Auto	$317.20
Rate for Payer: Multiplan Commercial	$317.20
Rate for Payer: Multiplan Workers Comp	$317.20
Rate for Payer: Parkland Medicaid	$351.36
Rate for Payer: Scott and White EPO/PPO	$244.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$351.36

*Wound Visit Levels -> New PT Wound Visit Level 5

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	7150485
Hospital Revenue Code	510
Rate for Payer: Cash Price	$405.28

*Wound Visit Levels -> New PT Wound Visit Level 5

Facility

$596.00

Service Code	HCPCS 99205
Hospital Charge Code	7150485
Hospital Revenue Code	510
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$429.12
Rate for Payer: Amerigroup CHIP/Medicaid	$53.64
Rate for Payer: BCBS of TX Blue Advantage	$178.80
Rate for Payer: BCBS of TX Blue Essentials	$214.56
Rate for Payer: BCBS of TX PPO	$238.40
Rate for Payer: Cash Price	$405.28
Rate for Payer: Cigna Medicaid	$429.12
Rate for Payer: Molina CHIP/Medicaid	$429.12
Rate for Payer: Multiplan Auto	$387.40
Rate for Payer: Multiplan Commercial	$387.40
Rate for Payer: Multiplan Workers Comp	$387.40
Rate for Payer: Parkland Medicaid	$429.12
Rate for Payer: Scott and White EPO/PPO	$298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$429.12

WRAP, STERILIZATION, QC, H500, 24 X 24

Facility

$13.63

Hospital Charge Code	993830
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.27

WRAP, STERILIZATION, QC, H500, 24 X 24

Facility

$13.63

Hospital Charge Code	993830
Hospital Revenue Code	272
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$9.81
Rate for Payer: Amerigroup CHIP/Medicaid	$1.23
Rate for Payer: BCBS of TX Blue Advantage	$4.09
Rate for Payer: BCBS of TX Blue Essentials	$4.91
Rate for Payer: BCBS of TX PPO	$5.45
Rate for Payer: Cash Price	$9.27
Rate for Payer: Cigna Medicaid	$9.81
Rate for Payer: Molina CHIP/Medicaid	$9.81
Rate for Payer: Multiplan Auto	$8.86
Rate for Payer: Multiplan Commercial	$8.86
Rate for Payer: Multiplan Workers Comp	$8.86
Rate for Payer: Parkland Medicaid	$9.81
Rate for Payer: Scott and White EPO/PPO	$6.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.81
Rate for Payer: Superior Health Plan EPO	$1.85

WRAP, STERILIZATION, QC, H600, 36X36

Facility

$9.33

Hospital Charge Code	992916
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.72
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.80
Rate for Payer: BCBS of TX Blue Essentials	$3.36
Rate for Payer: BCBS of TX PPO	$3.73
Rate for Payer: Cash Price	$6.34
Rate for Payer: Cigna Medicaid	$6.72
Rate for Payer: Molina CHIP/Medicaid	$6.72
Rate for Payer: Multiplan Auto	$6.06
Rate for Payer: Multiplan Commercial	$6.06
Rate for Payer: Multiplan Workers Comp	$6.06
Rate for Payer: Parkland Medicaid	$6.72
Rate for Payer: Scott and White EPO/PPO	$4.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.72
Rate for Payer: Superior Health Plan EPO	$1.27

WRAP, STERILIZATION, QC, H600, 36X36

Facility

$9.33

Hospital Charge Code	992916
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.34

WRAP, STERILIZATION, QC,H600, 48 X 48

Facility

$31.63

Hospital Charge Code	993068
Hospital Revenue Code	270
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$22.77
Rate for Payer: Amerigroup CHIP/Medicaid	$2.85
Rate for Payer: BCBS of TX Blue Advantage	$9.49
Rate for Payer: BCBS of TX Blue Essentials	$11.39
Rate for Payer: BCBS of TX PPO	$12.65
Rate for Payer: Cash Price	$21.51
Rate for Payer: Cigna Medicaid	$22.77
Rate for Payer: Molina CHIP/Medicaid	$22.77
Rate for Payer: Multiplan Auto	$20.56
Rate for Payer: Multiplan Commercial	$20.56
Rate for Payer: Multiplan Workers Comp	$20.56
Rate for Payer: Parkland Medicaid	$22.77
Rate for Payer: Scott and White EPO/PPO	$15.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.77
Rate for Payer: Superior Health Plan EPO	$4.30

WRAP, STERILIZATION, QC,H600, 48 X 48

Facility

$31.63

Hospital Charge Code	993068
Hospital Revenue Code	270
Rate for Payer: Cash Price	$21.51

WRAP STRL KMGRD 1STP 48X48IN KC600 QC

Facility

$15.82

Hospital Charge Code	992924
Hospital Revenue Code	270
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$11.39
Rate for Payer: Amerigroup CHIP/Medicaid	$1.42
Rate for Payer: BCBS of TX Blue Advantage	$4.75
Rate for Payer: BCBS of TX Blue Essentials	$5.70
Rate for Payer: BCBS of TX PPO	$6.33
Rate for Payer: Cash Price	$10.76
Rate for Payer: Cigna Medicaid	$11.39
Rate for Payer: Molina CHIP/Medicaid	$11.39
Rate for Payer: Multiplan Auto	$10.28
Rate for Payer: Multiplan Commercial	$10.28
Rate for Payer: Multiplan Workers Comp	$10.28
Rate for Payer: Parkland Medicaid	$11.39
Rate for Payer: Scott and White EPO/PPO	$7.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.39
Rate for Payer: Superior Health Plan EPO	$2.15

WRAP STRL KMGRD 1STP 48X48IN KC600 QC

Facility

$15.82

Hospital Charge Code	992924
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.76

WRENCH KIT 5873W TORQUE

Facility

$143.01

Hospital Charge Code	993854
Hospital Revenue Code	279
Rate for Payer: Cash Price	$97.25

WRENCH KIT 5873W TORQUE

Facility

$143.01

Hospital Charge Code	993854
Hospital Revenue Code	279
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$102.97
Rate for Payer: Amerigroup CHIP/Medicaid	$12.87
Rate for Payer: BCBS of TX Blue Advantage	$42.90
Rate for Payer: BCBS of TX Blue Essentials	$51.48
Rate for Payer: BCBS of TX PPO	$57.20
Rate for Payer: Cash Price	$97.25
Rate for Payer: Cigna Medicaid	$102.97
Rate for Payer: Molina CHIP/Medicaid	$102.97
Rate for Payer: Multiplan Auto	$92.96
Rate for Payer: Multiplan Commercial	$92.96
Rate for Payer: Multiplan Workers Comp	$92.96
Rate for Payer: Parkland Medicaid	$102.97
Rate for Payer: Scott and White EPO/PPO	$71.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.97
Rate for Payer: Superior Health Plan EPO	$19.45

WRISTBAND, ADULT, RED, ALLERGY ALERT

Facility

$0.49

Hospital Charge Code	992964
Hospital Revenue Code	270
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.35
Rate for Payer: Amerigroup CHIP/Medicaid	$0.04
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.18
Rate for Payer: BCBS of TX PPO	$0.20
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna Medicaid	$0.35
Rate for Payer: Molina CHIP/Medicaid	$0.35
Rate for Payer: Multiplan Auto	$0.32
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Workers Comp	$0.32
Rate for Payer: Parkland Medicaid	$0.35
Rate for Payer: Scott and White EPO/PPO	$0.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.35
Rate for Payer: Superior Health Plan EPO	$0.07

WRISTBAND, ADULT, RED, ALLERGY ALERT

Facility

$0.49

Hospital Charge Code	992964
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.33

WRISTBAND, SECURLINE, BLOOD, POLY SYNTHETIC

Facility

$4.97

Hospital Charge Code	992937
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.38

Know your out-of-pocket cost for care.

All Charges