White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WRISTBAND, SECURLINE, BLOOD, POLY SYNTHETIC

Facility

$4.97

Hospital Charge Code	992937
Hospital Revenue Code	270
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$3.58
Rate for Payer: Amerigroup CHIP/Medicaid	$0.45
Rate for Payer: BCBS of TX Blue Advantage	$1.49
Rate for Payer: BCBS of TX Blue Essentials	$1.79
Rate for Payer: BCBS of TX PPO	$1.99
Rate for Payer: Cash Price	$3.38
Rate for Payer: Cigna Medicaid	$3.58
Rate for Payer: Molina CHIP/Medicaid	$3.58
Rate for Payer: Multiplan Auto	$3.23
Rate for Payer: Multiplan Commercial	$3.23
Rate for Payer: Multiplan Workers Comp	$3.23
Rate for Payer: Parkland Medicaid	$3.58
Rate for Payer: Scott and White EPO/PPO	$2.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.58
Rate for Payer: Superior Health Plan EPO	$0.68

WRIST/FOREARM SUPPORT, RT UNIV, 10'

Facility

$188.67

Hospital Charge Code	993093
Hospital Revenue Code	270
Min. Negotiated Rate	$16.98
Max. Negotiated Rate	$135.84
Rate for Payer: Amerigroup CHIP/Medicaid	$16.98
Rate for Payer: BCBS of TX Blue Advantage	$56.60
Rate for Payer: BCBS of TX Blue Essentials	$67.92
Rate for Payer: BCBS of TX PPO	$75.47
Rate for Payer: Cash Price	$128.30
Rate for Payer: Cigna Medicaid	$135.84
Rate for Payer: Molina CHIP/Medicaid	$135.84
Rate for Payer: Multiplan Auto	$122.64
Rate for Payer: Multiplan Commercial	$122.64
Rate for Payer: Multiplan Workers Comp	$122.64
Rate for Payer: Parkland Medicaid	$135.84
Rate for Payer: Scott and White EPO/PPO	$94.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.84
Rate for Payer: Superior Health Plan EPO	$25.66

WRIST/FOREARM SUPPORT, RT UNIV, 10'

Facility

$188.67

Hospital Charge Code	993093
Hospital Revenue Code	270
Rate for Payer: Cash Price	$128.30

WRNR EVAL AND FUNCTION EA ADDL 15 BCE

Facility

$163.60

Service Code	HCPCS 92627
Hospital Charge Code	9120973
Hospital Revenue Code	440
Rate for Payer: Cash Price	$111.25

WRNR EVAL AND FUNCTION EA ADDL 15 BCE

Facility

$163.60

Service Code	HCPCS 92627
Hospital Charge Code	9120973
Hospital Revenue Code	440
Min. Negotiated Rate	$14.72
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.72
Rate for Payer: BCBS of TX Blue Advantage	$49.08
Rate for Payer: BCBS of TX Blue Essentials	$58.90
Rate for Payer: BCBS of TX PPO	$65.44
Rate for Payer: Cash Price	$111.25
Rate for Payer: Cash Price	$111.25
Rate for Payer: Cash Price	$111.25
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$117.79
Rate for Payer: Molina CHIP/Medicaid	$117.79
Rate for Payer: Multiplan Auto	$106.34
Rate for Payer: Multiplan Commercial	$106.34
Rate for Payer: Multiplan Workers Comp	$106.34
Rate for Payer: Parkland Medicaid	$117.79
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.79
Rate for Payer: Superior Health Plan EPO	$22.25

WRNR Neurology Est Pt Level I BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	9306541
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

WRNR Neurology Est Pt Level I BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	9306541
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

WRNR Neurology Est Pt Level I BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	7000060
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

WRNR Neurology Est Pt Level I BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	7000060
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

WRNR Neurology Est Pt Level II BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	9306542
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

WRNR Neurology Est Pt Level II BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	9306542
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

WRNR Neurology Est Pt Level III BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	9306543
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

WRNR Neurology Est Pt Level III BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	9306543
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

WRNR Neurology Est Pt Level IV BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	9306544
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

WRNR Neurology Est Pt Level IV BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	9306544
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

WRNR Neurology Est Pt Level V BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	9306545
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

WRNR Neurology Est Pt Level V BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	9306545
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

WRNR Neurology Est Pt Level V BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	8992974
Hospital Revenue Code	510
Rate for Payer: Cash Price	$289.68

WRNR Neurology Est Pt Level V BCE

Facility

$426.00

Service Code	HCPCS 99215
Hospital Charge Code	8992974
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

WRNR Neurology New Pt Level II BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	9306546
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

WRNR Neurology New Pt Level II BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	9306546
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

WRNR Neurology New Pt Level III BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	9306547
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

WRNR Neurology New Pt Level III BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	9306547
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

WRNR Neurology New Pt Level IV BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	9306548
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

WRNR Neurology New Pt Level IV BCE

Facility

$488.00

Service Code	HCPCS 99204
Hospital Charge Code	9306548
Hospital Revenue Code	510
Rate for Payer: Cash Price	$331.84

Know your out-of-pocket cost for care.

All Charges