White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PRT FM (ALL) -- DHF

Facility

$82.27

Hospital Charge Code	80337553
Hospital Revenue Code	270
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$53.48
Rate for Payer: Aetna Commercial	$45.25
Rate for Payer: Amerigroup CHIP/Medicaid	$7.40
Rate for Payer: BCBS of TX Blue Advantage	$24.68
Rate for Payer: BCBS of TX Blue Essentials	$29.62
Rate for Payer: BCBS of TX PPO	$32.91
Rate for Payer: Cash Price	$72.40
Rate for Payer: Multiplan Auto	$53.48
Rate for Payer: Multiplan Commercial	$53.48
Rate for Payer: Multiplan Workers Comp	$53.48
Rate for Payer: Scott and White EPO/PPO	$41.14
Rate for Payer: Superior Health Plan EPO	$11.19

PSYCH DIAGNOSTIC EVALUATION BCE

Facility

$480.00

Service Code	CPT 90791
Hospital Charge Code	100013
Hospital Revenue Code	914
Rate for Payer: Cash Price	$422.40

PSYCH DIAGNOSTIC EVALUATION BCE

Facility

$480.00

Service Code	CPT 90791
Hospital Charge Code	100013
Hospital Revenue Code	914
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$330.32
Rate for Payer: Aetna Commercial	$264.00
Rate for Payer: Aetna Medicare	$218.72
Rate for Payer: Amerigroup CHIP/Medicaid	$43.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$145.81
Rate for Payer: Amerigroup Medicare	$145.81
Rate for Payer: BCBS of TX Blue Advantage	$144.00
Rate for Payer: BCBS of TX Blue Essentials	$172.80
Rate for Payer: BCBS of TX Medicare	$145.81
Rate for Payer: BCBS of TX PPO	$192.00
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cash Price	$422.40
Rate for Payer: Cigna Commercial	$330.32
Rate for Payer: Cigna Medicaid	$118.95
Rate for Payer: Cigna Medicare	$145.81
Rate for Payer: Employer Direct Commercial	$145.81
Rate for Payer: Humana Medicare/TRICARE	$145.81
Rate for Payer: Molina CHIP/Medicaid	$118.95
Rate for Payer: Molina Dual Medicare/Medicaid	$145.81
Rate for Payer: Molina Medicare	$145.81
Rate for Payer: Multiplan Auto	$312.00
Rate for Payer: Multiplan Commercial	$312.00
Rate for Payer: Multiplan Workers Comp	$312.00
Rate for Payer: Parkland Medicaid	$118.95
Rate for Payer: Scott and White EPO/PPO	$2.61
Rate for Payer: Scott and White Medicare	$145.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.95
Rate for Payer: Superior Health Plan EPO	$145.81
Rate for Payer: Superior Health Plan Medicare	$145.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$145.81
Rate for Payer: Universal American Medicare	$145.81
Rate for Payer: Wellcare Medicare	$145.81
Rate for Payer: Wellmed Medicare	$145.81

PSYCHOSES

Facility

$25,961.60

Service Code	MSDRG 885
Min. Negotiated Rate	$9,406.68
Max. Negotiated Rate	$25,961.60
Rate for Payer: Aetna Commercial	$15,372.00
Rate for Payer: Aetna Medicare	$18,908.25
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,605.50
Rate for Payer: Amerigroup Medicare	$12,605.50
Rate for Payer: BCBS of TX Blue Advantage	$9,406.68
Rate for Payer: BCBS of TX Blue Essentials	$12,342.56
Rate for Payer: BCBS of TX Medicare	$12,605.50
Rate for Payer: BCBS of TX PPO	$13,714.48
Rate for Payer: Cigna Commercial	$17,599.23
Rate for Payer: Cigna Medicare	$12,605.50
Rate for Payer: Employer Direct Commercial	$12,605.50
Rate for Payer: Molina Dual Medicare/Medicaid	$12,605.50
Rate for Payer: Molina Medicare	$12,605.50
Rate for Payer: Multiplan Auto	$25,961.60
Rate for Payer: Multiplan Commercial	$25,961.60
Rate for Payer: Multiplan Workers Comp	$25,961.60
Rate for Payer: Scott and White EPO/PPO	$11,956.00
Rate for Payer: Scott and White Medicare	$12,605.50
Rate for Payer: Superior Health Plan EPO	$12,605.50
Rate for Payer: Superior Health Plan Medicare	$12,605.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,605.50
Rate for Payer: Universal American Medicare	$12,605.50
Rate for Payer: Wellcare Medicare	$12,605.50
Rate for Payer: Wellmed Medicare	$12,605.50

PT and PTT SO

Facility

$220.00

Service Code	CPT 85730
Hospital Charge Code	1600535
Hospital Revenue Code	305
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$143.00
Rate for Payer: Aetna Commercial	$6.32
Rate for Payer: Aetna Medicare	$9.02
Rate for Payer: Amerigroup CHIP/Medicaid	$2.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.01
Rate for Payer: Amerigroup Medicare	$6.01
Rate for Payer: BCBS of TX Blue Advantage	$9.92
Rate for Payer: BCBS of TX Blue Essentials	$11.90
Rate for Payer: BCBS of TX Medicare	$6.01
Rate for Payer: BCBS of TX PPO	$13.28
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cigna Medicaid	$6.01
Rate for Payer: Cigna Medicare	$6.01
Rate for Payer: Employer Direct Commercial	$6.01
Rate for Payer: Humana Medicare/TRICARE	$6.01
Rate for Payer: Molina CHIP/Medicaid	$6.01
Rate for Payer: Molina Dual Medicare/Medicaid	$6.01
Rate for Payer: Molina Medicare	$6.01
Rate for Payer: Multiplan Auto	$143.00
Rate for Payer: Multiplan Commercial	$143.00
Rate for Payer: Multiplan Workers Comp	$143.00
Rate for Payer: Parkland Medicaid	$6.01
Rate for Payer: Scott and White EPO/PPO	$7.51
Rate for Payer: Scott and White Medicare	$6.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.01
Rate for Payer: Superior Health Plan EPO	$6.01
Rate for Payer: Superior Health Plan Medicare	$6.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.01
Rate for Payer: Universal American Medicare	$6.01
Rate for Payer: Wellcare Medicare	$6.01
Rate for Payer: Wellmed Medicare	$6.01

PT Aquatic Assistant Units

Facility

$137.00

Service Code	CPT 97113 CQ,GP
Hospital Charge Code	5710045
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$68.97
Rate for Payer: BCBS of TX Blue Essentials	$82.45
Rate for Payer: BCBS of TX PPO	$91.96
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$89.05
Rate for Payer: Multiplan Commercial	$89.05
Rate for Payer: Multiplan Workers Comp	$89.05
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.63

PT Aquatic Assistant Units BCE

Facility

$137.00

Service Code	CPT 97113 CQ,GP
Hospital Charge Code	5710045
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$68.97
Rate for Payer: BCBS of TX Blue Essentials	$82.45
Rate for Payer: BCBS of TX PPO	$91.96
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$89.05
Rate for Payer: Multiplan Commercial	$89.05
Rate for Payer: Multiplan Workers Comp	$89.05
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.63

PT Aquatic Assistant Units BCE

Facility

$137.00

Service Code	CPT 97113 CQ,GP
Hospital Charge Code	5710045
Hospital Revenue Code	420
Rate for Payer: Cash Price	$120.56

PT Aquatic Units

Facility

$137.00

Service Code	CPT 97113 GP
Hospital Charge Code	5715304
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$68.97
Rate for Payer: BCBS of TX Blue Essentials	$82.45
Rate for Payer: BCBS of TX PPO	$91.96
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$89.05
Rate for Payer: Multiplan Commercial	$89.05
Rate for Payer: Multiplan Workers Comp	$89.05
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.63

PT Aquatic Units BCE

Facility

$137.00

Service Code	CPT 97113 GP
Hospital Charge Code	5715304
Hospital Revenue Code	420
Rate for Payer: Cash Price	$120.56

PT Aquatic Units BCE

Facility

$137.00

Service Code	CPT 97113 GP
Hospital Charge Code	5715304
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$68.97
Rate for Payer: BCBS of TX Blue Essentials	$82.45
Rate for Payer: BCBS of TX PPO	$91.96
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cash Price	$120.56
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$89.05
Rate for Payer: Multiplan Commercial	$89.05
Rate for Payer: Multiplan Workers Comp	$89.05
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.63

PT Attended E-Stim Assistant Units

Facility

$139.00

Service Code	CPT 97032 CQ,GP
Hospital Charge Code	4252046
Hospital Revenue Code	420
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.90

PT Attended E-Stim Assistant Units BCE

Facility

$139.00

Service Code	CPT 97032 CQ,GP
Hospital Charge Code	4252046
Hospital Revenue Code	420
Rate for Payer: Cash Price	$122.32

PT Attended E-Stim Assistant Units BCE

Facility

$139.00

Service Code	CPT 97032 CQ,GP
Hospital Charge Code	4252046
Hospital Revenue Code	420
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.90

PT Attended E-Stim Units

Facility

$139.00

Service Code	CPT 97032 GP
Hospital Charge Code	4252052
Hospital Revenue Code	420
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.90

PT Attended E-Stim Units BCE

Facility

$139.00

Service Code	CPT 97032 GP
Hospital Charge Code	4252052
Hospital Revenue Code	420
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.90

PT Attended E-Stim Units BCE

Facility

$139.00

Service Code	CPT 97032 GP
Hospital Charge Code	4252052
Hospital Revenue Code	420
Rate for Payer: Cash Price	$122.32

PT Biofeedback Assistant Units

Facility

$448.00

Service Code	CPT 90901 CQ,GP
Hospital Charge Code	5715678
Hospital Revenue Code	420
Min. Negotiated Rate	$35.74
Max. Negotiated Rate	$291.20
Rate for Payer: Aetna Commercial	$246.40
Rate for Payer: Amerigroup CHIP/Medicaid	$40.32
Rate for Payer: BCBS of TX Blue Advantage	$35.74
Rate for Payer: BCBS of TX Blue Essentials	$42.72
Rate for Payer: BCBS of TX PPO	$47.65
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$60.93

PT Biofeedback Assistant Units BCE

Facility

$448.00

Service Code	CPT 90901 CQ,GP
Hospital Charge Code	5715678
Hospital Revenue Code	420
Rate for Payer: Cash Price	$394.24

PT Biofeedback Assistant Units BCE

Facility

$448.00

Service Code	CPT 90901 CQ,GP
Hospital Charge Code	5715678
Hospital Revenue Code	420
Min. Negotiated Rate	$35.74
Max. Negotiated Rate	$291.20
Rate for Payer: Aetna Commercial	$246.40
Rate for Payer: Amerigroup CHIP/Medicaid	$40.32
Rate for Payer: BCBS of TX Blue Advantage	$35.74
Rate for Payer: BCBS of TX Blue Essentials	$42.72
Rate for Payer: BCBS of TX PPO	$47.65
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$60.93

PT Biofeedback Units

Facility

$448.00

Service Code	CPT 90901 GP
Hospital Charge Code	5715678
Hospital Revenue Code	420
Min. Negotiated Rate	$35.74
Max. Negotiated Rate	$291.20
Rate for Payer: Aetna Commercial	$246.40
Rate for Payer: Amerigroup CHIP/Medicaid	$40.32
Rate for Payer: BCBS of TX Blue Advantage	$35.74
Rate for Payer: BCBS of TX Blue Essentials	$42.72
Rate for Payer: BCBS of TX PPO	$47.65
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$60.93

PT Biofeedback Units BCE

Facility

$448.00

Service Code	CPT 90901 GP
Hospital Charge Code	5715678
Hospital Revenue Code	420
Min. Negotiated Rate	$35.74
Max. Negotiated Rate	$291.20
Rate for Payer: Aetna Commercial	$246.40
Rate for Payer: Amerigroup CHIP/Medicaid	$40.32
Rate for Payer: BCBS of TX Blue Advantage	$35.74
Rate for Payer: BCBS of TX Blue Essentials	$42.72
Rate for Payer: BCBS of TX PPO	$47.65
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$60.93

PTCH EXTERNL REFERENCE -- DHF

Facility

$2,329.02

Hospital Charge Code	40246159
Hospital Revenue Code	272
Min. Negotiated Rate	$209.61
Max. Negotiated Rate	$1,513.86
Rate for Payer: Aetna Commercial	$1,280.96
Rate for Payer: Amerigroup CHIP/Medicaid	$209.61
Rate for Payer: BCBS of TX Blue Advantage	$698.71
Rate for Payer: BCBS of TX Blue Essentials	$838.45
Rate for Payer: BCBS of TX PPO	$931.61
Rate for Payer: Cash Price	$2,049.54
Rate for Payer: Multiplan Auto	$1,513.86
Rate for Payer: Multiplan Commercial	$1,513.86
Rate for Payer: Multiplan Workers Comp	$1,513.86
Rate for Payer: Scott and White EPO/PPO	$1,164.51
Rate for Payer: Superior Health Plan EPO	$316.75

PTCH EXTERNL REFERENCE -- DHF

Facility

$2,329.02

Hospital Charge Code	40246159
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,049.54

PT Evaluation Units, High Complexity

Facility

$288.00

Service Code	CPT 97163 GP
Hospital Charge Code	4252202
Hospital Revenue Code	424
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$150.49
Rate for Payer: BCBS of TX Blue Essentials	$179.90
Rate for Payer: BCBS of TX PPO	$200.66
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$187.20
Rate for Payer: Multiplan Commercial	$187.20
Rate for Payer: Multiplan Workers Comp	$187.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$39.17

Know your out-of-pocket cost for care.

All Charges