White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PT Evaluation Units, High Complexity BCE

Facility

$288.00

Service Code	CPT 97163 GP
Hospital Charge Code	4252202
Hospital Revenue Code	424
Rate for Payer: Cash Price	$253.44

PT Evaluation Units, High Complexity BCE

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

PT Evaluation Units, Low Complexity

Facility

$127.00

Service Code	CPT 97161 GP
Hospital Charge Code	4252200
Hospital Revenue Code	424
Min. Negotiated Rate	$17.27
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	$111.76
Rate for Payer: Cash Price	$111.76
Rate for Payer: Cash Price	$111.76
Rate for Payer: Cash Price	$111.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$82.55
Rate for Payer: Multiplan Commercial	$82.55
Rate for Payer: Multiplan Workers Comp	$82.55
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.27

PT Evaluation Units, Low Complexity BCE

Facility

$127.00

Service Code	CPT 97161 GP
Hospital Charge Code	4252200
Hospital Revenue Code	424
Rate for Payer: Cash Price	$111.76

PT Evaluation Units, Low Complexity BCE

Facility

$127.00

Service Code	CPT 97161 GP
Hospital Charge Code	4252200
Hospital Revenue Code	424
Min. Negotiated Rate	$17.27
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	$111.76
Rate for Payer: Cash Price	$111.76
Rate for Payer: Cash Price	$111.76
Rate for Payer: Cash Price	$111.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$82.55
Rate for Payer: Multiplan Commercial	$82.55
Rate for Payer: Multiplan Workers Comp	$82.55
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.27

PT Evaluation Units, Moderate Complexity

Facility

$191.00

Service Code	CPT 97162 GP
Hospital Charge Code	4252201
Hospital Revenue Code	424
Min. Negotiated Rate	$25.98
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	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.98

PT Evaluation Units, Moderate Complexity BCE

Facility

$191.00

Service Code	CPT 97162 GP
Hospital Charge Code	4252201
Hospital Revenue Code	424
Rate for Payer: Cash Price	$168.08

PT Evaluation Units, Moderate Complexity BCE

Facility

$191.00

Service Code	CPT 97162 GP
Hospital Charge Code	4252201
Hospital Revenue Code	424
Min. Negotiated Rate	$25.98
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	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.98

PT Gait Training Assistant Units

Facility

$153.00

Service Code	CPT 97116 CQ,GP
Hospital Charge Code	4252048
Hospital Revenue Code	420
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$53.92
Rate for Payer: BCBS of TX Blue Essentials	$64.46
Rate for Payer: BCBS of TX PPO	$71.90
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$20.81

PT Gait Training Assistant Units BCE

Facility

$153.00

Service Code	CPT 97116 CQ,GP
Hospital Charge Code	4252048
Hospital Revenue Code	420
Rate for Payer: Cash Price	$134.64

PT Gait Training Assistant Units BCE

Facility

$153.00

Service Code	CPT 97116 CQ,GP
Hospital Charge Code	4252048
Hospital Revenue Code	420
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$53.92
Rate for Payer: BCBS of TX Blue Essentials	$64.46
Rate for Payer: BCBS of TX PPO	$71.90
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$20.81

PT Gait Training Units

Facility

$153.00

Service Code	CPT 97116 GP
Hospital Charge Code	4252027
Hospital Revenue Code	420
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$53.92
Rate for Payer: BCBS of TX Blue Essentials	$64.46
Rate for Payer: BCBS of TX PPO	$71.90
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$20.81

PT Gait Training Units BCE

Facility

$153.00

Service Code	CPT 97116 GP
Hospital Charge Code	4252027
Hospital Revenue Code	420
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$53.92
Rate for Payer: BCBS of TX Blue Essentials	$64.46
Rate for Payer: BCBS of TX PPO	$71.90
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cash Price	$134.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$20.81

PT Gait Training Units BCE

Facility

$153.00

Service Code	CPT 97116 GP
Hospital Charge Code	4252027
Hospital Revenue Code	420
Rate for Payer: Cash Price	$134.64

PT Group Therapy Units

Facility

$191.00

Service Code	CPT 97150 GP
Hospital Charge Code	4252029
Hospital Revenue Code	420
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$17.19
Rate for Payer: BCBS of TX Blue Advantage	$32.61
Rate for Payer: BCBS of TX Blue Essentials	$38.98
Rate for Payer: BCBS of TX PPO	$43.48
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.98

PT Group Therapy Units

Facility

$191.00

Service Code	CPT 97150 GP
Hospital Charge Code	4252029
Hospital Revenue Code	420
Rate for Payer: Cash Price	$168.08

PTH, Intact SO

Facility

$302.00

Service Code	CPT 83970
Hospital Charge Code	1707926
Hospital Revenue Code	301
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$196.30
Rate for Payer: Aetna Commercial	$43.35
Rate for Payer: Aetna Medicare	$61.92
Rate for Payer: Amerigroup CHIP/Medicaid	$16.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$41.28
Rate for Payer: Amerigroup Medicare	$41.28
Rate for Payer: BCBS of TX Blue Advantage	$68.11
Rate for Payer: BCBS of TX Blue Essentials	$81.73
Rate for Payer: BCBS of TX Medicare	$41.28
Rate for Payer: BCBS of TX PPO	$91.23
Rate for Payer: Cash Price	$265.76
Rate for Payer: Cash Price	$265.76
Rate for Payer: Cigna Medicaid	$41.28
Rate for Payer: Cigna Medicare	$41.28
Rate for Payer: Employer Direct Commercial	$41.28
Rate for Payer: Humana Medicare/TRICARE	$41.28
Rate for Payer: Molina CHIP/Medicaid	$41.28
Rate for Payer: Molina Dual Medicare/Medicaid	$41.28
Rate for Payer: Molina Medicare	$41.28
Rate for Payer: Multiplan Auto	$196.30
Rate for Payer: Multiplan Commercial	$196.30
Rate for Payer: Multiplan Workers Comp	$196.30
Rate for Payer: Parkland Medicaid	$41.28
Rate for Payer: Scott and White EPO/PPO	$51.60
Rate for Payer: Scott and White Medicare	$41.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.28
Rate for Payer: Superior Health Plan EPO	$41.28
Rate for Payer: Superior Health Plan Medicare	$41.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$41.28
Rate for Payer: Universal American Medicare	$41.28
Rate for Payer: Wellcare Medicare	$41.28
Rate for Payer: Wellmed Medicare	$41.28

PTHrP (PTH-Related Peptide) SO

Facility

$182.00

Service Code	CPT 82397
Hospital Charge Code	1704261
Hospital Revenue Code	301
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$118.30
Rate for Payer: Aetna Commercial	$14.82
Rate for Payer: Aetna Medicare	$21.18
Rate for Payer: Amerigroup CHIP/Medicaid	$5.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.12
Rate for Payer: Amerigroup Medicare	$14.12
Rate for Payer: BCBS of TX Blue Advantage	$23.30
Rate for Payer: BCBS of TX Blue Essentials	$27.96
Rate for Payer: BCBS of TX Medicare	$14.12
Rate for Payer: BCBS of TX PPO	$31.21
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cigna Medicaid	$14.12
Rate for Payer: Cigna Medicare	$14.12
Rate for Payer: Employer Direct Commercial	$14.12
Rate for Payer: Humana Medicare/TRICARE	$14.12
Rate for Payer: Molina CHIP/Medicaid	$14.12
Rate for Payer: Molina Dual Medicare/Medicaid	$14.12
Rate for Payer: Molina Medicare	$14.12
Rate for Payer: Multiplan Auto	$118.30
Rate for Payer: Multiplan Commercial	$118.30
Rate for Payer: Multiplan Workers Comp	$118.30
Rate for Payer: Parkland Medicaid	$14.12
Rate for Payer: Scott and White EPO/PPO	$17.65
Rate for Payer: Scott and White Medicare	$14.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.12
Rate for Payer: Superior Health Plan EPO	$14.12
Rate for Payer: Superior Health Plan Medicare	$14.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.12
Rate for Payer: Universal American Medicare	$14.12
Rate for Payer: Wellcare Medicare	$14.12
Rate for Payer: Wellmed Medicare	$14.12

PTHrP (PTH-Related Peptide) SO

Facility

$182.00

Service Code	CPT 82397
Hospital Charge Code	1704261
Hospital Revenue Code	301
Rate for Payer: Cash Price	$160.16

PT Iontophoresis Assistant Units

Facility

$111.00

Service Code	CPT 97033 CQ,GP
Hospital Charge Code	4252049
Hospital Revenue Code	420
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$15.10

PT Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	CPT 97033 CQ,GP
Hospital Charge Code	4252049
Hospital Revenue Code	420
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$15.10

PT Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	CPT 97033 CQ,GP
Hospital Charge Code	4252049
Hospital Revenue Code	420
Rate for Payer: Cash Price	$97.68

PT Iontophoresis Units

Facility

$111.00

Service Code	CPT 97033 GP
Hospital Charge Code	4252023
Hospital Revenue Code	420
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$15.10

PT Iontophoresis Units BCE

Facility

$111.00

Service Code	CPT 97033 GP
Hospital Charge Code	4252023
Hospital Revenue Code	420
Rate for Payer: Cash Price	$97.68

PT Iontophoresis Units BCE

Facility

$111.00

Service Code	CPT 97033 GP
Hospital Charge Code	4252023
Hospital Revenue Code	420
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$36.99
Rate for Payer: BCBS of TX Blue Essentials	$44.22
Rate for Payer: BCBS of TX PPO	$49.32
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$15.10

Know your out-of-pocket cost for care.

All Charges