White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PT Manual Therapy Assistant Units

Facility

$136.00

Service Code	CPT 97140 CQ,GP
Hospital Charge Code	4252051
Hospital Revenue Code	420
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.50

PT Manual Therapy Assistant Units BCE

Facility

$136.00

Service Code	CPT 97140 CQ,GP
Hospital Charge Code	4252051
Hospital Revenue Code	420
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.50

PT Manual Therapy Assistant Units BCE

Facility

$136.00

Service Code	CPT 97140 CQ,GP
Hospital Charge Code	4252051
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.68

PT Manual Therapy Units

Facility

$136.00

Service Code	CPT 97140 GP
Hospital Charge Code	4252028
Hospital Revenue Code	420
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.50

PT Manual Therapy Units BCE

Facility

$136.00

Service Code	CPT 97140 GP
Hospital Charge Code	4252028
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.68

PT Manual Therapy Units BCE

Facility

$136.00

Service Code	CPT 97140 GP
Hospital Charge Code	4252028
Hospital Revenue Code	420
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.50

PT Mechanical Traction Assistant Units

Facility

$182.00

Service Code	CPT 97012 CQ,GP
Hospital Charge Code	4200034
Hospital Revenue Code	420
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
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	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$24.75

PT Mechanical Traction Assistant Units BCE

Facility

$182.00

Service Code	CPT 97012 CQ,GP
Hospital Charge Code	4200034
Hospital Revenue Code	420
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
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	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$24.75

PT Mechanical Traction Assistant Units BCE

Facility

$182.00

Service Code	CPT 97012 CQ,GP
Hospital Charge Code	4200034
Hospital Revenue Code	420
Rate for Payer: Cash Price	$160.16

PT Mechanical Traction Units

Facility

$182.00

Service Code	CPT 97012 GP
Hospital Charge Code	5715600
Hospital Revenue Code	420
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
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	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$24.75

PT Mechanical Traction Units BCE

Facility

$182.00

Service Code	CPT 97012 GP
Hospital Charge Code	5715600
Hospital Revenue Code	420
Rate for Payer: Cash Price	$160.16

PT Mechanical Traction Units BCE

Facility

$182.00

Service Code	CPT 97012 GP
Hospital Charge Code	5715600
Hospital Revenue Code	420
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
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	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cash Price	$160.16
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$24.75

PT Negative-Pressure Wound Therapy <50cm Units

Facility

$304.00

Service Code	CPT 97605 GP
Hospital Charge Code	5707614
Hospital Revenue Code	420
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$405.37
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$27.36
Rate for Payer: BCBS of TX Blue Advantage	$304.03
Rate for Payer: BCBS of TX Blue Essentials	$363.44
Rate for Payer: BCBS of TX PPO	$405.37
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$41.34

PT Negative-Pressure Wound Therapy >50cm Units

Facility

$400.00

Service Code	CPT 97606 GP
Hospital Charge Code	5707613
Hospital Revenue Code	420
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$741.26
Rate for Payer: Aetna Commercial	$220.00
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: BCBS of TX Blue Advantage	$555.95
Rate for Payer: BCBS of TX Blue Essentials	$664.58
Rate for Payer: BCBS of TX PPO	$741.26
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$54.40

PT Negative-Pressure Wound Therapy <50cm Units BCE

Facility

$304.00

Service Code	CPT 97605 GP
Hospital Charge Code	5707614
Hospital Revenue Code	420
Rate for Payer: Cash Price	$267.52

PT Negative-Pressure Wound Therapy <50cm Units BCE

Facility

$304.00

Service Code	CPT 97605 GP
Hospital Charge Code	5707614
Hospital Revenue Code	420
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$405.37
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$27.36
Rate for Payer: BCBS of TX Blue Advantage	$304.03
Rate for Payer: BCBS of TX Blue Essentials	$363.44
Rate for Payer: BCBS of TX PPO	$405.37
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$41.34

PT Negative-Pressure Wound Therapy >50cm Units BCE

Facility

$400.00

Service Code	CPT 97606 GP
Hospital Charge Code	5707613
Hospital Revenue Code	420
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$741.26
Rate for Payer: Aetna Commercial	$220.00
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: BCBS of TX Blue Advantage	$555.95
Rate for Payer: BCBS of TX Blue Essentials	$664.58
Rate for Payer: BCBS of TX PPO	$741.26
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$54.40

PT Negative-Pressure Wound Therapy >50cm Units BCE

Facility

$400.00

Service Code	CPT 97606 GP
Hospital Charge Code	5707613
Hospital Revenue Code	420
Rate for Payer: Cash Price	$352.00

PT Neg-Pressure Wound Therapy <50cm Assist Units

Facility

$304.00

Service Code	CPT 97605 CQ,GP
Hospital Charge Code	5707614
Hospital Revenue Code	420
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$405.37
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$27.36
Rate for Payer: BCBS of TX Blue Advantage	$304.03
Rate for Payer: BCBS of TX Blue Essentials	$363.44
Rate for Payer: BCBS of TX PPO	$405.37
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$41.34

PT Neg-Pressure Wound Therapy >50cm Assist Units

Facility

$400.00

Service Code	CPT 97606 CQ,GP
Hospital Charge Code	5707613
Hospital Revenue Code	420
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$741.26
Rate for Payer: Aetna Commercial	$220.00
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: BCBS of TX Blue Advantage	$555.95
Rate for Payer: BCBS of TX Blue Essentials	$664.58
Rate for Payer: BCBS of TX PPO	$741.26
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$54.40

PT Neg-Pressure Wound Therapy <50cm Assist Units BCE

Facility

$304.00

Service Code	CPT 97605 CQ,GP
Hospital Charge Code	5707614
Hospital Revenue Code	420
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$405.37
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$274.63
Rate for Payer: Amerigroup CHIP/Medicaid	$27.36
Rate for Payer: BCBS of TX Blue Advantage	$304.03
Rate for Payer: BCBS of TX Blue Essentials	$363.44
Rate for Payer: BCBS of TX PPO	$405.37
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cash Price	$267.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$197.60
Rate for Payer: Multiplan Commercial	$197.60
Rate for Payer: Multiplan Workers Comp	$197.60
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$41.34

PT Neg-Pressure Wound Therapy >50cm Assist Units BCE

Facility

$400.00

Service Code	CPT 97606 CQ,GP
Hospital Charge Code	5707613
Hospital Revenue Code	420
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$741.26
Rate for Payer: Aetna Commercial	$220.00
Rate for Payer: Aetna Medicare	$547.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: BCBS of TX Blue Advantage	$555.95
Rate for Payer: BCBS of TX Blue Essentials	$664.58
Rate for Payer: BCBS of TX PPO	$741.26
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$54.40

PT Neuromuscular Reeducation Assistant Units

Facility

$129.00

Service Code	CPT 97112 CQ,GP
Hospital Charge Code	4252055
Hospital Revenue Code	420
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$62.08
Rate for Payer: BCBS of TX Blue Essentials	$74.21
Rate for Payer: BCBS of TX PPO	$82.78
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.54

PT Neuromuscular Reeducation Assistant Units BCE

Facility

$129.00

Service Code	CPT 97112 CQ,GP
Hospital Charge Code	4252055
Hospital Revenue Code	420
Rate for Payer: Cash Price	$113.52

PT Neuromuscular Reeducation Assistant Units BCE

Facility

$129.00

Service Code	CPT 97112 CQ,GP
Hospital Charge Code	4252055
Hospital Revenue Code	420
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$62.08
Rate for Payer: BCBS of TX Blue Essentials	$74.21
Rate for Payer: BCBS of TX PPO	$82.78
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.54

Know your out-of-pocket cost for care.

All Charges