White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PT Neuromuscular Reeducation Units

Facility

$129.00

Service Code	CPT 97112 GP
Hospital Charge Code	4252026
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 Units BCE

Facility

$129.00

Service Code	CPT 97112 GP
Hospital Charge Code	4252026
Hospital Revenue Code	420
Rate for Payer: Cash Price	$113.52

PT Neuromuscular Reeducation Units BCE

Facility

$129.00

Service Code	CPT 97112 GP
Hospital Charge Code	4252026
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 Orthotic Management, Train Assistant Units

Facility

$175.00

Service Code	CPT 97760 CQ,GP
Hospital Charge Code	5700076
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$84.65
Rate for Payer: BCBS of TX Blue Essentials	$101.19
Rate for Payer: BCBS of TX PPO	$112.87
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$23.80

PT Orthotic Management, Train Assistant Units BCE

Facility

$175.00

Service Code	CPT 97760 CQ,GP
Hospital Charge Code	5700076
Hospital Revenue Code	420
Rate for Payer: Cash Price	$154.00

PT Orthotic Management, Train Assistant Units BCE

Facility

$175.00

Service Code	CPT 97760 CQ,GP
Hospital Charge Code	5700076
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$84.65
Rate for Payer: BCBS of TX Blue Essentials	$101.19
Rate for Payer: BCBS of TX PPO	$112.87
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$23.80

PT Orthotic Management, Train Units

Facility

$175.00

Service Code	CPT 97760 GP
Hospital Charge Code	5707760
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$84.65
Rate for Payer: BCBS of TX Blue Essentials	$101.19
Rate for Payer: BCBS of TX PPO	$112.87
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$23.80

PT Orthotic Management, Train Units BCE

Facility

$175.00

Service Code	CPT 97760 GP
Hospital Charge Code	5707760
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$84.65
Rate for Payer: BCBS of TX Blue Essentials	$101.19
Rate for Payer: BCBS of TX PPO	$112.87
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$23.80

PT Orthotic Management, Train Units BCE

Facility

$175.00

Service Code	CPT 97760 GP
Hospital Charge Code	5707760
Hospital Revenue Code	420
Rate for Payer: Cash Price	$154.00

PT Orthotic Prosthetic Check Out Units

Facility

$202.00

Service Code	CPT 97763 GP
Hospital Charge Code	4272109
Hospital Revenue Code	420
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$131.30
Rate for Payer: Multiplan Commercial	$131.30
Rate for Payer: Multiplan Workers Comp	$131.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$27.47

PT Orthotic Prosthetic Check Out Units BCE

Facility

$202.00

Service Code	CPT 97763 GP
Hospital Charge Code	4272109
Hospital Revenue Code	420
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$131.30
Rate for Payer: Multiplan Commercial	$131.30
Rate for Payer: Multiplan Workers Comp	$131.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$27.47

PT Orthotic Prosthetic Check Out Units BCE

Facility

$202.00

Service Code	CPT 97763 GP
Hospital Charge Code	4272109
Hospital Revenue Code	420
Rate for Payer: Cash Price	$177.76

PT Orthotic/Prosthetic Manage,Train Assistant Units

Facility

$202.00

Service Code	CPT 97763 CQ,GP
Hospital Charge Code	4200055
Hospital Revenue Code	420
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$131.30
Rate for Payer: Multiplan Commercial	$131.30
Rate for Payer: Multiplan Workers Comp	$131.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$27.47

PT Orthotic/Prosthetic Manage,Train Assistant Units BCE

Facility

$202.00

Service Code	CPT 97763 CQ,GP
Hospital Charge Code	4200055
Hospital Revenue Code	420
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$131.30
Rate for Payer: Multiplan Commercial	$131.30
Rate for Payer: Multiplan Workers Comp	$131.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$27.47

PT Orthotic/Prosthetic Manage,Train Assistant Units BCE

Facility

$202.00

Service Code	CPT 97763 CQ,GP
Hospital Charge Code	4200055
Hospital Revenue Code	420
Rate for Payer: Cash Price	$177.76

PT Physical Performance Assistant Test

Facility

$275.00

Service Code	CPT 97750 CQ,GP
Hospital Charge Code	5718518
Hospital Revenue Code	420
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$151.25
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
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	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$37.40

PT Physical Performance Assistant Test BCE

Facility

$275.00

Service Code	CPT 97750 CQ,GP
Hospital Charge Code	5718518
Hospital Revenue Code	420
Rate for Payer: Cash Price	$242.00

PT Physical Performance Assistant Test BCE

Facility

$275.00

Service Code	CPT 97750 CQ,GP
Hospital Charge Code	5718518
Hospital Revenue Code	420
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$151.25
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
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	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$37.40

PT Physical Performance Test

Facility

$275.00

Service Code	CPT 97750 GP
Hospital Charge Code	5718518
Hospital Revenue Code	420
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$151.25
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
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	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$37.40

PT Physical Performance Test BCE

Facility

$275.00

Service Code	CPT 97750 GP
Hospital Charge Code	5718518
Hospital Revenue Code	420
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$151.25
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
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	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cash Price	$242.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$37.40

PT Re-Evaluation Units, 97164

Facility

$127.00

Service Code	CPT 97164 GP
Hospital Charge Code	4252203
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	$102.21
Rate for Payer: BCBS of TX Blue Essentials	$122.18
Rate for Payer: BCBS of TX PPO	$136.28
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 Re-Evaluation Units, 97164 BCE

Facility

$127.00

Service Code	CPT 97164 GP
Hospital Charge Code	4252203
Hospital Revenue Code	424
Rate for Payer: Cash Price	$111.76

PT Re-Evaluation Units, 97164 BCE

Facility

$127.00

Service Code	CPT 97164 GP
Hospital Charge Code	4252203
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	$102.21
Rate for Payer: BCBS of TX Blue Essentials	$122.18
Rate for Payer: BCBS of TX PPO	$136.28
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 Selective Wound Debride Addtl 20cm Assist Units

Facility

$351.00

Service Code	CPT 97598 CQ,GP
Hospital Charge Code	5707592
Hospital Revenue Code	420
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$228.15
Rate for Payer: Aetna Commercial	$193.05
Rate for Payer: Amerigroup CHIP/Medicaid	$31.59
Rate for Payer: BCBS of TX Blue Advantage	$20.06
Rate for Payer: BCBS of TX Blue Essentials	$23.98
Rate for Payer: BCBS of TX PPO	$26.75
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$228.15
Rate for Payer: Multiplan Commercial	$228.15
Rate for Payer: Multiplan Workers Comp	$228.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$47.74

PT Selective Wound Debride Addtl 20cm Assist Units BCE

Facility

$351.00

Service Code	CPT 97598 CQ,GP
Hospital Charge Code	5707592
Hospital Revenue Code	420
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$228.15
Rate for Payer: Aetna Commercial	$193.05
Rate for Payer: Amerigroup CHIP/Medicaid	$31.59
Rate for Payer: BCBS of TX Blue Advantage	$20.06
Rate for Payer: BCBS of TX Blue Essentials	$23.98
Rate for Payer: BCBS of TX PPO	$26.75
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$228.15
Rate for Payer: Multiplan Commercial	$228.15
Rate for Payer: Multiplan Workers Comp	$228.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$47.74

Know your out-of-pocket cost for care.

All Charges