White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PT Aquatic Assistant Units

Facility

$137.00

Service Code	HCPCS 97113
Hospital Charge Code	5710045
Hospital Revenue Code	420
Rate for Payer: Cash Price	$93.16

PT Aquatic Units

Facility

$137.00

Service Code	HCPCS 97113
Hospital Charge Code	5715304
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$41.10
Rate for Payer: BCBS of TX Blue Essentials	$49.32
Rate for Payer: BCBS of TX PPO	$54.80
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$98.64
Rate for Payer: Molina CHIP/Medicaid	$98.64
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: Parkland Medicaid	$98.64
Rate for Payer: Scott and White EPO/PPO	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.64
Rate for Payer: Superior Health Plan EPO	$18.63

PT Aquatic Units

Facility

$137.00

Service Code	HCPCS 97113
Hospital Charge Code	5715304
Hospital Revenue Code	420
Rate for Payer: Cash Price	$93.16

PT Attended E-Stim Assistant Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4252046
Hospital Revenue Code	420
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.04
Rate for Payer: BCBS of TX PPO	$55.60
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$100.08
Rate for Payer: Molina CHIP/Medicaid	$100.08
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: Parkland Medicaid	$100.08
Rate for Payer: Scott and White EPO/PPO	$17.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

PT Attended E-Stim Assistant Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4252046
Hospital Revenue Code	420
Rate for Payer: Cash Price	$94.52

PT Attended E-Stim Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4252052
Hospital Revenue Code	420
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.04
Rate for Payer: BCBS of TX PPO	$55.60
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$100.08
Rate for Payer: Molina CHIP/Medicaid	$100.08
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: Parkland Medicaid	$100.08
Rate for Payer: Scott and White EPO/PPO	$17.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

PT Attended E-Stim Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4252052
Hospital Revenue Code	420
Rate for Payer: Cash Price	$94.52

PT Biofeedback Assistant Units

Facility

$448.00

Service Code	HCPCS 90901
Hospital Charge Code	5715678
Hospital Revenue Code	420
Rate for Payer: Cash Price	$304.64

PT Biofeedback Assistant Units

Facility

$448.00

Service Code	HCPCS 90901
Hospital Charge Code	5715678
Hospital Revenue Code	420
Min. Negotiated Rate	$23.45
Max. Negotiated Rate	$322.56
Rate for Payer: Amerigroup CHIP/Medicaid	$40.32
Rate for Payer: BCBS of TX Blue Advantage	$134.40
Rate for Payer: BCBS of TX Blue Essentials	$161.28
Rate for Payer: BCBS of TX PPO	$179.20
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$322.56
Rate for Payer: Molina CHIP/Medicaid	$322.56
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: Parkland Medicaid	$322.56
Rate for Payer: Scott and White EPO/PPO	$23.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$322.56
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	$1,676.89
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	$1,583.73
Rate for Payer: Cigna Medicaid	$1,676.89
Rate for Payer: Molina CHIP/Medicaid	$1,676.89
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: Parkland Medicaid	$1,676.89
Rate for Payer: Scott and White EPO/PPO	$1,164.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,676.89
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	$1,583.73

PT Evaluation Units, High Complexity

Facility

$288.00

Service Code	HCPCS 97163
Hospital Charge Code	4252202
Hospital Revenue Code	424
Rate for Payer: Cash Price	$195.84

PT Evaluation Units, High Complexity

Facility

$288.00

Service Code	HCPCS 97163
Hospital Charge Code	4252202
Hospital Revenue Code	424
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$207.36
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$86.40
Rate for Payer: BCBS of TX Blue Essentials	$103.68
Rate for Payer: BCBS of TX PPO	$115.20
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$207.36
Rate for Payer: Molina CHIP/Medicaid	$207.36
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: Parkland Medicaid	$207.36
Rate for Payer: Scott and White EPO/PPO	$124.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$39.17

PT Evaluation Units, Low Complexity

Facility

$127.00

Service Code	HCPCS 97161
Hospital Charge Code	4252200
Hospital Revenue Code	424
Rate for Payer: Cash Price	$86.36

PT Evaluation Units, Low Complexity

Facility

$127.00

Service Code	HCPCS 97161
Hospital Charge Code	4252200
Hospital Revenue Code	424
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$38.10
Rate for Payer: BCBS of TX Blue Essentials	$45.72
Rate for Payer: BCBS of TX PPO	$50.80
Rate for Payer: Cash Price	$86.36
Rate for Payer: Cash Price	$86.36
Rate for Payer: Cash Price	$86.36
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$91.44
Rate for Payer: Molina CHIP/Medicaid	$91.44
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: Parkland Medicaid	$91.44
Rate for Payer: Scott and White EPO/PPO	$124.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.44
Rate for Payer: Superior Health Plan EPO	$17.27

PT Evaluation Units, Moderate Complexity

Facility

$191.00

Service Code	HCPCS 97162
Hospital Charge Code	9238547
Hospital Revenue Code	424
Rate for Payer: Cash Price	$129.88

PT Evaluation Units, Moderate Complexity

Facility

$191.00

Service Code	HCPCS 97162
Hospital Charge Code	9238547
Hospital Revenue Code	424
Min. Negotiated Rate	$25.98
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Molina CHIP/Medicaid	$137.52
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: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$124.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

PT Gait Training Units

Facility

$153.00

Service Code	HCPCS 97116
Hospital Charge Code	4252027
Hospital Revenue Code	420
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$45.90
Rate for Payer: BCBS of TX Blue Essentials	$55.08
Rate for Payer: BCBS of TX PPO	$61.20
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$110.16
Rate for Payer: Molina CHIP/Medicaid	$110.16
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: Parkland Medicaid	$110.16
Rate for Payer: Scott and White EPO/PPO	$36.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$20.81

PT Gait Training Units

Facility

$153.00

Service Code	HCPCS 97116
Hospital Charge Code	4252027
Hospital Revenue Code	420
Rate for Payer: Cash Price	$104.04

PT Group Therapy Units

Facility

$191.00

Service Code	HCPCS 97150
Hospital Charge Code	4252029
Hospital Revenue Code	420
Rate for Payer: Cash Price	$129.88

PT Group Therapy Units

Facility

$191.00

Service Code	HCPCS 97150
Hospital Charge Code	4252029
Hospital Revenue Code	420
Min. Negotiated Rate	$17.19
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$17.19
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Molina CHIP/Medicaid	$137.52
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: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$22.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

PT Iontophoresis Assistant Units

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	4252049
Hospital Revenue Code	420
Rate for Payer: Cash Price	$75.48

PT Iontophoresis Assistant Units

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	4252049
Hospital Revenue Code	420
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Molina CHIP/Medicaid	$79.92
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: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$23.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

PT Iontophoresis Units

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	4252023
Hospital Revenue Code	420
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Molina CHIP/Medicaid	$79.92
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: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$23.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

PT Iontophoresis Units

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	4252023
Hospital Revenue Code	420
Rate for Payer: Cash Price	$75.48

Know your out-of-pocket cost for care.

All Charges