White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PT Iontophoresis Units

Facility

$111.00

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

PT Iontophoresis Units

Facility

$111.00

Service Code	HCPCS 97033 GP
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

PT Manual Therapy Assistant Units

Facility

$136.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	4252051
Hospital Revenue Code	420
Rate for Payer: Cash Price	$92.48

PT Manual Therapy Assistant Units

Facility

$136.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	4252051
Hospital Revenue Code	420
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
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: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

PT Manual Therapy Units

Facility

$136.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	4252028
Hospital Revenue Code	420
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
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: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

PT Manual Therapy Units

Facility

$136.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	4252028
Hospital Revenue Code	420
Rate for Payer: Cash Price	$92.48

PT Mechanical Traction Assistant Units

Facility

$182.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	4200034
Hospital Revenue Code	420
Rate for Payer: Cash Price	$123.76

PT Mechanical Traction Assistant Units

Facility

$182.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	4200034
Hospital Revenue Code	420
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
Rate for Payer: BCBS of TX Blue Advantage	$54.60
Rate for Payer: BCBS of TX Blue Essentials	$65.52
Rate for Payer: BCBS of TX PPO	$72.80
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$131.04
Rate for Payer: Molina CHIP/Medicaid	$131.04
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	$131.04
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.04
Rate for Payer: Superior Health Plan EPO	$24.75

PT Mechanical Traction Units

Facility

$182.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	5715600
Hospital Revenue Code	420
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
Rate for Payer: BCBS of TX Blue Advantage	$54.60
Rate for Payer: BCBS of TX Blue Essentials	$65.52
Rate for Payer: BCBS of TX PPO	$72.80
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$131.04
Rate for Payer: Molina CHIP/Medicaid	$131.04
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	$131.04
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.04
Rate for Payer: Superior Health Plan EPO	$24.75

PT Mechanical Traction Units

Facility

$182.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	5715600
Hospital Revenue Code	420
Rate for Payer: Cash Price	$123.76

PT Neg-Pressure Wound Therapy >50cm Assist Units

Facility

$400.00

Service Code	HCPCS 97606 GP
Hospital Charge Code	5707613
Hospital Revenue Code	420
Rate for Payer: Cash Price	$272.00

PT Neg-Pressure Wound Therapy >50cm Assist Units

Facility

$400.00

Service Code	HCPCS 97606 GP
Hospital Charge Code	5707613
Hospital Revenue Code	420
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$288.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: BCBS of TX Blue Advantage	$120.00
Rate for Payer: BCBS of TX Blue Essentials	$144.00
Rate for Payer: BCBS of TX PPO	$160.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$288.00
Rate for Payer: Molina CHIP/Medicaid	$288.00
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: Parkland Medicaid	$288.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$288.00
Rate for Payer: Superior Health Plan EPO	$54.40

PT Neuromuscular Reeducation Assistant Units

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	4252055
Hospital Revenue Code	420
Rate for Payer: Cash Price	$87.72

PT Neuromuscular Reeducation Assistant Units

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	4252055
Hospital Revenue Code	420
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$38.70
Rate for Payer: BCBS of TX Blue Essentials	$46.44
Rate for Payer: BCBS of TX PPO	$51.60
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$92.88
Rate for Payer: Molina CHIP/Medicaid	$92.88
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: Parkland Medicaid	$92.88
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.88
Rate for Payer: Superior Health Plan EPO	$17.54

PT Neuromuscular Reeducation Units

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	4252026
Hospital Revenue Code	420
Rate for Payer: Cash Price	$87.72

PT Neuromuscular Reeducation Units

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	4252026
Hospital Revenue Code	420
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$38.70
Rate for Payer: BCBS of TX Blue Essentials	$46.44
Rate for Payer: BCBS of TX PPO	$51.60
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$92.88
Rate for Payer: Molina CHIP/Medicaid	$92.88
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: Parkland Medicaid	$92.88
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.88
Rate for Payer: Superior Health Plan EPO	$17.54

PT Orthotic Management, Train Assistant Units

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	5700076
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Molina CHIP/Medicaid	$126.00
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: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$23.80

PT Orthotic Management, Train Assistant Units

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	5700076
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

PT Orthotic Management, Train Units

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	5707760
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

PT Orthotic Management, Train Units

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	5707760
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Molina CHIP/Medicaid	$126.00
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: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$23.80

PT Orthotic Prosthetic Check Out Units

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	4272109
Hospital Revenue Code	420
Rate for Payer: Cash Price	$137.36

PT Orthotic Prosthetic Check Out Units

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	4272109
Hospital Revenue Code	420
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$60.60
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX PPO	$80.80
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$145.44
Rate for Payer: Molina CHIP/Medicaid	$145.44
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: Parkland Medicaid	$145.44
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.44
Rate for Payer: Superior Health Plan EPO	$27.47

PT Orthotic/Prosthetic Manage,Train Assistant Units

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	4200055
Hospital Revenue Code	420
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$60.60
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX PPO	$80.80
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$145.44
Rate for Payer: Molina CHIP/Medicaid	$145.44
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: Parkland Medicaid	$145.44
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.44
Rate for Payer: Superior Health Plan EPO	$27.47

PT Orthotic/Prosthetic Manage,Train Assistant Units

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	4200055
Hospital Revenue Code	420
Rate for Payer: Cash Price	$137.36

PT Physical Performance Assistant Test

Facility

$275.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	5718518
Hospital Revenue Code	420
Rate for Payer: Cash Price	$187.00

Know your out-of-pocket cost for care.

All Charges