White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PT Re-Evaluation Units, 97164

Facility

$127.00

Service Code	HCPCS 97164
Hospital Charge Code	4252203
Hospital Revenue Code	424
Rate for Payer: Cash Price	$86.36

PT Selective Wound Debride Addtl 20cm Assist Units

Facility

$351.00

Service Code	HCPCS 97598
Hospital Charge Code	5707592
Hospital Revenue Code	420
Rate for Payer: Cash Price	$238.68

PT Selective Wound Debride Addtl 20cm Assist Units

Facility

$351.00

Service Code	HCPCS 97598
Hospital Charge Code	5707592
Hospital Revenue Code	420
Min. Negotiated Rate	$29.85
Max. Negotiated Rate	$252.72
Rate for Payer: Amerigroup CHIP/Medicaid	$31.59
Rate for Payer: BCBS of TX Blue Advantage	$105.30
Rate for Payer: BCBS of TX Blue Essentials	$126.36
Rate for Payer: BCBS of TX PPO	$140.40
Rate for Payer: Cash Price	$238.68
Rate for Payer: Cash Price	$238.68
Rate for Payer: Cash Price	$238.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$252.72
Rate for Payer: Molina CHIP/Medicaid	$252.72
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: Parkland Medicaid	$252.72
Rate for Payer: Scott and White EPO/PPO	$29.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.72
Rate for Payer: Superior Health Plan EPO	$47.74

PT Selective Wound Debridement <20cm Assist Units

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	5707591
Hospital Revenue Code	361
Min. Negotiated Rate	$43.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$238.44
Rate for Payer: BCBS of TX Blue Essentials	$286.13
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$317.92
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$572.26
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$572.26
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$572.26
Rate for Payer: Scott and White EPO/PPO	$43.09
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.26
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

PT Selective Wound Debridement <20cm Assist Units

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	5707591
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

PT Self Care, Home Management Assistant Units

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	4252056
Hospital Revenue Code	420
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.25
Rate for Payer: BCBS of TX Blue Advantage	$37.50
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$90.00
Rate for Payer: Molina CHIP/Medicaid	$90.00
Rate for Payer: Multiplan Auto	$81.25
Rate for Payer: Multiplan Commercial	$81.25
Rate for Payer: Multiplan Workers Comp	$81.25
Rate for Payer: Parkland Medicaid	$90.00
Rate for Payer: Scott and White EPO/PPO	$40.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.00
Rate for Payer: Superior Health Plan EPO	$17.00

PT Self Care, Home Management Assistant Units

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	4252056
Hospital Revenue Code	420
Rate for Payer: Cash Price	$85.00

PT Self Care, Home Management Units

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	4252050
Hospital Revenue Code	420
Rate for Payer: Cash Price	$85.00

PT Self Care, Home Management Units

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	4252050
Hospital Revenue Code	420
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.25
Rate for Payer: BCBS of TX Blue Advantage	$37.50
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$90.00
Rate for Payer: Molina CHIP/Medicaid	$90.00
Rate for Payer: Multiplan Auto	$81.25
Rate for Payer: Multiplan Commercial	$81.25
Rate for Payer: Multiplan Workers Comp	$81.25
Rate for Payer: Parkland Medicaid	$90.00
Rate for Payer: Scott and White EPO/PPO	$40.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.00
Rate for Payer: Superior Health Plan EPO	$17.00

PTS, OTW, 2.5 X 250, 150cm

Facility

$1,029.67

Service Code	HCPCS C1725
Hospital Charge Code	992575
Hospital Revenue Code	272
Rate for Payer: Cash Price	$700.18

PTS, OTW, 2.5 X 250, 150cm

Facility

$1,029.67

Service Code	HCPCS C1725
Hospital Charge Code	992575
Hospital Revenue Code	272
Min. Negotiated Rate	$92.67
Max. Negotiated Rate	$741.36
Rate for Payer: Amerigroup CHIP/Medicaid	$92.67
Rate for Payer: BCBS of TX Blue Advantage	$308.90
Rate for Payer: BCBS of TX Blue Essentials	$370.68
Rate for Payer: BCBS of TX PPO	$411.87
Rate for Payer: Cash Price	$700.18
Rate for Payer: Cigna Medicaid	$741.36
Rate for Payer: Molina CHIP/Medicaid	$741.36
Rate for Payer: Multiplan Auto	$669.29
Rate for Payer: Multiplan Commercial	$669.29
Rate for Payer: Multiplan Workers Comp	$669.29
Rate for Payer: Parkland Medicaid	$741.36
Rate for Payer: Scott and White EPO/PPO	$514.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$741.36
Rate for Payer: Superior Health Plan EPO	$140.04

PTS, OTW, 4.0 X 100 150cm

Facility

$867.87

Service Code	HCPCS C1725
Hospital Charge Code	992577
Hospital Revenue Code	272
Min. Negotiated Rate	$78.11
Max. Negotiated Rate	$624.87
Rate for Payer: Amerigroup CHIP/Medicaid	$78.11
Rate for Payer: BCBS of TX Blue Advantage	$260.36
Rate for Payer: BCBS of TX Blue Essentials	$312.43
Rate for Payer: BCBS of TX PPO	$347.15
Rate for Payer: Cash Price	$590.15
Rate for Payer: Cigna Medicaid	$624.87
Rate for Payer: Molina CHIP/Medicaid	$624.87
Rate for Payer: Multiplan Auto	$564.12
Rate for Payer: Multiplan Commercial	$564.12
Rate for Payer: Multiplan Workers Comp	$564.12
Rate for Payer: Parkland Medicaid	$624.87
Rate for Payer: Scott and White EPO/PPO	$433.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$624.87
Rate for Payer: Superior Health Plan EPO	$118.03

PTS, OTW, 4.0 X 100 150cm

Facility

$867.87

Service Code	HCPCS C1725
Hospital Charge Code	992577
Hospital Revenue Code	272
Rate for Payer: Cash Price	$590.15

PTS, OTW, 4.0 X 80 150cm

Facility

$867.87

Service Code	HCPCS C1725
Hospital Charge Code	992576
Hospital Revenue Code	272
Min. Negotiated Rate	$78.11
Max. Negotiated Rate	$624.87
Rate for Payer: Amerigroup CHIP/Medicaid	$78.11
Rate for Payer: BCBS of TX Blue Advantage	$260.36
Rate for Payer: BCBS of TX Blue Essentials	$312.43
Rate for Payer: BCBS of TX PPO	$347.15
Rate for Payer: Cash Price	$590.15
Rate for Payer: Cigna Medicaid	$624.87
Rate for Payer: Molina CHIP/Medicaid	$624.87
Rate for Payer: Multiplan Auto	$564.12
Rate for Payer: Multiplan Commercial	$564.12
Rate for Payer: Multiplan Workers Comp	$564.12
Rate for Payer: Parkland Medicaid	$624.87
Rate for Payer: Scott and White EPO/PPO	$433.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$624.87
Rate for Payer: Superior Health Plan EPO	$118.03

PTS, OTW, 4.0 X 80 150cm

Facility

$867.87

Service Code	HCPCS C1725
Hospital Charge Code	992576
Hospital Revenue Code	272
Rate for Payer: Cash Price	$590.15

PT Therapeutic Activity Assistant Units

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	4252057
Hospital Revenue Code	420
Rate for Payer: Cash Price	$127.84

PT Therapeutic Activity Assistant Units

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	4252057
Hospital Revenue Code	420
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.92
Rate for Payer: BCBS of TX Blue Advantage	$56.40
Rate for Payer: BCBS of TX Blue Essentials	$67.68
Rate for Payer: BCBS of TX PPO	$75.20
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$135.36
Rate for Payer: Molina CHIP/Medicaid	$135.36
Rate for Payer: Multiplan Auto	$122.20
Rate for Payer: Multiplan Commercial	$122.20
Rate for Payer: Multiplan Workers Comp	$122.20
Rate for Payer: Parkland Medicaid	$135.36
Rate for Payer: Scott and White EPO/PPO	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.36
Rate for Payer: Superior Health Plan EPO	$25.57

PT Therapeutic Activity Units

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	4252030
Hospital Revenue Code	420
Rate for Payer: Cash Price	$127.84

PT Therapeutic Activity Units

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	4252030
Hospital Revenue Code	420
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.92
Rate for Payer: BCBS of TX Blue Advantage	$56.40
Rate for Payer: BCBS of TX Blue Essentials	$67.68
Rate for Payer: BCBS of TX PPO	$75.20
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$135.36
Rate for Payer: Molina CHIP/Medicaid	$135.36
Rate for Payer: Multiplan Auto	$122.20
Rate for Payer: Multiplan Commercial	$122.20
Rate for Payer: Multiplan Workers Comp	$122.20
Rate for Payer: Parkland Medicaid	$135.36
Rate for Payer: Scott and White EPO/PPO	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.36
Rate for Payer: Superior Health Plan EPO	$25.57

PT Therapeutic Exercise Assistant Units

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	4252058
Hospital Revenue Code	420
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$45.60
Rate for Payer: BCBS of TX Blue Essentials	$54.72
Rate for Payer: BCBS of TX PPO	$60.80
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$109.44
Rate for Payer: Molina CHIP/Medicaid	$109.44
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$109.44
Rate for Payer: Scott and White EPO/PPO	$36.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.44
Rate for Payer: Superior Health Plan EPO	$20.67

PT Therapeutic Exercise Assistant Units

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	4252058
Hospital Revenue Code	420
Rate for Payer: Cash Price	$103.36

PT Therapeutic Exercise Units

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	4252025
Hospital Revenue Code	420
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$45.60
Rate for Payer: BCBS of TX Blue Essentials	$54.72
Rate for Payer: BCBS of TX PPO	$60.80
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$109.44
Rate for Payer: Molina CHIP/Medicaid	$109.44
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$109.44
Rate for Payer: Scott and White EPO/PPO	$36.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.44
Rate for Payer: Superior Health Plan EPO	$20.67

PT Therapeutic Exercise Units

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	4252025
Hospital Revenue Code	420
Rate for Payer: Cash Price	$103.36

PT Ultrasound Assistant Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4252060
Hospital Revenue Code	420
Rate for Payer: Cash Price	$74.80

PT Ultrasound Assistant Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4252060
Hospital Revenue Code	420
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.90
Rate for Payer: BCBS of TX Blue Advantage	$33.00
Rate for Payer: BCBS of TX Blue Essentials	$39.60
Rate for Payer: BCBS of TX PPO	$44.00
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.20
Rate for Payer: Molina CHIP/Medicaid	$79.20
Rate for Payer: Multiplan Auto	$71.50
Rate for Payer: Multiplan Commercial	$71.50
Rate for Payer: Multiplan Workers Comp	$71.50
Rate for Payer: Parkland Medicaid	$79.20
Rate for Payer: Scott and White EPO/PPO	$17.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

Know your out-of-pocket cost for care.

All Charges