White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WRNR OTA Cog Func Ther Inter Intl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97129
Hospital Charge Code	8992546
Hospital Revenue Code	430
Min. Negotiated Rate	$20.47
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$20.47
Rate for Payer: BCBS of TX Blue Advantage	$68.24
Rate for Payer: BCBS of TX Blue Essentials	$81.89
Rate for Payer: BCBS of TX PPO	$90.99
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$163.78
Rate for Payer: Molina CHIP/Medicaid	$163.78
Rate for Payer: Multiplan Auto	$147.86
Rate for Payer: Multiplan Commercial	$147.86
Rate for Payer: Multiplan Workers Comp	$147.86
Rate for Payer: Parkland Medicaid	$163.78
Rate for Payer: Scott and White EPO/PPO	$27.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.78
Rate for Payer: Superior Health Plan EPO	$30.94

WRNR OTA Cog Func Ther Inter Intl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97129
Hospital Charge Code	8992546
Hospital Revenue Code	430
Rate for Payer: Cash Price	$154.68

WRNR OTA E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	8988808
Hospital Revenue Code	430
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

WRNR OTA E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	8988808
Hospital Revenue Code	430
Rate for Payer: Cash Price	$94.52

WRNR OTA EVAL HIGH COMPLEXITY BCE

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	8992545
Hospital Revenue Code	434
Min. Negotiated Rate	$52.22
Max. Negotiated Rate	$276.48
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$115.20
Rate for Payer: BCBS of TX Blue Essentials	$138.24
Rate for Payer: BCBS of TX PPO	$153.60
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$276.48
Rate for Payer: Molina CHIP/Medicaid	$276.48
Rate for Payer: Multiplan Auto	$249.60
Rate for Payer: Multiplan Commercial	$249.60
Rate for Payer: Multiplan Workers Comp	$249.60
Rate for Payer: Parkland Medicaid	$276.48
Rate for Payer: Scott and White EPO/PPO	$125.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$276.48
Rate for Payer: Superior Health Plan EPO	$52.22

WRNR OTA EVAL HIGH COMPLEXITY BCE

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	8992545
Hospital Revenue Code	434
Rate for Payer: Cash Price	$261.12

WRNR OTA EVAL LOW COMPLEXITY BCE

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	8990548
Hospital Revenue Code	434
Rate for Payer: Cash Price	$129.88

WRNR OTA EVAL LOW COMPLEXITY BCE

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	8990548
Hospital Revenue Code	434
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	$125.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

WRNR OTA EVAL MOD COMPLEXITY BCE

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	8988799
Hospital Revenue Code	434
Rate for Payer: Cash Price	$195.84

WRNR OTA EVAL MOD COMPLEXITY BCE

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	8988799
Hospital Revenue Code	434
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	$125.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$39.17

WRNR OTA Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140
Hospital Charge Code	8990550
Hospital Revenue Code	430
Min. Negotiated Rate	$16.74
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.74
Rate for Payer: BCBS of TX Blue Advantage	$55.80
Rate for Payer: BCBS of TX Blue Essentials	$66.96
Rate for Payer: BCBS of TX PPO	$74.40
Rate for Payer: Cash Price	$126.49
Rate for Payer: Cash Price	$126.49
Rate for Payer: Cash Price	$126.49
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$133.93
Rate for Payer: Molina CHIP/Medicaid	$133.93
Rate for Payer: Multiplan Auto	$120.91
Rate for Payer: Multiplan Commercial	$120.91
Rate for Payer: Multiplan Workers Comp	$120.91
Rate for Payer: Parkland Medicaid	$133.93
Rate for Payer: Scott and White EPO/PPO	$33.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.93
Rate for Payer: Superior Health Plan EPO	$25.30

WRNR OTA Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140
Hospital Charge Code	8990550
Hospital Revenue Code	430
Rate for Payer: Cash Price	$126.49

WRNR OTA Neuromuscular Reeducation BCE

Facility

$186.67

Service Code	HCPCS 97112
Hospital Charge Code	8988801
Hospital Revenue Code	430
Rate for Payer: Cash Price	$126.94

WRNR OTA Neuromuscular Reeducation BCE

Facility

$186.67

Service Code	HCPCS 97112
Hospital Charge Code	8988801
Hospital Revenue Code	430
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.80
Rate for Payer: BCBS of TX Blue Advantage	$56.00
Rate for Payer: BCBS of TX Blue Essentials	$67.20
Rate for Payer: BCBS of TX PPO	$74.67
Rate for Payer: Cash Price	$126.94
Rate for Payer: Cash Price	$126.94
Rate for Payer: Cash Price	$126.94
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$134.40
Rate for Payer: Molina CHIP/Medicaid	$134.40
Rate for Payer: Multiplan Auto	$121.34
Rate for Payer: Multiplan Commercial	$121.34
Rate for Payer: Multiplan Workers Comp	$121.34
Rate for Payer: Parkland Medicaid	$134.40
Rate for Payer: Scott and White EPO/PPO	$41.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$134.40
Rate for Payer: Superior Health Plan EPO	$25.39

WRNR OTA Orthotic Management and Training BCE

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	8988807
Hospital Revenue Code	430
Rate for Payer: Cash Price	$119.00

WRNR OTA Orthotic Management and Training BCE

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	8988807
Hospital Revenue Code	430
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	$58.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$23.80

WRNR OTA ORTH/PROSTH MGMT SBSQ ENCTR 15 MIN BCE

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	8988806
Hospital Revenue Code	430
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	$64.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.44
Rate for Payer: Superior Health Plan EPO	$27.47

WRNR OTA ORTH/PROSTH MGMT SBSQ ENCTR 15 MIN BCE

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	8988806
Hospital Revenue Code	430
Rate for Payer: Cash Price	$137.36

WRNR OTA RE-EVAL BCE

Facility

$181.00

Service Code	HCPCS 97168
Hospital Charge Code	8990549
Hospital Revenue Code	434
Min. Negotiated Rate	$24.62
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$54.30
Rate for Payer: BCBS of TX Blue Essentials	$65.16
Rate for Payer: BCBS of TX PPO	$72.40
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$130.32
Rate for Payer: Molina CHIP/Medicaid	$130.32
Rate for Payer: Multiplan Auto	$117.65
Rate for Payer: Multiplan Commercial	$117.65
Rate for Payer: Multiplan Workers Comp	$117.65
Rate for Payer: Parkland Medicaid	$130.32
Rate for Payer: Scott and White EPO/PPO	$86.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.32
Rate for Payer: Superior Health Plan EPO	$24.62

WRNR OTA RE-EVAL BCE

Facility

$181.00

Service Code	HCPCS 97168
Hospital Charge Code	8990549
Hospital Revenue Code	434
Rate for Payer: Cash Price	$123.08

WRNR OTA SELF-CARE/HOME MGMT TRAINING EA 15 MIN BCE

Facility

$185.25

Service Code	HCPCS 97535
Hospital Charge Code	8988804
Hospital Revenue Code	430
Rate for Payer: Cash Price	$125.97

WRNR OTA SELF-CARE/HOME MGMT TRAINING EA 15 MIN BCE

Facility

$185.25

Service Code	HCPCS 97535
Hospital Charge Code	8988804
Hospital Revenue Code	430
Min. Negotiated Rate	$16.67
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.67
Rate for Payer: BCBS of TX Blue Advantage	$55.58
Rate for Payer: BCBS of TX Blue Essentials	$66.69
Rate for Payer: BCBS of TX PPO	$74.10
Rate for Payer: Cash Price	$125.97
Rate for Payer: Cash Price	$125.97
Rate for Payer: Cash Price	$125.97
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$133.38
Rate for Payer: Molina CHIP/Medicaid	$133.38
Rate for Payer: Multiplan Auto	$120.41
Rate for Payer: Multiplan Commercial	$120.41
Rate for Payer: Multiplan Workers Comp	$120.41
Rate for Payer: Parkland Medicaid	$133.38
Rate for Payer: Scott and White EPO/PPO	$40.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.38
Rate for Payer: Superior Health Plan EPO	$25.19

WRNR OTA SENSORY INTEGRATIVE TECH EA 15 MIN BCE

Facility

$185.25

Service Code	HCPCS 97533
Hospital Charge Code	8992547
Hospital Revenue Code	430
Rate for Payer: Cash Price	$125.97

WRNR OTA SENSORY INTEGRATIVE TECH EA 15 MIN BCE

Facility

$185.25

Service Code	HCPCS 97533
Hospital Charge Code	8992547
Hospital Revenue Code	430
Min. Negotiated Rate	$16.67
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.67
Rate for Payer: BCBS of TX Blue Advantage	$55.58
Rate for Payer: BCBS of TX Blue Essentials	$66.69
Rate for Payer: BCBS of TX PPO	$74.10
Rate for Payer: Cash Price	$125.97
Rate for Payer: Cash Price	$125.97
Rate for Payer: Cash Price	$125.97
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$133.38
Rate for Payer: Molina CHIP/Medicaid	$133.38
Rate for Payer: Multiplan Auto	$120.41
Rate for Payer: Multiplan Commercial	$120.41
Rate for Payer: Multiplan Workers Comp	$120.41
Rate for Payer: Parkland Medicaid	$133.38
Rate for Payer: Scott and White EPO/PPO	$77.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.38
Rate for Payer: Superior Health Plan EPO	$25.19

WRNR OTA THERAPEUT ACTVITY DIRECT PT CNTCT EA 15 MIN BCE

Facility

$188.41

Service Code	HCPCS 97530
Hospital Charge Code	8988803
Hospital Revenue Code	430
Min. Negotiated Rate	$16.96
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.96
Rate for Payer: BCBS of TX Blue Advantage	$56.52
Rate for Payer: BCBS of TX Blue Essentials	$67.83
Rate for Payer: BCBS of TX PPO	$75.36
Rate for Payer: Cash Price	$128.12
Rate for Payer: Cash Price	$128.12
Rate for Payer: Cash Price	$128.12
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$135.66
Rate for Payer: Molina CHIP/Medicaid	$135.66
Rate for Payer: Multiplan Auto	$122.47
Rate for Payer: Multiplan Commercial	$122.47
Rate for Payer: Multiplan Workers Comp	$122.47
Rate for Payer: Parkland Medicaid	$135.66
Rate for Payer: Scott and White EPO/PPO	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.66
Rate for Payer: Superior Health Plan EPO	$25.62

Know your out-of-pocket cost for care.

All Charges