White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$128.12

WRNR OTA Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	8988800
Hospital Revenue Code	430
Rate for Payer: Cash Price	$103.36

WRNR OTA Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	8988800
Hospital Revenue Code	430
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

WRNR OTA THERAPEUTIC PROC GROUP 2/> INDIVIDUALS BCE

Facility

$191.00

Service Code	HCPCS 97150
Hospital Charge Code	8988802
Hospital Revenue Code	430
Rate for Payer: Cash Price	$129.88

WRNR OTA THERAPEUTIC PROC GROUP 2/> INDIVIDUALS BCE

Facility

$191.00

Service Code	HCPCS 97150
Hospital Charge Code	8988802
Hospital Revenue Code	430
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

WRNR OTA Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	9036977
Hospital Revenue Code	430
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

WRNR OTA Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	9036977
Hospital Revenue Code	430
Rate for Payer: Cash Price	$74.80

WRNR OT Cog Func Ther Inter Adtl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97130
Hospital Charge Code	9310558
Hospital Revenue Code	430
Rate for Payer: Cash Price	$154.68

WRNR OT Cog Func Ther Inter Adtl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97130
Hospital Charge Code	9310558
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	$25.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.78
Rate for Payer: Superior Health Plan EPO	$30.94

WRNR OT Cog Func Ther Inter Intl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97129
Hospital Charge Code	9310557
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 OT Cog Func Ther Inter Intl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97129
Hospital Charge Code	9310557
Hospital Revenue Code	430
Rate for Payer: Cash Price	$154.68

WRNR OT E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	9310545
Hospital Revenue Code	430
Rate for Payer: Cash Price	$94.52

WRNR OT E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	9310545
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 OT E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	9310563
Hospital Revenue Code	430
Rate for Payer: Cash Price	$94.52

WRNR OT E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	9310563
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 OT EVAL HIGH COMPLEXITY BCE

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	9310549
Hospital Revenue Code	434
Rate for Payer: Cash Price	$261.12

WRNR OT EVAL HIGH COMPLEXITY BCE

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	9310549
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 OT EVAL LOW COMPLEXITY BCE

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	9310547
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 OT EVAL LOW COMPLEXITY BCE

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	9310547
Hospital Revenue Code	434
Rate for Payer: Cash Price	$129.88

WRNR OT EVAL MOD COMPLEXITY BCE

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	9310548
Hospital Revenue Code	434
Rate for Payer: Cash Price	$195.84

WRNR OT EVAL MOD COMPLEXITY BCE

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	9310548
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 OT Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140
Hospital Charge Code	9310553
Hospital Revenue Code	430
Rate for Payer: Cash Price	$126.49

WRNR OT Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140
Hospital Charge Code	8993017
Hospital Revenue Code	430
Rate for Payer: Cash Price	$126.49

WRNR OT Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140
Hospital Charge Code	9310553
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 OT Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140
Hospital Charge Code	8993017
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

Know your out-of-pocket cost for care.

All Charges