White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WRNR OT THERAPEUTIC PROC GROUP 2/> INDIVIDUALS BCE

Facility

$191.00

Service Code	HCPCS 97150
Hospital Charge Code	9310554
Hospital Revenue Code	430
Rate for Payer: Cash Price	$129.88

WRNR OT Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	9038973
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

WRNR OT Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	9038973
Hospital Revenue Code	430
Rate for Payer: Cash Price	$74.80

WRNR OT Unattended E-Stim BCE

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	8993230
Hospital Revenue Code	430
Rate for Payer: Cash Price	$108.80

WRNR OT Unattended E-Stim BCE

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	8993230
Hospital Revenue Code	430
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Molina CHIP/Medicaid	$115.20
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$21.76

WRNR PTA BFB TRAING W/EMG &/MANO 1ST 15 MIN CNTCT BCE

Facility

$405.46

Service Code	HCPCS 90912 GP
Hospital Charge Code	8988795
Hospital Revenue Code	420
Min. Negotiated Rate	$36.49
Max. Negotiated Rate	$291.93
Rate for Payer: Amerigroup CHIP/Medicaid	$36.49
Rate for Payer: BCBS of TX Blue Advantage	$121.64
Rate for Payer: BCBS of TX Blue Essentials	$145.97
Rate for Payer: BCBS of TX PPO	$162.18
Rate for Payer: Cash Price	$275.71
Rate for Payer: Cash Price	$275.71
Rate for Payer: Cash Price	$275.71
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$291.93
Rate for Payer: Molina CHIP/Medicaid	$291.93
Rate for Payer: Multiplan Auto	$263.55
Rate for Payer: Multiplan Commercial	$263.55
Rate for Payer: Multiplan Workers Comp	$263.55
Rate for Payer: Parkland Medicaid	$291.93
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$291.93
Rate for Payer: Superior Health Plan EPO	$55.14

WRNR PTA BFB TRAING W/EMG &/MANO 1ST 15 MIN CNTCT BCE

Facility

$405.46

Service Code	HCPCS 90912 GP
Hospital Charge Code	8988795
Hospital Revenue Code	420
Rate for Payer: Cash Price	$275.71

WRNR PTA BFB TRAING W/EMG&/MANO EA ADDL 15 MIN CNTCT BCE

Facility

$185.00

Service Code	HCPCS 90913 GP
Hospital Charge Code	8992544
Hospital Revenue Code	420
Min. Negotiated Rate	$16.65
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.65
Rate for Payer: BCBS of TX Blue Advantage	$55.50
Rate for Payer: BCBS of TX Blue Essentials	$66.60
Rate for Payer: BCBS of TX PPO	$74.00
Rate for Payer: Cash Price	$125.80
Rate for Payer: Cash Price	$125.80
Rate for Payer: Cash Price	$125.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$133.20
Rate for Payer: Molina CHIP/Medicaid	$133.20
Rate for Payer: Multiplan Auto	$120.25
Rate for Payer: Multiplan Commercial	$120.25
Rate for Payer: Multiplan Workers Comp	$120.25
Rate for Payer: Parkland Medicaid	$133.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.20
Rate for Payer: Superior Health Plan EPO	$25.16

WRNR PTA BFB TRAING W/EMG&/MANO EA ADDL 15 MIN CNTCT BCE

Facility

$185.00

Service Code	HCPCS 90913 GP
Hospital Charge Code	8992544
Hospital Revenue Code	420
Rate for Payer: Cash Price	$125.80

WRNR PTA BIOFEEDBACK TRAINING ANY MODALITY BCE

Facility

$448.00

Service Code	HCPCS 90901 GP
Hospital Charge Code	8990547
Hospital Revenue Code	420
Rate for Payer: Cash Price	$304.64

WRNR PTA BIOFEEDBACK TRAINING ANY MODALITY BCE

Facility

$448.00

Service Code	HCPCS 90901 GP
Hospital Charge Code	8990547
Hospital Revenue Code	420
Min. Negotiated Rate	$40.32
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$322.56
Rate for Payer: Superior Health Plan EPO	$60.93

WRNR PTA E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	8988797
Hospital Revenue Code	420
Rate for Payer: Cash Price	$94.52

WRNR PTA E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	8988797
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

WRNR PTA Evaluation Low Complexity BCE

Facility

$127.00

Service Code	HCPCS 97161
Hospital Charge Code	8988788
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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.44
Rate for Payer: Superior Health Plan EPO	$17.27

WRNR PTA Evaluation Low Complexity BCE

Facility

$127.00

Service Code	HCPCS 97161
Hospital Charge Code	8988788
Hospital Revenue Code	424
Rate for Payer: Cash Price	$86.36

WRNR PTA Evaluation Moderate Complexity BCE

Facility

$191.00

Service Code	HCPCS 97162
Hospital Charge Code	9308541
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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

WRNR PTA Evaluation Moderate Complexity BCE

Facility

$191.00

Service Code	HCPCS 97162
Hospital Charge Code	9308541
Hospital Revenue Code	424
Rate for Payer: Cash Price	$129.88

WRNR PTA Gait Training Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	8988790
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$20.81

WRNR PTA Gait Training Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	8988790
Hospital Revenue Code	420
Rate for Payer: Cash Price	$104.04

WRNR PTA Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140 GP
Hospital Charge Code	8988791
Hospital Revenue Code	420
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$133.93
Rate for Payer: Superior Health Plan EPO	$25.30

WRNR PTA Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140 GP
Hospital Charge Code	8988791
Hospital Revenue Code	420
Rate for Payer: Cash Price	$126.49

WRNR PTA MASSAGE UNITS BCE

Facility

$143.74

Service Code	HCPCS 97124 GP
Hospital Charge Code	9050973
Hospital Revenue Code	420
Rate for Payer: Cash Price	$97.74

WRNR PTA MASSAGE UNITS BCE

Facility

$143.74

Service Code	HCPCS 97124 GP
Hospital Charge Code	9050973
Hospital Revenue Code	420
Min. Negotiated Rate	$12.94
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.94
Rate for Payer: BCBS of TX Blue Advantage	$43.12
Rate for Payer: BCBS of TX Blue Essentials	$51.75
Rate for Payer: BCBS of TX PPO	$57.50
Rate for Payer: Cash Price	$97.74
Rate for Payer: Cash Price	$97.74
Rate for Payer: Cash Price	$97.74
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$103.49
Rate for Payer: Molina CHIP/Medicaid	$103.49
Rate for Payer: Multiplan Auto	$93.43
Rate for Payer: Multiplan Commercial	$93.43
Rate for Payer: Multiplan Workers Comp	$93.43
Rate for Payer: Parkland Medicaid	$103.49
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$103.49
Rate for Payer: Superior Health Plan EPO	$19.55

WRNR PTA Neuromuscular Reeducation BCE

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	8988789
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

WRNR PTA Neuromuscular Reeducation BCE

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	8988789
Hospital Revenue Code	420
Rate for Payer: Cash Price	$87.72

Know your out-of-pocket cost for care.

All Charges