White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WRNR PTA Orthotic Management and Training BCE

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	8988794
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

WRNR PTA Orthotic Management and Training BCE

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	8988794
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

WRNR PTA ORTH/PROSTH MGMT SBSQ ENCTR 15 MIN BCE

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	8990546
Hospital Revenue Code	420
Rate for Payer: Cash Price	$137.36

WRNR PTA ORTH/PROSTH MGMT SBSQ ENCTR 15 MIN BCE

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	8990546
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

WRNR PTA Physical Performance Test BCE

Facility

$275.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	8988793
Hospital Revenue Code	420
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
Rate for Payer: BCBS of TX Blue Advantage	$82.50
Rate for Payer: BCBS of TX Blue Essentials	$99.00
Rate for Payer: BCBS of TX PPO	$110.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$198.00
Rate for Payer: Molina CHIP/Medicaid	$198.00
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Parkland Medicaid	$198.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.00
Rate for Payer: Superior Health Plan EPO	$37.40

WRNR PTA Physical Performance Test BCE

Facility

$275.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	8988793
Hospital Revenue Code	420
Rate for Payer: Cash Price	$187.00

WRNR PTA PROSTHETICS TRAINING INIT EA 15 MIN BCE

Facility

$163.50

Service Code	HCPCS 97761 GP
Hospital Charge Code	9310559
Hospital Revenue Code	420
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.71
Rate for Payer: BCBS of TX Blue Advantage	$49.05
Rate for Payer: BCBS of TX Blue Essentials	$58.86
Rate for Payer: BCBS of TX PPO	$65.40
Rate for Payer: Cash Price	$111.18
Rate for Payer: Cash Price	$111.18
Rate for Payer: Cash Price	$111.18
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$117.72
Rate for Payer: Molina CHIP/Medicaid	$117.72
Rate for Payer: Multiplan Auto	$106.28
Rate for Payer: Multiplan Commercial	$106.28
Rate for Payer: Multiplan Workers Comp	$106.28
Rate for Payer: Parkland Medicaid	$117.72
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.72
Rate for Payer: Superior Health Plan EPO	$22.24

WRNR PTA PROSTHETICS TRAINING INIT EA 15 MIN BCE

Facility

$163.50

Service Code	HCPCS 97761 GP
Hospital Charge Code	9310559
Hospital Revenue Code	420
Rate for Payer: Cash Price	$111.18

WRNR PTA Re-Evaluation BCE

Facility

$127.00

Service Code	HCPCS 97164
Hospital Charge Code	8990544
Hospital Revenue Code	424
Rate for Payer: Cash Price	$86.36

WRNR PTA Re-Evaluation BCE

Facility

$127.00

Service Code	HCPCS 97164
Hospital Charge Code	8990544
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 THERAPEUT ACTVITY DIRECT PT CNTCT EA 15 MIN BCE

Facility

$188.41

Service Code	HCPCS 97530 GP
Hospital Charge Code	8990545
Hospital Revenue Code	420
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.66
Rate for Payer: Superior Health Plan EPO	$25.62

WRNR PTA THERAPEUT ACTVITY DIRECT PT CNTCT EA 15 MIN BCE

Facility

$188.41

Service Code	HCPCS 97530 GP
Hospital Charge Code	8990545
Hospital Revenue Code	420
Rate for Payer: Cash Price	$128.12

WRNR PTA Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	8992542
Hospital Revenue Code	420
Rate for Payer: Cash Price	$103.36

WRNR PTA Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	8992542
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.44
Rate for Payer: Superior Health Plan EPO	$20.67

WRNR PTA THERAPEUTIC PROC GROUP 2/> INDIVIDUALS BCE

Facility

$191.00

Service Code	HCPCS 97150 GP
Hospital Charge Code	8992543
Hospital Revenue Code	420
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

WRNR PTA THERAPEUTIC PROC GROUP 2/> INDIVIDUALS BCE

Facility

$191.00

Service Code	HCPCS 97150 GP
Hospital Charge Code	8992543
Hospital Revenue Code	420
Rate for Payer: Cash Price	$129.88

WRNR PTA Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	8988796
Hospital Revenue Code	420
Rate for Payer: Cash Price	$74.80

WRNR PTA Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	8988796
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

WRNR PTA Unattended E-Stim Asst BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	8993232
Hospital Revenue Code	420
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 Unattended E-Stim Asst BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	8993232
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

WRNR PTA Unattended E-Stim Units BCE

Facility

$152.57

Service Code	HCPCS 97014 GP
Hospital Charge Code	8994974
Hospital Revenue Code	420
Rate for Payer: Cash Price	$103.75

WRNR PTA Unattended E-Stim Units BCE

Facility

$152.57

Service Code	HCPCS 97014 GP
Hospital Charge Code	8994974
Hospital Revenue Code	420
Min. Negotiated Rate	$13.73
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.73
Rate for Payer: BCBS of TX Blue Advantage	$45.77
Rate for Payer: BCBS of TX Blue Essentials	$54.93
Rate for Payer: BCBS of TX PPO	$61.03
Rate for Payer: Cash Price	$103.75
Rate for Payer: Cash Price	$103.75
Rate for Payer: Cash Price	$103.75
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$109.85
Rate for Payer: Molina CHIP/Medicaid	$109.85
Rate for Payer: Multiplan Auto	$99.17
Rate for Payer: Multiplan Commercial	$99.17
Rate for Payer: Multiplan Workers Comp	$99.17
Rate for Payer: Parkland Medicaid	$109.85
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.85
Rate for Payer: Superior Health Plan EPO	$20.75

WRNR PTA Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	8988798
Hospital Revenue Code	420
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.22
Rate for Payer: BCBS of TX Blue Advantage	$47.40
Rate for Payer: BCBS of TX Blue Essentials	$56.88
Rate for Payer: BCBS of TX PPO	$63.20
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$113.76
Rate for Payer: Molina CHIP/Medicaid	$113.76
Rate for Payer: Multiplan Auto	$102.70
Rate for Payer: Multiplan Commercial	$102.70
Rate for Payer: Multiplan Workers Comp	$102.70
Rate for Payer: Parkland Medicaid	$113.76
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.76
Rate for Payer: Superior Health Plan EPO	$21.49

WRNR PTA Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	8988798
Hospital Revenue Code	420
Rate for Payer: Cash Price	$107.44

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

Facility

$405.46

Service Code	HCPCS 90912 GP
Hospital Charge Code	9310542
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

Know your out-of-pocket cost for care.

All Charges