White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$275.71

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

Facility

$185.00

Service Code	HCPCS 90913 GP
Hospital Charge Code	9310543
Hospital Revenue Code	420
Rate for Payer: Cash Price	$125.80

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

Facility

$185.00

Service Code	HCPCS 90913 GP
Hospital Charge Code	9310543
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 PT BIOFEEDBACK TRAINING ANY MODALITY BCE

Facility

$448.00

Service Code	HCPCS 90901 GP
Hospital Charge Code	9310541
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 PT BIOFEEDBACK TRAINING ANY MODALITY BCE

Facility

$448.00

Service Code	HCPCS 90901 GP
Hospital Charge Code	9310541
Hospital Revenue Code	420
Rate for Payer: Cash Price	$304.64

WRNR PT Evaluation High Complexity BCE

Facility

$288.00

Service Code	HCPCS 97163
Hospital Charge Code	8992541
Hospital Revenue Code	424
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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$39.17

WRNR PT Evaluation High Complexity BCE

Facility

$288.00

Service Code	HCPCS 97163
Hospital Charge Code	8992541
Hospital Revenue Code	424
Rate for Payer: Cash Price	$195.84

WRNR PT Evaluation High Complexity BCE

Facility

$288.00

Service Code	HCPCS 97163
Hospital Charge Code	9308542
Hospital Revenue Code	424
Rate for Payer: Cash Price	$195.84

WRNR PT Evaluation High Complexity BCE

Facility

$288.00

Service Code	HCPCS 97163
Hospital Charge Code	9308542
Hospital Revenue Code	424
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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$39.17

WRNR PT Evaluation Low Complexity BCE

Facility

$127.00

Service Code	HCPCS 97161
Hospital Charge Code	9308540
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 PT Evaluation Low Complexity BCE

Facility

$127.00

Service Code	HCPCS 97161
Hospital Charge Code	9308540
Hospital Revenue Code	424
Rate for Payer: Cash Price	$86.36

WRNR PT Evaluation Moderate Complexity BCE

Facility

$191.00

Service Code	HCPCS 97162
Hospital Charge Code	4252201
Hospital Revenue Code	424
Rate for Payer: Cash Price	$129.88

WRNR PT Evaluation Moderate Complexity BCE

Facility

$191.00

Service Code	HCPCS 97162
Hospital Charge Code	4252201
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 PT Gait Training Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	9308546
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 PT Gait Training Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	4252048
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 PT Gait Training Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	4252048
Hospital Revenue Code	420
Rate for Payer: Cash Price	$104.04

WRNR PT Gait Training Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	9308546
Hospital Revenue Code	420
Rate for Payer: Cash Price	$104.04

WRNR PT Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140 GP
Hospital Charge Code	9308547
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 PT Manual Therapy Units BCE

Facility

$186.01

Service Code	HCPCS 97140 GP
Hospital Charge Code	9308547
Hospital Revenue Code	420
Rate for Payer: Cash Price	$126.49

WRNR PT Neuromuscular Reeducation BCE

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	9308545
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 PT Neuromuscular Reeducation BCE

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	9308545
Hospital Revenue Code	420
Rate for Payer: Cash Price	$87.72

WRNR PT Orthotic Management and Training BCE

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	9310540
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

WRNR PT Orthotic Management and Training BCE

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	9310540
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 PT ORTH/PROSTH MGMT SBSQ ENCTR 15 MIN BCE

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	9308551
Hospital Revenue Code	420
Rate for Payer: Cash Price	$137.36

WRNR PT ORTH/PROSTH MGMT SBSQ ENCTR 15 MIN BCE

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	9308551
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

Know your out-of-pocket cost for care.

All Charges