White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatars

Facility

$15,074.51

Service Code	CPT 28306
Hospital Charge Code	36028306
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$2,398.52
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$2,398.52
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$2,398.52
Rate for Payer: Scott and White EPO/PPO	$144.31
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,398.52
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Osteotomy, with or without lengthening, shortening or angular correction, metatarsal other than fir

Facility

$10,000.00

Service Code	CPT 28308
Hospital Charge Code	36028308
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

OST PASTE STMA -- DHF

Facility

$17.36

Service Code	HCPCS A4406
Hospital Charge Code	80331457
Hospital Revenue Code	272
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$12.83
Rate for Payer: Aetna Commercial	$9.55
Rate for Payer: Amerigroup CHIP/Medicaid	$1.56
Rate for Payer: BCBS of TX Blue Advantage	$9.64
Rate for Payer: BCBS of TX Blue Essentials	$11.57
Rate for Payer: BCBS of TX PPO	$12.83
Rate for Payer: Cash Price	$15.28
Rate for Payer: Cash Price	$15.28
Rate for Payer: Multiplan Auto	$11.28
Rate for Payer: Multiplan Commercial	$11.28
Rate for Payer: Multiplan Workers Comp	$11.28
Rate for Payer: Scott and White EPO/PPO	$8.68
Rate for Payer: Superior Health Plan EPO	$2.36

OST PASTE STMA -- DHF

Facility

$17.36

Service Code	HCPCS A4406
Hospital Charge Code	80331457
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.28

OST SKIN BOND -- DHF

Facility

$367.82

Hospital Charge Code	80332000
Hospital Revenue Code	272
Min. Negotiated Rate	$33.10
Max. Negotiated Rate	$239.08
Rate for Payer: Aetna Commercial	$202.30
Rate for Payer: Amerigroup CHIP/Medicaid	$33.10
Rate for Payer: BCBS of TX Blue Advantage	$110.35
Rate for Payer: BCBS of TX Blue Essentials	$132.42
Rate for Payer: BCBS of TX PPO	$147.13
Rate for Payer: Cash Price	$323.68
Rate for Payer: Multiplan Auto	$239.08
Rate for Payer: Multiplan Commercial	$239.08
Rate for Payer: Multiplan Workers Comp	$239.08
Rate for Payer: Scott and White EPO/PPO	$183.91
Rate for Payer: Superior Health Plan EPO	$50.02

OST SKIN BOND -- DHF

Facility

$367.82

Hospital Charge Code	80332000
Hospital Revenue Code	272
Rate for Payer: Cash Price	$323.68

OST SKIN PROTEC -- DHF

Facility

$16.54

Hospital Charge Code	80332257
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14.56

OST SKIN PROTEC -- DHF

Facility

$16.54

Hospital Charge Code	80332257
Hospital Revenue Code	272
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$10.75
Rate for Payer: Aetna Commercial	$9.10
Rate for Payer: Amerigroup CHIP/Medicaid	$1.49
Rate for Payer: BCBS of TX Blue Advantage	$4.96
Rate for Payer: BCBS of TX Blue Essentials	$5.95
Rate for Payer: BCBS of TX PPO	$6.62
Rate for Payer: Cash Price	$14.56
Rate for Payer: Multiplan Auto	$10.75
Rate for Payer: Multiplan Commercial	$10.75
Rate for Payer: Multiplan Workers Comp	$10.75
Rate for Payer: Scott and White EPO/PPO	$8.27
Rate for Payer: Superior Health Plan EPO	$2.25

OT Application of Short Arm Splint, Static Units

Facility

$618.00

Service Code	CPT 29125 GO
Hospital Charge Code	4300554
Hospital Revenue Code	430
Rate for Payer: Cash Price	$543.84

OT Application of Short Arm Splint, Static Units

Facility

$618.00

Service Code	CPT 29125 GO
Hospital Charge Code	4300554
Hospital Revenue Code	430
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$401.70
Rate for Payer: Aetna Commercial	$339.90
Rate for Payer: Aetna Medicare	$175.23
Rate for Payer: Amerigroup CHIP/Medicaid	$55.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$116.82
Rate for Payer: Amerigroup Medicare	$116.82
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$116.82
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$543.84
Rate for Payer: Cash Price	$543.84
Rate for Payer: Cash Price	$543.84
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicare	$116.82
Rate for Payer: Employer Direct Commercial	$116.82
Rate for Payer: Humana Medicare/TRICARE	$116.82
Rate for Payer: Molina Dual Medicare/Medicaid	$116.82
Rate for Payer: Molina Medicare	$116.82
Rate for Payer: Multiplan Auto	$401.70
Rate for Payer: Multiplan Commercial	$401.70
Rate for Payer: Multiplan Workers Comp	$401.70
Rate for Payer: Scott and White EPO/PPO	$2.09
Rate for Payer: Scott and White Medicare	$116.82
Rate for Payer: Superior Health Plan EPO	$116.82
Rate for Payer: Superior Health Plan Medicare	$116.82
Rate for Payer: Universal American Dual Medicare/Medicaid	$116.82
Rate for Payer: Universal American Medicare	$116.82
Rate for Payer: Wellcare Medicare	$116.82
Rate for Payer: Wellmed Medicare	$116.82

OT Attended E-Stim Assistant Units

Facility

$139.00

Service Code	CPT 97032 CO,GO
Hospital Charge Code	4300008
Hospital Revenue Code	430
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.90

OT Attended E-Stim Assistant Units BCE

Facility

$139.00

Service Code	CPT 97032 CO,GO
Hospital Charge Code	4300008
Hospital Revenue Code	430
Rate for Payer: Cash Price	$122.32

OT Attended E-Stim Assistant Units BCE

Facility

$139.00

Service Code	CPT 97032 CO,GO
Hospital Charge Code	4300008
Hospital Revenue Code	430
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.90

OT Attended E-Stim Units

Facility

$139.00

Service Code	CPT 97032 GO
Hospital Charge Code	4300042
Hospital Revenue Code	430
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.90

OT Attended E-Stim Units BCE

Facility

$139.00

Service Code	CPT 97032 GO
Hospital Charge Code	4300042
Hospital Revenue Code	430
Rate for Payer: Cash Price	$122.32

OT Attended E-Stim Units BCE

Facility

$139.00

Service Code	CPT 97032 GO
Hospital Charge Code	4300042
Hospital Revenue Code	430
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.49
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cash Price	$122.32
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.90

OT Evaluation Units, High Complexity

Facility

$384.00

Service Code	CPT 97167 GO
Hospital Charge Code	4305102
Hospital Revenue Code	434
Min. Negotiated Rate	$52.22
Max. Negotiated Rate	$249.60
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$161.79
Rate for Payer: BCBS of TX Blue Essentials	$193.40
Rate for Payer: BCBS of TX PPO	$215.71
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$52.22

OT Evaluation Units, High Complexity BCE

Facility

$384.00

Service Code	CPT 97167 GO
Hospital Charge Code	4305102
Hospital Revenue Code	434
Rate for Payer: Cash Price	$337.92

OT Evaluation Units, High Complexity BCE

Facility

$384.00

Service Code	CPT 97167 GO
Hospital Charge Code	4305102
Hospital Revenue Code	434
Min. Negotiated Rate	$52.22
Max. Negotiated Rate	$249.60
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$161.79
Rate for Payer: BCBS of TX Blue Essentials	$193.40
Rate for Payer: BCBS of TX PPO	$215.71
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cash Price	$337.92
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$52.22

OT Evaluation Units, Low Complexity

Facility

$191.00

Service Code	CPT 97165 GO
Hospital Charge Code	4305100
Hospital Revenue Code	434
Min. Negotiated Rate	$25.98
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$161.79
Rate for Payer: BCBS of TX Blue Essentials	$193.40
Rate for Payer: BCBS of TX PPO	$215.71
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.98

OT Evaluation Units, Low Complexity BCE

Facility

$191.00

Service Code	CPT 97165 GO
Hospital Charge Code	4305100
Hospital Revenue Code	434
Min. Negotiated Rate	$25.98
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$161.79
Rate for Payer: BCBS of TX Blue Essentials	$193.40
Rate for Payer: BCBS of TX PPO	$215.71
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cash Price	$168.08
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.98

OT Evaluation Units, Low Complexity BCE

Facility

$191.00

Service Code	CPT 97165 GO
Hospital Charge Code	4305100
Hospital Revenue Code	434
Rate for Payer: Cash Price	$168.08

OT Evaluation Units, Moderate Complexity

Facility

$288.00

Service Code	CPT 97166 GO
Hospital Charge Code	4305101
Hospital Revenue Code	434
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$161.79
Rate for Payer: BCBS of TX Blue Essentials	$193.40
Rate for Payer: BCBS of TX PPO	$215.71
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$39.17

OT Evaluation Units, Moderate Complexity BCE

Facility

$288.00

Service Code	CPT 97166 GO
Hospital Charge Code	4305101
Hospital Revenue Code	434
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$161.79
Rate for Payer: BCBS of TX Blue Essentials	$193.40
Rate for Payer: BCBS of TX PPO	$215.71
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cash Price	$253.44
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$39.17

OT Evaluation Units, Moderate Complexity BCE

Facility

$288.00

Service Code	CPT 97166 GO
Hospital Charge Code	4305101
Hospital Revenue Code	434
Rate for Payer: Cash Price	$253.44

Know your out-of-pocket cost for care.

All Charges