White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTITIS MEDIA AND URI WITH MCC

Facility

$22,575.80

Service Code	MSDRG 152
Min. Negotiated Rate	$8,710.94
Max. Negotiated Rate	$22,575.80
Rate for Payer: Aetna Commercial	$13,367.25
Rate for Payer: Aetna Medicare	$17,000.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,333.85
Rate for Payer: Amerigroup Medicare	$11,333.85
Rate for Payer: BCBS of TX Blue Advantage	$8,710.94
Rate for Payer: BCBS of TX Blue Essentials	$10,753.43
Rate for Payer: BCBS of TX Medicare	$11,333.85
Rate for Payer: BCBS of TX PPO	$11,948.72
Rate for Payer: Cigna Commercial	$15,304.02
Rate for Payer: Cigna Medicare	$11,333.85
Rate for Payer: Employer Direct Commercial	$11,333.85
Rate for Payer: Humana Medicare/TRICARE	$11,333.85
Rate for Payer: Molina Dual Medicare/Medicaid	$11,333.85
Rate for Payer: Molina Medicare	$11,333.85
Rate for Payer: Multiplan Auto	$22,575.80
Rate for Payer: Multiplan Commercial	$22,575.80
Rate for Payer: Multiplan Workers Comp	$22,575.80
Rate for Payer: Scott and White EPO/PPO	$10,396.75
Rate for Payer: Scott and White Medicare	$11,333.85
Rate for Payer: Superior Health Plan EPO	$11,333.85
Rate for Payer: Superior Health Plan Medicare	$11,333.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,333.85
Rate for Payer: Universal American Medicare	$11,333.85
Rate for Payer: Wellcare Medicare	$11,333.85
Rate for Payer: Wellmed Medicare	$11,333.85

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$13,961.20

Service Code	MSDRG 153
Min. Negotiated Rate	$6,021.72
Max. Negotiated Rate	$13,961.20
Rate for Payer: Aetna Commercial	$8,266.50
Rate for Payer: Aetna Medicare	$12,147.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,098.35
Rate for Payer: Amerigroup Medicare	$8,098.35
Rate for Payer: BCBS of TX Blue Advantage	$6,021.72
Rate for Payer: BCBS of TX Blue Essentials	$7,345.06
Rate for Payer: BCBS of TX Medicare	$8,098.35
Rate for Payer: BCBS of TX PPO	$8,161.50
Rate for Payer: Cigna Commercial	$9,464.22
Rate for Payer: Cigna Medicare	$8,098.35
Rate for Payer: Employer Direct Commercial	$8,098.35
Rate for Payer: Humana Medicare/TRICARE	$8,098.35
Rate for Payer: Molina Dual Medicare/Medicaid	$8,098.35
Rate for Payer: Molina Medicare	$8,098.35
Rate for Payer: Multiplan Auto	$13,961.20
Rate for Payer: Multiplan Commercial	$13,961.20
Rate for Payer: Multiplan Workers Comp	$13,961.20
Rate for Payer: Scott and White EPO/PPO	$6,429.50
Rate for Payer: Scott and White Medicare	$8,098.35
Rate for Payer: Superior Health Plan EPO	$8,098.35
Rate for Payer: Superior Health Plan Medicare	$8,098.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,098.35
Rate for Payer: Universal American Medicare	$8,098.35
Rate for Payer: Wellcare Medicare	$8,098.35
Rate for Payer: Wellmed Medicare	$8,098.35

OT Manual Therapy Assistant Units

Facility

$136.00

Service Code	CPT 97140 CO,GO
Hospital Charge Code	4300006
Hospital Revenue Code	430
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.50

OT Manual Therapy Assistant Units BCE

Facility

$136.00

Service Code	CPT 97140 CO,GO
Hospital Charge Code	4300006
Hospital Revenue Code	430
Rate for Payer: Cash Price	$119.68

OT Manual Therapy Assistant Units BCE

Facility

$136.00

Service Code	CPT 97140 CO,GO
Hospital Charge Code	4300006
Hospital Revenue Code	430
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.50

OT Manual Therapy Units

Facility

$136.00

Service Code	CPT 97140 GO
Hospital Charge Code	4300117
Hospital Revenue Code	430
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.50

OT Manual Therapy Units BCE

Facility

$136.00

Service Code	CPT 97140 GO
Hospital Charge Code	4300117
Hospital Revenue Code	430
Rate for Payer: Cash Price	$119.68

OT Manual Therapy Units BCE

Facility

$136.00

Service Code	CPT 97140 GO
Hospital Charge Code	4300117
Hospital Revenue Code	430
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$49.54
Rate for Payer: BCBS of TX Blue Essentials	$59.22
Rate for Payer: BCBS of TX PPO	$66.05
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cash Price	$119.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$18.50

OT Neuromuscular Reeducation Assistant Units

Facility

$129.00

Service Code	CPT 97112 CO,GO
Hospital Charge Code	4300009
Hospital Revenue Code	430
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$62.08
Rate for Payer: BCBS of TX Blue Essentials	$74.21
Rate for Payer: BCBS of TX PPO	$82.78
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.54

OT Neuromuscular Reeducation Assistant Units BCE

Facility

$129.00

Service Code	CPT 97112 CO,GO
Hospital Charge Code	4300009
Hospital Revenue Code	430
Rate for Payer: Cash Price	$113.52

OT Neuromuscular Reeducation Assistant Units BCE

Facility

$129.00

Service Code	CPT 97112 CO,GO
Hospital Charge Code	4300009
Hospital Revenue Code	430
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$62.08
Rate for Payer: BCBS of TX Blue Essentials	$74.21
Rate for Payer: BCBS of TX PPO	$82.78
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.54

OT Neuromuscular Reeducation Units

Facility

$129.00

Service Code	CPT 97112 GO
Hospital Charge Code	4300125
Hospital Revenue Code	430
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$62.08
Rate for Payer: BCBS of TX Blue Essentials	$74.21
Rate for Payer: BCBS of TX PPO	$82.78
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.54

OT Neuromuscular Reeducation Units BCE

Facility

$129.00

Service Code	CPT 97112 GO
Hospital Charge Code	4300125
Hospital Revenue Code	430
Rate for Payer: Cash Price	$113.52

OT Neuromuscular Reeducation Units BCE

Facility

$129.00

Service Code	CPT 97112 GO
Hospital Charge Code	4300125
Hospital Revenue Code	430
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$62.08
Rate for Payer: BCBS of TX Blue Essentials	$74.21
Rate for Payer: BCBS of TX PPO	$82.78
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cash Price	$113.52
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.54

OT Non-Selective Wound Debridement Assistant Units

Facility

$358.00

Service Code	CPT 97602 CO,GO
Hospital Charge Code	5817623
Hospital Revenue Code	430
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$405.37
Rate for Payer: Aetna Commercial	$196.90
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$304.03
Rate for Payer: BCBS of TX Blue Essentials	$363.44
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$405.37
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$27.68
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$27.68
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$232.70
Rate for Payer: Multiplan Commercial	$232.70
Rate for Payer: Multiplan Workers Comp	$232.70
Rate for Payer: Parkland Medicaid	$27.68
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.68
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

OT Non-Selective Wound Debridement Assistant Units BCE

Facility

$358.00

Service Code	CPT 97602 CO,GO
Hospital Charge Code	5817623
Hospital Revenue Code	430
Rate for Payer: Cash Price	$315.04

OT Non-Selective Wound Debridement Assistant Units BCE

Facility

$358.00

Service Code	CPT 97602 CO,GO
Hospital Charge Code	5817623
Hospital Revenue Code	430
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$405.37
Rate for Payer: Aetna Commercial	$196.90
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$304.03
Rate for Payer: BCBS of TX Blue Essentials	$363.44
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$405.37
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$27.68
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$27.68
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$232.70
Rate for Payer: Multiplan Commercial	$232.70
Rate for Payer: Multiplan Workers Comp	$232.70
Rate for Payer: Parkland Medicaid	$27.68
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.68
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

OT Non-Selective Wound Debridement Units

Facility

$358.00

Service Code	CPT 97602 GO
Hospital Charge Code	5817623
Hospital Revenue Code	430
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$405.37
Rate for Payer: Aetna Commercial	$196.90
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$304.03
Rate for Payer: BCBS of TX Blue Essentials	$363.44
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$405.37
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$27.68
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$27.68
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$232.70
Rate for Payer: Multiplan Commercial	$232.70
Rate for Payer: Multiplan Workers Comp	$232.70
Rate for Payer: Parkland Medicaid	$27.68
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.68
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

OT Non-Selective Wound Debridement Units BCE

Facility

$358.00

Service Code	CPT 97602 GO
Hospital Charge Code	5817623
Hospital Revenue Code	430
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$405.37
Rate for Payer: Aetna Commercial	$196.90
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$304.03
Rate for Payer: BCBS of TX Blue Essentials	$363.44
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$405.37
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cash Price	$315.04
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$27.68
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$27.68
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$232.70
Rate for Payer: Multiplan Commercial	$232.70
Rate for Payer: Multiplan Workers Comp	$232.70
Rate for Payer: Parkland Medicaid	$27.68
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.68
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

Otolaryngologic examination under general anesthesia

Facility

$10,000.00

Service Code	CPT 69210
Hospital Charge Code	36069210
Hospital Revenue Code	360
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$55.94
Rate for Payer: Amerigroup Medicare	$55.94
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$55.94
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicare	$55.94
Rate for Payer: Employer Direct Commercial	$55.94
Rate for Payer: Humana Medicare/TRICARE	$55.94
Rate for Payer: Molina Dual Medicare/Medicaid	$55.94
Rate for Payer: Molina Medicare	$55.94
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: Scott and White EPO/PPO	$1.23
Rate for Payer: Scott and White Medicare	$55.94
Rate for Payer: Superior Health Plan EPO	$55.94
Rate for Payer: Superior Health Plan Medicare	$55.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$55.94
Rate for Payer: Universal American Medicare	$55.94
Rate for Payer: Wellcare Medicare	$55.94
Rate for Payer: Wellmed Medicare	$55.94

OT Orthotic Management, Train Assistant Units

Facility

$175.00

Service Code	CPT 97760 CO,GO
Hospital Charge Code	4300015
Hospital Revenue Code	430
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$84.65
Rate for Payer: BCBS of TX Blue Essentials	$101.19
Rate for Payer: BCBS of TX PPO	$112.87
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$23.80

OT Orthotic Management, Train Assistant Units BCE

Facility

$175.00

Service Code	CPT 97760 CO,GO
Hospital Charge Code	4300015
Hospital Revenue Code	430
Rate for Payer: Cash Price	$154.00

OT Orthotic Management, Train Assistant Units BCE

Facility

$175.00

Service Code	CPT 97760 CO,GO
Hospital Charge Code	4300015
Hospital Revenue Code	430
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$84.65
Rate for Payer: BCBS of TX Blue Essentials	$101.19
Rate for Payer: BCBS of TX PPO	$112.87
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$23.80

OT Orthotic Management, Train Units

Facility

$175.00

Service Code	CPT 97760 GO
Hospital Charge Code	4305070
Hospital Revenue Code	430
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$84.65
Rate for Payer: BCBS of TX Blue Essentials	$101.19
Rate for Payer: BCBS of TX PPO	$112.87
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$23.80

OT Orthotic Management, Train Units BCE

Facility

$175.00

Service Code	CPT 97760 GO
Hospital Charge Code	4305070
Hospital Revenue Code	430
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$84.65
Rate for Payer: BCBS of TX Blue Essentials	$101.19
Rate for Payer: BCBS of TX PPO	$112.87
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cash Price	$154.00
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$23.80

Know your out-of-pocket cost for care.

All Charges