White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OT Orthotic Management, Train Units BCE

Facility

$175.00

Service Code	CPT 97760 GO
Hospital Charge Code	4305070
Hospital Revenue Code	430
Rate for Payer: Cash Price	$154.00

OT Orthotic/Prosthetic Manage,Train Assistant Units

Facility

$202.00

Service Code	CPT 97763 CO,GO
Hospital Charge Code	4300019
Hospital Revenue Code	430
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$27.47

OT Orthotic/Prosthetic Manage,Train Assistant Units BCE

Facility

$202.00

Service Code	CPT 97763 CO,GO
Hospital Charge Code	4300019
Hospital Revenue Code	430
Rate for Payer: Cash Price	$177.76

OT Orthotic/Prosthetic Manage,Train Assistant Units BCE

Facility

$202.00

Service Code	CPT 97763 CO,GO
Hospital Charge Code	4300019
Hospital Revenue Code	430
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$27.47

OT Orthotic, Prosthetic Use, Check Out

Facility

$202.00

Service Code	CPT 97763 GO
Hospital Charge Code	4305106
Hospital Revenue Code	430
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$27.47

OT Orthotic, Prosthetic Use, Check Out BCE

Facility

$202.00

Service Code	CPT 97763 GO
Hospital Charge Code	4305106
Hospital Revenue Code	430
Rate for Payer: Cash Price	$177.76

OT Orthotic, Prosthetic Use, Check Out BCE

Facility

$202.00

Service Code	CPT 97763 GO
Hospital Charge Code	4305106
Hospital Revenue Code	430
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$89.68
Rate for Payer: BCBS of TX Blue Essentials	$107.20
Rate for Payer: BCBS of TX PPO	$119.57
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cash Price	$177.76
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$27.47

OT Paraffin Bath Assistant Units

Facility

$142.00

Service Code	CPT 97018 CO,GO
Hospital Charge Code	5810008
Hospital Revenue Code	430
Min. Negotiated Rate	$12.55
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$12.55
Rate for Payer: BCBS of TX Blue Essentials	$15.00
Rate for Payer: BCBS of TX PPO	$16.73
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$19.31

OT Paraffin Bath Assistant Units BCE

Facility

$142.00

Service Code	CPT 97018 CO,GO
Hospital Charge Code	5810008
Hospital Revenue Code	430
Rate for Payer: Cash Price	$124.96

OT Paraffin Bath Assistant Units BCE

Facility

$142.00

Service Code	CPT 97018 CO,GO
Hospital Charge Code	5810008
Hospital Revenue Code	430
Min. Negotiated Rate	$12.55
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$12.55
Rate for Payer: BCBS of TX Blue Essentials	$15.00
Rate for Payer: BCBS of TX PPO	$16.73
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$19.31

OT Paraffin Bath Units

Facility

$142.00

Service Code	CPT 97018 GO
Hospital Charge Code	4270011
Hospital Revenue Code	430
Min. Negotiated Rate	$12.55
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$12.55
Rate for Payer: BCBS of TX Blue Essentials	$15.00
Rate for Payer: BCBS of TX PPO	$16.73
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$19.31

OT Paraffin Bath Units BCE

Facility

$142.00

Service Code	CPT 97018 GO
Hospital Charge Code	4270011
Hospital Revenue Code	430
Min. Negotiated Rate	$12.55
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$12.55
Rate for Payer: BCBS of TX Blue Essentials	$15.00
Rate for Payer: BCBS of TX PPO	$16.73
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$19.31

OT Paraffin Bath Units BCE

Facility

$142.00

Service Code	CPT 97018 GO
Hospital Charge Code	4270011
Hospital Revenue Code	430
Rate for Payer: Cash Price	$124.96

OT Re-Evaluation Units, 97168

Facility

$181.00

Service Code	CPT 97168 GO
Hospital Charge Code	4305103
Hospital Revenue Code	434
Min. Negotiated Rate	$24.62
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	$110.99
Rate for Payer: BCBS of TX Blue Essentials	$132.68
Rate for Payer: BCBS of TX PPO	$147.99
Rate for Payer: Cash Price	$159.28
Rate for Payer: Cash Price	$159.28
Rate for Payer: Cash Price	$159.28
Rate for Payer: Cash Price	$159.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$117.65
Rate for Payer: Multiplan Commercial	$117.65
Rate for Payer: Multiplan Workers Comp	$117.65
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$24.62

OT Re-Evaluation Units, 97168 BCE

Facility

$181.00

Service Code	CPT 97168 GO
Hospital Charge Code	4305103
Hospital Revenue Code	434
Min. Negotiated Rate	$24.62
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	$110.99
Rate for Payer: BCBS of TX Blue Essentials	$132.68
Rate for Payer: BCBS of TX PPO	$147.99
Rate for Payer: Cash Price	$159.28
Rate for Payer: Cash Price	$159.28
Rate for Payer: Cash Price	$159.28
Rate for Payer: Cash Price	$159.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$117.65
Rate for Payer: Multiplan Commercial	$117.65
Rate for Payer: Multiplan Workers Comp	$117.65
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$24.62

OT Re-Evaluation Units, 97168 BCE

Facility

$181.00

Service Code	CPT 97168 GO
Hospital Charge Code	4305103
Hospital Revenue Code	434
Rate for Payer: Cash Price	$159.28

OT Selective Wound Debride Addtl 20cm Assist Units

Facility

$351.00

Service Code	CPT 97598 CO,GO
Hospital Charge Code	5817598
Hospital Revenue Code	430
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$228.15
Rate for Payer: Aetna Commercial	$193.05
Rate for Payer: Amerigroup CHIP/Medicaid	$31.59
Rate for Payer: BCBS of TX Blue Advantage	$20.06
Rate for Payer: BCBS of TX Blue Essentials	$23.98
Rate for Payer: BCBS of TX PPO	$26.75
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$228.15
Rate for Payer: Multiplan Commercial	$228.15
Rate for Payer: Multiplan Workers Comp	$228.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$47.74

OT Selective Wound Debride Addtl 20cm Assist Units BCE

Facility

$351.00

Service Code	CPT 97598 CO,GO
Hospital Charge Code	5817598
Hospital Revenue Code	430
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$228.15
Rate for Payer: Aetna Commercial	$193.05
Rate for Payer: Amerigroup CHIP/Medicaid	$31.59
Rate for Payer: BCBS of TX Blue Advantage	$20.06
Rate for Payer: BCBS of TX Blue Essentials	$23.98
Rate for Payer: BCBS of TX PPO	$26.75
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$228.15
Rate for Payer: Multiplan Commercial	$228.15
Rate for Payer: Multiplan Workers Comp	$228.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$47.74

OT Selective Wound Debride Addtl 20cm Assist Units BCE

Facility

$351.00

Service Code	CPT 97598 CO,GO
Hospital Charge Code	5817598
Hospital Revenue Code	430
Rate for Payer: Cash Price	$308.88

OT Selective Wound Debridement <20cm AssistUnits

Facility

$399.00

Service Code	CPT 97597 CO,GO
Hospital Charge Code	5807597
Hospital Revenue Code	430
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$274.64
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$35.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$42.65
Rate for Payer: BCBS of TX Blue Essentials	$50.98
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$56.86
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cigna Commercial	$200.00
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$259.35
Rate for Payer: Multiplan Commercial	$259.35
Rate for Payer: Multiplan Workers Comp	$259.35
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 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 Selective Wound Debridement <20cm AssistUnits BCE

Facility

$399.00

Service Code	CPT 97597 CO,GO
Hospital Charge Code	5807597
Hospital Revenue Code	430
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$274.64
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$35.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$42.65
Rate for Payer: BCBS of TX Blue Essentials	$50.98
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$56.86
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cigna Commercial	$200.00
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$259.35
Rate for Payer: Multiplan Commercial	$259.35
Rate for Payer: Multiplan Workers Comp	$259.35
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 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 Selective Wound Debridement <20cm AssistUnits BCE

Facility

$399.00

Service Code	CPT 97597 CO,GO
Hospital Charge Code	5807597
Hospital Revenue Code	430
Rate for Payer: Cash Price	$351.12

OT Selective Wound Debridement <20cm Units

Facility

$399.00

Service Code	CPT 97597 GO
Hospital Charge Code	5807597
Hospital Revenue Code	430
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$274.64
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$35.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$42.65
Rate for Payer: BCBS of TX Blue Essentials	$50.98
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$56.86
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cigna Commercial	$200.00
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$259.35
Rate for Payer: Multiplan Commercial	$259.35
Rate for Payer: Multiplan Workers Comp	$259.35
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 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 Selective Wound Debridement <20cm Units BCE

Facility

$399.00

Service Code	CPT 97597 GO
Hospital Charge Code	5807597
Hospital Revenue Code	430
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$274.64
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$35.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$42.65
Rate for Payer: BCBS of TX Blue Essentials	$50.98
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$56.86
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cash Price	$351.12
Rate for Payer: Cigna Commercial	$200.00
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 Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$259.35
Rate for Payer: Multiplan Commercial	$259.35
Rate for Payer: Multiplan Workers Comp	$259.35
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 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 Selective Wound Debridement Addtl 20cm Units

Facility

$351.00

Service Code	CPT 97598 GO
Hospital Charge Code	5817598
Hospital Revenue Code	430
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$228.15
Rate for Payer: Aetna Commercial	$193.05
Rate for Payer: Amerigroup CHIP/Medicaid	$31.59
Rate for Payer: BCBS of TX Blue Advantage	$20.06
Rate for Payer: BCBS of TX Blue Essentials	$23.98
Rate for Payer: BCBS of TX PPO	$26.75
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cash Price	$308.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$228.15
Rate for Payer: Multiplan Commercial	$228.15
Rate for Payer: Multiplan Workers Comp	$228.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$47.74

Know your out-of-pocket cost for care.

All Charges