White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OT Selective Wound Debridement Addtl 20cm Units BCE

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

OT Self Care, Home Management Units

Facility

$125.00

Service Code	CPT 97535 GO
Hospital Charge Code	4300489
Hospital Revenue Code	430
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.25
Rate for Payer: BCBS of TX Blue Advantage	$60.83
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX PPO	$81.11
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$81.25
Rate for Payer: Multiplan Commercial	$81.25
Rate for Payer: Multiplan Workers Comp	$81.25
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.00

OT Self Care, Home Management Units BCE

Facility

$125.00

Service Code	CPT 97535 GO
Hospital Charge Code	4300489
Hospital Revenue Code	430
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.25
Rate for Payer: BCBS of TX Blue Advantage	$60.83
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX PPO	$81.11
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$81.25
Rate for Payer: Multiplan Commercial	$81.25
Rate for Payer: Multiplan Workers Comp	$81.25
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.00

OT Self Care, Home Management Units BCE

Facility

$125.00

Service Code	CPT 97535 GO
Hospital Charge Code	4300489
Hospital Revenue Code	430
Rate for Payer: Cash Price	$110.00

OT Self Care, Home Mgmt Assistant Units

Facility

$125.00

Service Code	CPT 97535 CO,GO
Hospital Charge Code	4300014
Hospital Revenue Code	430
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.25
Rate for Payer: BCBS of TX Blue Advantage	$60.83
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX PPO	$81.11
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$81.25
Rate for Payer: Multiplan Commercial	$81.25
Rate for Payer: Multiplan Workers Comp	$81.25
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.00

OT Self Care, Home Mgmt Assistant Units BCE

Facility

$125.00

Service Code	CPT 97535 CO,GO
Hospital Charge Code	4300014
Hospital Revenue Code	430
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.25
Rate for Payer: BCBS of TX Blue Advantage	$60.83
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX PPO	$81.11
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$81.25
Rate for Payer: Multiplan Commercial	$81.25
Rate for Payer: Multiplan Workers Comp	$81.25
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$17.00

OT Self Care, Home Mgmt Assistant Units BCE

Facility

$125.00

Service Code	CPT 97535 CO,GO
Hospital Charge Code	4300014
Hospital Revenue Code	430
Rate for Payer: Cash Price	$110.00

OT Therapeutic Activities Assistant Units

Facility

$188.00

Service Code	CPT 97530 CO,GO
Hospital Charge Code	4300010
Hospital Revenue Code	430
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.92
Rate for Payer: BCBS of TX Blue Advantage	$70.85
Rate for Payer: BCBS of TX Blue Essentials	$84.70
Rate for Payer: BCBS of TX PPO	$94.47
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$122.20
Rate for Payer: Multiplan Commercial	$122.20
Rate for Payer: Multiplan Workers Comp	$122.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.57

OT Therapeutic Activities Assistant Units BCE

Facility

$188.00

Service Code	CPT 97530 CO,GO
Hospital Charge Code	4300010
Hospital Revenue Code	430
Rate for Payer: Cash Price	$165.44

OT Therapeutic Activities Assistant Units BCE

Facility

$188.00

Service Code	CPT 97530 CO,GO
Hospital Charge Code	4300010
Hospital Revenue Code	430
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.92
Rate for Payer: BCBS of TX Blue Advantage	$70.85
Rate for Payer: BCBS of TX Blue Essentials	$84.70
Rate for Payer: BCBS of TX PPO	$94.47
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$122.20
Rate for Payer: Multiplan Commercial	$122.20
Rate for Payer: Multiplan Workers Comp	$122.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.57

OT Therapeutic Activities Units

Facility

$188.00

Service Code	CPT 97530 GO
Hospital Charge Code	4300307
Hospital Revenue Code	430
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.92
Rate for Payer: BCBS of TX Blue Advantage	$70.85
Rate for Payer: BCBS of TX Blue Essentials	$84.70
Rate for Payer: BCBS of TX PPO	$94.47
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$122.20
Rate for Payer: Multiplan Commercial	$122.20
Rate for Payer: Multiplan Workers Comp	$122.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.57

OT Therapeutic Activities Units BCE

Facility

$188.00

Service Code	CPT 97530 GO
Hospital Charge Code	4300307
Hospital Revenue Code	430
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.92
Rate for Payer: BCBS of TX Blue Advantage	$70.85
Rate for Payer: BCBS of TX Blue Essentials	$84.70
Rate for Payer: BCBS of TX PPO	$94.47
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$122.20
Rate for Payer: Multiplan Commercial	$122.20
Rate for Payer: Multiplan Workers Comp	$122.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$25.57

OT Therapeutic Activities Units BCE

Facility

$188.00

Service Code	CPT 97530 GO
Hospital Charge Code	4300307
Hospital Revenue Code	430
Rate for Payer: Cash Price	$165.44

OT Therapeutic Exercise Assistant Units

Facility

$152.00

Service Code	CPT 97110 CO,GO
Hospital Charge Code	4300011
Hospital Revenue Code	430
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$54.55
Rate for Payer: BCBS of TX Blue Essentials	$65.21
Rate for Payer: BCBS of TX PPO	$72.73
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$20.67

OT Therapeutic Exercise Assistant Units BCE

Facility

$152.00

Service Code	CPT 97110 CO,GO
Hospital Charge Code	4300011
Hospital Revenue Code	430
Rate for Payer: Cash Price	$133.76

OT Therapeutic Exercise Assistant Units BCE

Facility

$152.00

Service Code	CPT 97110 CO,GO
Hospital Charge Code	4300011
Hospital Revenue Code	430
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$54.55
Rate for Payer: BCBS of TX Blue Essentials	$65.21
Rate for Payer: BCBS of TX PPO	$72.73
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$20.67

OT Therapeutic Exercise Units

Facility

$152.00

Service Code	CPT 97110 GO
Hospital Charge Code	4300414
Hospital Revenue Code	430
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$54.55
Rate for Payer: BCBS of TX Blue Essentials	$65.21
Rate for Payer: BCBS of TX PPO	$72.73
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$20.67

OT Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	CPT 97110 GO
Hospital Charge Code	4300414
Hospital Revenue Code	430
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$54.55
Rate for Payer: BCBS of TX Blue Essentials	$65.21
Rate for Payer: BCBS of TX PPO	$72.73
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$20.67

OT Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	CPT 97110 GO
Hospital Charge Code	4300414
Hospital Revenue Code	430
Rate for Payer: Cash Price	$133.76

OT Ultrasound Assistant Units

Facility

$110.00

Service Code	CPT 97035 CO,GO
Hospital Charge Code	4300002
Hospital Revenue Code	430
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.90
Rate for Payer: BCBS of TX Blue Advantage	$24.46
Rate for Payer: BCBS of TX Blue Essentials	$29.24
Rate for Payer: BCBS of TX PPO	$32.62
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$14.96

OT Ultrasound Assistant Units BCE

Facility

$110.00

Service Code	CPT 97035 CO,GO
Hospital Charge Code	4300002
Hospital Revenue Code	430
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.90
Rate for Payer: BCBS of TX Blue Advantage	$24.46
Rate for Payer: BCBS of TX Blue Essentials	$29.24
Rate for Payer: BCBS of TX PPO	$32.62
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$14.96

OT Ultrasound Assistant Units BCE

Facility

$110.00

Service Code	CPT 97035 CO,GO
Hospital Charge Code	4300002
Hospital Revenue Code	430
Rate for Payer: Cash Price	$96.80

OT Ultrasound Units

Facility

$110.00

Service Code	CPT 97035 GO
Hospital Charge Code	4300448
Hospital Revenue Code	430
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.90
Rate for Payer: BCBS of TX Blue Advantage	$24.46
Rate for Payer: BCBS of TX Blue Essentials	$29.24
Rate for Payer: BCBS of TX PPO	$32.62
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$14.96

OT Ultrasound Units BCE

Facility

$110.00

Service Code	CPT 97035 GO
Hospital Charge Code	4300448
Hospital Revenue Code	430
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.90
Rate for Payer: BCBS of TX Blue Advantage	$24.46
Rate for Payer: BCBS of TX Blue Essentials	$29.24
Rate for Payer: BCBS of TX PPO	$32.62
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$14.96

OT Ultrasound Units BCE

Facility

$110.00

Service Code	CPT 97035 GO
Hospital Charge Code	4300448
Hospital Revenue Code	430
Rate for Payer: Cash Price	$96.80

Know your out-of-pocket cost for care.

All Charges