White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTAH OT Orthotic Prosthetic Manage, Train Units BCE

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	8995061
Hospital Revenue Code	430
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	$64.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.44
Rate for Payer: Superior Health Plan EPO	$27.47

OTAH OT Orthotic Prosthetic Manage, Train Units BCE

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	8995061
Hospital Revenue Code	430
Rate for Payer: Cash Price	$137.36

OTAH OT PROSTHETICS TRAINING INIT EA 15 MIN BCE

Facility

$163.50

Service Code	HCPCS 97761
Hospital Charge Code	8995060
Hospital Revenue Code	430
Rate for Payer: Cash Price	$111.18

OTAH OT PROSTHETICS TRAINING INIT EA 15 MIN BCE

Facility

$163.50

Service Code	HCPCS 97761
Hospital Charge Code	8995060
Hospital Revenue Code	430
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.71
Rate for Payer: BCBS of TX Blue Advantage	$49.05
Rate for Payer: BCBS of TX Blue Essentials	$58.86
Rate for Payer: BCBS of TX PPO	$65.40
Rate for Payer: Cash Price	$111.18
Rate for Payer: Cash Price	$111.18
Rate for Payer: Cash Price	$111.18
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$117.72
Rate for Payer: Molina CHIP/Medicaid	$117.72
Rate for Payer: Multiplan Auto	$106.28
Rate for Payer: Multiplan Commercial	$106.28
Rate for Payer: Multiplan Workers Comp	$106.28
Rate for Payer: Parkland Medicaid	$117.72
Rate for Payer: Scott and White EPO/PPO	$51.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.72
Rate for Payer: Superior Health Plan EPO	$22.24

OTAH OT RE-EVAL BCE

Facility

$181.00

Service Code	HCPCS 97168
Hospital Charge Code	8976541
Hospital Revenue Code	434
Min. Negotiated Rate	$24.62
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$54.30
Rate for Payer: BCBS of TX Blue Essentials	$65.16
Rate for Payer: BCBS of TX PPO	$72.40
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$130.32
Rate for Payer: Molina CHIP/Medicaid	$130.32
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: Parkland Medicaid	$130.32
Rate for Payer: Scott and White EPO/PPO	$86.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.32
Rate for Payer: Superior Health Plan EPO	$24.62

OTAH OT RE-EVAL BCE

Facility

$181.00

Service Code	HCPCS 97168
Hospital Charge Code	8976541
Hospital Revenue Code	434
Rate for Payer: Cash Price	$123.08

OTAH OT Self Care, Home Management Units BCE

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	8997094
Hospital Revenue Code	430
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.25
Rate for Payer: BCBS of TX Blue Advantage	$37.50
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$90.00
Rate for Payer: Molina CHIP/Medicaid	$90.00
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: Parkland Medicaid	$90.00
Rate for Payer: Scott and White EPO/PPO	$40.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.00
Rate for Payer: Superior Health Plan EPO	$17.00

OTAH OT Self Care, Home Management Units BCE

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	8997094
Hospital Revenue Code	430
Rate for Payer: Cash Price	$85.00

OTAH OT Therapeutic Activity Units BCE

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	8995058
Hospital Revenue Code	430
Rate for Payer: Cash Price	$127.84

OTAH OT Therapeutic Activity Units BCE

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	8995058
Hospital Revenue Code	430
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.92
Rate for Payer: BCBS of TX Blue Advantage	$56.40
Rate for Payer: BCBS of TX Blue Essentials	$67.68
Rate for Payer: BCBS of TX PPO	$75.20
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$135.36
Rate for Payer: Molina CHIP/Medicaid	$135.36
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: Parkland Medicaid	$135.36
Rate for Payer: Scott and White EPO/PPO	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.36
Rate for Payer: Superior Health Plan EPO	$25.57

OTAH OT Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	8997090
Hospital Revenue Code	430
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.68
Rate for Payer: BCBS of TX Blue Advantage	$45.60
Rate for Payer: BCBS of TX Blue Essentials	$54.72
Rate for Payer: BCBS of TX PPO	$60.80
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cash Price	$103.36
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$109.44
Rate for Payer: Molina CHIP/Medicaid	$109.44
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: Parkland Medicaid	$109.44
Rate for Payer: Scott and White EPO/PPO	$36.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.44
Rate for Payer: Superior Health Plan EPO	$20.67

OTAH OT Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	8997090
Hospital Revenue Code	430
Rate for Payer: Cash Price	$103.36

OTAH OT Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	8995056
Hospital Revenue Code	430
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.90
Rate for Payer: BCBS of TX Blue Advantage	$33.00
Rate for Payer: BCBS of TX Blue Essentials	$39.60
Rate for Payer: BCBS of TX PPO	$44.00
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cash Price	$74.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.20
Rate for Payer: Molina CHIP/Medicaid	$79.20
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: Parkland Medicaid	$79.20
Rate for Payer: Scott and White EPO/PPO	$17.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

OTAH OT Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	8995056
Hospital Revenue Code	430
Rate for Payer: Cash Price	$74.80

OTAH OT Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542
Hospital Charge Code	8993019
Hospital Revenue Code	430
Rate for Payer: Cash Price	$107.44

OTAH OT Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542
Hospital Charge Code	8993019
Hospital Revenue Code	430
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.22
Rate for Payer: BCBS of TX Blue Advantage	$47.40
Rate for Payer: BCBS of TX Blue Essentials	$56.88
Rate for Payer: BCBS of TX PPO	$63.20
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$113.76
Rate for Payer: Molina CHIP/Medicaid	$113.76
Rate for Payer: Multiplan Auto	$102.70
Rate for Payer: Multiplan Commercial	$102.70
Rate for Payer: Multiplan Workers Comp	$102.70
Rate for Payer: Parkland Medicaid	$113.76
Rate for Payer: Scott and White EPO/PPO	$39.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.76
Rate for Payer: Superior Health Plan EPO	$21.49

OTAH PTA Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	8997087
Hospital Revenue Code	420
Rate for Payer: Cash Price	$75.48

OTAH PTA Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	9238552
Hospital Revenue Code	420
Rate for Payer: Cash Price	$75.48

OTAH PTA Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	8997087
Hospital Revenue Code	420
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Molina CHIP/Medicaid	$79.92
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$23.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

OTAH PTA Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	9238552
Hospital Revenue Code	420
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Molina CHIP/Medicaid	$79.92
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$23.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

OTAH PT Aquatic Assistant Units BCE

Facility

$137.00

Service Code	HCPCS 97113
Hospital Charge Code	9238541
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$41.10
Rate for Payer: BCBS of TX Blue Essentials	$49.32
Rate for Payer: BCBS of TX PPO	$54.80
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$98.64
Rate for Payer: Molina CHIP/Medicaid	$98.64
Rate for Payer: Multiplan Auto	$89.05
Rate for Payer: Multiplan Commercial	$89.05
Rate for Payer: Multiplan Workers Comp	$89.05
Rate for Payer: Parkland Medicaid	$98.64
Rate for Payer: Scott and White EPO/PPO	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.64
Rate for Payer: Superior Health Plan EPO	$18.63

OTAH PT Aquatic Assistant Units BCE

Facility

$137.00

Service Code	HCPCS 97113
Hospital Charge Code	9238541
Hospital Revenue Code	420
Rate for Payer: Cash Price	$93.16

OTAH PT Aquatic Units BCE

Facility

$137.00

Service Code	HCPCS 97113
Hospital Charge Code	9238540
Hospital Revenue Code	420
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.33
Rate for Payer: BCBS of TX Blue Advantage	$41.10
Rate for Payer: BCBS of TX Blue Essentials	$49.32
Rate for Payer: BCBS of TX PPO	$54.80
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cash Price	$93.16
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$98.64
Rate for Payer: Molina CHIP/Medicaid	$98.64
Rate for Payer: Multiplan Auto	$89.05
Rate for Payer: Multiplan Commercial	$89.05
Rate for Payer: Multiplan Workers Comp	$89.05
Rate for Payer: Parkland Medicaid	$98.64
Rate for Payer: Scott and White EPO/PPO	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$98.64
Rate for Payer: Superior Health Plan EPO	$18.63

OTAH PT Aquatic Units BCE

Facility

$137.00

Service Code	HCPCS 97113
Hospital Charge Code	9238540
Hospital Revenue Code	420
Rate for Payer: Cash Price	$93.16

OTAH PT Attended E-Stim Assistant Units BCE

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	9238543
Hospital Revenue Code	420
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.04
Rate for Payer: BCBS of TX PPO	$55.60
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$100.08
Rate for Payer: Molina CHIP/Medicaid	$100.08
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: Parkland Medicaid	$100.08
Rate for Payer: Scott and White EPO/PPO	$17.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

Know your out-of-pocket cost for care.

All Charges