White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTAH OT Biofeedback Units BCE

Facility

$448.00

Service Code	HCPCS 90901
Hospital Charge Code	8993014
Hospital Revenue Code	430
Rate for Payer: Cash Price	$304.64

OTAH OT EVAL HIGH COMPLEXITY BCE

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	8978541
Hospital Revenue Code	434
Min. Negotiated Rate	$52.22
Max. Negotiated Rate	$276.48
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$115.20
Rate for Payer: BCBS of TX Blue Essentials	$138.24
Rate for Payer: BCBS of TX PPO	$153.60
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$276.48
Rate for Payer: Molina CHIP/Medicaid	$276.48
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: Parkland Medicaid	$276.48
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$276.48
Rate for Payer: Superior Health Plan EPO	$52.22

OTAH OT EVAL HIGH COMPLEXITY BCE

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	8978541
Hospital Revenue Code	434
Rate for Payer: Cash Price	$261.12

OTAH OT EVAL LOW COMPLEXITY BCE

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	8976540
Hospital Revenue Code	434
Min. Negotiated Rate	$25.98
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Molina CHIP/Medicaid	$137.52
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: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

OTAH OT EVAL LOW COMPLEXITY BCE

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	8976540
Hospital Revenue Code	434
Rate for Payer: Cash Price	$129.88

OTAH OT EVAL MOD COMPLEXITY BCE

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	8978540
Hospital Revenue Code	434
Rate for Payer: Cash Price	$195.84

OTAH OT EVAL MOD COMPLEXITY BCE

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	8978540
Hospital Revenue Code	434
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$207.36
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$86.40
Rate for Payer: BCBS of TX Blue Essentials	$103.68
Rate for Payer: BCBS of TX PPO	$115.20
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$207.36
Rate for Payer: Molina CHIP/Medicaid	$207.36
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: Parkland Medicaid	$207.36
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$39.17

OTAH OT Iontophoresis Units BCE

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	8993016
Hospital Revenue Code	430
Rate for Payer: Cash Price	$75.48

OTAH OT Iontophoresis Units BCE

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	8993016
Hospital Revenue Code	430
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

OTAH OT Neuromuscular Reeducation Units BCE

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	8995057
Hospital Revenue Code	430
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$38.70
Rate for Payer: BCBS of TX Blue Essentials	$46.44
Rate for Payer: BCBS of TX PPO	$51.60
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$92.88
Rate for Payer: Molina CHIP/Medicaid	$92.88
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: Parkland Medicaid	$92.88
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.88
Rate for Payer: Superior Health Plan EPO	$17.54

OTAH OT Neuromuscular Reeducation Units BCE

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	8995057
Hospital Revenue Code	430
Rate for Payer: Cash Price	$87.72

OTAH OT Orthotic Management, Train Units BCE

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	8995059
Hospital Revenue Code	430
Rate for Payer: Cash Price	$119.00

OTAH OT Orthotic Management, Train Units BCE

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	8995059
Hospital Revenue Code	430
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Molina CHIP/Medicaid	$126.00
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: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$23.80

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	$180.00
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
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.72
Rate for Payer: Superior Health Plan EPO	$22.24

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 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 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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.32
Rate for Payer: Superior Health Plan EPO	$24.62

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 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.00
Rate for Payer: Superior Health Plan EPO	$17.00

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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.36
Rate for Payer: Superior Health Plan EPO	$25.57

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 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	$180.00
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

Know your out-of-pocket cost for care.

All Charges