White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.76
Rate for Payer: Superior Health Plan EPO	$21.49

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 PTA Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	HCPCS 97033 GP
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	$180.00
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 GP
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	$180.00
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 GP
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 GP
Hospital Charge Code	8997087
Hospital Revenue Code	420
Rate for Payer: Cash Price	$75.48

OTAH PT Aquatic Assistant Units BCE

Facility

$137.00

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

OTAH PT Aquatic Assistant Units BCE

Facility

$137.00

Service Code	HCPCS 97113 GP
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	$180.00
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 GP
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	$180.00
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 GP
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 GP
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

OTAH PT Attended E-Stim Assistant Units BCE

Facility

$139.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	9238543
Hospital Revenue Code	420
Rate for Payer: Cash Price	$94.52

OTAH PT Attended E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	9238542
Hospital Revenue Code	420
Rate for Payer: Cash Price	$94.52

OTAH PT Attended E-Stim Units BCE

Facility

$139.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	9238542
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

OTAH PTA Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	9018973
Hospital Revenue Code	420
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.76
Rate for Payer: Superior Health Plan EPO	$21.49

OTAH PTA Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	9018973
Hospital Revenue Code	420
Rate for Payer: Cash Price	$107.44

OTAH PT Biofeedback Assistant Units BCE

Facility

$448.00

Service Code	HCPCS 90901 GP
Hospital Charge Code	9238545
Hospital Revenue Code	420
Rate for Payer: Cash Price	$304.64

OTAH PT Biofeedback Assistant Units BCE

Facility

$448.00

Service Code	HCPCS 90901 GP
Hospital Charge Code	9238545
Hospital Revenue Code	420
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$322.56
Rate for Payer: Amerigroup CHIP/Medicaid	$40.32
Rate for Payer: BCBS of TX Blue Advantage	$134.40
Rate for Payer: BCBS of TX Blue Essentials	$161.28
Rate for Payer: BCBS of TX PPO	$179.20
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$322.56
Rate for Payer: Molina CHIP/Medicaid	$322.56
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Parkland Medicaid	$322.56
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$322.56
Rate for Payer: Superior Health Plan EPO	$60.93

OTAH PT Biofeedback Units BCE

Facility

$448.00

Service Code	HCPCS 90901 GP
Hospital Charge Code	9238544
Hospital Revenue Code	420
Rate for Payer: Cash Price	$304.64

OTAH PT Biofeedback Units BCE

Facility

$448.00

Service Code	HCPCS 90901 GP
Hospital Charge Code	9238544
Hospital Revenue Code	420
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$322.56
Rate for Payer: Amerigroup CHIP/Medicaid	$40.32
Rate for Payer: BCBS of TX Blue Advantage	$134.40
Rate for Payer: BCBS of TX Blue Essentials	$161.28
Rate for Payer: BCBS of TX PPO	$179.20
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$322.56
Rate for Payer: Molina CHIP/Medicaid	$322.56
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Parkland Medicaid	$322.56
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$322.56
Rate for Payer: Superior Health Plan EPO	$60.93

OTAH PT Evaluation Units, High Complexity BCE

Facility

$288.00

Service Code	HCPCS 97163
Hospital Charge Code	9238548
Hospital Revenue Code	424
Rate for Payer: Cash Price	$195.84

OTAH PT Evaluation Units, High Complexity BCE

Facility

$288.00

Service Code	HCPCS 97163
Hospital Charge Code	9238548
Hospital Revenue Code	424
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 PT Evaluation Units, Low Complexity BCE

Facility

$127.00

Service Code	HCPCS 97161
Hospital Charge Code	9238546
Hospital Revenue Code	424
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$38.10
Rate for Payer: BCBS of TX Blue Essentials	$45.72
Rate for Payer: BCBS of TX PPO	$50.80
Rate for Payer: Cash Price	$86.36
Rate for Payer: Cash Price	$86.36
Rate for Payer: Cash Price	$86.36
Rate for Payer: Cash Price	$86.36
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$91.44
Rate for Payer: Molina CHIP/Medicaid	$91.44
Rate for Payer: Multiplan Auto	$82.55
Rate for Payer: Multiplan Commercial	$82.55
Rate for Payer: Multiplan Workers Comp	$82.55
Rate for Payer: Parkland Medicaid	$91.44
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$91.44
Rate for Payer: Superior Health Plan EPO	$17.27

Know your out-of-pocket cost for care.

All Charges