White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTAH PT Evaluation Units, Low Complexity BCE

Facility

$127.00

Service Code	HCPCS 97161
Hospital Charge Code	9238546
Hospital Revenue Code	424
Rate for Payer: Cash Price	$86.36

OTAH PT Evaluation Units, Moderate Complexity BCE

Facility

$191.00

Service Code	HCPCS 97162
Hospital Charge Code	8992540
Hospital Revenue Code	424
Rate for Payer: Cash Price	$129.88

OTAH PT Evaluation Units, Moderate Complexity BCE

Facility

$191.00

Service Code	HCPCS 97162
Hospital Charge Code	8992540
Hospital Revenue Code	424
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 PT Gait Training Assistant Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	9238550
Hospital Revenue Code	420
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$45.90
Rate for Payer: BCBS of TX Blue Essentials	$55.08
Rate for Payer: BCBS of TX PPO	$61.20
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$110.16
Rate for Payer: Molina CHIP/Medicaid	$110.16
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Parkland Medicaid	$110.16
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$20.81

OTAH PT Gait Training Assistant Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	9238550
Hospital Revenue Code	420
Rate for Payer: Cash Price	$104.04

OTAH PT Gait Training Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	9238549
Hospital Revenue Code	420
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.77
Rate for Payer: BCBS of TX Blue Advantage	$45.90
Rate for Payer: BCBS of TX Blue Essentials	$55.08
Rate for Payer: BCBS of TX PPO	$61.20
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cash Price	$104.04
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$110.16
Rate for Payer: Molina CHIP/Medicaid	$110.16
Rate for Payer: Multiplan Auto	$99.45
Rate for Payer: Multiplan Commercial	$99.45
Rate for Payer: Multiplan Workers Comp	$99.45
Rate for Payer: Parkland Medicaid	$110.16
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.16
Rate for Payer: Superior Health Plan EPO	$20.81

OTAH PT Gait Training Units BCE

Facility

$153.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	9238549
Hospital Revenue Code	420
Rate for Payer: Cash Price	$104.04

OTAH PT Iontophoresis Units BCE

Facility

$111.00

Service Code	HCPCS 97033 GP
Hospital Charge Code	9238551
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 PT Iontophoresis Units BCE

Facility

$111.00

Service Code	HCPCS 97033 GP
Hospital Charge Code	9238551
Hospital Revenue Code	420
Rate for Payer: Cash Price	$75.48

OTAH PT Manual Therapy Assistant Units BCE

Facility

$136.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	9238554
Hospital Revenue Code	420
Rate for Payer: Cash Price	$92.48

OTAH PT Manual Therapy Assistant Units BCE

Facility

$136.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	9238554
Hospital Revenue Code	420
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

OTAH PT Manual Therapy Units BCE

Facility

$136.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	9238553
Hospital Revenue Code	420
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

OTAH PT Manual Therapy Units BCE

Facility

$136.00

Service Code	HCPCS 97140 GP
Hospital Charge Code	9238553
Hospital Revenue Code	420
Rate for Payer: Cash Price	$92.48

OTAH PT Mechanical Traction Assistant Units BCE

Facility

$182.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	9238556
Hospital Revenue Code	420
Rate for Payer: Cash Price	$123.76

OTAH PT Mechanical Traction Assistant Units BCE

Facility

$182.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	9238556
Hospital Revenue Code	420
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
Rate for Payer: BCBS of TX Blue Advantage	$54.60
Rate for Payer: BCBS of TX Blue Essentials	$65.52
Rate for Payer: BCBS of TX PPO	$72.80
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$131.04
Rate for Payer: Molina CHIP/Medicaid	$131.04
Rate for Payer: Multiplan Auto	$118.30
Rate for Payer: Multiplan Commercial	$118.30
Rate for Payer: Multiplan Workers Comp	$118.30
Rate for Payer: Parkland Medicaid	$131.04
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.04
Rate for Payer: Superior Health Plan EPO	$24.75

OTAH PT Mechanical Traction Units BCE

Facility

$182.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	9238555
Hospital Revenue Code	420
Rate for Payer: Cash Price	$123.76

OTAH PT Mechanical Traction Units BCE

Facility

$182.00

Service Code	HCPCS 97012 GP
Hospital Charge Code	9238555
Hospital Revenue Code	420
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
Rate for Payer: BCBS of TX Blue Advantage	$54.60
Rate for Payer: BCBS of TX Blue Essentials	$65.52
Rate for Payer: BCBS of TX PPO	$72.80
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cash Price	$123.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$131.04
Rate for Payer: Molina CHIP/Medicaid	$131.04
Rate for Payer: Multiplan Auto	$118.30
Rate for Payer: Multiplan Commercial	$118.30
Rate for Payer: Multiplan Workers Comp	$118.30
Rate for Payer: Parkland Medicaid	$131.04
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.04
Rate for Payer: Superior Health Plan EPO	$24.75

OTAH PT Negative-Pressure Wound Therapy <50cm Units BCE

Facility

$794.80

Service Code	HCPCS 97605
Hospital Charge Code	5707614
Hospital Revenue Code	361
Min. Negotiated Rate	$71.53
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$71.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$238.44
Rate for Payer: BCBS of TX Blue Essentials	$286.13
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$317.92
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cash Price	$540.46
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$572.26
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$572.26
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$572.26
Rate for Payer: Scott and White EPO/PPO	$397.40
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$572.26
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

OTAH PT Negative-Pressure Wound Therapy <50cm Units BCE

Facility

$794.80

Service Code	HCPCS 97605
Hospital Charge Code	5707614
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

OTAH PT Negative-Pressure Wound Therapy >50cm Units BCE

Facility

$400.00

Service Code	HCPCS 97606 GP
Hospital Charge Code	9238560
Hospital Revenue Code	420
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$288.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: BCBS of TX Blue Advantage	$120.00
Rate for Payer: BCBS of TX Blue Essentials	$144.00
Rate for Payer: BCBS of TX PPO	$160.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$288.00
Rate for Payer: Molina CHIP/Medicaid	$288.00
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Parkland Medicaid	$288.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$288.00
Rate for Payer: Superior Health Plan EPO	$54.40

OTAH PT Negative-Pressure Wound Therapy >50cm Units BCE

Facility

$400.00

Service Code	HCPCS 97606 GP
Hospital Charge Code	9238558
Hospital Revenue Code	420
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$288.00
Rate for Payer: Amerigroup CHIP/Medicaid	$36.00
Rate for Payer: BCBS of TX Blue Advantage	$120.00
Rate for Payer: BCBS of TX Blue Essentials	$144.00
Rate for Payer: BCBS of TX PPO	$160.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$288.00
Rate for Payer: Molina CHIP/Medicaid	$288.00
Rate for Payer: Multiplan Auto	$260.00
Rate for Payer: Multiplan Commercial	$260.00
Rate for Payer: Multiplan Workers Comp	$260.00
Rate for Payer: Parkland Medicaid	$288.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$288.00
Rate for Payer: Superior Health Plan EPO	$54.40

OTAH PT Negative-Pressure Wound Therapy >50cm Units BCE

Facility

$400.00

Service Code	HCPCS 97606 GP
Hospital Charge Code	9238560
Hospital Revenue Code	420
Rate for Payer: Cash Price	$272.00

OTAH PT Negative-Pressure Wound Therapy >50cm Units BCE

Facility

$400.00

Service Code	HCPCS 97606 GP
Hospital Charge Code	9238558
Hospital Revenue Code	420
Rate for Payer: Cash Price	$272.00

OTAH PT Neg-Pressure Wound Therapy <50cm Assist Units BCE

Facility

$794.80

Service Code	HCPCS 97605
Hospital Charge Code	9238559
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

OTAH PT Neg-Pressure Wound Therapy <50cm Assist Units BCE

Facility

$794.80

Service Code	HCPCS 97605
Hospital Charge Code	9238557
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

Know your out-of-pocket cost for care.

All Charges