White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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
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 Neg-Pressure Wound Therapy >50cm Assist Units BCE

Facility

$400.00

Service Code	HCPCS 97606 GP
Hospital Charge Code	7150626
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 Neg-Pressure Wound Therapy >50cm Assist Units BCE

Facility

$400.00

Service Code	HCPCS 97606 GP
Hospital Charge Code	7150626
Hospital Revenue Code	420
Rate for Payer: Cash Price	$272.00

OTAH PT Neuromuscular Reeducation Assistant Units BCE

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	9238562
Hospital Revenue Code	420
Rate for Payer: Cash Price	$87.72

OTAH PT Neuromuscular Reeducation Assistant Units BCE

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	9238562
Hospital Revenue Code	420
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 PT Neuromuscular Reeducation Units BCE

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	9238561
Hospital Revenue Code	420
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 PT Neuromuscular Reeducation Units BCE

Facility

$129.00

Service Code	HCPCS 97112 GP
Hospital Charge Code	9238561
Hospital Revenue Code	420
Rate for Payer: Cash Price	$87.72

OTAH PT Orthotic Management, Train Assistant Units BCE

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	9238564
Hospital Revenue Code	420
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 PT Orthotic Management, Train Assistant Units BCE

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	9238564
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

OTAH PT Orthotic Management, Train Units BCE

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	9238563
Hospital Revenue Code	420
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 PT Orthotic Management, Train Units BCE

Facility

$175.00

Service Code	HCPCS 97760 GP
Hospital Charge Code	9238563
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

OTAH PT Orthotic/Prosthetic Manage,Train Assistant Units BCE

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	9238566
Hospital Revenue Code	420
Rate for Payer: Cash Price	$137.36

OTAH PT Orthotic/Prosthetic Manage,Train Assistant Units BCE

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	9238566
Hospital Revenue Code	420
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 PT Orthotic Prosthetic Manage, Train Units BCE

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	9238565
Hospital Revenue Code	420
Rate for Payer: Cash Price	$137.36

OTAH PT Orthotic Prosthetic Manage, Train Units BCE

Facility

$202.00

Service Code	HCPCS 97763 GP
Hospital Charge Code	9238565
Hospital Revenue Code	420
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 PT Physical Performance Assistant Test BCE

Facility

$275.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	9238568
Hospital Revenue Code	420
Rate for Payer: Cash Price	$187.00

OTAH PT Physical Performance Assistant Test BCE

Facility

$275.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	9238568
Hospital Revenue Code	420
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
Rate for Payer: BCBS of TX Blue Advantage	$82.50
Rate for Payer: BCBS of TX Blue Essentials	$99.00
Rate for Payer: BCBS of TX PPO	$110.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$198.00
Rate for Payer: Molina CHIP/Medicaid	$198.00
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Parkland Medicaid	$198.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.00
Rate for Payer: Superior Health Plan EPO	$37.40

OTAH PT Physical Performance Test BCE

Facility

$275.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	9238567
Hospital Revenue Code	420
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$24.75
Rate for Payer: BCBS of TX Blue Advantage	$82.50
Rate for Payer: BCBS of TX Blue Essentials	$99.00
Rate for Payer: BCBS of TX PPO	$110.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cash Price	$187.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$198.00
Rate for Payer: Molina CHIP/Medicaid	$198.00
Rate for Payer: Multiplan Auto	$178.75
Rate for Payer: Multiplan Commercial	$178.75
Rate for Payer: Multiplan Workers Comp	$178.75
Rate for Payer: Parkland Medicaid	$198.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.00
Rate for Payer: Superior Health Plan EPO	$37.40

OTAH PT Physical Performance Test BCE

Facility

$275.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	9238567
Hospital Revenue Code	420
Rate for Payer: Cash Price	$187.00

OTAH PT Re-Evaluation Units, 97164 BCE

Facility

$127.00

Service Code	HCPCS 97164
Hospital Charge Code	9238569
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

OTAH PT Re-Evaluation Units, 97164 BCE

Facility

$127.00

Service Code	HCPCS 97164
Hospital Charge Code	9238569
Hospital Revenue Code	424
Rate for Payer: Cash Price	$86.36

OTAH PT Selective Wound Debride Addtl 20cm Assist Units BCE

Facility

$351.00

Service Code	HCPCS 97598 GP
Hospital Charge Code	9238573
Hospital Revenue Code	420
Rate for Payer: Cash Price	$238.68

OTAH PT Selective Wound Debride Addtl 20cm Assist Units BCE

Facility

$351.00

Service Code	HCPCS 97598 GP
Hospital Charge Code	9238573
Hospital Revenue Code	420
Min. Negotiated Rate	$31.59
Max. Negotiated Rate	$252.72
Rate for Payer: Amerigroup CHIP/Medicaid	$31.59
Rate for Payer: BCBS of TX Blue Advantage	$105.30
Rate for Payer: BCBS of TX Blue Essentials	$126.36
Rate for Payer: BCBS of TX PPO	$140.40
Rate for Payer: Cash Price	$238.68
Rate for Payer: Cash Price	$238.68
Rate for Payer: Cash Price	$238.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$252.72
Rate for Payer: Molina CHIP/Medicaid	$252.72
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: Parkland Medicaid	$252.72
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.72
Rate for Payer: Superior Health Plan EPO	$47.74

OTAH PT Selective Wound Debridement <20cm Assist Units BCE

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	9238571
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

Know your out-of-pocket cost for care.

All Charges