White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTAH PT Selective Wound Debridement <20cm Assist Units BCE

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	9238571
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 Selective Wound Debridement <20cm Units BCE

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	9238570
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

OTAH PT Selective Wound Debridement <20cm Units BCE

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	9238570
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 Selective Wound Debridement Addtl 20cm Units BCE

Facility

$351.00

Service Code	HCPCS 97598 GP
Hospital Charge Code	9238572
Hospital Revenue Code	420
Rate for Payer: Cash Price	$238.68

OTAH PT Selective Wound Debridement Addtl 20cm Units BCE

Facility

$351.00

Service Code	HCPCS 97598 GP
Hospital Charge Code	9238572
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 Self Care, Home Management Assistant Units BCE

Facility

$125.00

Service Code	HCPCS 97535 GP
Hospital Charge Code	9238575
Hospital Revenue Code	420
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 PT Self Care, Home Management Assistant Units BCE

Facility

$125.00

Service Code	HCPCS 97535 GP
Hospital Charge Code	9238575
Hospital Revenue Code	420
Rate for Payer: Cash Price	$85.00

OTAH PT Self Care, Home Management Units BCE

Facility

$125.00

Service Code	HCPCS 97535 GP
Hospital Charge Code	9238574
Hospital Revenue Code	420
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 PT Self Care, Home Management Units BCE

Facility

$125.00

Service Code	HCPCS 97535 GP
Hospital Charge Code	9238574
Hospital Revenue Code	420
Rate for Payer: Cash Price	$85.00

OTAH PT Therapeutic Activity Assistant Units BCE

Facility

$188.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	9238579
Hospital Revenue Code	420
Rate for Payer: Cash Price	$127.84

OTAH PT Therapeutic Activity Assistant Units BCE

Facility

$188.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	9238579
Hospital Revenue Code	420
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 PT Therapeutic Activity Units BCE

Facility

$188.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	9238578
Hospital Revenue Code	420
Rate for Payer: Cash Price	$127.84

OTAH PT Therapeutic Activity Units BCE

Facility

$188.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	9238578
Hospital Revenue Code	420
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 PT Therapeutic Exercise Assistant Units BCE

Facility

$152.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	9238577
Hospital Revenue Code	420
Rate for Payer: Cash Price	$103.36

OTAH PT Therapeutic Exercise Assistant Units BCE

Facility

$152.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	9238577
Hospital Revenue Code	420
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 PT Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	9238576
Hospital Revenue Code	420
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 PT Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	9238576
Hospital Revenue Code	420
Rate for Payer: Cash Price	$103.36

OTAH PT Ultrasound Assistant Units BCE

Facility

$110.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	9238581
Hospital Revenue Code	420
Rate for Payer: Cash Price	$74.80

OTAH PT Ultrasound Assistant Units BCE

Facility

$110.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	9238581
Hospital Revenue Code	420
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 PT Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	9238580
Hospital Revenue Code	420
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 PT Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	9238580
Hospital Revenue Code	420
Rate for Payer: Cash Price	$74.80

OTAH PT Unattended E-Stim Assistant Units BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	8993229
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

OTAH PT Unattended E-Stim Assistant Units BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	9238583
Hospital Revenue Code	420
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Molina CHIP/Medicaid	$115.20
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$21.76

OTAH PT Unattended E-Stim Assistant Units BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	9238583
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

OTAH PT Unattended E-Stim Assistant Units BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	8993229
Hospital Revenue Code	420
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.40
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Molina CHIP/Medicaid	$115.20
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$21.76

Know your out-of-pocket cost for care.

All Charges