White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTAH PT Therapeutic Exercise Assistant Units BCE

Facility

$152.00

Service Code	HCPCS 97110
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	$36.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.44
Rate for Payer: Superior Health Plan EPO	$20.67

OTAH PT Therapeutic Exercise Assistant Units BCE

Facility

$152.00

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

OTAH PT Therapeutic Exercise Units BCE

Facility

$152.00

Service Code	HCPCS 97110
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	$36.29
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
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
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	$17.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

OTAH PT Ultrasound Assistant Units BCE

Facility

$110.00

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

OTAH PT Ultrasound Units BCE

Facility

$110.00

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

OTAH PT Ultrasound Units BCE

Facility

$110.00

Service Code	HCPCS 97035
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	$17.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

OTAH PT Unattended E-Stim Assistant Units BCE

Facility

$160.00

Service Code	HCPCS 97014
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
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
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

OTAH PT Unattended E-Stim Assistant Units BCE

Facility

$160.00

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

OTAH PT Unattended E-Stim Units BCE

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	8993231
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 Units BCE

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	9238582
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 Units BCE

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	9238582
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

OTAH PT Unattended E-Stim Units BCE

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	8993231
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

OTAH PT Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542
Hospital Charge Code	9016973
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	$39.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.76
Rate for Payer: Superior Health Plan EPO	$21.49

OTAH PT Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542
Hospital Charge Code	9016973
Hospital Revenue Code	420
Rate for Payer: Cash Price	$107.44

OTAH PT Work Hardening-Each Addl Hour Assistant Units BCE

Facility

$175.00

Service Code	HCPCS 97546
Hospital Charge Code	9238585
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

OTAH PT Work Hardening-Each Addl Hour Assistant Units BCE

Facility

$175.00

Service Code	HCPCS 97546
Hospital Charge Code	9238585
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 Work Hardening-Each Addl Hour Units BCE

Facility

$175.00

Service Code	HCPCS 97546
Hospital Charge Code	9238584
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 Work Hardening-Each Addl Hour Units BCE

Facility

$175.00

Service Code	HCPCS 97546
Hospital Charge Code	9238584
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

OTAH SLP Auditory Processing Tx Units BCE

Facility

$326.00

Service Code	HCPCS 92507
Hospital Charge Code	9280551
Hospital Revenue Code	441
Rate for Payer: Cash Price	$221.68

OTAH SLP Auditory Processing Tx Units BCE

Facility

$326.00

Service Code	HCPCS 92507
Hospital Charge Code	9280551
Hospital Revenue Code	441
Min. Negotiated Rate	$44.34
Max. Negotiated Rate	$234.72
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$97.80
Rate for Payer: BCBS of TX Blue Essentials	$117.36
Rate for Payer: BCBS of TX PPO	$130.40
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$234.72
Rate for Payer: Molina CHIP/Medicaid	$234.72
Rate for Payer: Multiplan Auto	$211.90
Rate for Payer: Multiplan Commercial	$211.90
Rate for Payer: Multiplan Workers Comp	$211.90
Rate for Payer: Parkland Medicaid	$234.72
Rate for Payer: Scott and White EPO/PPO	$94.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$234.72
Rate for Payer: Superior Health Plan EPO	$44.34

OTAH SLP Behavioral, Qualitative Analysis Units BCE

Facility

$521.00

Service Code	HCPCS 92524
Hospital Charge Code	9280546
Hospital Revenue Code	444
Rate for Payer: Cash Price	$354.28

Know your out-of-pocket cost for care.

All Charges