White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$14,025.80

Service Code	MSDRG 153
Min. Negotiated Rate	$6,121.48
Max. Negotiated Rate	$14,025.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,170.37
Rate for Payer: Amerigroup Medicare	$10,170.37
Rate for Payer: BCBS of TX Medicare	$10,170.37
Rate for Payer: Cigna Commercial	$9,508.02
Rate for Payer: Cigna Medicare	$10,170.37
Rate for Payer: Employer Direct Commercial	$10,170.37
Rate for Payer: Humana Medicare/TRICARE	$10,170.37
Rate for Payer: Molina Dual Medicare/Medicaid	$10,170.37
Rate for Payer: Molina Medicare	$10,170.37
Rate for Payer: Multiplan Auto	$14,025.80
Rate for Payer: Multiplan Commercial	$14,025.80
Rate for Payer: Multiplan Workers Comp	$14,025.80
Rate for Payer: Scott and White EPO/PPO	$6,459.25
Rate for Payer: Scott and White Medicare	$10,170.37
Rate for Payer: Superior Health Plan EPO	$10,170.37
Rate for Payer: Superior Health Plan Medicare	$10,170.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,170.37
Rate for Payer: Universal American Medicare	$10,170.37
Rate for Payer: Wellcare Medicare	$10,170.37
Rate for Payer: Wellmed Medicare	$10,170.37

OTITIS MEDIA & URI W MCC

Facility

$22,461.80

Service Code	MSDRG 152
Min. Negotiated Rate	$8,962.06
Max. Negotiated Rate	$22,461.80
Rate for Payer: BCBS of TX Blue Advantage	$8,962.06
Rate for Payer: BCBS of TX Blue Essentials	$10,753.43
Rate for Payer: BCBS of TX PPO	$11,948.72

OTITIS MEDIA & URI W/O MCC

Facility

$14,025.80

Service Code	MSDRG 153
Min. Negotiated Rate	$6,121.48
Max. Negotiated Rate	$14,025.80
Rate for Payer: BCBS of TX Blue Advantage	$6,121.48
Rate for Payer: BCBS of TX Blue Essentials	$7,345.06
Rate for Payer: BCBS of TX PPO	$8,161.50

OT Manual Therapy Assistant Units

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	4300006
Hospital Revenue Code	430
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

OT Manual Therapy Assistant Units

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	4300006
Hospital Revenue Code	430
Rate for Payer: Cash Price	$92.48

OT Manual Therapy Units

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	4300117
Hospital Revenue Code	430
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

OT Manual Therapy Units

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	4300117
Hospital Revenue Code	430
Rate for Payer: Cash Price	$92.48

OT Neuromuscular Reeducation Assistant Units

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	4300009
Hospital Revenue Code	430
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

OT Neuromuscular Reeducation Assistant Units

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	4300009
Hospital Revenue Code	430
Rate for Payer: Cash Price	$87.72

OT Neuromuscular Reeducation Units

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	4300125
Hospital Revenue Code	430
Rate for Payer: Cash Price	$87.72

OT Neuromuscular Reeducation Units

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	4300125
Hospital Revenue Code	430
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

OT Non-Selective Wound Debridement Assistant Units

Facility

$358.00

Service Code	HCPCS 97602
Hospital Charge Code	5817623
Hospital Revenue Code	430
Rate for Payer: Cash Price	$243.44

OT Non-Selective Wound Debridement Assistant Units

Facility

$358.00

Service Code	HCPCS 97602
Hospital Charge Code	5817623
Hospital Revenue Code	430
Min. Negotiated Rate	$32.22
Max. Negotiated Rate	$257.76
Rate for Payer: Amerigroup CHIP/Medicaid	$32.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$107.40
Rate for Payer: BCBS of TX Blue Essentials	$128.88
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$143.20
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cash Price	$243.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$257.76
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	$257.76
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$232.70
Rate for Payer: Multiplan Commercial	$232.70
Rate for Payer: Multiplan Workers Comp	$232.70
Rate for Payer: Parkland Medicaid	$257.76
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$257.76
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

Otolaryngologic examination under general anesthesia

Facility

$10,000.00

Service Code	CPT 69210
Hospital Charge Code	36069210
Hospital Revenue Code	360
Min. Negotiated Rate	$59.26
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
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: Scott and White EPO/PPO	$109.63
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

Otolaryngologic examination under general anesthesia

Facility

$359.10

Service Code	HCPCS 69210
Hospital Charge Code	8914559
Hospital Revenue Code	360
Min. Negotiated Rate	$32.32
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$32.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cash Price	$244.19
Rate for Payer: Cash Price	$244.19
Rate for Payer: Cash Price	$244.19
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$258.55
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$258.55
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
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	$258.55
Rate for Payer: Scott and White EPO/PPO	$109.63
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$258.55
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

Otolaryngologic examination under general anesthesia

Facility

$359.10

Service Code	HCPCS 69210
Hospital Charge Code	8914559
Hospital Revenue Code	360
Rate for Payer: Cash Price	$244.19

Otolaryngologic examination under general anesthesia

Facility

$359.10

Service Code	HCPCS 69210
Hospital Charge Code	9900884
Hospital Revenue Code	360
Rate for Payer: Cash Price	$244.19

Otolaryngologic examination under general anesthesia

Facility

$359.10

Service Code	HCPCS 69210
Hospital Charge Code	9900884
Hospital Revenue Code	360
Min. Negotiated Rate	$32.32
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$32.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$59.26
Rate for Payer: Amerigroup Medicare	$59.26
Rate for Payer: BCBS of TX Blue Advantage	$91.87
Rate for Payer: BCBS of TX Blue Essentials	$110.02
Rate for Payer: BCBS of TX Medicare	$59.26
Rate for Payer: BCBS of TX PPO	$138.63
Rate for Payer: Cash Price	$244.19
Rate for Payer: Cash Price	$244.19
Rate for Payer: Cash Price	$244.19
Rate for Payer: Cigna Commercial	$125.27
Rate for Payer: Cigna Medicaid	$258.55
Rate for Payer: Cigna Medicare	$59.26
Rate for Payer: Employer Direct Commercial	$59.26
Rate for Payer: Humana Medicare/TRICARE	$59.26
Rate for Payer: Molina CHIP/Medicaid	$258.55
Rate for Payer: Molina Dual Medicare/Medicaid	$59.26
Rate for Payer: Molina Medicare	$59.26
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	$258.55
Rate for Payer: Scott and White EPO/PPO	$109.63
Rate for Payer: Scott and White Medicare	$59.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$258.55
Rate for Payer: Superior Health Plan EPO	$59.26
Rate for Payer: Superior Health Plan Medicare	$59.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$59.26
Rate for Payer: Universal American Medicare	$59.26
Rate for Payer: Wellcare Medicare	$59.26
Rate for Payer: Wellmed Medicare	$59.26

OT Orthotic Management, Train Assistant Units

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	4300015
Hospital Revenue Code	430
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

OT Orthotic Management, Train Assistant Units

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	4300015
Hospital Revenue Code	430
Rate for Payer: Cash Price	$119.00

OT Orthotic Management, Train Units

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	4305070
Hospital Revenue Code	430
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

OT Orthotic Management, Train Units

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	4305070
Hospital Revenue Code	430
Rate for Payer: Cash Price	$119.00

OT Orthotic/Prosthetic Manage,Train Assistant Units

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	4300019
Hospital Revenue Code	430
Rate for Payer: Cash Price	$137.36

OT Orthotic/Prosthetic Manage,Train Assistant Units

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	4300019
Hospital Revenue Code	430
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

OT Orthotic, Prosthetic Use, Check Out

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	4305106
Hospital Revenue Code	430
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

Know your out-of-pocket cost for care.

All Charges