White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$103.49
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	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	$103.49
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	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	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	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	$103.49
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	$58.96
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	$58.96
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
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	$64.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.44
Rate for Payer: Superior Health Plan EPO	$27.47

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 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	$64.74
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
Rate for Payer: Cash Price	$137.36

OT Paraffin Bath Assistant Units

Facility

$142.00

Service Code	HCPCS 97018
Hospital Charge Code	5810008
Hospital Revenue Code	430
Min. Negotiated Rate	$6.96
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$42.60
Rate for Payer: BCBS of TX Blue Essentials	$51.12
Rate for Payer: BCBS of TX PPO	$56.80
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$102.24
Rate for Payer: Molina CHIP/Medicaid	$102.24
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$102.24
Rate for Payer: Scott and White EPO/PPO	$6.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.24
Rate for Payer: Superior Health Plan EPO	$19.31

OT Paraffin Bath Assistant Units

Facility

$142.00

Service Code	HCPCS 97018
Hospital Charge Code	5810008
Hospital Revenue Code	430
Rate for Payer: Cash Price	$96.56

OT Paraffin Bath Units

Facility

$142.00

Service Code	HCPCS 97018
Hospital Charge Code	4270011
Hospital Revenue Code	430
Min. Negotiated Rate	$6.96
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.78
Rate for Payer: BCBS of TX Blue Advantage	$42.60
Rate for Payer: BCBS of TX Blue Essentials	$51.12
Rate for Payer: BCBS of TX PPO	$56.80
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cash Price	$96.56
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$102.24
Rate for Payer: Molina CHIP/Medicaid	$102.24
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$102.24
Rate for Payer: Scott and White EPO/PPO	$6.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.24
Rate for Payer: Superior Health Plan EPO	$19.31

OT Paraffin Bath Units

Facility

$142.00

Service Code	HCPCS 97018
Hospital Charge Code	4270011
Hospital Revenue Code	430
Rate for Payer: Cash Price	$96.56

OT Re-Evaluation Units, 97168

Facility

$181.00

Service Code	HCPCS 97168
Hospital Charge Code	4305103
Hospital Revenue Code	434
Rate for Payer: Cash Price	$123.08

OT Re-Evaluation Units, 97168

Facility

$181.00

Service Code	HCPCS 97168
Hospital Charge Code	4305103
Hospital Revenue Code	434
Min. Negotiated Rate	$24.62
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$54.30
Rate for Payer: BCBS of TX Blue Essentials	$65.16
Rate for Payer: BCBS of TX PPO	$72.40
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cash Price	$123.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$130.32
Rate for Payer: Molina CHIP/Medicaid	$130.32
Rate for Payer: Multiplan Auto	$117.65
Rate for Payer: Multiplan Commercial	$117.65
Rate for Payer: Multiplan Workers Comp	$117.65
Rate for Payer: Parkland Medicaid	$130.32
Rate for Payer: Scott and White EPO/PPO	$86.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.32
Rate for Payer: Superior Health Plan EPO	$24.62

OT Selective Wound Debride Addtl 20cm Assist Units

Facility

$351.00

Service Code	HCPCS 97598
Hospital Charge Code	5817598
Hospital Revenue Code	430
Min. Negotiated Rate	$29.85
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	$29.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$252.72
Rate for Payer: Superior Health Plan EPO	$47.74

OT Selective Wound Debride Addtl 20cm Assist Units

Facility

$351.00

Service Code	HCPCS 97598
Hospital Charge Code	5817598
Hospital Revenue Code	430
Rate for Payer: Cash Price	$238.68

OT Selective Wound Debridement <20cm AssistUnits

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	5807597
Hospital Revenue Code	361
Min. Negotiated Rate	$43.09
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	$43.09
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

OT Selective Wound Debridement <20cm AssistUnits

Facility

$794.80

Service Code	HCPCS 97597
Hospital Charge Code	5807597
Hospital Revenue Code	361
Rate for Payer: Cash Price	$540.46

OT Self Care, Home Management Units

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	4300489
Hospital Revenue Code	430
Rate for Payer: Cash Price	$85.00

Know your out-of-pocket cost for care.

All Charges