White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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 Assistant Units

Facility

$142.00

Service Code	HCPCS 97018
Hospital Charge Code	5810008
Hospital Revenue Code	430
Min. Negotiated Rate	$12.78
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	$180.00
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 Paraffin Bath Units

Facility

$142.00

Service Code	HCPCS 97018
Hospital Charge Code	4270011
Hospital Revenue Code	430
Min. Negotiated Rate	$12.78
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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$102.24
Rate for Payer: Superior Health Plan EPO	$19.31

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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.32
Rate for Payer: Superior Health Plan EPO	$24.62

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 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	$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

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	$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

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

OT Self Care, Home Management Units

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	4300489
Hospital Revenue Code	430
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

OT Self Care, Home Mgmt Assistant Units

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	4300014
Hospital Revenue Code	430
Rate for Payer: Cash Price	$85.00

OT Self Care, Home Mgmt Assistant Units

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	4300014
Hospital Revenue Code	430
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

OT Therapeutic Activities Assistant Units

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	4300010
Hospital Revenue Code	430
Rate for Payer: Cash Price	$127.84

OT Therapeutic Activities Assistant Units

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	4300010
Hospital Revenue Code	430
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

OT Therapeutic Activities Units

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	4300307
Hospital Revenue Code	430
Rate for Payer: Cash Price	$127.84

OT Therapeutic Activities Units

Facility

$188.00

Service Code	HCPCS 97530
Hospital Charge Code	4300307
Hospital Revenue Code	430
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

OT Therapeutic Exercise Assistant Units

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	4300011
Hospital Revenue Code	430
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

OT Therapeutic Exercise Assistant Units

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	4300011
Hospital Revenue Code	430
Rate for Payer: Cash Price	$103.36

OT Therapeutic Exercise Units

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	4300414
Hospital Revenue Code	430
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

OT Therapeutic Exercise Units

Facility

$152.00

Service Code	HCPCS 97110
Hospital Charge Code	4300414
Hospital Revenue Code	430
Rate for Payer: Cash Price	$103.36

OT Ultrasound Assistant Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4300002
Hospital Revenue Code	430
Rate for Payer: Cash Price	$74.80

OT Ultrasound Assistant Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4300002
Hospital Revenue Code	430
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

Know your out-of-pocket cost for care.

All Charges