White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$40.41
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	$40.41
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
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	$45.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.36
Rate for Payer: Superior Health Plan EPO	$25.57

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 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	$45.36
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
Rate for Payer: Cash Price	$103.36

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	$36.29
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
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

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
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

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 Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4300448
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	$17.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.20
Rate for Payer: Superior Health Plan EPO	$14.96

OT Ultrasound Units

Facility

$110.00

Service Code	HCPCS 97035
Hospital Charge Code	4300448
Hospital Revenue Code	430
Rate for Payer: Cash Price	$74.80

OT Unattended E-Stim Assistant Units

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	4300007
Hospital Revenue Code	430
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

OT Unattended E-Stim Assistant Units

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	4300007
Hospital Revenue Code	430
Rate for Payer: Cash Price	$108.80

OT Unattended E-Stim Units

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	4300041
Hospital Revenue Code	430
Rate for Payer: Cash Price	$108.80

OT Unattended E-Stim Units

Facility

$160.00

Service Code	HCPCS 97014
Hospital Charge Code	4300041
Hospital Revenue Code	430
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

Ova + Parasite Exam SO

Facility

$155.00

Service Code	HCPCS 87177
Hospital Charge Code	1604081
Hospital Revenue Code	306
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$111.60
Rate for Payer: Amerigroup CHIP/Medicaid	$3.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.90
Rate for Payer: Amerigroup Medicare	$8.90
Rate for Payer: BCBS of TX Blue Advantage	$46.50
Rate for Payer: BCBS of TX Blue Essentials	$55.80
Rate for Payer: BCBS of TX Medicare	$8.90
Rate for Payer: BCBS of TX PPO	$62.00
Rate for Payer: Cash Price	$105.40
Rate for Payer: Cash Price	$105.40
Rate for Payer: Cigna Medicaid	$111.60
Rate for Payer: Cigna Medicare	$8.90
Rate for Payer: Employer Direct Commercial	$8.90
Rate for Payer: Humana Medicare/TRICARE	$8.90
Rate for Payer: Molina CHIP/Medicaid	$111.60
Rate for Payer: Molina Dual Medicare/Medicaid	$8.90
Rate for Payer: Molina Medicare	$8.90
Rate for Payer: Multiplan Auto	$100.75
Rate for Payer: Multiplan Commercial	$100.75
Rate for Payer: Multiplan Workers Comp	$100.75
Rate for Payer: Parkland Medicaid	$111.60
Rate for Payer: Scott and White EPO/PPO	$11.12
Rate for Payer: Scott and White Medicare	$8.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.60
Rate for Payer: Superior Health Plan EPO	$8.90
Rate for Payer: Superior Health Plan Medicare	$8.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.90
Rate for Payer: Universal American Medicare	$8.90
Rate for Payer: Wellcare Medicare	$8.90
Rate for Payer: Wellmed Medicare	$8.90

Ova + Parasite Exam SO

Facility

$155.00

Service Code	HCPCS 87177
Hospital Charge Code	1604081
Hospital Revenue Code	306
Rate for Payer: Cash Price	$105.40

OVERTUBE, ENDOSCOPIC GASTRIC 8.6-10.0MM 25CM L -- DHF

Facility

$753.64

Hospital Charge Code	80321474
Hospital Revenue Code	272
Rate for Payer: Cash Price	$512.48

OVERTUBE, ENDOSCOPIC GASTRIC 8.6-10.0MM 25CM L -- DHF

Facility

$753.64

Hospital Charge Code	80321474
Hospital Revenue Code	272
Min. Negotiated Rate	$67.83
Max. Negotiated Rate	$542.62
Rate for Payer: Amerigroup CHIP/Medicaid	$67.83
Rate for Payer: BCBS of TX Blue Advantage	$226.09
Rate for Payer: BCBS of TX Blue Essentials	$271.31
Rate for Payer: BCBS of TX PPO	$301.46
Rate for Payer: Cash Price	$512.48
Rate for Payer: Cigna Medicaid	$542.62
Rate for Payer: Molina CHIP/Medicaid	$542.62
Rate for Payer: Multiplan Auto	$489.87
Rate for Payer: Multiplan Commercial	$489.87
Rate for Payer: Multiplan Workers Comp	$489.87
Rate for Payer: Parkland Medicaid	$542.62
Rate for Payer: Scott and White EPO/PPO	$376.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$542.62
Rate for Payer: Superior Health Plan EPO	$102.50

OXcarbazepine 300 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77739502
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

OXcarbazepine 300 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77739502
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

Know your out-of-pocket cost for care.

All Charges