White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SLEEVE SKIN ARM REGULAR

Facility

$16.34

Hospital Charge Code	8576467
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14.38

SLEVE ALLERGAN -- DHF

Facility

$42.83

Hospital Charge Code	81850901
Hospital Revenue Code	270
Rate for Payer: Cash Price	$37.69

SLEVE ALLERGAN -- DHF

Facility

$42.83

Hospital Charge Code	81850901
Hospital Revenue Code	270
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$27.84
Rate for Payer: Aetna Commercial	$23.56
Rate for Payer: Amerigroup CHIP/Medicaid	$3.85
Rate for Payer: BCBS of TX Blue Advantage	$12.85
Rate for Payer: BCBS of TX Blue Essentials	$15.42
Rate for Payer: BCBS of TX PPO	$17.13
Rate for Payer: Cash Price	$37.69
Rate for Payer: Multiplan Auto	$27.84
Rate for Payer: Multiplan Commercial	$27.84
Rate for Payer: Multiplan Workers Comp	$27.84
Rate for Payer: Scott and White EPO/PPO	$21.41
Rate for Payer: Superior Health Plan EPO	$5.82

SLING, ARM COMFORT BLUE SM -- DHF

Facility

$96.69

Service Code	HCPCS A4565
Hospital Charge Code	81144453
Hospital Revenue Code	271
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$62.85
Rate for Payer: Aetna Commercial	$53.18
Rate for Payer: Amerigroup CHIP/Medicaid	$8.70
Rate for Payer: BCBS of TX Blue Advantage	$12.96
Rate for Payer: BCBS of TX Blue Essentials	$15.56
Rate for Payer: BCBS of TX PPO	$17.25
Rate for Payer: Cash Price	$85.09
Rate for Payer: Cash Price	$85.09
Rate for Payer: Multiplan Auto	$62.85
Rate for Payer: Multiplan Commercial	$62.85
Rate for Payer: Multiplan Workers Comp	$62.85
Rate for Payer: Scott and White EPO/PPO	$13.14
Rate for Payer: Superior Health Plan EPO	$13.15

SLING, ARM FASHION NAVY X-LARGE -- DHF

Facility

$96.69

Service Code	HCPCS A4565
Hospital Charge Code	81144453
Hospital Revenue Code	271
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$62.85
Rate for Payer: Aetna Commercial	$53.18
Rate for Payer: Amerigroup CHIP/Medicaid	$8.70
Rate for Payer: BCBS of TX Blue Advantage	$12.96
Rate for Payer: BCBS of TX Blue Essentials	$15.56
Rate for Payer: BCBS of TX PPO	$17.25
Rate for Payer: Cash Price	$85.09
Rate for Payer: Cash Price	$85.09
Rate for Payer: Multiplan Auto	$62.85
Rate for Payer: Multiplan Commercial	$62.85
Rate for Payer: Multiplan Workers Comp	$62.85
Rate for Payer: Scott and White EPO/PPO	$13.14
Rate for Payer: Superior Health Plan EPO	$13.15

SLING, ARM FASHION NAVY X-LARGE -- DHF

Facility

$96.69

Service Code	HCPCS A4565
Hospital Charge Code	81144453
Hospital Revenue Code	271
Rate for Payer: Cash Price	$85.09

SLITTER CATH -- DHF

Facility

$151.58

Hospital Charge Code	40049900
Hospital Revenue Code	272
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$98.53
Rate for Payer: Aetna Commercial	$83.37
Rate for Payer: Amerigroup CHIP/Medicaid	$13.64
Rate for Payer: BCBS of TX Blue Advantage	$45.47
Rate for Payer: BCBS of TX Blue Essentials	$54.57
Rate for Payer: BCBS of TX PPO	$60.63
Rate for Payer: Cash Price	$133.39
Rate for Payer: Multiplan Auto	$98.53
Rate for Payer: Multiplan Commercial	$98.53
Rate for Payer: Multiplan Workers Comp	$98.53
Rate for Payer: Scott and White EPO/PPO	$75.79
Rate for Payer: Superior Health Plan EPO	$20.61

SLITTER CATH -- DHF

Facility

$151.58

Hospital Charge Code	40049900
Hospital Revenue Code	272
Rate for Payer: Cash Price	$133.39

SLOK SET CAP

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	8394475
Hospital Revenue Code	278
Min. Negotiated Rate	$225.90
Max. Negotiated Rate	$451.81
Rate for Payer: Aetna Commercial	$271.08
Rate for Payer: Cash Price	$795.18
Rate for Payer: Cigna Commercial	$225.90
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Scott and White EPO/PPO	$451.81

SLOK SET CAP

Facility

$903.61

Service Code	HCPCS C1713
Hospital Charge Code	8394475
Hospital Revenue Code	278
Min. Negotiated Rate	$81.32
Max. Negotiated Rate	$451.81
Rate for Payer: Aetna Commercial	$271.08
Rate for Payer: Amerigroup CHIP/Medicaid	$81.32
Rate for Payer: BCBS of TX Blue Advantage	$271.08
Rate for Payer: BCBS of TX Blue Essentials	$325.30
Rate for Payer: BCBS of TX PPO	$361.44
Rate for Payer: Cash Price	$795.18
Rate for Payer: Multiplan Auto	$451.81
Rate for Payer: Multiplan Commercial	$451.81
Rate for Payer: Multiplan Workers Comp	$451.81
Rate for Payer: Scott and White EPO/PPO	$451.81
Rate for Payer: Superior Health Plan EPO	$122.89

.Slow Grower Broth Suscep 182925 SO

Facility

$251.00

Service Code	CPT 87186
Hospital Charge Code	1604610
Hospital Revenue Code	306
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$163.15
Rate for Payer: Aetna Commercial	$9.08
Rate for Payer: Aetna Medicare	$12.97
Rate for Payer: Amerigroup CHIP/Medicaid	$3.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.65
Rate for Payer: Amerigroup Medicare	$8.65
Rate for Payer: BCBS of TX Blue Advantage	$14.27
Rate for Payer: BCBS of TX Blue Essentials	$17.13
Rate for Payer: BCBS of TX Medicare	$8.65
Rate for Payer: BCBS of TX PPO	$19.12
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cash Price	$220.88
Rate for Payer: Cigna Medicaid	$8.65
Rate for Payer: Cigna Medicare	$8.65
Rate for Payer: Employer Direct Commercial	$8.65
Rate for Payer: Humana Medicare/TRICARE	$8.65
Rate for Payer: Molina CHIP/Medicaid	$8.65
Rate for Payer: Molina Dual Medicare/Medicaid	$8.65
Rate for Payer: Molina Medicare	$8.65
Rate for Payer: Multiplan Auto	$163.15
Rate for Payer: Multiplan Commercial	$163.15
Rate for Payer: Multiplan Workers Comp	$163.15
Rate for Payer: Parkland Medicaid	$8.65
Rate for Payer: Scott and White EPO/PPO	$10.81
Rate for Payer: Scott and White Medicare	$8.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.65
Rate for Payer: Superior Health Plan EPO	$8.65
Rate for Payer: Superior Health Plan Medicare	$8.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.65
Rate for Payer: Universal American Medicare	$8.65
Rate for Payer: Wellcare Medicare	$8.65
Rate for Payer: Wellmed Medicare	$8.65

SLP Assessment of Aphasia Units

Facility

$496.00

Service Code	CPT 96105 GN
Hospital Charge Code	4490025
Hospital Revenue Code	444
Min. Negotiated Rate	$67.46
Max. Negotiated Rate	$322.40
Rate for Payer: Aetna Commercial	$272.80
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$148.80
Rate for Payer: BCBS of TX Blue Essentials	$178.56
Rate for Payer: BCBS of TX PPO	$198.40
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$322.40
Rate for Payer: Multiplan Commercial	$322.40
Rate for Payer: Multiplan Workers Comp	$322.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$67.46

SLP Assessment of Aphasia Units BCE

Facility

$496.00

Service Code	CPT 96105 GN
Hospital Charge Code	4490025
Hospital Revenue Code	444
Min. Negotiated Rate	$67.46
Max. Negotiated Rate	$322.40
Rate for Payer: Aetna Commercial	$272.80
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$148.80
Rate for Payer: BCBS of TX Blue Essentials	$178.56
Rate for Payer: BCBS of TX PPO	$198.40
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cash Price	$436.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$322.40
Rate for Payer: Multiplan Commercial	$322.40
Rate for Payer: Multiplan Workers Comp	$322.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$67.46

SLP Assessment of Aphasia Units BCE

Facility

$496.00

Service Code	CPT 96105 GN
Hospital Charge Code	4490025
Hospital Revenue Code	444
Rate for Payer: Cash Price	$436.48

SLP Auditory Processing Tx Units

Facility

$326.00

Service Code	CPT 92507 GN
Hospital Charge Code	4405445
Hospital Revenue Code	441
Min. Negotiated Rate	$44.34
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$139.84
Rate for Payer: BCBS of TX Blue Essentials	$167.17
Rate for Payer: BCBS of TX PPO	$186.46
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$44.34

SLP Auditory Processing Tx Units BCE

Facility

$326.00

Service Code	CPT 92507 GN
Hospital Charge Code	4405445
Hospital Revenue Code	441
Rate for Payer: Cash Price	$286.88

SLP Auditory Processing Tx Units BCE

Facility

$326.00

Service Code	CPT 92507 GN
Hospital Charge Code	4405445
Hospital Revenue Code	441
Min. Negotiated Rate	$44.34
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$139.84
Rate for Payer: BCBS of TX Blue Essentials	$167.17
Rate for Payer: BCBS of TX PPO	$186.46
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cash Price	$286.88
Rate for Payer: Cigna Commercial	$200.00
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: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$44.34

SLP Eval Lang Comprehension,Express Unit

Facility

$396.00

Service Code	CPT 92523 GN
Hospital Charge Code	4450055
Hospital Revenue Code	444
Min. Negotiated Rate	$53.86
Max. Negotiated Rate	$463.21
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$347.41
Rate for Payer: BCBS of TX Blue Essentials	$415.29
Rate for Payer: BCBS of TX PPO	$463.21
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$257.40
Rate for Payer: Multiplan Commercial	$257.40
Rate for Payer: Multiplan Workers Comp	$257.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$53.86

SLP Eval Lang Comprehension,Express Unit BCE

Facility

$396.00

Service Code	CPT 92523 GN
Hospital Charge Code	4450055
Hospital Revenue Code	444
Min. Negotiated Rate	$53.86
Max. Negotiated Rate	$463.21
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$347.41
Rate for Payer: BCBS of TX Blue Essentials	$415.29
Rate for Payer: BCBS of TX PPO	$463.21
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cash Price	$348.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$257.40
Rate for Payer: Multiplan Commercial	$257.40
Rate for Payer: Multiplan Workers Comp	$257.40
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$53.86

SLP Eval Lang Comprehension,Express Unit BCE

Facility

$396.00

Service Code	CPT 92523 GN
Hospital Charge Code	4450055
Hospital Revenue Code	444
Rate for Payer: Cash Price	$348.48

SLP Eval of Speech Sound Prod Units

Facility

$364.00

Service Code	CPT 92522 GN
Hospital Charge Code	4450054
Hospital Revenue Code	444
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$236.60
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$163.04
Rate for Payer: BCBS of TX Blue Essentials	$194.90
Rate for Payer: BCBS of TX PPO	$217.38
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$236.60
Rate for Payer: Multiplan Commercial	$236.60
Rate for Payer: Multiplan Workers Comp	$236.60
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$49.50

SLP Eval of Speech Sound Prod Units BCE

Facility

$364.00

Service Code	CPT 92522 GN
Hospital Charge Code	4450054
Hospital Revenue Code	444
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$236.60
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$163.04
Rate for Payer: BCBS of TX Blue Essentials	$194.90
Rate for Payer: BCBS of TX PPO	$217.38
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cash Price	$320.32
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$236.60
Rate for Payer: Multiplan Commercial	$236.60
Rate for Payer: Multiplan Workers Comp	$236.60
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$49.50

SLP Eval of Speech Sound Prod Units BCE

Facility

$364.00

Service Code	CPT 92522 GN
Hospital Charge Code	4450054
Hospital Revenue Code	444
Rate for Payer: Cash Price	$320.32

SLP Evaluation of Speech Fluency Units

Facility

$462.00

Service Code	CPT 92521 GN
Hospital Charge Code	4450053
Hospital Revenue Code	444
Min. Negotiated Rate	$62.83
Max. Negotiated Rate	$300.30
Rate for Payer: Aetna Commercial	$221.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$201.30
Rate for Payer: BCBS of TX Blue Essentials	$240.64
Rate for Payer: BCBS of TX PPO	$268.40
Rate for Payer: Cash Price	$406.56
Rate for Payer: Cash Price	$406.56
Rate for Payer: Cash Price	$406.56
Rate for Payer: Cash Price	$406.56
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$300.30
Rate for Payer: Multiplan Commercial	$300.30
Rate for Payer: Multiplan Workers Comp	$300.30
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$62.83

SLP Evaluation of Speech Fluency Units

Facility

$462.00

Service Code	CPT 92521 GN
Hospital Charge Code	4450053
Hospital Revenue Code	444
Rate for Payer: Cash Price	$406.56

Know your out-of-pocket cost for care.

All Charges