White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SLP Standardized Cognitive Performance Test Units

Facility

$544.00

Service Code	CPT 96125 GN
Hospital Charge Code	4450060
Hospital Revenue Code	440
Rate for Payer: Cash Price	$478.72

SLP Swallow Dysfunction Oral Feed Units

Facility

$279.00

Service Code	CPT 92526 GN
Hospital Charge Code	4405411
Hospital Revenue Code	441
Min. Negotiated Rate	$37.94
Max. Negotiated Rate	$204.02
Rate for Payer: Aetna Commercial	$153.45
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$153.02
Rate for Payer: BCBS of TX Blue Essentials	$182.92
Rate for Payer: BCBS of TX PPO	$204.02
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$181.35
Rate for Payer: Multiplan Commercial	$181.35
Rate for Payer: Multiplan Workers Comp	$181.35
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$37.94

SLP Swallow Dysfunction Oral Feed Units BCE

Facility

$279.00

Service Code	CPT 92526 GN
Hospital Charge Code	4405411
Hospital Revenue Code	441
Rate for Payer: Cash Price	$245.52

SLP Swallow Dysfunction Oral Feed Units BCE

Facility

$279.00

Service Code	CPT 92526 GN
Hospital Charge Code	4405411
Hospital Revenue Code	441
Min. Negotiated Rate	$37.94
Max. Negotiated Rate	$204.02
Rate for Payer: Aetna Commercial	$153.45
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$153.02
Rate for Payer: BCBS of TX Blue Essentials	$182.92
Rate for Payer: BCBS of TX PPO	$204.02
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$181.35
Rate for Payer: Multiplan Commercial	$181.35
Rate for Payer: Multiplan Workers Comp	$181.35
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$37.94

SLP Tx Generating Device Units

Facility

$366.00

Service Code	CPT 92609 GN
Hospital Charge Code	4410034
Hospital Revenue Code	440
Min. Negotiated Rate	$32.94
Max. Negotiated Rate	$257.52
Rate for Payer: Aetna Commercial	$201.30
Rate for Payer: Amerigroup CHIP/Medicaid	$32.94
Rate for Payer: BCBS of TX Blue Advantage	$193.14
Rate for Payer: BCBS of TX Blue Essentials	$230.88
Rate for Payer: BCBS of TX PPO	$257.52
Rate for Payer: Cash Price	$322.08
Rate for Payer: Cash Price	$322.08
Rate for Payer: Cash Price	$322.08
Rate for Payer: Cash Price	$322.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$237.90
Rate for Payer: Multiplan Commercial	$237.90
Rate for Payer: Multiplan Workers Comp	$237.90
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$49.78

SLP Tx Generating Device Units BCE

Facility

$366.00

Service Code	CPT 92609 GN
Hospital Charge Code	4410034
Hospital Revenue Code	440
Rate for Payer: Cash Price	$322.08

SLP Tx Generating Device Units BCE

Facility

$366.00

Service Code	CPT 92609 GN
Hospital Charge Code	4410034
Hospital Revenue Code	440
Min. Negotiated Rate	$32.94
Max. Negotiated Rate	$257.52
Rate for Payer: Aetna Commercial	$201.30
Rate for Payer: Amerigroup CHIP/Medicaid	$32.94
Rate for Payer: BCBS of TX Blue Advantage	$193.14
Rate for Payer: BCBS of TX Blue Essentials	$230.88
Rate for Payer: BCBS of TX PPO	$257.52
Rate for Payer: Cash Price	$322.08
Rate for Payer: Cash Price	$322.08
Rate for Payer: Cash Price	$322.08
Rate for Payer: Cash Price	$322.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$237.90
Rate for Payer: Multiplan Commercial	$237.90
Rate for Payer: Multiplan Workers Comp	$237.90
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$49.78

SLV CONNECTOR IS4/DF4 -- DHF

Facility

$606.36

Hospital Charge Code	81771461
Hospital Revenue Code	272
Min. Negotiated Rate	$54.57
Max. Negotiated Rate	$394.13
Rate for Payer: Aetna Commercial	$333.50
Rate for Payer: Amerigroup CHIP/Medicaid	$54.57
Rate for Payer: BCBS of TX Blue Advantage	$181.91
Rate for Payer: BCBS of TX Blue Essentials	$218.29
Rate for Payer: BCBS of TX PPO	$242.54
Rate for Payer: Cash Price	$533.60
Rate for Payer: Multiplan Auto	$394.13
Rate for Payer: Multiplan Commercial	$394.13
Rate for Payer: Multiplan Workers Comp	$394.13
Rate for Payer: Scott and White EPO/PPO	$303.18
Rate for Payer: Superior Health Plan EPO	$82.46

SLV CONNECTOR IS4/DF4 -- DHF

Facility

$606.36

Hospital Charge Code	81771461
Hospital Revenue Code	272
Rate for Payer: Cash Price	$533.60

SMEAR COMPLEX STAIN

Facility

$141.00

Service Code	CPT 87209
Hospital Charge Code	1605989
Hospital Revenue Code	306
Rate for Payer: Cash Price	$124.08

SMEAR COMPLEX STAIN

Facility

$141.00

Service Code	CPT 87209
Hospital Charge Code	1605989
Hospital Revenue Code	306
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$91.65
Rate for Payer: Aetna Commercial	$18.88
Rate for Payer: Aetna Medicare	$26.97
Rate for Payer: Amerigroup CHIP/Medicaid	$7.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17.98
Rate for Payer: Amerigroup Medicare	$17.98
Rate for Payer: BCBS of TX Blue Advantage	$29.67
Rate for Payer: BCBS of TX Blue Essentials	$35.60
Rate for Payer: BCBS of TX Medicare	$17.98
Rate for Payer: BCBS of TX PPO	$39.74
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cigna Medicaid	$17.98
Rate for Payer: Cigna Medicare	$17.98
Rate for Payer: Employer Direct Commercial	$17.98
Rate for Payer: Humana Medicare/TRICARE	$17.98
Rate for Payer: Molina CHIP/Medicaid	$17.98
Rate for Payer: Molina Dual Medicare/Medicaid	$17.98
Rate for Payer: Molina Medicare	$17.98
Rate for Payer: Multiplan Auto	$91.65
Rate for Payer: Multiplan Commercial	$91.65
Rate for Payer: Multiplan Workers Comp	$91.65
Rate for Payer: Parkland Medicaid	$17.98
Rate for Payer: Scott and White EPO/PPO	$22.48
Rate for Payer: Scott and White Medicare	$17.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.98
Rate for Payer: Superior Health Plan EPO	$17.98
Rate for Payer: Superior Health Plan Medicare	$17.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$17.98
Rate for Payer: Universal American Medicare	$17.98
Rate for Payer: Wellcare Medicare	$17.98
Rate for Payer: Wellmed Medicare	$17.98

SMEAR FLUORESCENT AND AFB W/INTERPR

Facility

$24.00

Service Code	CPT 87206
Hospital Charge Code	1603885
Hospital Revenue Code	306
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$15.60
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Aetna Medicare	$8.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.39
Rate for Payer: Amerigroup Medicare	$5.39
Rate for Payer: BCBS of TX Blue Advantage	$8.89
Rate for Payer: BCBS of TX Blue Essentials	$10.67
Rate for Payer: BCBS of TX Medicare	$5.39
Rate for Payer: BCBS of TX PPO	$11.91
Rate for Payer: Cash Price	$21.12
Rate for Payer: Cash Price	$21.12
Rate for Payer: Cigna Medicaid	$5.39
Rate for Payer: Cigna Medicare	$5.39
Rate for Payer: Employer Direct Commercial	$5.39
Rate for Payer: Humana Medicare/TRICARE	$5.39
Rate for Payer: Molina CHIP/Medicaid	$5.39
Rate for Payer: Molina Dual Medicare/Medicaid	$5.39
Rate for Payer: Molina Medicare	$5.39
Rate for Payer: Multiplan Auto	$15.60
Rate for Payer: Multiplan Commercial	$15.60
Rate for Payer: Multiplan Workers Comp	$15.60
Rate for Payer: Parkland Medicaid	$5.39
Rate for Payer: Scott and White EPO/PPO	$6.74
Rate for Payer: Scott and White Medicare	$5.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.39
Rate for Payer: Superior Health Plan EPO	$5.39
Rate for Payer: Superior Health Plan Medicare	$5.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.39
Rate for Payer: Universal American Medicare	$5.39
Rate for Payer: Wellcare Medicare	$5.39
Rate for Payer: Wellmed Medicare	$5.39

SMEAR FLUORESCENT AND AFB W/INTERPR

Facility

$24.00

Service Code	CPT 87206
Hospital Charge Code	1603885
Hospital Revenue Code	306
Rate for Payer: Cash Price	$21.12

Smoke/Tobacco Counseling >10 min

Facility

$97.00

Service Code	CPT 99407
Hospital Charge Code	5500376
Hospital Revenue Code	942
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$53.35
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$8.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$45.78
Rate for Payer: BCBS of TX Blue Essentials	$54.72
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$61.04
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$20.07
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$20.07
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$20.07
Rate for Payer: Scott and White EPO/PPO	$0.47
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.07
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

Smoke/Tobacco Counseling 3-10 min

Facility

$53.00

Service Code	CPT 99406
Hospital Charge Code	5500375
Hospital Revenue Code	942
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$59.45
Rate for Payer: Aetna Commercial	$29.15
Rate for Payer: Aetna Medicare	$39.36
Rate for Payer: Amerigroup CHIP/Medicaid	$4.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.24
Rate for Payer: Amerigroup Medicare	$26.24
Rate for Payer: BCBS of TX Blue Advantage	$21.94
Rate for Payer: BCBS of TX Blue Essentials	$26.23
Rate for Payer: BCBS of TX Medicare	$26.24
Rate for Payer: BCBS of TX PPO	$29.26
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cash Price	$46.64
Rate for Payer: Cigna Commercial	$59.45
Rate for Payer: Cigna Medicaid	$10.29
Rate for Payer: Cigna Medicare	$26.24
Rate for Payer: Employer Direct Commercial	$26.24
Rate for Payer: Humana Medicare/TRICARE	$26.24
Rate for Payer: Molina CHIP/Medicaid	$10.29
Rate for Payer: Molina Dual Medicare/Medicaid	$26.24
Rate for Payer: Molina Medicare	$26.24
Rate for Payer: Multiplan Auto	$34.45
Rate for Payer: Multiplan Commercial	$34.45
Rate for Payer: Multiplan Workers Comp	$34.45
Rate for Payer: Parkland Medicaid	$10.29
Rate for Payer: Scott and White EPO/PPO	$0.47
Rate for Payer: Scott and White Medicare	$26.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.29
Rate for Payer: Superior Health Plan EPO	$26.24
Rate for Payer: Superior Health Plan Medicare	$26.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.24
Rate for Payer: Universal American Medicare	$26.24
Rate for Payer: Wellcare Medicare	$26.24
Rate for Payer: Wellmed Medicare	$26.24

SNARE OV/CRS/HEX -- DHF

Facility

$1,126.42

Hospital Charge Code	80826704
Hospital Revenue Code	272
Min. Negotiated Rate	$101.38
Max. Negotiated Rate	$732.17
Rate for Payer: Aetna Commercial	$619.53
Rate for Payer: Amerigroup CHIP/Medicaid	$101.38
Rate for Payer: BCBS of TX Blue Advantage	$337.93
Rate for Payer: BCBS of TX Blue Essentials	$405.51
Rate for Payer: BCBS of TX PPO	$450.57
Rate for Payer: Cash Price	$991.25
Rate for Payer: Multiplan Auto	$732.17
Rate for Payer: Multiplan Commercial	$732.17
Rate for Payer: Multiplan Workers Comp	$732.17
Rate for Payer: Scott and White EPO/PPO	$563.21
Rate for Payer: Superior Health Plan EPO	$153.19

SNARE OV/CRS/HEX -- DHF

Facility

$1,126.42

Hospital Charge Code	80826704
Hospital Revenue Code	272
Rate for Payer: Cash Price	$991.25

sodium bicarbonate 650 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815310
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

sodium bicarbonate 650 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815310
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sodium bicarbonate 8.4% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77815473
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

sodium bicarbonate 8.4% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77815473
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

sodium biphosphate-sodium phosphate 7 g-19 g Enema 133 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815785
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sodium biphosphate-sodium phosphate 7 g-19 g Enema 133 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815785
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.30
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

Sodium Chloride 0.45% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77339500
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

Sodium Chloride 0.45% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77339500
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges