White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTAH SLP Behavioral, Qualitative Analysis Units BCE

Facility

$521.00

Service Code	HCPCS 92524
Hospital Charge Code	9280546
Hospital Revenue Code	444
Min. Negotiated Rate	$70.86
Max. Negotiated Rate	$375.12
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$156.30
Rate for Payer: BCBS of TX Blue Essentials	$187.56
Rate for Payer: BCBS of TX PPO	$208.40
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$375.12
Rate for Payer: Molina CHIP/Medicaid	$375.12
Rate for Payer: Multiplan Auto	$338.65
Rate for Payer: Multiplan Commercial	$338.65
Rate for Payer: Multiplan Workers Comp	$338.65
Rate for Payer: Parkland Medicaid	$375.12
Rate for Payer: Scott and White EPO/PPO	$135.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.12
Rate for Payer: Superior Health Plan EPO	$70.86

OTAH SLP Cog Func Ther Inter Adtl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97130
Hospital Charge Code	9280541
Hospital Revenue Code	440
Min. Negotiated Rate	$20.47
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$20.47
Rate for Payer: BCBS of TX Blue Advantage	$68.24
Rate for Payer: BCBS of TX Blue Essentials	$81.89
Rate for Payer: BCBS of TX PPO	$90.99
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$163.78
Rate for Payer: Molina CHIP/Medicaid	$163.78
Rate for Payer: Multiplan Auto	$147.86
Rate for Payer: Multiplan Commercial	$147.86
Rate for Payer: Multiplan Workers Comp	$147.86
Rate for Payer: Parkland Medicaid	$163.78
Rate for Payer: Scott and White EPO/PPO	$25.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.78
Rate for Payer: Superior Health Plan EPO	$30.94

OTAH SLP Cog Func Ther Inter Adtl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97130
Hospital Charge Code	9280541
Hospital Revenue Code	440
Rate for Payer: Cash Price	$154.68

OTAH SLP Cog Func Ther Inter Intl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97129
Hospital Charge Code	9280540
Hospital Revenue Code	440
Rate for Payer: Cash Price	$154.68

OTAH SLP Cog Func Ther Inter Intl 15m Units BCE

Facility

$227.47

Service Code	HCPCS 97129
Hospital Charge Code	9280540
Hospital Revenue Code	440
Min. Negotiated Rate	$20.47
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$20.47
Rate for Payer: BCBS of TX Blue Advantage	$68.24
Rate for Payer: BCBS of TX Blue Essentials	$81.89
Rate for Payer: BCBS of TX PPO	$90.99
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cash Price	$154.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$163.78
Rate for Payer: Molina CHIP/Medicaid	$163.78
Rate for Payer: Multiplan Auto	$147.86
Rate for Payer: Multiplan Commercial	$147.86
Rate for Payer: Multiplan Workers Comp	$147.86
Rate for Payer: Parkland Medicaid	$163.78
Rate for Payer: Scott and White EPO/PPO	$27.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.78
Rate for Payer: Superior Health Plan EPO	$30.94

OTAH SLP Eval Lang Comprehension, Express Unit BCE

Facility

$396.00

Service Code	HCPCS 92523
Hospital Charge Code	9280545
Hospital Revenue Code	444
Min. Negotiated Rate	$53.86
Max. Negotiated Rate	$285.12
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$118.80
Rate for Payer: BCBS of TX Blue Essentials	$142.56
Rate for Payer: BCBS of TX PPO	$158.40
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cash Price	$269.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$285.12
Rate for Payer: Molina CHIP/Medicaid	$285.12
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: Parkland Medicaid	$285.12
Rate for Payer: Scott and White EPO/PPO	$282.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$285.12
Rate for Payer: Superior Health Plan EPO	$53.86

OTAH SLP Eval Lang Comprehension, Express Unit BCE

Facility

$396.00

Service Code	HCPCS 92523
Hospital Charge Code	9280545
Hospital Revenue Code	444
Rate for Payer: Cash Price	$269.28

OTAH SLP Eval of Speech Sound Prod Units BCE

Facility

$364.00

Service Code	HCPCS 92522
Hospital Charge Code	4450054
Hospital Revenue Code	444
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$262.08
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$109.20
Rate for Payer: BCBS of TX Blue Essentials	$131.04
Rate for Payer: BCBS of TX PPO	$145.60
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cash Price	$247.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$262.08
Rate for Payer: Molina CHIP/Medicaid	$262.08
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: Parkland Medicaid	$262.08
Rate for Payer: Scott and White EPO/PPO	$137.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$262.08
Rate for Payer: Superior Health Plan EPO	$49.50

OTAH SLP Eval of Speech Sound Prod Units BCE

Facility

$364.00

Service Code	HCPCS 92522
Hospital Charge Code	4450054
Hospital Revenue Code	444
Rate for Payer: Cash Price	$247.52

OTAH SLP Evaluation of Speech Fluency Units BCE

Facility

$462.00

Service Code	HCPCS 92521
Hospital Charge Code	4450053
Hospital Revenue Code	444
Rate for Payer: Cash Price	$314.16

OTAH SLP Evaluation of Speech Fluency Units BCE

Facility

$462.00

Service Code	HCPCS 92521
Hospital Charge Code	4450053
Hospital Revenue Code	444
Min. Negotiated Rate	$62.83
Max. Negotiated Rate	$332.64
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$138.60
Rate for Payer: BCBS of TX Blue Essentials	$166.32
Rate for Payer: BCBS of TX PPO	$184.80
Rate for Payer: Cash Price	$314.16
Rate for Payer: Cash Price	$314.16
Rate for Payer: Cash Price	$314.16
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$332.64
Rate for Payer: Molina CHIP/Medicaid	$332.64
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: Parkland Medicaid	$332.64
Rate for Payer: Scott and White EPO/PPO	$164.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$332.64
Rate for Payer: Superior Health Plan EPO	$62.83

OTAH SLP Fluoroscopic Evaluation Units BCE

Facility

$506.00

Service Code	HCPCS 92611
Hospital Charge Code	9280550
Hospital Revenue Code	444
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$364.32
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$151.80
Rate for Payer: BCBS of TX Blue Essentials	$182.16
Rate for Payer: BCBS of TX PPO	$202.40
Rate for Payer: Cash Price	$344.08
Rate for Payer: Cash Price	$344.08
Rate for Payer: Cash Price	$344.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$364.32
Rate for Payer: Molina CHIP/Medicaid	$364.32
Rate for Payer: Multiplan Auto	$328.90
Rate for Payer: Multiplan Commercial	$328.90
Rate for Payer: Multiplan Workers Comp	$328.90
Rate for Payer: Parkland Medicaid	$364.32
Rate for Payer: Scott and White EPO/PPO	$113.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$364.32
Rate for Payer: Superior Health Plan EPO	$68.82

OTAH SLP Fluoroscopic Evaluation Units BCE

Facility

$506.00

Service Code	HCPCS 92611
Hospital Charge Code	9280550
Hospital Revenue Code	444
Rate for Payer: Cash Price	$344.08

OTAH SLP Non-Speech AAC Device Eval Units BCE

Facility

$403.57

Service Code	HCPCS 92605
Hospital Charge Code	9280547
Hospital Revenue Code	444
Rate for Payer: Cash Price	$274.43

OTAH SLP Non-Speech AAC Device Eval Units BCE

Facility

$403.57

Service Code	HCPCS 92605
Hospital Charge Code	9280547
Hospital Revenue Code	444
Min. Negotiated Rate	$54.89
Max. Negotiated Rate	$290.57
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$121.07
Rate for Payer: BCBS of TX Blue Essentials	$145.29
Rate for Payer: BCBS of TX PPO	$161.43
Rate for Payer: Cash Price	$274.43
Rate for Payer: Cash Price	$274.43
Rate for Payer: Cash Price	$274.43
Rate for Payer: Cash Price	$274.43
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$290.57
Rate for Payer: Molina CHIP/Medicaid	$290.57
Rate for Payer: Multiplan Auto	$262.32
Rate for Payer: Multiplan Commercial	$262.32
Rate for Payer: Multiplan Workers Comp	$262.32
Rate for Payer: Parkland Medicaid	$290.57
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$290.57
Rate for Payer: Superior Health Plan EPO	$54.89

OTAH SLP Pharyngeal Swallow Eval Units BCE

Facility

$448.00

Service Code	HCPCS 92610
Hospital Charge Code	4405619
Hospital Revenue Code	444
Rate for Payer: Cash Price	$304.64

OTAH SLP Pharyngeal Swallow Eval Units BCE

Facility

$448.00

Service Code	HCPCS 92610
Hospital Charge Code	4405619
Hospital Revenue Code	444
Min. Negotiated Rate	$60.93
Max. Negotiated Rate	$322.56
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$134.40
Rate for Payer: BCBS of TX Blue Essentials	$161.28
Rate for Payer: BCBS of TX PPO	$179.20
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$322.56
Rate for Payer: Molina CHIP/Medicaid	$322.56
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Parkland Medicaid	$322.56
Rate for Payer: Scott and White EPO/PPO	$86.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$322.56
Rate for Payer: Superior Health Plan EPO	$60.93

OTAH SLP SENSORY INTEGRATIVE TECHNQ EA 15 MIN BCE

Facility

$164.90

Service Code	HCPCS 97533
Hospital Charge Code	9280542
Hospital Revenue Code	440
Min. Negotiated Rate	$14.84
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.84
Rate for Payer: BCBS of TX Blue Advantage	$49.47
Rate for Payer: BCBS of TX Blue Essentials	$59.36
Rate for Payer: BCBS of TX PPO	$65.96
Rate for Payer: Cash Price	$112.13
Rate for Payer: Cash Price	$112.13
Rate for Payer: Cash Price	$112.13
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$118.73
Rate for Payer: Molina CHIP/Medicaid	$118.73
Rate for Payer: Multiplan Auto	$107.19
Rate for Payer: Multiplan Commercial	$107.19
Rate for Payer: Multiplan Workers Comp	$107.19
Rate for Payer: Parkland Medicaid	$118.73
Rate for Payer: Scott and White EPO/PPO	$77.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.73
Rate for Payer: Superior Health Plan EPO	$22.43

OTAH SLP SENSORY INTEGRATIVE TECHNQ EA 15 MIN BCE

Facility

$164.90

Service Code	HCPCS 97533
Hospital Charge Code	9280542
Hospital Revenue Code	440
Rate for Payer: Cash Price	$112.13

OTAH SLP Standardized Cognitive Performance Test Units BCE

Facility

$544.00

Service Code	HCPCS 96125
Hospital Charge Code	9280548
Hospital Revenue Code	440
Min. Negotiated Rate	$48.96
Max. Negotiated Rate	$391.68
Rate for Payer: Amerigroup CHIP/Medicaid	$48.96
Rate for Payer: BCBS of TX Blue Advantage	$163.20
Rate for Payer: BCBS of TX Blue Essentials	$195.84
Rate for Payer: BCBS of TX PPO	$217.60
Rate for Payer: Cash Price	$369.92
Rate for Payer: Cash Price	$369.92
Rate for Payer: Cash Price	$369.92
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$391.68
Rate for Payer: Molina CHIP/Medicaid	$391.68
Rate for Payer: Multiplan Auto	$353.60
Rate for Payer: Multiplan Commercial	$353.60
Rate for Payer: Multiplan Workers Comp	$353.60
Rate for Payer: Parkland Medicaid	$391.68
Rate for Payer: Scott and White EPO/PPO	$126.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$391.68
Rate for Payer: Superior Health Plan EPO	$73.98

OTAH SLP Standardized Cognitive Performance Test Units BCE

Facility

$544.00

Service Code	HCPCS 96125
Hospital Charge Code	9280548
Hospital Revenue Code	440
Rate for Payer: Cash Price	$369.92

OTAH SLP Swallow Dysfunction Oral Feed Units BCE

Facility

$279.00

Service Code	HCPCS 92526
Hospital Charge Code	9280553
Hospital Revenue Code	441
Min. Negotiated Rate	$37.94
Max. Negotiated Rate	$200.88
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$83.70
Rate for Payer: BCBS of TX Blue Essentials	$100.44
Rate for Payer: BCBS of TX PPO	$111.60
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$200.88
Rate for Payer: Molina CHIP/Medicaid	$200.88
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: Parkland Medicaid	$200.88
Rate for Payer: Scott and White EPO/PPO	$104.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$200.88
Rate for Payer: Superior Health Plan EPO	$37.94

OTAH SLP Swallow Dysfunction Oral Feed Units BCE

Facility

$279.00

Service Code	HCPCS 92526
Hospital Charge Code	9280553
Hospital Revenue Code	441
Rate for Payer: Cash Price	$189.72

OT Application of Short Arm Splint, Static Units

Facility

$618.00

Service Code	HCPCS 29125
Hospital Charge Code	4300554
Hospital Revenue Code	430
Rate for Payer: Cash Price	$420.24

OT Application of Short Arm Splint, Static Units

Facility

$618.00

Service Code	HCPCS 29125
Hospital Charge Code	4300554
Hospital Revenue Code	430
Min. Negotiated Rate	$49.89
Max. Negotiated Rate	$444.96
Rate for Payer: Amerigroup CHIP/Medicaid	$55.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cash Price	$420.24
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$444.96
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$444.96
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$401.70
Rate for Payer: Multiplan Commercial	$401.70
Rate for Payer: Multiplan Workers Comp	$401.70
Rate for Payer: Parkland Medicaid	$444.96
Rate for Payer: Scott and White EPO/PPO	$49.89
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$444.96
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

Know your out-of-pocket cost for care.

All Charges