White Rock Medical Center

All Charges

Charge

Type

Setting

Price

OTAH PT Unattended E-Stim Units BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	8993231
Hospital Revenue Code	420
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

OTAH PT Unattended E-Stim Units BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	9238582
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

OTAH PT Unattended E-Stim Units BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	9238582
Hospital Revenue Code	420
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

OTAH PT Unattended E-Stim Units BCE

Facility

$160.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	8993231
Hospital Revenue Code	420
Rate for Payer: Cash Price	$108.80

OTAH PT Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	9016973
Hospital Revenue Code	420
Rate for Payer: Cash Price	$107.44

OTAH PT Wheelchair Management BCE

Facility

$158.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	9016973
Hospital Revenue Code	420
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$14.22
Rate for Payer: BCBS of TX Blue Advantage	$47.40
Rate for Payer: BCBS of TX Blue Essentials	$56.88
Rate for Payer: BCBS of TX PPO	$63.20
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cash Price	$107.44
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$113.76
Rate for Payer: Molina CHIP/Medicaid	$113.76
Rate for Payer: Multiplan Auto	$102.70
Rate for Payer: Multiplan Commercial	$102.70
Rate for Payer: Multiplan Workers Comp	$102.70
Rate for Payer: Parkland Medicaid	$113.76
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.76
Rate for Payer: Superior Health Plan EPO	$21.49

OTAH PT Work Hardening-Each Addl Hour Assistant Units BCE

Facility

$175.00

Service Code	HCPCS 97546 GP
Hospital Charge Code	9238585
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Molina CHIP/Medicaid	$126.00
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$23.80

OTAH PT Work Hardening-Each Addl Hour Assistant Units BCE

Facility

$175.00

Service Code	HCPCS 97546 GP
Hospital Charge Code	9238585
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

OTAH PT Work Hardening-Each Addl Hour Units BCE

Facility

$175.00

Service Code	HCPCS 97546 GP
Hospital Charge Code	9238584
Hospital Revenue Code	420
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Molina CHIP/Medicaid	$126.00
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$23.80

OTAH PT Work Hardening-Each Addl Hour Units BCE

Facility

$175.00

Service Code	HCPCS 97546 GP
Hospital Charge Code	9238584
Hospital Revenue Code	420
Rate for Payer: Cash Price	$119.00

OTAH SLP Auditory Processing Tx Units BCE

Facility

$326.00

Service Code	HCPCS 92507
Hospital Charge Code	9280551
Hospital Revenue Code	441
Rate for Payer: Cash Price	$221.68

OTAH SLP Auditory Processing Tx Units BCE

Facility

$326.00

Service Code	HCPCS 92507
Hospital Charge Code	9280551
Hospital Revenue Code	441
Min. Negotiated Rate	$44.34
Max. Negotiated Rate	$234.72
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$97.80
Rate for Payer: BCBS of TX Blue Essentials	$117.36
Rate for Payer: BCBS of TX PPO	$130.40
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$234.72
Rate for Payer: Molina CHIP/Medicaid	$234.72
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: Parkland Medicaid	$234.72
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$234.72
Rate for Payer: Superior Health Plan EPO	$44.34

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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.12
Rate for Payer: Superior Health Plan EPO	$70.86

OTAH SLP Behavioral, Qualitative Analysis Units BCE

Facility

$521.00

Service Code	HCPCS 92524
Hospital Charge Code	9280546
Hospital Revenue Code	444
Rate for Payer: Cash Price	$354.28

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 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	$180.00
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 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	$180.00
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 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 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 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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$285.12
Rate for Payer: Superior Health Plan EPO	$53.86

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: 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	$180.00
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
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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$332.64
Rate for Payer: Superior Health Plan EPO	$62.83

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 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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$364.32
Rate for Payer: Superior Health Plan EPO	$68.82

Know your out-of-pocket cost for care.

All Charges