White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$322.56
Rate for Payer: Superior Health Plan EPO	$60.93

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 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 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$118.73
Rate for Payer: Superior Health Plan EPO	$22.43

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 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$391.68
Rate for Payer: Superior Health Plan EPO	$73.98

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: 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	$180.00
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	$55.62
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: 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	$180.00
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

OT Attended E-Stim Assistant Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4300008
Hospital Revenue Code	430
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.04
Rate for Payer: BCBS of TX PPO	$55.60
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$100.08
Rate for Payer: Molina CHIP/Medicaid	$100.08
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Parkland Medicaid	$100.08
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

OT Attended E-Stim Assistant Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4300008
Hospital Revenue Code	430
Rate for Payer: Cash Price	$94.52

OT Attended E-Stim Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4300042
Hospital Revenue Code	430
Rate for Payer: Cash Price	$94.52

OT Attended E-Stim Units

Facility

$139.00

Service Code	HCPCS 97032
Hospital Charge Code	4300042
Hospital Revenue Code	430
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.51
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.04
Rate for Payer: BCBS of TX PPO	$55.60
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cash Price	$94.52
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$100.08
Rate for Payer: Molina CHIP/Medicaid	$100.08
Rate for Payer: Multiplan Auto	$90.35
Rate for Payer: Multiplan Commercial	$90.35
Rate for Payer: Multiplan Workers Comp	$90.35
Rate for Payer: Parkland Medicaid	$100.08
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$100.08
Rate for Payer: Superior Health Plan EPO	$18.90

OT Evaluation Units, High Complexity

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	4305102
Hospital Revenue Code	434
Rate for Payer: Cash Price	$261.12

OT Evaluation Units, High Complexity

Facility

$384.00

Service Code	HCPCS 97167
Hospital Charge Code	4305102
Hospital Revenue Code	434
Min. Negotiated Rate	$52.22
Max. Negotiated Rate	$276.48
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$115.20
Rate for Payer: BCBS of TX Blue Essentials	$138.24
Rate for Payer: BCBS of TX PPO	$153.60
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cash Price	$261.12
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$276.48
Rate for Payer: Molina CHIP/Medicaid	$276.48
Rate for Payer: Multiplan Auto	$249.60
Rate for Payer: Multiplan Commercial	$249.60
Rate for Payer: Multiplan Workers Comp	$249.60
Rate for Payer: Parkland Medicaid	$276.48
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$276.48
Rate for Payer: Superior Health Plan EPO	$52.22

OT Evaluation Units, Low Complexity

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	4305100
Hospital Revenue Code	434
Min. Negotiated Rate	$25.98
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$57.30
Rate for Payer: BCBS of TX Blue Essentials	$68.76
Rate for Payer: BCBS of TX PPO	$76.40
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cash Price	$129.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$137.52
Rate for Payer: Molina CHIP/Medicaid	$137.52
Rate for Payer: Multiplan Auto	$124.15
Rate for Payer: Multiplan Commercial	$124.15
Rate for Payer: Multiplan Workers Comp	$124.15
Rate for Payer: Parkland Medicaid	$137.52
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.52
Rate for Payer: Superior Health Plan EPO	$25.98

OT Evaluation Units, Low Complexity

Facility

$191.00

Service Code	HCPCS 97165
Hospital Charge Code	4305100
Hospital Revenue Code	434
Rate for Payer: Cash Price	$129.88

OT Evaluation Units, Moderate Complexity

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	4305101
Hospital Revenue Code	434
Rate for Payer: Cash Price	$195.84

OT Evaluation Units, Moderate Complexity

Facility

$288.00

Service Code	HCPCS 97166
Hospital Charge Code	4305101
Hospital Revenue Code	434
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$207.36
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$86.40
Rate for Payer: BCBS of TX Blue Essentials	$103.68
Rate for Payer: BCBS of TX PPO	$115.20
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cash Price	$195.84
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$207.36
Rate for Payer: Molina CHIP/Medicaid	$207.36
Rate for Payer: Multiplan Auto	$187.20
Rate for Payer: Multiplan Commercial	$187.20
Rate for Payer: Multiplan Workers Comp	$187.20
Rate for Payer: Parkland Medicaid	$207.36
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$207.36
Rate for Payer: Superior Health Plan EPO	$39.17

OTHER AFTERCARE AND CONVALESCENCE

Facility

$16,420.92

Service Code	APR-DRG 8624
Min. Negotiated Rate	$15,482.22
Max. Negotiated Rate	$16,420.92
Rate for Payer: Amerigroup CHIP/Medicaid	$15,482.22
Rate for Payer: Cigna Medicaid	$15,482.22
Rate for Payer: Molina CHIP/Medicaid	$15,482.22
Rate for Payer: Parkland Medicaid	$15,482.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,420.92

OTHER AFTERCARE AND CONVALESCENCE

Facility

$7,384.23

Service Code	APR-DRG 8622
Min. Negotiated Rate	$6,962.11
Max. Negotiated Rate	$7,384.23
Rate for Payer: Amerigroup CHIP/Medicaid	$6,962.11
Rate for Payer: Cigna Medicaid	$6,962.11
Rate for Payer: Molina CHIP/Medicaid	$6,962.11
Rate for Payer: Parkland Medicaid	$6,962.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,384.23

Know your out-of-pocket cost for care.

All Charges