White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SLP Eval of Speech Sound Prod Units

Facility

$364.00

Service Code	HCPCS 92522
Hospital Charge Code	9310565
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

SLP Evaluation of Speech Fluency Units

Facility

$462.00

Service Code	HCPCS 92521
Hospital Charge Code	9310564
Hospital Revenue Code	444
Rate for Payer: Cash Price	$314.16

SLP Evaluation of Speech Fluency Units

Facility

$462.00

Service Code	HCPCS 92521
Hospital Charge Code	9310564
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

SLP Fiberoptic Swallow Eval Units

Facility

$603.00

Service Code	HCPCS 92612
Hospital Charge Code	5902612
Hospital Revenue Code	444
Rate for Payer: Cash Price	$410.04

SLP Fiberoptic Swallow Eval Units

Facility

$603.00

Service Code	HCPCS 92612
Hospital Charge Code	5902612
Hospital Revenue Code	444
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$434.16
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$180.90
Rate for Payer: BCBS of TX Blue Essentials	$217.08
Rate for Payer: BCBS of TX PPO	$241.20
Rate for Payer: Cash Price	$410.04
Rate for Payer: Cash Price	$410.04
Rate for Payer: Cash Price	$410.04
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$434.16
Rate for Payer: Molina CHIP/Medicaid	$434.16
Rate for Payer: Multiplan Auto	$391.95
Rate for Payer: Multiplan Commercial	$391.95
Rate for Payer: Multiplan Workers Comp	$391.95
Rate for Payer: Parkland Medicaid	$434.16
Rate for Payer: Scott and White EPO/PPO	$81.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$434.16
Rate for Payer: Superior Health Plan EPO	$82.01

SLP Flexible Endoscopic Evaluation Units

Facility

$711.00

Service Code	HCPCS 92616
Hospital Charge Code	5902616
Hospital Revenue Code	444
Rate for Payer: Cash Price	$483.48

SLP Flexible Endoscopic Evaluation Units

Facility

$711.00

Service Code	HCPCS 92616
Hospital Charge Code	5902616
Hospital Revenue Code	444
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$511.92
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$213.30
Rate for Payer: BCBS of TX Blue Essentials	$255.96
Rate for Payer: BCBS of TX PPO	$284.40
Rate for Payer: Cash Price	$483.48
Rate for Payer: Cash Price	$483.48
Rate for Payer: Cash Price	$483.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$511.92
Rate for Payer: Molina CHIP/Medicaid	$511.92
Rate for Payer: Multiplan Auto	$462.15
Rate for Payer: Multiplan Commercial	$462.15
Rate for Payer: Multiplan Workers Comp	$462.15
Rate for Payer: Parkland Medicaid	$511.92
Rate for Payer: Scott and White EPO/PPO	$121.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$511.92
Rate for Payer: Superior Health Plan EPO	$96.70

SLP Flexible Fiberoptic Endoscopic Eval Units

Facility

$646.00

Service Code	HCPCS 92614
Hospital Charge Code	5902614
Hospital Revenue Code	444
Rate for Payer: Cash Price	$439.28

SLP Flexible Fiberoptic Endoscopic Eval Units

Facility

$646.00

Service Code	HCPCS 92614
Hospital Charge Code	5902614
Hospital Revenue Code	444
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$465.12
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$193.80
Rate for Payer: BCBS of TX Blue Essentials	$232.56
Rate for Payer: BCBS of TX PPO	$258.40
Rate for Payer: Cash Price	$439.28
Rate for Payer: Cash Price	$439.28
Rate for Payer: Cash Price	$439.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$465.12
Rate for Payer: Molina CHIP/Medicaid	$465.12
Rate for Payer: Multiplan Auto	$419.90
Rate for Payer: Multiplan Commercial	$419.90
Rate for Payer: Multiplan Workers Comp	$419.90
Rate for Payer: Parkland Medicaid	$465.12
Rate for Payer: Scott and White EPO/PPO	$79.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$465.12
Rate for Payer: Superior Health Plan EPO	$87.86

SLP Fluoroscopic Evaluation Units

Facility

$506.00

Service Code	HCPCS 92611
Hospital Charge Code	4405627
Hospital Revenue Code	444
Rate for Payer: Cash Price	$344.08

SLP Fluoroscopic Evaluation Units

Facility

$506.00

Service Code	HCPCS 92611
Hospital Charge Code	4405627
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

SLP Neurobehavioral Status Examination Units

Facility

$527.00

Service Code	HCPCS 96116
Hospital Charge Code	5900830
Hospital Revenue Code	918
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$458.51
Rate for Payer: Amerigroup CHIP/Medicaid	$47.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$158.10
Rate for Payer: BCBS of TX Blue Essentials	$189.72
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$210.80
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cigna Commercial	$458.51
Rate for Payer: Cigna Medicaid	$379.44
Rate for Payer: Cigna Medicare	$216.91
Rate for Payer: Employer Direct Commercial	$216.91
Rate for Payer: Humana Medicare/TRICARE	$216.91
Rate for Payer: Molina CHIP/Medicaid	$379.44
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
Rate for Payer: Multiplan Auto	$342.55
Rate for Payer: Multiplan Commercial	$342.55
Rate for Payer: Multiplan Workers Comp	$342.55
Rate for Payer: Parkland Medicaid	$379.44
Rate for Payer: Scott and White EPO/PPO	$97.56
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$379.44
Rate for Payer: Superior Health Plan EPO	$216.91
Rate for Payer: Superior Health Plan Medicare	$216.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$216.91
Rate for Payer: Universal American Medicare	$216.91
Rate for Payer: Wellcare Medicare	$216.91
Rate for Payer: Wellmed Medicare	$216.91

SLP Neurobehavioral Status Examination Units

Facility

$527.00

Service Code	HCPCS 96116
Hospital Charge Code	5900830
Hospital Revenue Code	918
Rate for Payer: Cash Price	$358.36

SLP Speech AAC Eval Addl Half Hour Units

Facility

$91.00

Service Code	HCPCS 92608
Hospital Charge Code	5902628
Hospital Revenue Code	444
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$27.30
Rate for Payer: BCBS of TX Blue Essentials	$32.76
Rate for Payer: BCBS of TX PPO	$36.40
Rate for Payer: Cash Price	$61.88
Rate for Payer: Cash Price	$61.88
Rate for Payer: Cash Price	$61.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$65.52
Rate for Payer: Molina CHIP/Medicaid	$65.52
Rate for Payer: Multiplan Auto	$59.15
Rate for Payer: Multiplan Commercial	$59.15
Rate for Payer: Multiplan Workers Comp	$59.15
Rate for Payer: Parkland Medicaid	$65.52
Rate for Payer: Scott and White EPO/PPO	$60.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.52
Rate for Payer: Superior Health Plan EPO	$12.38

SLP Speech AAC Eval Addl Half Hour Units

Facility

$91.00

Service Code	HCPCS 92608
Hospital Charge Code	5902628
Hospital Revenue Code	444
Rate for Payer: Cash Price	$61.88

SLP Speech AAC Eval First Hour Units

Facility

$457.00

Service Code	HCPCS 92607
Hospital Charge Code	4410033
Hospital Revenue Code	444
Min. Negotiated Rate	$62.15
Max. Negotiated Rate	$329.04
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$137.10
Rate for Payer: BCBS of TX Blue Essentials	$164.52
Rate for Payer: BCBS of TX PPO	$182.80
Rate for Payer: Cash Price	$310.76
Rate for Payer: Cash Price	$310.76
Rate for Payer: Cash Price	$310.76
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$329.04
Rate for Payer: Molina CHIP/Medicaid	$329.04
Rate for Payer: Multiplan Auto	$297.05
Rate for Payer: Multiplan Commercial	$297.05
Rate for Payer: Multiplan Workers Comp	$297.05
Rate for Payer: Parkland Medicaid	$329.04
Rate for Payer: Scott and White EPO/PPO	$153.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$329.04
Rate for Payer: Superior Health Plan EPO	$62.15

SLP Speech AAC Eval First Hour Units

Facility

$457.00

Service Code	HCPCS 92607
Hospital Charge Code	4410033
Hospital Revenue Code	444
Rate for Payer: Cash Price	$310.76

SLP Swallow Dysfunction Oral Feed Units

Facility

$279.00

Service Code	HCPCS 92526
Hospital Charge Code	4405411
Hospital Revenue Code	441
Rate for Payer: Cash Price	$189.72

SLP Swallow Dysfunction Oral Feed Units

Facility

$279.00

Service Code	HCPCS 92526
Hospital Charge Code	4405411
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

SLP Tx Generating Device Units

Facility

$366.00

Service Code	HCPCS 92609
Hospital Charge Code	4410034
Hospital Revenue Code	440
Min. Negotiated Rate	$32.94
Max. Negotiated Rate	$263.52
Rate for Payer: Amerigroup CHIP/Medicaid	$32.94
Rate for Payer: BCBS of TX Blue Advantage	$109.80
Rate for Payer: BCBS of TX Blue Essentials	$131.76
Rate for Payer: BCBS of TX PPO	$146.40
Rate for Payer: Cash Price	$248.88
Rate for Payer: Cash Price	$248.88
Rate for Payer: Cash Price	$248.88
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$263.52
Rate for Payer: Molina CHIP/Medicaid	$263.52
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: Parkland Medicaid	$263.52
Rate for Payer: Scott and White EPO/PPO	$127.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$263.52
Rate for Payer: Superior Health Plan EPO	$49.78

SLP Tx Generating Device Units

Facility

$366.00

Service Code	HCPCS 92609
Hospital Charge Code	4410034
Hospital Revenue Code	440
Rate for Payer: Cash Price	$248.88

SLV CONNECTOR IS4/DF4 -- DHF

Facility

$606.36

Hospital Charge Code	81771461
Hospital Revenue Code	272
Rate for Payer: Cash Price	$412.32

SLV CONNECTOR IS4/DF4 -- DHF

Facility

$606.36

Hospital Charge Code	81771461
Hospital Revenue Code	272
Min. Negotiated Rate	$54.57
Max. Negotiated Rate	$436.58
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	$412.32
Rate for Payer: Cigna Medicaid	$436.58
Rate for Payer: Molina CHIP/Medicaid	$436.58
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: Parkland Medicaid	$436.58
Rate for Payer: Scott and White EPO/PPO	$303.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$436.58
Rate for Payer: Superior Health Plan EPO	$82.46

SLV, STABILITY, TROCAR, XCEL, 5MMX100MM

Facility

$77.06

Hospital Charge Code	992825
Hospital Revenue Code	272
Min. Negotiated Rate	$6.94
Max. Negotiated Rate	$55.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6.94
Rate for Payer: BCBS of TX Blue Advantage	$23.12
Rate for Payer: BCBS of TX Blue Essentials	$27.74
Rate for Payer: BCBS of TX PPO	$30.82
Rate for Payer: Cash Price	$52.40
Rate for Payer: Cigna Medicaid	$55.48
Rate for Payer: Molina CHIP/Medicaid	$55.48
Rate for Payer: Multiplan Auto	$50.09
Rate for Payer: Multiplan Commercial	$50.09
Rate for Payer: Multiplan Workers Comp	$50.09
Rate for Payer: Parkland Medicaid	$55.48
Rate for Payer: Scott and White EPO/PPO	$38.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55.48
Rate for Payer: Superior Health Plan EPO	$10.48

SLV, STABILITY, TROCAR, XCEL, 5MMX100MM

Facility

$77.06

Hospital Charge Code	992825
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.40

Know your out-of-pocket cost for care.

All Charges