White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SLITTER CATH -- DHF

Facility

$151.58

Hospital Charge Code	40049900
Hospital Revenue Code	272
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$109.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.64
Rate for Payer: BCBS of TX Blue Advantage	$45.47
Rate for Payer: BCBS of TX Blue Essentials	$54.57
Rate for Payer: BCBS of TX PPO	$60.63
Rate for Payer: Cash Price	$103.07
Rate for Payer: Cigna Medicaid	$109.14
Rate for Payer: Molina CHIP/Medicaid	$109.14
Rate for Payer: Multiplan Auto	$98.53
Rate for Payer: Multiplan Commercial	$98.53
Rate for Payer: Multiplan Workers Comp	$98.53
Rate for Payer: Parkland Medicaid	$109.14
Rate for Payer: Scott and White EPO/PPO	$75.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.14
Rate for Payer: Superior Health Plan EPO	$20.61

Slotted Head Positioner 9 W X 8 D X 4 H Inch Foam Freestandi

Facility

$91.67

Hospital Charge Code	993037
Hospital Revenue Code	270
Rate for Payer: Cash Price	$62.34

Slotted Head Positioner 9 W X 8 D X 4 H Inch Foam Freestandi

Facility

$91.67

Hospital Charge Code	993037
Hospital Revenue Code	270
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$66.00
Rate for Payer: Amerigroup CHIP/Medicaid	$8.25
Rate for Payer: BCBS of TX Blue Advantage	$27.50
Rate for Payer: BCBS of TX Blue Essentials	$33.00
Rate for Payer: BCBS of TX PPO	$36.67
Rate for Payer: Cash Price	$62.34
Rate for Payer: Cigna Medicaid	$66.00
Rate for Payer: Molina CHIP/Medicaid	$66.00
Rate for Payer: Multiplan Auto	$59.59
Rate for Payer: Multiplan Commercial	$59.59
Rate for Payer: Multiplan Workers Comp	$59.59
Rate for Payer: Parkland Medicaid	$66.00
Rate for Payer: Scott and White EPO/PPO	$45.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.00
Rate for Payer: Superior Health Plan EPO	$12.47

SLOTTED PLATE

Facility

$879.52

Service Code	HCPCS C1734
Hospital Charge Code	992241
Hospital Revenue Code	278
Min. Negotiated Rate	$219.88
Max. Negotiated Rate	$439.76
Rate for Payer: Cash Price	$598.07
Rate for Payer: Cigna Commercial	$219.88
Rate for Payer: Multiplan Auto	$439.76
Rate for Payer: Multiplan Commercial	$439.76
Rate for Payer: Multiplan Workers Comp	$439.76
Rate for Payer: Scott and White EPO/PPO	$439.76

SLOTTED PLATE

Facility

$879.52

Service Code	HCPCS C1734
Hospital Charge Code	992241
Hospital Revenue Code	278
Min. Negotiated Rate	$79.16
Max. Negotiated Rate	$633.25
Rate for Payer: Amerigroup CHIP/Medicaid	$79.16
Rate for Payer: BCBS of TX Blue Advantage	$263.86
Rate for Payer: BCBS of TX Blue Essentials	$316.63
Rate for Payer: BCBS of TX PPO	$351.81
Rate for Payer: Cash Price	$598.07
Rate for Payer: Cigna Medicaid	$633.25
Rate for Payer: Molina CHIP/Medicaid	$633.25
Rate for Payer: Multiplan Auto	$439.76
Rate for Payer: Multiplan Commercial	$439.76
Rate for Payer: Multiplan Workers Comp	$439.76
Rate for Payer: Parkland Medicaid	$633.25
Rate for Payer: Scott and White EPO/PPO	$439.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$633.25
Rate for Payer: Superior Health Plan EPO	$119.61

SLP Assessment of Aphasia Units

Facility

$496.00

Service Code	HCPCS 96105
Hospital Charge Code	9114973
Hospital Revenue Code	444
Min. Negotiated Rate	$67.46
Max. Negotiated Rate	$357.12
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$148.80
Rate for Payer: BCBS of TX Blue Essentials	$178.56
Rate for Payer: BCBS of TX PPO	$198.40
Rate for Payer: Cash Price	$337.28
Rate for Payer: Cash Price	$337.28
Rate for Payer: Cash Price	$337.28
Rate for Payer: Cash Price	$337.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$357.12
Rate for Payer: Molina CHIP/Medicaid	$357.12
Rate for Payer: Multiplan Auto	$322.40
Rate for Payer: Multiplan Commercial	$322.40
Rate for Payer: Multiplan Workers Comp	$322.40
Rate for Payer: Parkland Medicaid	$357.12
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$357.12
Rate for Payer: Superior Health Plan EPO	$67.46

SLP Assessment of Aphasia Units

Facility

$496.00

Service Code	HCPCS 96105
Hospital Charge Code	9114973
Hospital Revenue Code	444
Rate for Payer: Cash Price	$337.28

SLP Auditory Processing Tx Units

Facility

$326.00

Service Code	HCPCS 92507
Hospital Charge Code	4405445
Hospital Revenue Code	441
Rate for Payer: Cash Price	$221.68

SLP Auditory Processing Tx Units

Facility

$326.00

Service Code	HCPCS 92507
Hospital Charge Code	4405445
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

SLP Eval Lang Comprehension,Express Unit

Facility

$396.00

Service Code	HCPCS 92523
Hospital Charge Code	4450055
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

SLP Eval Lang Comprehension,Express Unit

Facility

$396.00

Service Code	HCPCS 92523
Hospital Charge Code	4450055
Hospital Revenue Code	444
Rate for Payer: Cash Price	$269.28

SLP Eval of Speech Sound Prod Units

Facility

$364.00

Service Code	HCPCS 92522
Hospital Charge Code	9310565
Hospital Revenue Code	444
Rate for Payer: Cash Price	$247.52

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: 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

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: 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

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: BCBS of TX PPO	$241.20
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: Cash Price	$410.04
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	$180.00
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
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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$511.92
Rate for Payer: Superior Health Plan EPO	$96.70

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 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	$80.00
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: 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	$180.00
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
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

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 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 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	$263.50
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

Know your out-of-pocket cost for care.

All Charges