White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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: 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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.52
Rate for Payer: Superior Health Plan EPO	$12.38

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: 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	$180.00
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: 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

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

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	$180.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$263.52
Rate for Payer: Superior Health Plan EPO	$49.78

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 CONNECTOR IS4/DF4 -- DHF

Facility

$606.36

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

SLV, STABILITY, TROCAR, XCEL, 5MMX100MM

Facility

$77.06

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

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

SMART Stent 7mm X 40mm

Facility

$3,795.18

Service Code	HCPCS C1876
Hospital Charge Code	991293
Hospital Revenue Code	278
Min. Negotiated Rate	$341.57
Max. Negotiated Rate	$2,732.53
Rate for Payer: Amerigroup CHIP/Medicaid	$341.57
Rate for Payer: BCBS of TX Blue Advantage	$1,138.55
Rate for Payer: BCBS of TX Blue Essentials	$1,366.26
Rate for Payer: BCBS of TX PPO	$1,518.07
Rate for Payer: Cash Price	$2,580.72
Rate for Payer: Cigna Medicaid	$2,732.53
Rate for Payer: Molina CHIP/Medicaid	$2,732.53
Rate for Payer: Multiplan Auto	$1,897.59
Rate for Payer: Multiplan Commercial	$1,897.59
Rate for Payer: Multiplan Workers Comp	$1,897.59
Rate for Payer: Parkland Medicaid	$2,732.53
Rate for Payer: Scott and White EPO/PPO	$1,897.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,732.53
Rate for Payer: Superior Health Plan EPO	$516.14

SMART Stent 7mm X 40mm

Facility

$3,795.18

Service Code	HCPCS C1876
Hospital Charge Code	991293
Hospital Revenue Code	278
Min. Negotiated Rate	$948.79
Max. Negotiated Rate	$1,897.59
Rate for Payer: Cash Price	$2,580.72
Rate for Payer: Cigna Commercial	$948.79
Rate for Payer: Multiplan Auto	$1,897.59
Rate for Payer: Multiplan Commercial	$1,897.59
Rate for Payer: Multiplan Workers Comp	$1,897.59
Rate for Payer: Scott and White EPO/PPO	$1,897.59

SMART Stent 7mm X 80mm

Facility

$3,795.18

Service Code	HCPCS C1876
Hospital Charge Code	991294
Hospital Revenue Code	278
Min. Negotiated Rate	$948.79
Max. Negotiated Rate	$1,897.59
Rate for Payer: Cash Price	$2,580.72
Rate for Payer: Cigna Commercial	$948.79
Rate for Payer: Multiplan Auto	$1,897.59
Rate for Payer: Multiplan Commercial	$1,897.59
Rate for Payer: Multiplan Workers Comp	$1,897.59
Rate for Payer: Scott and White EPO/PPO	$1,897.59

SMART Stent 7mm X 80mm

Facility

$3,795.18

Service Code	HCPCS C1876
Hospital Charge Code	991294
Hospital Revenue Code	278
Min. Negotiated Rate	$341.57
Max. Negotiated Rate	$2,732.53
Rate for Payer: Amerigroup CHIP/Medicaid	$341.57
Rate for Payer: BCBS of TX Blue Advantage	$1,138.55
Rate for Payer: BCBS of TX Blue Essentials	$1,366.26
Rate for Payer: BCBS of TX PPO	$1,518.07
Rate for Payer: Cash Price	$2,580.72
Rate for Payer: Cigna Medicaid	$2,732.53
Rate for Payer: Molina CHIP/Medicaid	$2,732.53
Rate for Payer: Multiplan Auto	$1,897.59
Rate for Payer: Multiplan Commercial	$1,897.59
Rate for Payer: Multiplan Workers Comp	$1,897.59
Rate for Payer: Parkland Medicaid	$2,732.53
Rate for Payer: Scott and White EPO/PPO	$1,897.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,732.53
Rate for Payer: Superior Health Plan EPO	$516.14

SMART Vascular Stent

Facility

$5,373.49

Service Code	HCPCS C1876
Hospital Charge Code	991292
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.37
Max. Negotiated Rate	$2,686.74
Rate for Payer: Cash Price	$3,653.97
Rate for Payer: Cigna Commercial	$1,343.37
Rate for Payer: Multiplan Auto	$2,686.74
Rate for Payer: Multiplan Commercial	$2,686.74
Rate for Payer: Multiplan Workers Comp	$2,686.74
Rate for Payer: Scott and White EPO/PPO	$2,686.74

SMART Vascular Stent

Facility

$5,373.49

Service Code	HCPCS C1876
Hospital Charge Code	991292
Hospital Revenue Code	278
Min. Negotiated Rate	$483.61
Max. Negotiated Rate	$3,868.91
Rate for Payer: Amerigroup CHIP/Medicaid	$483.61
Rate for Payer: BCBS of TX Blue Advantage	$1,612.05
Rate for Payer: BCBS of TX Blue Essentials	$1,934.46
Rate for Payer: BCBS of TX PPO	$2,149.40
Rate for Payer: Cash Price	$3,653.97
Rate for Payer: Cigna Medicaid	$3,868.91
Rate for Payer: Molina CHIP/Medicaid	$3,868.91
Rate for Payer: Multiplan Auto	$2,686.74
Rate for Payer: Multiplan Commercial	$2,686.74
Rate for Payer: Multiplan Workers Comp	$2,686.74
Rate for Payer: Parkland Medicaid	$3,868.91
Rate for Payer: Scott and White EPO/PPO	$2,686.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,868.91
Rate for Payer: Superior Health Plan EPO	$730.79

SMART VASCULAR STENT SYSTEM SFA 6MM X 120MM X 120CM

Facility

$5,376.51

Service Code	HCPCS C1876
Hospital Charge Code	991289
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.13
Max. Negotiated Rate	$2,688.26
Rate for Payer: Cash Price	$3,656.03
Rate for Payer: Cigna Commercial	$1,344.13
Rate for Payer: Multiplan Auto	$2,688.26
Rate for Payer: Multiplan Commercial	$2,688.26
Rate for Payer: Multiplan Workers Comp	$2,688.26
Rate for Payer: Scott and White EPO/PPO	$2,688.26

SMART VASCULAR STENT SYSTEM SFA 6MM X 120MM X 120CM

Facility

$5,376.51

Service Code	HCPCS C1876
Hospital Charge Code	991289
Hospital Revenue Code	278
Min. Negotiated Rate	$483.89
Max. Negotiated Rate	$3,871.09
Rate for Payer: Amerigroup CHIP/Medicaid	$483.89
Rate for Payer: BCBS of TX Blue Advantage	$1,612.95
Rate for Payer: BCBS of TX Blue Essentials	$1,935.54
Rate for Payer: BCBS of TX PPO	$2,150.60
Rate for Payer: Cash Price	$3,656.03
Rate for Payer: Cigna Medicaid	$3,871.09
Rate for Payer: Molina CHIP/Medicaid	$3,871.09
Rate for Payer: Multiplan Auto	$2,688.26
Rate for Payer: Multiplan Commercial	$2,688.26
Rate for Payer: Multiplan Workers Comp	$2,688.26
Rate for Payer: Parkland Medicaid	$3,871.09
Rate for Payer: Scott and White EPO/PPO	$2,688.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,871.09
Rate for Payer: Superior Health Plan EPO	$731.21

SMSL50201

Facility

$680.22

Service Code	HCPCS C1713
Hospital Charge Code	991240
Hospital Revenue Code	278
Min. Negotiated Rate	$170.06
Max. Negotiated Rate	$340.11
Rate for Payer: Cash Price	$462.55
Rate for Payer: Cigna Commercial	$170.06
Rate for Payer: Multiplan Auto	$340.11
Rate for Payer: Multiplan Commercial	$340.11
Rate for Payer: Multiplan Workers Comp	$340.11
Rate for Payer: Scott and White EPO/PPO	$340.11

SMSL50201

Facility

$680.22

Service Code	HCPCS C1713
Hospital Charge Code	991240
Hospital Revenue Code	278
Min. Negotiated Rate	$61.22
Max. Negotiated Rate	$489.76
Rate for Payer: Amerigroup CHIP/Medicaid	$61.22
Rate for Payer: BCBS of TX Blue Advantage	$204.07
Rate for Payer: BCBS of TX Blue Essentials	$244.88
Rate for Payer: BCBS of TX PPO	$272.09
Rate for Payer: Cash Price	$462.55
Rate for Payer: Cigna Medicaid	$489.76
Rate for Payer: Molina CHIP/Medicaid	$489.76
Rate for Payer: Multiplan Auto	$340.11
Rate for Payer: Multiplan Commercial	$340.11
Rate for Payer: Multiplan Workers Comp	$340.11
Rate for Payer: Parkland Medicaid	$489.76
Rate for Payer: Scott and White EPO/PPO	$340.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$489.76
Rate for Payer: Superior Health Plan EPO	$92.51

SNARE OV/CRS/HEX -- DHF

Facility

$1,126.42

Hospital Charge Code	80826704
Hospital Revenue Code	272
Rate for Payer: Cash Price	$765.97

SNARE OV/CRS/HEX -- DHF

Facility

$1,126.42

Hospital Charge Code	80826704
Hospital Revenue Code	272
Min. Negotiated Rate	$101.38
Max. Negotiated Rate	$811.02
Rate for Payer: Amerigroup CHIP/Medicaid	$101.38
Rate for Payer: BCBS of TX Blue Advantage	$337.93
Rate for Payer: BCBS of TX Blue Essentials	$405.51
Rate for Payer: BCBS of TX PPO	$450.57
Rate for Payer: Cash Price	$765.97
Rate for Payer: Cigna Medicaid	$811.02
Rate for Payer: Molina CHIP/Medicaid	$811.02
Rate for Payer: Multiplan Auto	$732.17
Rate for Payer: Multiplan Commercial	$732.17
Rate for Payer: Multiplan Workers Comp	$732.17
Rate for Payer: Parkland Medicaid	$811.02
Rate for Payer: Scott and White EPO/PPO	$563.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$811.02
Rate for Payer: Superior Health Plan EPO	$153.19

SOAP HAND FOAMING SPECTRUM 1000ML

Facility

$56.26

Hospital Charge Code	993274
Hospital Revenue Code	270
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$40.51
Rate for Payer: Amerigroup CHIP/Medicaid	$5.06
Rate for Payer: BCBS of TX Blue Advantage	$16.88
Rate for Payer: BCBS of TX Blue Essentials	$20.25
Rate for Payer: BCBS of TX PPO	$22.50
Rate for Payer: Cash Price	$38.26
Rate for Payer: Cigna Medicaid	$40.51
Rate for Payer: Molina CHIP/Medicaid	$40.51
Rate for Payer: Multiplan Auto	$36.57
Rate for Payer: Multiplan Commercial	$36.57
Rate for Payer: Multiplan Workers Comp	$36.57
Rate for Payer: Parkland Medicaid	$40.51
Rate for Payer: Scott and White EPO/PPO	$28.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.51
Rate for Payer: Superior Health Plan EPO	$7.65

Know your out-of-pocket cost for care.

All Charges