White Rock Medical Center

All Charges

Charge

Type

Setting

Price

WRNR SLP Standardized Cognitive Perf Test BCE

Facility

$544.00

Service Code	HCPCS 96125
Hospital Charge Code	4450060
Hospital Revenue Code	440
Rate for Payer: Cash Price	$369.92

WRNR SLP Standardized Cognitive Perf Test BCE

Facility

$544.00

Service Code	HCPCS 96125
Hospital Charge Code	9310569
Hospital Revenue Code	440
Rate for Payer: Cash Price	$369.92

WRNR SLP Standardized Cognitive Perf Test BCE

Facility

$544.00

Service Code	HCPCS 96125
Hospital Charge Code	9310569
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	$126.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$391.68
Rate for Payer: Superior Health Plan EPO	$73.98

WRNR SLP Standardized Cognitive Perf Test BCE

Facility

$544.00

Service Code	HCPCS 96125
Hospital Charge Code	4450060
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	$126.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$391.68
Rate for Payer: Superior Health Plan EPO	$73.98

WRNR SLP Swallow Dysfunction Oral Feed Units BCE

Facility

$279.00

Service Code	HCPCS 92526
Hospital Charge Code	9310576
Hospital Revenue Code	440
Rate for Payer: Cash Price	$189.72

WRNR SLP Swallow Dysfunction Oral Feed Units BCE

Facility

$279.00

Service Code	HCPCS 92526
Hospital Charge Code	9310576
Hospital Revenue Code	440
Min. Negotiated Rate	$25.11
Max. Negotiated Rate	$200.88
Rate for Payer: Amerigroup CHIP/Medicaid	$25.11
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

WRNR ST Assessment of Aphasia Units BCE

Facility

$496.00

Service Code	HCPCS 96105
Hospital Charge Code	4490025
Hospital Revenue Code	440
Rate for Payer: Cash Price	$337.28

WRNR ST Assessment of Aphasia Units BCE

Facility

$496.00

Service Code	HCPCS 96105
Hospital Charge Code	4490025
Hospital Revenue Code	440
Min. Negotiated Rate	$44.64
Max. Negotiated Rate	$357.12
Rate for Payer: Amerigroup CHIP/Medicaid	$44.64
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: 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	$118.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$357.12
Rate for Payer: Superior Health Plan EPO	$67.46

WS-1607ST

Facility

$198.44

Service Code	HCPCS C1769
Hospital Charge Code	994022
Hospital Revenue Code	272
Min. Negotiated Rate	$17.86
Max. Negotiated Rate	$142.88
Rate for Payer: Amerigroup CHIP/Medicaid	$17.86
Rate for Payer: BCBS of TX Blue Advantage	$59.53
Rate for Payer: BCBS of TX Blue Essentials	$71.44
Rate for Payer: BCBS of TX PPO	$79.38
Rate for Payer: Cash Price	$134.94
Rate for Payer: Cigna Medicaid	$142.88
Rate for Payer: Molina CHIP/Medicaid	$142.88
Rate for Payer: Multiplan Auto	$128.99
Rate for Payer: Multiplan Commercial	$128.99
Rate for Payer: Multiplan Workers Comp	$128.99
Rate for Payer: Parkland Medicaid	$142.88
Rate for Payer: Scott and White EPO/PPO	$99.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$142.88
Rate for Payer: Superior Health Plan EPO	$26.99

WS-1607ST

Facility

$198.44

Service Code	HCPCS C1769
Hospital Charge Code	994022
Hospital Revenue Code	272
Rate for Payer: Cash Price	$134.94

XB3.0 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992447
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

XB3.0 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992447
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

XB 3.5 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992448
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

XB 3.5 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992448
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

xb 4.0 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992445
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

xb 4.0 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992445
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

XBLAD 3.5 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992444
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

XBLAD 3.5 Guide Catheter

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992444
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

XBLAD 4.0

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992449
Hospital Revenue Code	272
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$140.56
Rate for Payer: Amerigroup CHIP/Medicaid	$17.57
Rate for Payer: BCBS of TX Blue Advantage	$58.57
Rate for Payer: BCBS of TX Blue Essentials	$70.28
Rate for Payer: BCBS of TX PPO	$78.09
Rate for Payer: Cash Price	$132.75
Rate for Payer: Cigna Medicaid	$140.56
Rate for Payer: Molina CHIP/Medicaid	$140.56
Rate for Payer: Multiplan Auto	$126.89
Rate for Payer: Multiplan Commercial	$126.89
Rate for Payer: Multiplan Workers Comp	$126.89
Rate for Payer: Parkland Medicaid	$140.56
Rate for Payer: Scott and White EPO/PPO	$97.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$140.56
Rate for Payer: Superior Health Plan EPO	$26.55

XBLAD 4.0

Facility

$195.22

Service Code	HCPCS C1887
Hospital Charge Code	992449
Hospital Revenue Code	272
Rate for Payer: Cash Price	$132.75

XPERT MRSA NXG TEST 10 TESTS 10/KT

Facility

$762.72

Hospital Charge Code	993650
Hospital Revenue Code	270
Rate for Payer: Cash Price	$518.65

XPERT MRSA NXG TEST 10 TESTS 10/KT

Facility

$762.72

Hospital Charge Code	993650
Hospital Revenue Code	270
Min. Negotiated Rate	$68.64
Max. Negotiated Rate	$549.16
Rate for Payer: Amerigroup CHIP/Medicaid	$68.64
Rate for Payer: BCBS of TX Blue Advantage	$228.82
Rate for Payer: BCBS of TX Blue Essentials	$274.58
Rate for Payer: BCBS of TX PPO	$305.09
Rate for Payer: Cash Price	$518.65
Rate for Payer: Cigna Medicaid	$549.16
Rate for Payer: Molina CHIP/Medicaid	$549.16
Rate for Payer: Multiplan Auto	$495.77
Rate for Payer: Multiplan Commercial	$495.77
Rate for Payer: Multiplan Workers Comp	$495.77
Rate for Payer: Parkland Medicaid	$549.16
Rate for Payer: Scott and White EPO/PPO	$381.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$549.16
Rate for Payer: Superior Health Plan EPO	$103.73

XR Abdomen Complete 3 Views

Facility

$819.00

Service Code	HCPCS 74021
Hospital Charge Code	3181560
Hospital Revenue Code	320
Min. Negotiated Rate	$43.10
Max. Negotiated Rate	$589.68
Rate for Payer: Amerigroup CHIP/Medicaid	$43.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$556.92
Rate for Payer: Cash Price	$556.92
Rate for Payer: Cash Price	$556.92
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$589.68
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$589.68
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$532.35
Rate for Payer: Multiplan Commercial	$532.35
Rate for Payer: Multiplan Workers Comp	$532.35
Rate for Payer: Parkland Medicaid	$589.68
Rate for Payer: Scott and White EPO/PPO	$53.11
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$589.68
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

XR Abdomen Complete 3 Views

Facility

$819.00

Service Code	HCPCS 74021
Hospital Charge Code	3181560
Hospital Revenue Code	320
Rate for Payer: Cash Price	$556.92

XR Abdomen KUB 1 View

Facility

$739.00

Service Code	HCPCS 74018
Hospital Charge Code	3181556
Hospital Revenue Code	320
Rate for Payer: Cash Price	$502.52

Know your out-of-pocket cost for care.

All Charges