White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PM AZURE XT W1DR01

Facility

$24,698.80

Service Code	HCPCS C1785
Hospital Charge Code	109967
Hospital Revenue Code	275
Min. Negotiated Rate	$6,174.70
Max. Negotiated Rate	$12,349.40
Rate for Payer: Aetna Commercial	$7,409.64
Rate for Payer: Cash Price	$21,734.94
Rate for Payer: Cigna Commercial	$6,174.70
Rate for Payer: Multiplan Auto	$12,349.40
Rate for Payer: Multiplan Commercial	$12,349.40
Rate for Payer: Multiplan Workers Comp	$12,349.40
Rate for Payer: Scott and White EPO/PPO	$12,349.40

PM COBALT XT DTPB2D4

Facility

$114,608.43

Service Code	HCPCS C1721
Hospital Charge Code	8476467
Hospital Revenue Code	275
Min. Negotiated Rate	$10,314.76
Max. Negotiated Rate	$57,304.22
Rate for Payer: Aetna Commercial	$34,382.53
Rate for Payer: Amerigroup CHIP/Medicaid	$10,314.76
Rate for Payer: BCBS of TX Blue Advantage	$34,382.53
Rate for Payer: BCBS of TX Blue Essentials	$41,259.03
Rate for Payer: BCBS of TX PPO	$45,843.37
Rate for Payer: Cash Price	$100,855.42
Rate for Payer: Multiplan Auto	$57,304.22
Rate for Payer: Multiplan Commercial	$57,304.22
Rate for Payer: Multiplan Workers Comp	$57,304.22
Rate for Payer: Scott and White EPO/PPO	$57,304.22
Rate for Payer: Superior Health Plan EPO	$15,586.75

PM COBALT XT DTPB2D4

Facility

$114,608.43

Service Code	HCPCS C1721
Hospital Charge Code	8476467
Hospital Revenue Code	275
Min. Negotiated Rate	$28,652.11
Max. Negotiated Rate	$57,304.22
Rate for Payer: Aetna Commercial	$34,382.53
Rate for Payer: Cash Price	$100,855.42
Rate for Payer: Cigna Commercial	$28,652.11
Rate for Payer: Multiplan Auto	$57,304.22
Rate for Payer: Multiplan Commercial	$57,304.22
Rate for Payer: Multiplan Workers Comp	$57,304.22
Rate for Payer: Scott and White EPO/PPO	$57,304.22

PM MRI ASSURITY 1272

Facility

$35,685.24

Service Code	HCPCS C1786
Hospital Charge Code	8450466
Hospital Revenue Code	275
Min. Negotiated Rate	$3,211.67
Max. Negotiated Rate	$17,842.62
Rate for Payer: Aetna Commercial	$10,705.57
Rate for Payer: Amerigroup CHIP/Medicaid	$3,211.67
Rate for Payer: BCBS of TX Blue Advantage	$10,705.57
Rate for Payer: BCBS of TX Blue Essentials	$12,846.69
Rate for Payer: BCBS of TX PPO	$14,274.10
Rate for Payer: Cash Price	$31,403.01
Rate for Payer: Multiplan Auto	$17,842.62
Rate for Payer: Multiplan Commercial	$17,842.62
Rate for Payer: Multiplan Workers Comp	$17,842.62
Rate for Payer: Scott and White EPO/PPO	$17,842.62
Rate for Payer: Superior Health Plan EPO	$4,853.19

PM MRI ASSURITY 1272

Facility

$35,685.24

Service Code	HCPCS C1786
Hospital Charge Code	8450466
Hospital Revenue Code	275
Min. Negotiated Rate	$8,921.31
Max. Negotiated Rate	$17,842.62
Rate for Payer: Aetna Commercial	$10,705.57
Rate for Payer: Cash Price	$31,403.01
Rate for Payer: Cigna Commercial	$8,921.31
Rate for Payer: Multiplan Auto	$17,842.62
Rate for Payer: Multiplan Commercial	$17,842.62
Rate for Payer: Multiplan Workers Comp	$17,842.62
Rate for Payer: Scott and White EPO/PPO	$17,842.62

pneumococcal 23-polyvalent vaccine Inj Soln 0.5 mL

Facility

$307.40

Service Code	HCPCS 90732
Hospital Charge Code	77764479
Hospital Revenue Code	636
Min. Negotiated Rate	$76.85
Max. Negotiated Rate	$153.70
Rate for Payer: Cash Price	$209.03
Rate for Payer: Cigna Commercial	$76.85
Rate for Payer: Scott and White EPO/PPO	$153.70

pneumococcal 23-polyvalent vaccine Inj Soln 0.5 mL

Facility

$307.40

Service Code	HCPCS 90732
Hospital Charge Code	77764479
Hospital Revenue Code	636
Min. Negotiated Rate	$27.67
Max. Negotiated Rate	$226.23
Rate for Payer: Aetna Commercial	$169.07
Rate for Payer: Amerigroup CHIP/Medicaid	$27.67
Rate for Payer: BCBS of TX Blue Advantage	$169.97
Rate for Payer: BCBS of TX Blue Essentials	$203.96
Rate for Payer: BCBS of TX PPO	$226.23
Rate for Payer: Cash Price	$209.03
Rate for Payer: Cash Price	$209.03
Rate for Payer: Multiplan Auto	$199.81
Rate for Payer: Multiplan Commercial	$199.81
Rate for Payer: Multiplan Workers Comp	$199.81
Rate for Payer: Scott and White EPO/PPO	$153.70
Rate for Payer: Superior Health Plan EPO	$41.81

PNEUMOTHORAX TRAY

Facility

$903.51

Hospital Charge Code	8082755
Hospital Revenue Code	270
Rate for Payer: Cash Price	$795.09

PNEUMOTHORAX TRAY

Facility

$903.51

Hospital Charge Code	8082755
Hospital Revenue Code	270
Min. Negotiated Rate	$81.32
Max. Negotiated Rate	$587.28
Rate for Payer: Aetna Commercial	$496.93
Rate for Payer: Amerigroup CHIP/Medicaid	$81.32
Rate for Payer: BCBS of TX Blue Advantage	$271.05
Rate for Payer: BCBS of TX Blue Essentials	$325.26
Rate for Payer: BCBS of TX PPO	$361.40
Rate for Payer: Cash Price	$795.09
Rate for Payer: Multiplan Auto	$587.28
Rate for Payer: Multiplan Commercial	$587.28
Rate for Payer: Multiplan Workers Comp	$587.28
Rate for Payer: Scott and White EPO/PPO	$451.76
Rate for Payer: Superior Health Plan EPO	$122.88

PNEUMOTHORAX WITH CC

Facility

$20,463.00

Service Code	MSDRG 200
Min. Negotiated Rate	$9,039.46
Max. Negotiated Rate	$20,463.00
Rate for Payer: Aetna Commercial	$12,116.25
Rate for Payer: Aetna Medicare	$15,810.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,540.31
Rate for Payer: Amerigroup Medicare	$10,540.31
Rate for Payer: BCBS of TX Blue Advantage	$9,039.46
Rate for Payer: BCBS of TX Blue Essentials	$11,090.86
Rate for Payer: BCBS of TX Medicare	$10,540.31
Rate for Payer: BCBS of TX PPO	$12,323.66
Rate for Payer: Cigna Commercial	$13,871.76
Rate for Payer: Cigna Medicare	$10,540.31
Rate for Payer: Employer Direct Commercial	$10,540.31
Rate for Payer: Humana Medicare/TRICARE	$10,540.31
Rate for Payer: Molina Dual Medicare/Medicaid	$10,540.31
Rate for Payer: Molina Medicare	$10,540.31
Rate for Payer: Multiplan Auto	$20,463.00
Rate for Payer: Multiplan Commercial	$20,463.00
Rate for Payer: Multiplan Workers Comp	$20,463.00
Rate for Payer: Scott and White EPO/PPO	$9,423.75
Rate for Payer: Scott and White Medicare	$10,540.31
Rate for Payer: Superior Health Plan EPO	$10,540.31
Rate for Payer: Superior Health Plan Medicare	$10,540.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,540.31
Rate for Payer: Universal American Medicare	$10,540.31
Rate for Payer: Wellcare Medicare	$10,540.31
Rate for Payer: Wellmed Medicare	$10,540.31

PNEUMOTHORAX WITH MCC

Facility

$33,707.90

Service Code	MSDRG 199
Min. Negotiated Rate	$15,514.87
Max. Negotiated Rate	$33,707.90
Rate for Payer: Aetna Commercial	$19,958.62
Rate for Payer: Aetna Medicare	$23,272.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,514.87
Rate for Payer: Amerigroup Medicare	$15,514.87
Rate for Payer: BCBS of TX Blue Advantage	$15,563.42
Rate for Payer: BCBS of TX Blue Essentials	$18,396.71
Rate for Payer: BCBS of TX Medicare	$15,514.87
Rate for Payer: BCBS of TX PPO	$20,441.58
Rate for Payer: Cigna Commercial	$22,850.41
Rate for Payer: Cigna Medicare	$15,514.87
Rate for Payer: Employer Direct Commercial	$15,514.87
Rate for Payer: Humana Medicare/TRICARE	$15,514.87
Rate for Payer: Molina Dual Medicare/Medicaid	$15,514.87
Rate for Payer: Molina Medicare	$15,514.87
Rate for Payer: Multiplan Auto	$33,707.90
Rate for Payer: Multiplan Commercial	$33,707.90
Rate for Payer: Multiplan Workers Comp	$33,707.90
Rate for Payer: Scott and White EPO/PPO	$15,523.38
Rate for Payer: Scott and White Medicare	$15,514.87
Rate for Payer: Superior Health Plan EPO	$15,514.87
Rate for Payer: Superior Health Plan Medicare	$15,514.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,514.87
Rate for Payer: Universal American Medicare	$15,514.87
Rate for Payer: Wellcare Medicare	$15,514.87
Rate for Payer: Wellmed Medicare	$15,514.87

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$13,415.90

Service Code	MSDRG 201
Min. Negotiated Rate	$6,178.38
Max. Negotiated Rate	$13,415.90
Rate for Payer: Aetna Commercial	$7,943.62
Rate for Payer: Aetna Medicare	$11,840.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,893.55
Rate for Payer: Amerigroup Medicare	$7,893.55
Rate for Payer: BCBS of TX Blue Advantage	$6,365.72
Rate for Payer: BCBS of TX Blue Essentials	$7,211.95
Rate for Payer: BCBS of TX Medicare	$7,893.55
Rate for Payer: BCBS of TX PPO	$8,013.59
Rate for Payer: Cigna Commercial	$9,094.57
Rate for Payer: Cigna Medicare	$7,893.55
Rate for Payer: Employer Direct Commercial	$7,893.55
Rate for Payer: Humana Medicare/TRICARE	$7,893.55
Rate for Payer: Molina Dual Medicare/Medicaid	$7,893.55
Rate for Payer: Molina Medicare	$7,893.55
Rate for Payer: Multiplan Auto	$13,415.90
Rate for Payer: Multiplan Commercial	$13,415.90
Rate for Payer: Multiplan Workers Comp	$13,415.90
Rate for Payer: Scott and White EPO/PPO	$6,178.38
Rate for Payer: Scott and White Medicare	$7,893.55
Rate for Payer: Superior Health Plan EPO	$7,893.55
Rate for Payer: Superior Health Plan Medicare	$7,893.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,893.55
Rate for Payer: Universal American Medicare	$7,893.55
Rate for Payer: Wellcare Medicare	$7,893.55
Rate for Payer: Wellmed Medicare	$7,893.55

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$30,322.10

Service Code	MSDRG 917
Min. Negotiated Rate	$12,304.02
Max. Negotiated Rate	$30,322.10
Rate for Payer: Aetna Commercial	$17,953.88
Rate for Payer: Aetna Medicare	$21,364.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,243.21
Rate for Payer: Amerigroup Medicare	$14,243.21
Rate for Payer: BCBS of TX Blue Advantage	$12,304.02
Rate for Payer: BCBS of TX Blue Essentials	$15,207.11
Rate for Payer: BCBS of TX Medicare	$14,243.21
Rate for Payer: BCBS of TX PPO	$16,897.44
Rate for Payer: Cigna Commercial	$20,555.19
Rate for Payer: Cigna Medicare	$14,243.21
Rate for Payer: Employer Direct Commercial	$14,243.21
Rate for Payer: Humana Medicare/TRICARE	$14,243.21
Rate for Payer: Molina Dual Medicare/Medicaid	$14,243.21
Rate for Payer: Molina Medicare	$14,243.21
Rate for Payer: Multiplan Auto	$30,322.10
Rate for Payer: Multiplan Commercial	$30,322.10
Rate for Payer: Multiplan Workers Comp	$30,322.10
Rate for Payer: Scott and White EPO/PPO	$13,964.12
Rate for Payer: Scott and White Medicare	$14,243.21
Rate for Payer: Superior Health Plan EPO	$14,243.21
Rate for Payer: Superior Health Plan Medicare	$14,243.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,243.21
Rate for Payer: Universal American Medicare	$14,243.21
Rate for Payer: Wellcare Medicare	$14,243.21
Rate for Payer: Wellmed Medicare	$14,243.21

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$16,357.10

Service Code	MSDRG 918
Min. Negotiated Rate	$6,118.90
Max. Negotiated Rate	$16,357.10
Rate for Payer: Aetna Commercial	$9,685.12
Rate for Payer: Aetna Medicare	$13,497.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,998.21
Rate for Payer: Amerigroup Medicare	$8,998.21
Rate for Payer: BCBS of TX Blue Advantage	$6,118.90
Rate for Payer: BCBS of TX Blue Essentials	$8,035.41
Rate for Payer: BCBS of TX Medicare	$8,998.21
Rate for Payer: BCBS of TX PPO	$8,928.57
Rate for Payer: Cigna Commercial	$11,088.39
Rate for Payer: Cigna Medicare	$8,998.21
Rate for Payer: Employer Direct Commercial	$8,998.21
Rate for Payer: Humana Medicare/TRICARE	$8,998.21
Rate for Payer: Molina Dual Medicare/Medicaid	$8,998.21
Rate for Payer: Molina Medicare	$8,998.21
Rate for Payer: Multiplan Auto	$16,357.10
Rate for Payer: Multiplan Commercial	$16,357.10
Rate for Payer: Multiplan Workers Comp	$16,357.10
Rate for Payer: Scott and White EPO/PPO	$7,532.88
Rate for Payer: Scott and White Medicare	$8,998.21
Rate for Payer: Superior Health Plan EPO	$8,998.21
Rate for Payer: Superior Health Plan Medicare	$8,998.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,998.21
Rate for Payer: Universal American Medicare	$8,998.21
Rate for Payer: Wellcare Medicare	$8,998.21
Rate for Payer: Wellmed Medicare	$8,998.21

polyethylene glycol 3350 Oral Powder-Recon 17 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77765270
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

polyethylene glycol 3350 Oral Powder-Recon 17 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77765270
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

Polysomnography 4+ parameters 95810

Facility

$6,048.00

Service Code	CPT 95810 52
Hospital Charge Code	6200018
Hospital Revenue Code	920
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$3,931.20
Rate for Payer: Aetna Commercial	$845.88
Rate for Payer: Aetna Medicare	$1,434.28
Rate for Payer: Amerigroup CHIP/Medicaid	$544.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$956.19
Rate for Payer: Amerigroup Medicare	$956.19
Rate for Payer: BCBS of TX Blue Advantage	$871.64
Rate for Payer: BCBS of TX Blue Essentials	$1,041.96
Rate for Payer: BCBS of TX Medicare	$956.19
Rate for Payer: BCBS of TX PPO	$1,162.18
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cigna Commercial	$2,166.06
Rate for Payer: Cigna Medicare	$956.19
Rate for Payer: Employer Direct Commercial	$956.19
Rate for Payer: Humana Medicare/TRICARE	$956.19
Rate for Payer: Molina Dual Medicare/Medicaid	$956.19
Rate for Payer: Molina Medicare	$956.19
Rate for Payer: Multiplan Auto	$3,931.20
Rate for Payer: Multiplan Commercial	$3,931.20
Rate for Payer: Multiplan Workers Comp	$3,931.20
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Scott and White Medicare	$956.19
Rate for Payer: Superior Health Plan EPO	$956.19
Rate for Payer: Superior Health Plan Medicare	$956.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$956.19
Rate for Payer: Universal American Medicare	$956.19
Rate for Payer: Wellcare Medicare	$956.19
Rate for Payer: Wellmed Medicare	$956.19

Polysomnography 4+ parameters 95810

Facility

$6,048.00

Service Code	CPT 95810
Hospital Charge Code	6200018
Hospital Revenue Code	920
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$3,931.20
Rate for Payer: Aetna Commercial	$845.88
Rate for Payer: Aetna Medicare	$1,434.28
Rate for Payer: Amerigroup CHIP/Medicaid	$544.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$956.19
Rate for Payer: Amerigroup Medicare	$956.19
Rate for Payer: BCBS of TX Blue Advantage	$871.64
Rate for Payer: BCBS of TX Blue Essentials	$1,041.96
Rate for Payer: BCBS of TX Medicare	$956.19
Rate for Payer: BCBS of TX PPO	$1,162.18
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cigna Commercial	$2,166.06
Rate for Payer: Cigna Medicare	$956.19
Rate for Payer: Employer Direct Commercial	$956.19
Rate for Payer: Humana Medicare/TRICARE	$956.19
Rate for Payer: Molina Dual Medicare/Medicaid	$956.19
Rate for Payer: Molina Medicare	$956.19
Rate for Payer: Multiplan Auto	$3,931.20
Rate for Payer: Multiplan Commercial	$3,931.20
Rate for Payer: Multiplan Workers Comp	$3,931.20
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Scott and White Medicare	$956.19
Rate for Payer: Superior Health Plan EPO	$956.19
Rate for Payer: Superior Health Plan Medicare	$956.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$956.19
Rate for Payer: Universal American Medicare	$956.19
Rate for Payer: Wellcare Medicare	$956.19
Rate for Payer: Wellmed Medicare	$956.19

Polysomnography 4+ parameters 95810 BCE

Facility

$6,048.00

Service Code	CPT 95810
Hospital Charge Code	6200018
Hospital Revenue Code	920
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$3,931.20
Rate for Payer: Aetna Commercial	$845.88
Rate for Payer: Aetna Medicare	$1,434.28
Rate for Payer: Amerigroup CHIP/Medicaid	$544.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$956.19
Rate for Payer: Amerigroup Medicare	$956.19
Rate for Payer: BCBS of TX Blue Advantage	$871.64
Rate for Payer: BCBS of TX Blue Essentials	$1,041.96
Rate for Payer: BCBS of TX Medicare	$956.19
Rate for Payer: BCBS of TX PPO	$1,162.18
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cash Price	$5,322.24
Rate for Payer: Cigna Commercial	$2,166.06
Rate for Payer: Cigna Medicare	$956.19
Rate for Payer: Employer Direct Commercial	$956.19
Rate for Payer: Humana Medicare/TRICARE	$956.19
Rate for Payer: Molina Dual Medicare/Medicaid	$956.19
Rate for Payer: Molina Medicare	$956.19
Rate for Payer: Multiplan Auto	$3,931.20
Rate for Payer: Multiplan Commercial	$3,931.20
Rate for Payer: Multiplan Workers Comp	$3,931.20
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Scott and White Medicare	$956.19
Rate for Payer: Superior Health Plan EPO	$956.19
Rate for Payer: Superior Health Plan Medicare	$956.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$956.19
Rate for Payer: Universal American Medicare	$956.19
Rate for Payer: Wellcare Medicare	$956.19
Rate for Payer: Wellmed Medicare	$956.19

Polysomnography 4+ parameters 95810 BCE

Facility

$6,048.00

Service Code	CPT 95810
Hospital Charge Code	6200018
Hospital Revenue Code	920
Rate for Payer: Cash Price	$5,322.24

Polysomnography 4+ parameters w/PAP 95811

Facility

$6,459.00

Service Code	CPT 95811
Hospital Charge Code	6200026
Hospital Revenue Code	920
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$4,198.35
Rate for Payer: Aetna Commercial	$884.27
Rate for Payer: Aetna Medicare	$1,434.28
Rate for Payer: Amerigroup CHIP/Medicaid	$581.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$956.19
Rate for Payer: Amerigroup Medicare	$956.19
Rate for Payer: BCBS of TX Blue Advantage	$916.16
Rate for Payer: BCBS of TX Blue Essentials	$1,095.18
Rate for Payer: BCBS of TX Medicare	$956.19
Rate for Payer: BCBS of TX PPO	$1,221.55
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cigna Commercial	$2,166.06
Rate for Payer: Cigna Medicare	$956.19
Rate for Payer: Employer Direct Commercial	$956.19
Rate for Payer: Humana Medicare/TRICARE	$956.19
Rate for Payer: Molina Dual Medicare/Medicaid	$956.19
Rate for Payer: Molina Medicare	$956.19
Rate for Payer: Multiplan Auto	$4,198.35
Rate for Payer: Multiplan Commercial	$4,198.35
Rate for Payer: Multiplan Workers Comp	$4,198.35
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Scott and White Medicare	$956.19
Rate for Payer: Superior Health Plan EPO	$956.19
Rate for Payer: Superior Health Plan Medicare	$956.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$956.19
Rate for Payer: Universal American Medicare	$956.19
Rate for Payer: Wellcare Medicare	$956.19
Rate for Payer: Wellmed Medicare	$956.19

Polysomnography 4+ parameters w/PAP 95811

Facility

$6,459.00

Service Code	CPT 95811 52
Hospital Charge Code	6200026
Hospital Revenue Code	920
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$4,198.35
Rate for Payer: Aetna Commercial	$884.27
Rate for Payer: Aetna Medicare	$1,434.28
Rate for Payer: Amerigroup CHIP/Medicaid	$581.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$956.19
Rate for Payer: Amerigroup Medicare	$956.19
Rate for Payer: BCBS of TX Blue Advantage	$916.16
Rate for Payer: BCBS of TX Blue Essentials	$1,095.18
Rate for Payer: BCBS of TX Medicare	$956.19
Rate for Payer: BCBS of TX PPO	$1,221.55
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cigna Commercial	$2,166.06
Rate for Payer: Cigna Medicare	$956.19
Rate for Payer: Employer Direct Commercial	$956.19
Rate for Payer: Humana Medicare/TRICARE	$956.19
Rate for Payer: Molina Dual Medicare/Medicaid	$956.19
Rate for Payer: Molina Medicare	$956.19
Rate for Payer: Multiplan Auto	$4,198.35
Rate for Payer: Multiplan Commercial	$4,198.35
Rate for Payer: Multiplan Workers Comp	$4,198.35
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Scott and White Medicare	$956.19
Rate for Payer: Superior Health Plan EPO	$956.19
Rate for Payer: Superior Health Plan Medicare	$956.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$956.19
Rate for Payer: Universal American Medicare	$956.19
Rate for Payer: Wellcare Medicare	$956.19
Rate for Payer: Wellmed Medicare	$956.19

Polysomnography 4+ parameters w/PAP 95811 BCE

Facility

$6,459.00

Service Code	CPT 95811
Hospital Charge Code	6200026
Hospital Revenue Code	920
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$4,198.35
Rate for Payer: Aetna Commercial	$884.27
Rate for Payer: Aetna Medicare	$1,434.28
Rate for Payer: Amerigroup CHIP/Medicaid	$581.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$956.19
Rate for Payer: Amerigroup Medicare	$956.19
Rate for Payer: BCBS of TX Blue Advantage	$916.16
Rate for Payer: BCBS of TX Blue Essentials	$1,095.18
Rate for Payer: BCBS of TX Medicare	$956.19
Rate for Payer: BCBS of TX PPO	$1,221.55
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cash Price	$5,683.92
Rate for Payer: Cigna Commercial	$2,166.06
Rate for Payer: Cigna Medicare	$956.19
Rate for Payer: Employer Direct Commercial	$956.19
Rate for Payer: Humana Medicare/TRICARE	$956.19
Rate for Payer: Molina Dual Medicare/Medicaid	$956.19
Rate for Payer: Molina Medicare	$956.19
Rate for Payer: Multiplan Auto	$4,198.35
Rate for Payer: Multiplan Commercial	$4,198.35
Rate for Payer: Multiplan Workers Comp	$4,198.35
Rate for Payer: Scott and White EPO/PPO	$17.10
Rate for Payer: Scott and White Medicare	$956.19
Rate for Payer: Superior Health Plan EPO	$956.19
Rate for Payer: Superior Health Plan Medicare	$956.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$956.19
Rate for Payer: Universal American Medicare	$956.19
Rate for Payer: Wellcare Medicare	$956.19
Rate for Payer: Wellmed Medicare	$956.19

Polysomnography 4+ parameters w/PAP 95811 BCE

Facility

$6,459.00

Service Code	CPT 95811
Hospital Charge Code	6200026
Hospital Revenue Code	920
Rate for Payer: Cash Price	$5,683.92

Porphobilinogen, Qn, Random Ur SO

Facility

$112.00

Service Code	CPT 84110
Hospital Charge Code	1704873
Hospital Revenue Code	301
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$72.80
Rate for Payer: Aetna Commercial	$8.86
Rate for Payer: Aetna Medicare	$12.66
Rate for Payer: Amerigroup CHIP/Medicaid	$3.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.44
Rate for Payer: Amerigroup Medicare	$8.44
Rate for Payer: BCBS of TX Blue Advantage	$13.93
Rate for Payer: BCBS of TX Blue Essentials	$16.71
Rate for Payer: BCBS of TX Medicare	$8.44
Rate for Payer: BCBS of TX PPO	$18.65
Rate for Payer: Cash Price	$98.56
Rate for Payer: Cash Price	$98.56
Rate for Payer: Cigna Medicaid	$8.44
Rate for Payer: Cigna Medicare	$8.44
Rate for Payer: Employer Direct Commercial	$8.44
Rate for Payer: Humana Medicare/TRICARE	$8.44
Rate for Payer: Molina CHIP/Medicaid	$8.44
Rate for Payer: Molina Dual Medicare/Medicaid	$8.44
Rate for Payer: Molina Medicare	$8.44
Rate for Payer: Multiplan Auto	$72.80
Rate for Payer: Multiplan Commercial	$72.80
Rate for Payer: Multiplan Workers Comp	$72.80
Rate for Payer: Parkland Medicaid	$8.44
Rate for Payer: Scott and White EPO/PPO	$10.55
Rate for Payer: Scott and White Medicare	$8.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.44
Rate for Payer: Superior Health Plan EPO	$8.44
Rate for Payer: Superior Health Plan Medicare	$8.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.44
Rate for Payer: Universal American Medicare	$8.44
Rate for Payer: Wellcare Medicare	$8.44
Rate for Payer: Wellmed Medicare	$8.44

Know your out-of-pocket cost for care.

All Charges