White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SLEEK OTW 4.0X 10 X 150 SHAFT

Facility

$1,024.90

Service Code	HCPCS C1766
Hospital Charge Code	992497
Hospital Revenue Code	272
Min. Negotiated Rate	$92.24
Max. Negotiated Rate	$737.93
Rate for Payer: Amerigroup CHIP/Medicaid	$92.24
Rate for Payer: BCBS of TX Blue Advantage	$307.47
Rate for Payer: BCBS of TX Blue Essentials	$368.96
Rate for Payer: BCBS of TX PPO	$409.96
Rate for Payer: Cash Price	$696.93
Rate for Payer: Cigna Medicaid	$737.93
Rate for Payer: Molina CHIP/Medicaid	$737.93
Rate for Payer: Multiplan Auto	$666.18
Rate for Payer: Multiplan Commercial	$666.18
Rate for Payer: Multiplan Workers Comp	$666.18
Rate for Payer: Parkland Medicaid	$737.93
Rate for Payer: Scott and White EPO/PPO	$512.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$737.93
Rate for Payer: Superior Health Plan EPO	$139.39

*Sleep Study Charges Modifier 52 -> Home Sleep Test Type 3 Unattended G0399

Facility

$819.00

Service Code	HCPCS G0399
Hospital Charge Code	6910399
Hospital Revenue Code	920
Rate for Payer: Cash Price	$556.92

*Sleep Study Charges Modifier 52 -> Home Sleep Test Type 3 Unattended G0399

Facility

$819.00

Service Code	HCPCS G0399
Hospital Charge Code	6910399
Hospital Revenue Code	920
Min. Negotiated Rate	$73.71
Max. Negotiated Rate	$589.68
Rate for Payer: Amerigroup CHIP/Medicaid	$73.71
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$216.91
Rate for Payer: Amerigroup Medicare	$216.91
Rate for Payer: BCBS of TX Blue Advantage	$245.70
Rate for Payer: BCBS of TX Blue Essentials	$294.84
Rate for Payer: BCBS of TX Medicare	$216.91
Rate for Payer: BCBS of TX PPO	$327.60
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	$458.51
Rate for Payer: Cigna Medicaid	$589.68
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	$589.68
Rate for Payer: Molina Dual Medicare/Medicaid	$216.91
Rate for Payer: Molina Medicare	$216.91
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	$409.50
Rate for Payer: Scott and White Medicare	$216.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$589.68
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

*Sleep Study Charges Modifier 52 -> Multi Sleep Latency Test 95805

Facility

$3,115.00

Service Code	HCPCS 95805
Hospital Charge Code	6912115
Hospital Revenue Code	920
Rate for Payer: Cash Price	$2,118.20

*Sleep Study Charges Modifier 52 -> Multi Sleep Latency Test 95805

Facility

$3,115.00

Service Code	HCPCS 95805
Hospital Charge Code	6912115
Hospital Revenue Code	920
Min. Negotiated Rate	$280.35
Max. Negotiated Rate	$2,242.80
Rate for Payer: Amerigroup CHIP/Medicaid	$280.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$862.65
Rate for Payer: Amerigroup Medicare	$862.65
Rate for Payer: BCBS of TX Blue Advantage	$934.50
Rate for Payer: BCBS of TX Blue Essentials	$1,121.40
Rate for Payer: BCBS of TX Medicare	$862.65
Rate for Payer: BCBS of TX PPO	$1,246.00
Rate for Payer: Cash Price	$2,118.20
Rate for Payer: Cash Price	$2,118.20
Rate for Payer: Cash Price	$2,118.20
Rate for Payer: Cigna Commercial	$1,823.49
Rate for Payer: Cigna Medicaid	$2,242.80
Rate for Payer: Cigna Medicare	$862.65
Rate for Payer: Employer Direct Commercial	$862.65
Rate for Payer: Humana Medicare/TRICARE	$862.65
Rate for Payer: Molina CHIP/Medicaid	$2,242.80
Rate for Payer: Molina Dual Medicare/Medicaid	$862.65
Rate for Payer: Molina Medicare	$862.65
Rate for Payer: Multiplan Auto	$2,024.75
Rate for Payer: Multiplan Commercial	$2,024.75
Rate for Payer: Multiplan Workers Comp	$2,024.75
Rate for Payer: Parkland Medicaid	$2,242.80
Rate for Payer: Scott and White EPO/PPO	$533.51
Rate for Payer: Scott and White Medicare	$862.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,242.80
Rate for Payer: Superior Health Plan EPO	$862.65
Rate for Payer: Superior Health Plan Medicare	$862.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$862.65
Rate for Payer: Universal American Medicare	$862.65
Rate for Payer: Wellcare Medicare	$862.65
Rate for Payer: Wellmed Medicare	$862.65

*Sleep Study Charges Modifier 52 -> Polysomnography 4+ parameters 95810

Facility

$6,048.00

Service Code	HCPCS 95810
Hospital Charge Code	6200018
Hospital Revenue Code	920
Rate for Payer: Cash Price	$4,112.64

*Sleep Study Charges Modifier 52 -> Polysomnography 4+ parameters 95810

Facility

$6,048.00

Service Code	HCPCS 95810
Hospital Charge Code	6200018
Hospital Revenue Code	920
Min. Negotiated Rate	$544.32
Max. Negotiated Rate	$4,354.56
Rate for Payer: Amerigroup CHIP/Medicaid	$544.32
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$862.65
Rate for Payer: Amerigroup Medicare	$862.65
Rate for Payer: BCBS of TX Blue Advantage	$1,814.40
Rate for Payer: BCBS of TX Blue Essentials	$2,177.28
Rate for Payer: BCBS of TX Medicare	$862.65
Rate for Payer: BCBS of TX PPO	$2,419.20
Rate for Payer: Cash Price	$4,112.64
Rate for Payer: Cash Price	$4,112.64
Rate for Payer: Cash Price	$4,112.64
Rate for Payer: Cigna Commercial	$1,823.49
Rate for Payer: Cigna Medicaid	$4,354.56
Rate for Payer: Cigna Medicare	$862.65
Rate for Payer: Employer Direct Commercial	$862.65
Rate for Payer: Humana Medicare/TRICARE	$862.65
Rate for Payer: Molina CHIP/Medicaid	$4,354.56
Rate for Payer: Molina Dual Medicare/Medicaid	$862.65
Rate for Payer: Molina Medicare	$862.65
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: Parkland Medicaid	$4,354.56
Rate for Payer: Scott and White EPO/PPO	$770.71
Rate for Payer: Scott and White Medicare	$862.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,354.56
Rate for Payer: Superior Health Plan EPO	$862.65
Rate for Payer: Superior Health Plan Medicare	$862.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$862.65
Rate for Payer: Universal American Medicare	$862.65
Rate for Payer: Wellcare Medicare	$862.65
Rate for Payer: Wellmed Medicare	$862.65

*Sleep Study Charges Modifier 52 -> Polysomnography 4+ parameters w/PAP 95811

Facility

$6,459.00

Service Code	HCPCS 95811
Hospital Charge Code	6200026
Hospital Revenue Code	920
Rate for Payer: Cash Price	$4,392.12

*Sleep Study Charges Modifier 52 -> Polysomnography 4+ parameters w/PAP 95811

Facility

$6,459.00

Service Code	HCPCS 95811
Hospital Charge Code	6200026
Hospital Revenue Code	920
Min. Negotiated Rate	$581.31
Max. Negotiated Rate	$4,650.48
Rate for Payer: Amerigroup CHIP/Medicaid	$581.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$862.65
Rate for Payer: Amerigroup Medicare	$862.65
Rate for Payer: BCBS of TX Blue Advantage	$1,937.70
Rate for Payer: BCBS of TX Blue Essentials	$2,325.24
Rate for Payer: BCBS of TX Medicare	$862.65
Rate for Payer: BCBS of TX PPO	$2,583.60
Rate for Payer: Cash Price	$4,392.12
Rate for Payer: Cash Price	$4,392.12
Rate for Payer: Cash Price	$4,392.12
Rate for Payer: Cigna Commercial	$1,823.49
Rate for Payer: Cigna Medicaid	$4,650.48
Rate for Payer: Cigna Medicare	$862.65
Rate for Payer: Employer Direct Commercial	$862.65
Rate for Payer: Humana Medicare/TRICARE	$862.65
Rate for Payer: Molina CHIP/Medicaid	$4,650.48
Rate for Payer: Molina Dual Medicare/Medicaid	$862.65
Rate for Payer: Molina Medicare	$862.65
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: Parkland Medicaid	$4,650.48
Rate for Payer: Scott and White EPO/PPO	$805.65
Rate for Payer: Scott and White Medicare	$862.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,650.48
Rate for Payer: Superior Health Plan EPO	$862.65
Rate for Payer: Superior Health Plan Medicare	$862.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$862.65
Rate for Payer: Universal American Medicare	$862.65
Rate for Payer: Wellcare Medicare	$862.65
Rate for Payer: Wellmed Medicare	$862.65

SLEEVE Kii 5X100 CFF02

Facility

$408.60

Hospital Charge Code	80810344
Hospital Revenue Code	272
Rate for Payer: Cash Price	$277.85

SLEEVE Kii 5X100 CFF02

Facility

$408.60

Hospital Charge Code	80810344
Hospital Revenue Code	272
Min. Negotiated Rate	$36.77
Max. Negotiated Rate	$294.19
Rate for Payer: Amerigroup CHIP/Medicaid	$36.77
Rate for Payer: BCBS of TX Blue Advantage	$122.58
Rate for Payer: BCBS of TX Blue Essentials	$147.10
Rate for Payer: BCBS of TX PPO	$163.44
Rate for Payer: Cash Price	$277.85
Rate for Payer: Cigna Medicaid	$294.19
Rate for Payer: Molina CHIP/Medicaid	$294.19
Rate for Payer: Multiplan Auto	$265.59
Rate for Payer: Multiplan Commercial	$265.59
Rate for Payer: Multiplan Workers Comp	$265.59
Rate for Payer: Parkland Medicaid	$294.19
Rate for Payer: Scott and White EPO/PPO	$204.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$294.19
Rate for Payer: Superior Health Plan EPO	$55.57

SLEEVE, SHOULDER TRACTN/ROTATN FOAM W/VELCRO STRLE -- DHF

Facility

$583.71

Hospital Charge Code	81771446
Hospital Revenue Code	272
Min. Negotiated Rate	$52.53
Max. Negotiated Rate	$420.27
Rate for Payer: Amerigroup CHIP/Medicaid	$52.53
Rate for Payer: BCBS of TX Blue Advantage	$175.11
Rate for Payer: BCBS of TX Blue Essentials	$210.14
Rate for Payer: BCBS of TX PPO	$233.48
Rate for Payer: Cash Price	$396.92
Rate for Payer: Cigna Medicaid	$420.27
Rate for Payer: Molina CHIP/Medicaid	$420.27
Rate for Payer: Multiplan Auto	$379.41
Rate for Payer: Multiplan Commercial	$379.41
Rate for Payer: Multiplan Workers Comp	$379.41
Rate for Payer: Parkland Medicaid	$420.27
Rate for Payer: Scott and White EPO/PPO	$291.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.27
Rate for Payer: Superior Health Plan EPO	$79.38

SLEEVE, SHOULDER TRACTN/ROTATN FOAM W/VELCRO STRLE -- DHF

Facility

$583.71

Hospital Charge Code	81771446
Hospital Revenue Code	272
Rate for Payer: Cash Price	$396.92

SLEEVE SKIN ARM REGULAR

Facility

$16.34

Hospital Charge Code	8576467
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.11

SLEEVE SKIN ARM REGULAR

Facility

$16.34

Hospital Charge Code	8576467
Hospital Revenue Code	272
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$11.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1.47
Rate for Payer: BCBS of TX Blue Advantage	$4.90
Rate for Payer: BCBS of TX Blue Essentials	$5.88
Rate for Payer: BCBS of TX PPO	$6.54
Rate for Payer: Cash Price	$11.11
Rate for Payer: Cigna Medicaid	$11.76
Rate for Payer: Molina CHIP/Medicaid	$11.76
Rate for Payer: Multiplan Auto	$10.62
Rate for Payer: Multiplan Commercial	$10.62
Rate for Payer: Multiplan Workers Comp	$10.62
Rate for Payer: Parkland Medicaid	$11.76
Rate for Payer: Scott and White EPO/PPO	$8.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.76
Rate for Payer: Superior Health Plan EPO	$2.22

SLEEVE, SKIN ARM REGULAR

Facility

$10.46

Hospital Charge Code	993437
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7.11

SLEEVE, SKIN ARM REGULAR

Facility

$10.46

Hospital Charge Code	993437
Hospital Revenue Code	272
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$7.53
Rate for Payer: Amerigroup CHIP/Medicaid	$0.94
Rate for Payer: BCBS of TX Blue Advantage	$3.14
Rate for Payer: BCBS of TX Blue Essentials	$3.77
Rate for Payer: BCBS of TX PPO	$4.18
Rate for Payer: Cash Price	$7.11
Rate for Payer: Cigna Medicaid	$7.53
Rate for Payer: Molina CHIP/Medicaid	$7.53
Rate for Payer: Multiplan Auto	$6.80
Rate for Payer: Multiplan Commercial	$6.80
Rate for Payer: Multiplan Workers Comp	$6.80
Rate for Payer: Parkland Medicaid	$7.53
Rate for Payer: Scott and White EPO/PPO	$5.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.53
Rate for Payer: Superior Health Plan EPO	$1.42

SLEEVE, STABILITY, TROCAR, XCEL, 12MMX100MM

Facility

$77.06

Hospital Charge Code	992850
Hospital Revenue Code	272
Rate for Payer: Cash Price	$52.40

SLEEVE, STABILITY, TROCAR, XCEL, 12MMX100MM

Facility

$77.06

Hospital Charge Code	992850
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

SLEEVE TRAC STAR FOM FRARM WRST VLCR

Facility

$499.40

Hospital Charge Code	992609
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

SLEEVE TRAC STAR FOM FRARM WRST VLCR

Facility

$499.40

Hospital Charge Code	992609
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$359.57
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$339.59
Rate for Payer: Cigna Medicaid	$359.57
Rate for Payer: Molina CHIP/Medicaid	$359.57
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Parkland Medicaid	$359.57
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$359.57
Rate for Payer: Superior Health Plan EPO	$67.92

SLEVE ALLERGAN -- DHF

Facility

$42.83

Hospital Charge Code	81850901
Hospital Revenue Code	270
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$30.84
Rate for Payer: Amerigroup CHIP/Medicaid	$3.85
Rate for Payer: BCBS of TX Blue Advantage	$12.85
Rate for Payer: BCBS of TX Blue Essentials	$15.42
Rate for Payer: BCBS of TX PPO	$17.13
Rate for Payer: Cash Price	$29.12
Rate for Payer: Cigna Medicaid	$30.84
Rate for Payer: Molina CHIP/Medicaid	$30.84
Rate for Payer: Multiplan Auto	$27.84
Rate for Payer: Multiplan Commercial	$27.84
Rate for Payer: Multiplan Workers Comp	$27.84
Rate for Payer: Parkland Medicaid	$30.84
Rate for Payer: Scott and White EPO/PPO	$21.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.84
Rate for Payer: Superior Health Plan EPO	$5.82

SLEVE ALLERGAN -- DHF

Facility

$42.83

Hospital Charge Code	81850901
Hospital Revenue Code	270
Rate for Payer: Cash Price	$29.12

SLING, ARM, DELUXE, XL

Facility

$12.26

Hospital Charge Code	993225
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.34

SLING, ARM, DELUXE, XL

Facility

$12.26

Hospital Charge Code	993225
Hospital Revenue Code	270
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$8.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1.10
Rate for Payer: BCBS of TX Blue Advantage	$3.68
Rate for Payer: BCBS of TX Blue Essentials	$4.41
Rate for Payer: BCBS of TX PPO	$4.90
Rate for Payer: Cash Price	$8.34
Rate for Payer: Cigna Medicaid	$8.83
Rate for Payer: Molina CHIP/Medicaid	$8.83
Rate for Payer: Multiplan Auto	$7.97
Rate for Payer: Multiplan Commercial	$7.97
Rate for Payer: Multiplan Workers Comp	$7.97
Rate for Payer: Parkland Medicaid	$8.83
Rate for Payer: Scott and White EPO/PPO	$6.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.83
Rate for Payer: Superior Health Plan EPO	$1.67

Know your out-of-pocket cost for care.

All Charges