White Rock Medical Center

All Charges

Charge

Type

Setting

Price

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC

Facility

$50,067.14

Service Code	MSDRG 736
Min. Negotiated Rate	$35,895.54
Max. Negotiated Rate	$50,067.14
Rate for Payer: Aetna Commercial	$43,731.00
Rate for Payer: Aetna Medicare	$45,891.11
Rate for Payer: BCBS of TX Blue Advantage	$35,895.54
Rate for Payer: BCBS of TX Blue Essentials	$41,591.76
Rate for Payer: BCBS of TX PPO	$46,214.86
Rate for Payer: Cigna Commercial	$50,067.14

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$18,888.99

Service Code	MSDRG 738
Min. Negotiated Rate	$12,002.16
Max. Negotiated Rate	$18,888.99
Rate for Payer: Aetna Commercial	$15,351.75
Rate for Payer: Aetna Medicare	$18,888.99
Rate for Payer: BCBS of TX Blue Advantage	$12,002.16
Rate for Payer: BCBS of TX Blue Essentials	$14,367.14
Rate for Payer: BCBS of TX PPO	$15,964.11
Rate for Payer: Cigna Commercial	$17,576.05

VAC-U-MIX -- DHF

Facility

$1,218.97

Hospital Charge Code	81779001
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,072.69

VAC-U-MIX -- DHF

Facility

$1,218.97

Hospital Charge Code	81779001
Hospital Revenue Code	272
Min. Negotiated Rate	$109.71
Max. Negotiated Rate	$792.33
Rate for Payer: Aetna Commercial	$670.43
Rate for Payer: Amerigroup CHIP/Medicaid	$109.71
Rate for Payer: BCBS of TX Blue Advantage	$365.69
Rate for Payer: BCBS of TX Blue Essentials	$438.83
Rate for Payer: BCBS of TX PPO	$487.59
Rate for Payer: Cash Price	$1,072.69
Rate for Payer: Multiplan Auto	$792.33
Rate for Payer: Multiplan Commercial	$792.33
Rate for Payer: Multiplan Workers Comp	$792.33
Rate for Payer: Scott and White EPO/PPO	$609.49
Rate for Payer: Superior Health Plan EPO	$165.78

VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC

Facility

$22,223.29

Service Code	MSDRG 746
Min. Negotiated Rate	$12,685.00
Max. Negotiated Rate	$22,223.29
Rate for Payer: Aetna Commercial	$18,856.12
Rate for Payer: Aetna Medicare	$22,223.29
Rate for Payer: BCBS of TX Blue Advantage	$12,685.00
Rate for Payer: BCBS of TX Blue Essentials	$17,312.19
Rate for Payer: BCBS of TX PPO	$19,236.51
Rate for Payer: Cigna Commercial	$21,588.17

VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC

Facility

$13,778.85

Service Code	MSDRG 747
Min. Negotiated Rate	$8,053.04
Max. Negotiated Rate	$13,778.85
Rate for Payer: Aetna Commercial	$9,981.00
Rate for Payer: Aetna Medicare	$13,778.85
Rate for Payer: BCBS of TX Blue Advantage	$8,053.04
Rate for Payer: BCBS of TX Blue Essentials	$9,887.67
Rate for Payer: BCBS of TX PPO	$10,986.72
Rate for Payer: Cigna Commercial	$11,427.14

Vaginal Delivery Charge:Complex

Facility

$4,890.00

Hospital Charge Code	300053
Hospital Revenue Code	720
Min. Negotiated Rate	$440.10
Max. Negotiated Rate	$3,178.50
Rate for Payer: Aetna Commercial	$2,689.50
Rate for Payer: Amerigroup CHIP/Medicaid	$440.10
Rate for Payer: BCBS of TX Blue Advantage	$1,467.00
Rate for Payer: BCBS of TX Blue Essentials	$1,760.40
Rate for Payer: BCBS of TX PPO	$1,956.00
Rate for Payer: Cash Price	$4,303.20
Rate for Payer: Multiplan Auto	$3,178.50
Rate for Payer: Multiplan Commercial	$3,178.50
Rate for Payer: Multiplan Workers Comp	$3,178.50
Rate for Payer: Scott and White EPO/PPO	$2,445.00
Rate for Payer: Superior Health Plan EPO	$665.04

Vaginal Delivery Charge Complex BCE

Facility

$4,890.00

Hospital Charge Code	300053
Hospital Revenue Code	720
Min. Negotiated Rate	$440.10
Max. Negotiated Rate	$3,178.50
Rate for Payer: Aetna Commercial	$2,689.50
Rate for Payer: Amerigroup CHIP/Medicaid	$440.10
Rate for Payer: BCBS of TX Blue Advantage	$1,467.00
Rate for Payer: BCBS of TX Blue Essentials	$1,760.40
Rate for Payer: BCBS of TX PPO	$1,956.00
Rate for Payer: Cash Price	$4,303.20
Rate for Payer: Multiplan Auto	$3,178.50
Rate for Payer: Multiplan Commercial	$3,178.50
Rate for Payer: Multiplan Workers Comp	$3,178.50
Rate for Payer: Scott and White EPO/PPO	$2,445.00
Rate for Payer: Superior Health Plan EPO	$665.04

Vaginal Delivery Charge Complex BCE

Facility

$4,890.00

Hospital Charge Code	300053
Hospital Revenue Code	720
Rate for Payer: Cash Price	$4,303.20

Vaginal Delivery Charge:Simple

Facility

$3,760.00

Hospital Charge Code	300046
Hospital Revenue Code	720
Min. Negotiated Rate	$338.40
Max. Negotiated Rate	$2,444.00
Rate for Payer: Aetna Commercial	$2,068.00
Rate for Payer: Amerigroup CHIP/Medicaid	$338.40
Rate for Payer: BCBS of TX Blue Advantage	$1,128.00
Rate for Payer: BCBS of TX Blue Essentials	$1,353.60
Rate for Payer: BCBS of TX PPO	$1,504.00
Rate for Payer: Cash Price	$3,308.80
Rate for Payer: Multiplan Auto	$2,444.00
Rate for Payer: Multiplan Commercial	$2,444.00
Rate for Payer: Multiplan Workers Comp	$2,444.00
Rate for Payer: Scott and White EPO/PPO	$1,880.00
Rate for Payer: Superior Health Plan EPO	$511.36

Vaginal Delivery Charge Simple BCE

Facility

$3,760.00

Hospital Charge Code	300046
Hospital Revenue Code	720
Rate for Payer: Cash Price	$3,308.80

Vaginal Delivery Charge Simple BCE

Facility

$3,760.00

Hospital Charge Code	300046
Hospital Revenue Code	720
Min. Negotiated Rate	$338.40
Max. Negotiated Rate	$2,444.00
Rate for Payer: Aetna Commercial	$2,068.00
Rate for Payer: Amerigroup CHIP/Medicaid	$338.40
Rate for Payer: BCBS of TX Blue Advantage	$1,128.00
Rate for Payer: BCBS of TX Blue Essentials	$1,353.60
Rate for Payer: BCBS of TX PPO	$1,504.00
Rate for Payer: Cash Price	$3,308.80
Rate for Payer: Multiplan Auto	$2,444.00
Rate for Payer: Multiplan Commercial	$2,444.00
Rate for Payer: Multiplan Workers Comp	$2,444.00
Rate for Payer: Scott and White EPO/PPO	$1,880.00
Rate for Payer: Superior Health Plan EPO	$511.36

VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C

Facility

$17,320.81

Service Code	MSDRG 768
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$17,320.81
Rate for Payer: Aetna Commercial	$13,703.62
Rate for Payer: Aetna Medicare	$17,320.81
Rate for Payer: BCBS of TX Blue Advantage	$10,932.32
Rate for Payer: BCBS of TX Blue Essentials	$11,674.92
Rate for Payer: BCBS of TX PPO	$12,972.63
Rate for Payer: Cigna Commercial	$4,586.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC

Facility

$12,274.92

Service Code	MSDRG 806
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$12,274.92
Rate for Payer: Aetna Commercial	$8,400.38
Rate for Payer: Aetna Medicare	$12,274.92
Rate for Payer: BCBS of TX Blue Essentials	$7,299.66
Rate for Payer: BCBS of TX PPO	$8,111.05
Rate for Payer: Cigna Commercial	$4,586.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC

Facility

$15,074.04

Service Code	MSDRG 805
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$15,074.04
Rate for Payer: Aetna Commercial	$11,342.25
Rate for Payer: Aetna Medicare	$15,074.04
Rate for Payer: BCBS of TX Blue Essentials	$10,558.40
Rate for Payer: BCBS of TX PPO	$11,732.01
Rate for Payer: Cigna Commercial	$4,586.00

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC

Facility

$11,285.86

Service Code	MSDRG 807
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$11,285.86
Rate for Payer: Aetna Commercial	$7,360.88
Rate for Payer: Aetna Medicare	$11,285.86
Rate for Payer: BCBS of TX Blue Essentials	$6,335.87
Rate for Payer: BCBS of TX PPO	$7,040.12
Rate for Payer: Cigna Commercial	$4,586.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC

Facility

$14,942.39

Service Code	MSDRG 797
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$14,942.39
Rate for Payer: Aetna Commercial	$11,203.88
Rate for Payer: Aetna Medicare	$14,942.39
Rate for Payer: BCBS of TX Blue Essentials	$8,739.16
Rate for Payer: BCBS of TX PPO	$9,710.56
Rate for Payer: Cigna Commercial	$4,586.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC

Facility

$19,464.85

Service Code	MSDRG 796
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$19,464.85
Rate for Payer: Aetna Commercial	$15,957.00
Rate for Payer: Aetna Medicare	$19,464.85
Rate for Payer: BCBS of TX Blue Essentials	$15,150.36
Rate for Payer: BCBS of TX PPO	$16,834.38
Rate for Payer: Cigna Commercial	$4,586.00

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC

Facility

$13,221.17

Service Code	MSDRG 798
Min. Negotiated Rate	$4,586.00
Max. Negotiated Rate	$13,221.17
Rate for Payer: Aetna Commercial	$9,126.00
Rate for Payer: Aetna Medicare	$13,221.17
Rate for Payer: BCBS of TX Blue Essentials	$8,739.16
Rate for Payer: BCBS of TX PPO	$9,710.56
Rate for Payer: Cigna Commercial	$4,586.00

valACYclovir 500 mg Tab

Facility

$54.45

Service Code	HCPCS J8499
Hospital Charge Code	77868406
Hospital Revenue Code	636
Min. Negotiated Rate	$13.61
Max. Negotiated Rate	$27.23
Rate for Payer: Cash Price	$37.03
Rate for Payer: Cigna Commercial	$13.61
Rate for Payer: Scott and White EPO/PPO	$27.23

valACYclovir 500 mg Tab

Facility

$54.45

Service Code	HCPCS J8499
Hospital Charge Code	77868406
Hospital Revenue Code	636
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$35.39
Rate for Payer: Amerigroup CHIP/Medicaid	$4.90
Rate for Payer: BCBS of TX Blue Advantage	$16.34
Rate for Payer: BCBS of TX Blue Essentials	$19.60
Rate for Payer: BCBS of TX PPO	$21.78
Rate for Payer: Cash Price	$37.03
Rate for Payer: Multiplan Auto	$35.39
Rate for Payer: Multiplan Commercial	$35.39
Rate for Payer: Multiplan Workers Comp	$35.39
Rate for Payer: Scott and White EPO/PPO	$27.23
Rate for Payer: Superior Health Plan EPO	$7.41

Valproic Acid Level

Facility

$373.00

Service Code	CPT 80164
Hospital Charge Code	1602960
Hospital Revenue Code	300
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$242.45
Rate for Payer: Aetna Commercial	$14.21
Rate for Payer: Aetna Medicare	$20.31
Rate for Payer: Amerigroup CHIP/Medicaid	$5.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.54
Rate for Payer: Amerigroup Medicare	$13.54
Rate for Payer: BCBS of TX Blue Advantage	$22.34
Rate for Payer: BCBS of TX Blue Essentials	$26.81
Rate for Payer: BCBS of TX Medicare	$13.54
Rate for Payer: BCBS of TX PPO	$29.92
Rate for Payer: Cash Price	$328.24
Rate for Payer: Cash Price	$328.24
Rate for Payer: Cigna Medicaid	$13.54
Rate for Payer: Cigna Medicare	$13.54
Rate for Payer: Employer Direct Commercial	$13.54
Rate for Payer: Humana Medicare/TRICARE	$13.54
Rate for Payer: Molina CHIP/Medicaid	$13.54
Rate for Payer: Molina Dual Medicare/Medicaid	$13.54
Rate for Payer: Molina Medicare	$13.54
Rate for Payer: Multiplan Auto	$242.45
Rate for Payer: Multiplan Commercial	$242.45
Rate for Payer: Multiplan Workers Comp	$242.45
Rate for Payer: Parkland Medicaid	$13.54
Rate for Payer: Scott and White EPO/PPO	$16.93
Rate for Payer: Scott and White Medicare	$13.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.54
Rate for Payer: Superior Health Plan EPO	$13.54
Rate for Payer: Superior Health Plan Medicare	$13.54
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.54
Rate for Payer: Universal American Medicare	$13.54
Rate for Payer: Wellcare Medicare	$13.54
Rate for Payer: Wellmed Medicare	$13.54

Valproic Acid Level

Facility

$373.00

Service Code	CPT 80164
Hospital Charge Code	1602960
Hospital Revenue Code	300
Rate for Payer: Cash Price	$328.24

valsartan 80 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77869252
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

valsartan 80 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77869252
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

Know your out-of-pocket cost for care.

All Charges