White Rock Medical Center

All Charges

Charge

Type

Setting

Price

VASCU-GUARD PERIPHERAL VAS PATCH 0.8X8MM

Facility

$1,100.42

Service Code	HCPCS C1768
Hospital Charge Code	131744
Hospital Revenue Code	278
Min. Negotiated Rate	$275.10
Max. Negotiated Rate	$550.21
Rate for Payer: Aetna Commercial	$330.13
Rate for Payer: Cash Price	$968.37
Rate for Payer: Cigna Commercial	$275.10
Rate for Payer: Multiplan Auto	$550.21
Rate for Payer: Multiplan Commercial	$550.21
Rate for Payer: Multiplan Workers Comp	$550.21
Rate for Payer: Scott and White EPO/PPO	$550.21

vasopressin 20 units/mL Sol

Facility

$128.17

Service Code	HCPCS J2601
Hospital Charge Code	78398993
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

vasopressin 20 units/mL Sol

Facility

$128.17

Service Code	HCPCS J2601
Hospital Charge Code	78398993
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

vasopressin 20 units/mL Solx

Facility

$128.17

Service Code	HCPCS J2601
Hospital Charge Code	78875811
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

vasopressin 20 units/mL Solx

Facility

$128.17

Service Code	HCPCS J2601
Hospital Charge Code	78875811
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

VASOPRESSIN (ANTIDIURETIC HORMONE)

Facility

$94.00

Service Code	CPT 84588
Hospital Charge Code	1706217
Hospital Revenue Code	301
Rate for Payer: Cash Price	$82.72

VASOPRESSIN (ANTIDIURETIC HORMONE)

Facility

$94.00

Service Code	CPT 84588
Hospital Charge Code	1706217
Hospital Revenue Code	301
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$75.01
Rate for Payer: Aetna Commercial	$35.63
Rate for Payer: Aetna Medicare	$50.91
Rate for Payer: Amerigroup CHIP/Medicaid	$13.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$33.94
Rate for Payer: Amerigroup Medicare	$33.94
Rate for Payer: BCBS of TX Blue Advantage	$56.00
Rate for Payer: BCBS of TX Blue Essentials	$67.20
Rate for Payer: BCBS of TX Medicare	$33.94
Rate for Payer: BCBS of TX PPO	$75.01
Rate for Payer: Cash Price	$82.72
Rate for Payer: Cash Price	$82.72
Rate for Payer: Cigna Medicaid	$33.94
Rate for Payer: Cigna Medicare	$33.94
Rate for Payer: Employer Direct Commercial	$33.94
Rate for Payer: Humana Medicare/TRICARE	$33.94
Rate for Payer: Molina CHIP/Medicaid	$33.94
Rate for Payer: Molina Dual Medicare/Medicaid	$33.94
Rate for Payer: Molina Medicare	$33.94
Rate for Payer: Multiplan Auto	$61.10
Rate for Payer: Multiplan Commercial	$61.10
Rate for Payer: Multiplan Workers Comp	$61.10
Rate for Payer: Parkland Medicaid	$33.94
Rate for Payer: Scott and White EPO/PPO	$42.42
Rate for Payer: Scott and White Medicare	$33.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33.94
Rate for Payer: Superior Health Plan EPO	$33.94
Rate for Payer: Superior Health Plan Medicare	$33.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$33.94
Rate for Payer: Universal American Medicare	$33.94
Rate for Payer: Wellcare Medicare	$33.94
Rate for Payer: Wellmed Medicare	$33.94

VAULT ALIF PEEK CAGE 32MM X 08MM X13MM

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	145335
Hospital Revenue Code	278
Min. Negotiated Rate	$9,036.14
Max. Negotiated Rate	$18,072.29
Rate for Payer: Aetna Commercial	$10,843.37
Rate for Payer: Cash Price	$31,807.23
Rate for Payer: Cigna Commercial	$9,036.14
Rate for Payer: Multiplan Auto	$18,072.29
Rate for Payer: Multiplan Commercial	$18,072.29
Rate for Payer: Multiplan Workers Comp	$18,072.29
Rate for Payer: Scott and White EPO/PPO	$18,072.29

VAULT ALIF PEEK CAGE 32MM X 08MM X13MM

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	145335
Hospital Revenue Code	278
Min. Negotiated Rate	$3,253.01
Max. Negotiated Rate	$18,072.29
Rate for Payer: Aetna Commercial	$10,843.37
Rate for Payer: Amerigroup CHIP/Medicaid	$3,253.01
Rate for Payer: BCBS of TX Blue Advantage	$10,843.37
Rate for Payer: BCBS of TX Blue Essentials	$13,012.05
Rate for Payer: BCBS of TX PPO	$14,457.83
Rate for Payer: Cash Price	$31,807.23
Rate for Payer: Multiplan Auto	$18,072.29
Rate for Payer: Multiplan Commercial	$18,072.29
Rate for Payer: Multiplan Workers Comp	$18,072.29
Rate for Payer: Scott and White EPO/PPO	$18,072.29
Rate for Payer: Superior Health Plan EPO	$4,915.66

VAULT LOCKING CAP

Facility

$4,518.07

Service Code	HCPCS C1713
Hospital Charge Code	144134
Hospital Revenue Code	278
Min. Negotiated Rate	$406.63
Max. Negotiated Rate	$2,259.04
Rate for Payer: Aetna Commercial	$1,355.42
Rate for Payer: Amerigroup CHIP/Medicaid	$406.63
Rate for Payer: BCBS of TX Blue Advantage	$1,355.42
Rate for Payer: BCBS of TX Blue Essentials	$1,626.51
Rate for Payer: BCBS of TX PPO	$1,807.23
Rate for Payer: Cash Price	$3,975.90
Rate for Payer: Multiplan Auto	$2,259.04
Rate for Payer: Multiplan Commercial	$2,259.04
Rate for Payer: Multiplan Workers Comp	$2,259.04
Rate for Payer: Scott and White EPO/PPO	$2,259.04
Rate for Payer: Superior Health Plan EPO	$614.46

VAULT LOCKING CAP

Facility

$4,518.07

Service Code	HCPCS C1713
Hospital Charge Code	144134
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.52
Max. Negotiated Rate	$2,259.04
Rate for Payer: Aetna Commercial	$1,355.42
Rate for Payer: Cash Price	$3,975.90
Rate for Payer: Cigna Commercial	$1,129.52
Rate for Payer: Multiplan Auto	$2,259.04
Rate for Payer: Multiplan Commercial	$2,259.04
Rate for Payer: Multiplan Workers Comp	$2,259.04
Rate for Payer: Scott and White EPO/PPO	$2,259.04

VDRL, CSF SO

Facility

$164.00

Service Code	CPT 86592
Hospital Charge Code	1605450
Hospital Revenue Code	302
Rate for Payer: Cash Price	$144.32

VDRL, CSF SO

Facility

$164.00

Service Code	CPT 86592
Hospital Charge Code	1605450
Hospital Revenue Code	302
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$106.60
Rate for Payer: Aetna Commercial	$4.48
Rate for Payer: Aetna Medicare	$6.40
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$7.05
Rate for Payer: BCBS of TX Blue Essentials	$8.45
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$9.44
Rate for Payer: Cash Price	$144.32
Rate for Payer: Cash Price	$144.32
Rate for Payer: Cigna Medicaid	$4.27
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$4.27
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$106.60
Rate for Payer: Multiplan Commercial	$106.60
Rate for Payer: Multiplan Workers Comp	$106.60
Rate for Payer: Parkland Medicaid	$4.27
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.27
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

VEEG EA 12-26HR INTMT MNTR

Facility

$6,399.00

Service Code	CPT 95715
Hospital Charge Code	8568476
Hospital Revenue Code	740
Rate for Payer: Cash Price	$5,631.12

VEEG EA 12-26HR INTMT MNTR

Facility

$6,399.00

Service Code	CPT 95715
Hospital Charge Code	8568476
Hospital Revenue Code	740
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$4,159.35
Rate for Payer: Aetna Commercial	$3,519.45
Rate for Payer: Aetna Medicare	$735.27
Rate for Payer: Amerigroup CHIP/Medicaid	$575.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$490.18
Rate for Payer: Amerigroup Medicare	$490.18
Rate for Payer: BCBS of TX Blue Advantage	$844.96
Rate for Payer: BCBS of TX Blue Essentials	$1,010.07
Rate for Payer: BCBS of TX Medicare	$490.18
Rate for Payer: BCBS of TX PPO	$1,126.62
Rate for Payer: Cash Price	$5,631.12
Rate for Payer: Cash Price	$5,631.12
Rate for Payer: Cash Price	$5,631.12
Rate for Payer: Cigna Commercial	$1,110.40
Rate for Payer: Cigna Medicare	$490.18
Rate for Payer: Employer Direct Commercial	$490.18
Rate for Payer: Humana Medicare/TRICARE	$490.18
Rate for Payer: Molina Dual Medicare/Medicaid	$490.18
Rate for Payer: Molina Medicare	$490.18
Rate for Payer: Multiplan Auto	$4,159.35
Rate for Payer: Multiplan Commercial	$4,159.35
Rate for Payer: Multiplan Workers Comp	$4,159.35
Rate for Payer: Scott and White EPO/PPO	$8.77
Rate for Payer: Scott and White Medicare	$490.18
Rate for Payer: Superior Health Plan EPO	$490.18
Rate for Payer: Superior Health Plan Medicare	$490.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$490.18
Rate for Payer: Universal American Medicare	$490.18
Rate for Payer: Wellcare Medicare	$490.18
Rate for Payer: Wellmed Medicare	$490.18

VEEG EA 12-26 HR UNMNTR

Facility

$4,038.00

Service Code	CPT 95714
Hospital Charge Code	8568475
Hospital Revenue Code	740
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$2,624.70
Rate for Payer: Aetna Commercial	$2,220.90
Rate for Payer: Aetna Medicare	$735.27
Rate for Payer: Amerigroup CHIP/Medicaid	$363.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$490.18
Rate for Payer: Amerigroup Medicare	$490.18
Rate for Payer: BCBS of TX Blue Advantage	$844.96
Rate for Payer: BCBS of TX Blue Essentials	$1,010.07
Rate for Payer: BCBS of TX Medicare	$490.18
Rate for Payer: BCBS of TX PPO	$1,126.62
Rate for Payer: Cash Price	$3,553.44
Rate for Payer: Cash Price	$3,553.44
Rate for Payer: Cash Price	$3,553.44
Rate for Payer: Cigna Commercial	$1,110.40
Rate for Payer: Cigna Medicare	$490.18
Rate for Payer: Employer Direct Commercial	$490.18
Rate for Payer: Humana Medicare/TRICARE	$490.18
Rate for Payer: Molina Dual Medicare/Medicaid	$490.18
Rate for Payer: Molina Medicare	$490.18
Rate for Payer: Multiplan Auto	$2,624.70
Rate for Payer: Multiplan Commercial	$2,624.70
Rate for Payer: Multiplan Workers Comp	$2,624.70
Rate for Payer: Scott and White EPO/PPO	$8.77
Rate for Payer: Scott and White Medicare	$490.18
Rate for Payer: Superior Health Plan EPO	$490.18
Rate for Payer: Superior Health Plan Medicare	$490.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$490.18
Rate for Payer: Universal American Medicare	$490.18
Rate for Payer: Wellcare Medicare	$490.18
Rate for Payer: Wellmed Medicare	$490.18

VEEG EA 12-26 HR UNMNTR

Facility

$4,038.00

Service Code	CPT 95714
Hospital Charge Code	8568475
Hospital Revenue Code	740
Rate for Payer: Cash Price	$3,553.44

VEIN LIGATION AND STRIPPING

Facility

$53,678.80

Service Code	MSDRG 263
Min. Negotiated Rate	$17,648.06
Max. Negotiated Rate	$53,678.80
Rate for Payer: Aetna Commercial	$31,783.50
Rate for Payer: Aetna Medicare	$34,523.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$23,015.58
Rate for Payer: Amerigroup Medicare	$23,015.58
Rate for Payer: BCBS of TX Blue Advantage	$17,648.06
Rate for Payer: BCBS of TX Blue Essentials	$24,685.11
Rate for Payer: BCBS of TX Medicare	$23,015.58
Rate for Payer: BCBS of TX PPO	$27,428.97
Rate for Payer: Cigna Commercial	$36,388.58
Rate for Payer: Cigna Medicare	$23,015.58
Rate for Payer: Employer Direct Commercial	$23,015.58
Rate for Payer: Humana Medicare/TRICARE	$23,015.58
Rate for Payer: Molina Dual Medicare/Medicaid	$23,015.58
Rate for Payer: Molina Medicare	$23,015.58
Rate for Payer: Multiplan Auto	$53,678.80
Rate for Payer: Multiplan Commercial	$53,678.80
Rate for Payer: Multiplan Workers Comp	$53,678.80
Rate for Payer: Scott and White EPO/PPO	$24,720.50
Rate for Payer: Scott and White Medicare	$23,015.58
Rate for Payer: Superior Health Plan EPO	$23,015.58
Rate for Payer: Superior Health Plan Medicare	$23,015.58
Rate for Payer: Universal American Dual Medicare/Medicaid	$23,015.58
Rate for Payer: Universal American Medicare	$23,015.58
Rate for Payer: Wellcare Medicare	$23,015.58
Rate for Payer: Wellmed Medicare	$23,015.58

venlafaxine 75 mg ER Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77872547
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

venlafaxine 75 mg ER Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77872547
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

venlafaxine 75mg Tab

Facility

$9.50

Service Code	HCPCS J3490
Hospital Charge Code	78432853
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.46

venlafaxine 75mg Tab

Facility

$9.50

Service Code	HCPCS J3490
Hospital Charge Code	78432853
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$6.18
Rate for Payer: Amerigroup CHIP/Medicaid	$0.86
Rate for Payer: BCBS of TX Blue Advantage	$2.85
Rate for Payer: BCBS of TX Blue Essentials	$3.42
Rate for Payer: BCBS of TX PPO	$3.80
Rate for Payer: Cash Price	$6.46
Rate for Payer: Multiplan Auto	$6.18
Rate for Payer: Multiplan Commercial	$6.18
Rate for Payer: Multiplan Workers Comp	$6.18
Rate for Payer: Scott and White EPO/PPO	$4.75
Rate for Payer: Superior Health Plan EPO	$1.29

VENOGRAM EXTREMITY BI

Facility

$1,800.00

Service Code	CPT 75822
Hospital Charge Code	4615823
Hospital Revenue Code	323
Min. Negotiated Rate	$26.19
Max. Negotiated Rate	$3,317.93
Rate for Payer: Aetna Commercial	$75.70
Rate for Payer: Aetna Medicare	$2,197.02
Rate for Payer: Amerigroup CHIP/Medicaid	$132.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Amerigroup Medicare	$1,464.68
Rate for Payer: BCBS of TX Blue Advantage	$131.42
Rate for Payer: BCBS of TX Blue Essentials	$157.71
Rate for Payer: BCBS of TX Medicare	$1,464.68
Rate for Payer: BCBS of TX PPO	$176.03
Rate for Payer: Cash Price	$1,584.00
Rate for Payer: Cash Price	$1,584.00
Rate for Payer: Cash Price	$1,584.00
Rate for Payer: Cigna Commercial	$3,317.93
Rate for Payer: Cigna Medicaid	$132.99
Rate for Payer: Cigna Medicare	$1,464.68
Rate for Payer: Employer Direct Commercial	$1,464.68
Rate for Payer: Humana Medicare/TRICARE	$1,464.68
Rate for Payer: Molina CHIP/Medicaid	$132.99
Rate for Payer: Molina Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Molina Medicare	$1,464.68
Rate for Payer: Multiplan Auto	$1,170.00
Rate for Payer: Multiplan Commercial	$1,170.00
Rate for Payer: Multiplan Workers Comp	$1,170.00
Rate for Payer: Parkland Medicaid	$132.99
Rate for Payer: Scott and White EPO/PPO	$26.19
Rate for Payer: Scott and White Medicare	$1,464.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.99
Rate for Payer: Superior Health Plan EPO	$1,464.68
Rate for Payer: Superior Health Plan Medicare	$1,464.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,464.68
Rate for Payer: Universal American Medicare	$1,464.68
Rate for Payer: Wellcare Medicare	$1,464.68
Rate for Payer: Wellmed Medicare	$1,464.68

VENOGRAM EXTREMITY BI

Facility

$1,800.00

Service Code	CPT 75822
Hospital Charge Code	4615823
Hospital Revenue Code	323
Rate for Payer: Cash Price	$1,584.00

VENOGRAM EXTREMITY UNI

Facility

$1,448.00

Service Code	CPT 75820
Hospital Charge Code	2330024
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,274.24

Know your out-of-pocket cost for care.

All Charges