White Rock Medical Center

All Charges

Charge

Type

Setting

Price

VIRUS INOCULATION, SHELL VIA

Facility

$97.00

Service Code	CPT 87254
Hospital Charge Code	1708841
Hospital Revenue Code	306
Rate for Payer: Cash Price	$85.36

VIRUS INOCULATION, SHELL VIA

Facility

$97.00

Service Code	CPT 87254
Hospital Charge Code	1708841
Hospital Revenue Code	306
Min. Negotiated Rate	$7.63
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$20.54
Rate for Payer: Aetna Medicare	$29.34
Rate for Payer: Amerigroup CHIP/Medicaid	$7.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.56
Rate for Payer: Amerigroup Medicare	$19.56
Rate for Payer: BCBS of TX Blue Advantage	$32.27
Rate for Payer: BCBS of TX Blue Essentials	$38.73
Rate for Payer: BCBS of TX Medicare	$19.56
Rate for Payer: BCBS of TX PPO	$43.23
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Medicaid	$19.56
Rate for Payer: Cigna Medicare	$19.56
Rate for Payer: Employer Direct Commercial	$19.56
Rate for Payer: Humana Medicare/TRICARE	$19.56
Rate for Payer: Molina CHIP/Medicaid	$19.56
Rate for Payer: Molina Dual Medicare/Medicaid	$19.56
Rate for Payer: Molina Medicare	$19.56
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$19.56
Rate for Payer: Scott and White EPO/PPO	$24.45
Rate for Payer: Scott and White Medicare	$19.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19.56
Rate for Payer: Superior Health Plan EPO	$19.56
Rate for Payer: Superior Health Plan Medicare	$19.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.56
Rate for Payer: Universal American Medicare	$19.56
Rate for Payer: Wellcare Medicare	$19.56
Rate for Payer: Wellmed Medicare	$19.56

VISCERAL SELECT/SUPRA

Facility

$4,398.00

Service Code	CPT 75726
Hospital Charge Code	4615727
Hospital Revenue Code	323
Min. Negotiated Rate	$89.02
Max. Negotiated Rate	$11,384.78
Rate for Payer: Aetna Commercial	$89.02
Rate for Payer: Aetna Medicare	$7,538.62
Rate for Payer: Amerigroup CHIP/Medicaid	$171.41
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,025.75
Rate for Payer: Amerigroup Medicare	$5,025.75
Rate for Payer: BCBS of TX Blue Advantage	$7,583.71
Rate for Payer: BCBS of TX Blue Essentials	$9,100.46
Rate for Payer: BCBS of TX Medicare	$5,025.75
Rate for Payer: BCBS of TX PPO	$10,157.58
Rate for Payer: Cash Price	$3,870.24
Rate for Payer: Cash Price	$3,870.24
Rate for Payer: Cash Price	$3,870.24
Rate for Payer: Cigna Commercial	$11,384.78
Rate for Payer: Cigna Medicaid	$171.41
Rate for Payer: Cigna Medicare	$5,025.75
Rate for Payer: Employer Direct Commercial	$5,025.75
Rate for Payer: Humana Medicare/TRICARE	$5,025.75
Rate for Payer: Molina CHIP/Medicaid	$171.41
Rate for Payer: Molina Dual Medicare/Medicaid	$5,025.75
Rate for Payer: Molina Medicare	$5,025.75
Rate for Payer: Multiplan Auto	$2,858.70
Rate for Payer: Multiplan Commercial	$2,858.70
Rate for Payer: Multiplan Workers Comp	$2,858.70
Rate for Payer: Parkland Medicaid	$171.41
Rate for Payer: Scott and White EPO/PPO	$89.88
Rate for Payer: Scott and White Medicare	$5,025.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$171.41
Rate for Payer: Superior Health Plan EPO	$5,025.75
Rate for Payer: Superior Health Plan Medicare	$5,025.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,025.75
Rate for Payer: Universal American Medicare	$5,025.75
Rate for Payer: Wellcare Medicare	$5,025.75
Rate for Payer: Wellmed Medicare	$5,025.75

VISCERAL SELECT/SUPRA

Facility

$4,398.00

Service Code	CPT 75726
Hospital Charge Code	4615727
Hospital Revenue Code	323
Rate for Payer: Cash Price	$3,870.24

Viscosity, Serum SO

Facility

$44.00

Service Code	CPT 85810
Hospital Charge Code	1701580
Hospital Revenue Code	305
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$28.60
Rate for Payer: Aetna Commercial	$12.25
Rate for Payer: Aetna Medicare	$17.50
Rate for Payer: Amerigroup CHIP/Medicaid	$4.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.67
Rate for Payer: Amerigroup Medicare	$11.67
Rate for Payer: BCBS of TX Blue Advantage	$19.26
Rate for Payer: BCBS of TX Blue Essentials	$23.11
Rate for Payer: BCBS of TX Medicare	$11.67
Rate for Payer: BCBS of TX PPO	$25.79
Rate for Payer: Cash Price	$38.72
Rate for Payer: Cash Price	$38.72
Rate for Payer: Cigna Medicaid	$11.67
Rate for Payer: Cigna Medicare	$11.67
Rate for Payer: Employer Direct Commercial	$11.67
Rate for Payer: Humana Medicare/TRICARE	$11.67
Rate for Payer: Molina CHIP/Medicaid	$11.67
Rate for Payer: Molina Dual Medicare/Medicaid	$11.67
Rate for Payer: Molina Medicare	$11.67
Rate for Payer: Multiplan Auto	$28.60
Rate for Payer: Multiplan Commercial	$28.60
Rate for Payer: Multiplan Workers Comp	$28.60
Rate for Payer: Parkland Medicaid	$11.67
Rate for Payer: Scott and White EPO/PPO	$14.59
Rate for Payer: Scott and White Medicare	$11.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.67
Rate for Payer: Superior Health Plan EPO	$11.67
Rate for Payer: Superior Health Plan Medicare	$11.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.67
Rate for Payer: Universal American Medicare	$11.67
Rate for Payer: Wellcare Medicare	$11.67
Rate for Payer: Wellmed Medicare	$11.67

Viscosity, Serum SO

Facility

$44.00

Service Code	CPT 85810
Hospital Charge Code	1701580
Hospital Revenue Code	305
Rate for Payer: Cash Price	$38.72

Vitamin A, Serum SO

Facility

$198.00

Service Code	CPT 84590
Hospital Charge Code	1701598
Hospital Revenue Code	301
Rate for Payer: Cash Price	$174.24

Vitamin A, Serum SO

Facility

$198.00

Service Code	CPT 84590
Hospital Charge Code	1701598
Hospital Revenue Code	301
Min. Negotiated Rate	$4.53
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna Commercial	$12.20
Rate for Payer: Aetna Medicare	$17.42
Rate for Payer: Amerigroup CHIP/Medicaid	$4.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.61
Rate for Payer: Amerigroup Medicare	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$19.16
Rate for Payer: BCBS of TX Blue Essentials	$22.99
Rate for Payer: BCBS of TX Medicare	$11.61
Rate for Payer: BCBS of TX PPO	$25.66
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cash Price	$174.24
Rate for Payer: Cigna Medicaid	$11.61
Rate for Payer: Cigna Medicare	$11.61
Rate for Payer: Employer Direct Commercial	$11.61
Rate for Payer: Humana Medicare/TRICARE	$11.61
Rate for Payer: Molina CHIP/Medicaid	$11.61
Rate for Payer: Molina Dual Medicare/Medicaid	$11.61
Rate for Payer: Molina Medicare	$11.61
Rate for Payer: Multiplan Auto	$128.70
Rate for Payer: Multiplan Commercial	$128.70
Rate for Payer: Multiplan Workers Comp	$128.70
Rate for Payer: Parkland Medicaid	$11.61
Rate for Payer: Scott and White EPO/PPO	$14.51
Rate for Payer: Scott and White Medicare	$11.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.61
Rate for Payer: Superior Health Plan EPO	$11.61
Rate for Payer: Superior Health Plan Medicare	$11.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.61
Rate for Payer: Universal American Medicare	$11.61
Rate for Payer: Wellcare Medicare	$11.61
Rate for Payer: Wellmed Medicare	$11.61

Vitamin B12 Level

Facility

$322.00

Service Code	CPT 82607
Hospital Charge Code	1602382
Hospital Revenue Code	301
Rate for Payer: Cash Price	$283.36

Vitamin B12 Level

Facility

$322.00

Service Code	CPT 82607
Hospital Charge Code	1602382
Hospital Revenue Code	301
Min. Negotiated Rate	$5.88
Max. Negotiated Rate	$209.30
Rate for Payer: Aetna Commercial	$15.84
Rate for Payer: Aetna Medicare	$22.62
Rate for Payer: Amerigroup CHIP/Medicaid	$5.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.08
Rate for Payer: Amerigroup Medicare	$15.08
Rate for Payer: BCBS of TX Blue Advantage	$24.88
Rate for Payer: BCBS of TX Blue Essentials	$29.86
Rate for Payer: BCBS of TX Medicare	$15.08
Rate for Payer: BCBS of TX PPO	$33.33
Rate for Payer: Cash Price	$283.36
Rate for Payer: Cash Price	$283.36
Rate for Payer: Cigna Medicaid	$15.08
Rate for Payer: Cigna Medicare	$15.08
Rate for Payer: Employer Direct Commercial	$15.08
Rate for Payer: Humana Medicare/TRICARE	$15.08
Rate for Payer: Molina CHIP/Medicaid	$15.08
Rate for Payer: Molina Dual Medicare/Medicaid	$15.08
Rate for Payer: Molina Medicare	$15.08
Rate for Payer: Multiplan Auto	$209.30
Rate for Payer: Multiplan Commercial	$209.30
Rate for Payer: Multiplan Workers Comp	$209.30
Rate for Payer: Parkland Medicaid	$15.08
Rate for Payer: Scott and White EPO/PPO	$18.85
Rate for Payer: Scott and White Medicare	$15.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.08
Rate for Payer: Superior Health Plan EPO	$15.08
Rate for Payer: Superior Health Plan Medicare	$15.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.08
Rate for Payer: Universal American Medicare	$15.08
Rate for Payer: Wellcare Medicare	$15.08
Rate for Payer: Wellmed Medicare	$15.08

Vitamin B1 (Thiamine), Blood SO

Facility

$190.00

Service Code	CPT 84425
Hospital Charge Code	1708726
Hospital Revenue Code	301
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$123.50
Rate for Payer: Aetna Commercial	$22.30
Rate for Payer: Aetna Medicare	$31.84
Rate for Payer: Amerigroup CHIP/Medicaid	$8.28
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.23
Rate for Payer: Amerigroup Medicare	$21.23
Rate for Payer: BCBS of TX Blue Advantage	$35.03
Rate for Payer: BCBS of TX Blue Essentials	$42.04
Rate for Payer: BCBS of TX Medicare	$21.23
Rate for Payer: BCBS of TX PPO	$46.92
Rate for Payer: Cash Price	$167.20
Rate for Payer: Cash Price	$167.20
Rate for Payer: Cigna Medicaid	$21.23
Rate for Payer: Cigna Medicare	$21.23
Rate for Payer: Employer Direct Commercial	$21.23
Rate for Payer: Humana Medicare/TRICARE	$21.23
Rate for Payer: Molina CHIP/Medicaid	$21.23
Rate for Payer: Molina Dual Medicare/Medicaid	$21.23
Rate for Payer: Molina Medicare	$21.23
Rate for Payer: Multiplan Auto	$123.50
Rate for Payer: Multiplan Commercial	$123.50
Rate for Payer: Multiplan Workers Comp	$123.50
Rate for Payer: Parkland Medicaid	$21.23
Rate for Payer: Scott and White EPO/PPO	$26.54
Rate for Payer: Scott and White Medicare	$21.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.23
Rate for Payer: Superior Health Plan EPO	$21.23
Rate for Payer: Superior Health Plan Medicare	$21.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.23
Rate for Payer: Universal American Medicare	$21.23
Rate for Payer: Wellcare Medicare	$21.23
Rate for Payer: Wellmed Medicare	$21.23

Vitamin B1 (Thiamine), Blood SO

Facility

$190.00

Service Code	CPT 84425
Hospital Charge Code	1708726
Hospital Revenue Code	301
Rate for Payer: Cash Price	$167.20

Vitamin B2, Whole Blood SO

Facility

$208.00

Service Code	CPT 84252
Hospital Charge Code	1706720
Hospital Revenue Code	301
Min. Negotiated Rate	$7.89
Max. Negotiated Rate	$135.20
Rate for Payer: Aetna Commercial	$21.24
Rate for Payer: Aetna Medicare	$30.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20.24
Rate for Payer: Amerigroup Medicare	$20.24
Rate for Payer: BCBS of TX Blue Advantage	$33.40
Rate for Payer: BCBS of TX Blue Essentials	$40.08
Rate for Payer: BCBS of TX Medicare	$20.24
Rate for Payer: BCBS of TX PPO	$44.73
Rate for Payer: Cash Price	$183.04
Rate for Payer: Cash Price	$183.04
Rate for Payer: Cigna Medicaid	$20.24
Rate for Payer: Cigna Medicare	$20.24
Rate for Payer: Employer Direct Commercial	$20.24
Rate for Payer: Humana Medicare/TRICARE	$20.24
Rate for Payer: Molina CHIP/Medicaid	$20.24
Rate for Payer: Molina Dual Medicare/Medicaid	$20.24
Rate for Payer: Molina Medicare	$20.24
Rate for Payer: Multiplan Auto	$135.20
Rate for Payer: Multiplan Commercial	$135.20
Rate for Payer: Multiplan Workers Comp	$135.20
Rate for Payer: Parkland Medicaid	$20.24
Rate for Payer: Scott and White EPO/PPO	$25.30
Rate for Payer: Scott and White Medicare	$20.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.24
Rate for Payer: Superior Health Plan EPO	$20.24
Rate for Payer: Superior Health Plan Medicare	$20.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$20.24
Rate for Payer: Universal American Medicare	$20.24
Rate for Payer: Wellcare Medicare	$20.24
Rate for Payer: Wellmed Medicare	$20.24

Vitamin B2, Whole Blood SO

Facility

$208.00

Service Code	CPT 84252
Hospital Charge Code	1706720
Hospital Revenue Code	301
Rate for Payer: Cash Price	$183.04

Vitamin B6, Plasma SO

Facility

$272.00

Service Code	CPT 84207
Hospital Charge Code	1706134
Hospital Revenue Code	301
Rate for Payer: Cash Price	$239.36

Vitamin B6, Plasma SO

Facility

$272.00

Service Code	CPT 84207
Hospital Charge Code	1706134
Hospital Revenue Code	301
Min. Negotiated Rate	$10.96
Max. Negotiated Rate	$176.80
Rate for Payer: Aetna Commercial	$29.50
Rate for Payer: Aetna Medicare	$42.15
Rate for Payer: Amerigroup CHIP/Medicaid	$10.96
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28.10
Rate for Payer: Amerigroup Medicare	$28.10
Rate for Payer: BCBS of TX Blue Advantage	$46.36
Rate for Payer: BCBS of TX Blue Essentials	$55.64
Rate for Payer: BCBS of TX Medicare	$28.10
Rate for Payer: BCBS of TX PPO	$62.10
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cash Price	$239.36
Rate for Payer: Cigna Medicaid	$28.10
Rate for Payer: Cigna Medicare	$28.10
Rate for Payer: Employer Direct Commercial	$28.10
Rate for Payer: Humana Medicare/TRICARE	$28.10
Rate for Payer: Molina CHIP/Medicaid	$28.10
Rate for Payer: Molina Dual Medicare/Medicaid	$28.10
Rate for Payer: Molina Medicare	$28.10
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$28.10
Rate for Payer: Scott and White EPO/PPO	$35.12
Rate for Payer: Scott and White Medicare	$28.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.10
Rate for Payer: Superior Health Plan EPO	$28.10
Rate for Payer: Superior Health Plan Medicare	$28.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$28.10
Rate for Payer: Universal American Medicare	$28.10
Rate for Payer: Wellcare Medicare	$28.10
Rate for Payer: Wellmed Medicare	$28.10

Vitamin C SO

Facility

$133.00

Service Code	CPT 82180
Hospital Charge Code	1705961
Hospital Revenue Code	301
Rate for Payer: Cash Price	$117.04

Vitamin C SO

Facility

$133.00

Service Code	CPT 82180
Hospital Charge Code	1705961
Hospital Revenue Code	301
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$86.45
Rate for Payer: Aetna Commercial	$10.38
Rate for Payer: Aetna Medicare	$14.84
Rate for Payer: Amerigroup CHIP/Medicaid	$3.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.89
Rate for Payer: Amerigroup Medicare	$9.89
Rate for Payer: BCBS of TX Blue Advantage	$16.32
Rate for Payer: BCBS of TX Blue Essentials	$19.58
Rate for Payer: BCBS of TX Medicare	$9.89
Rate for Payer: BCBS of TX PPO	$21.86
Rate for Payer: Cash Price	$117.04
Rate for Payer: Cash Price	$117.04
Rate for Payer: Cigna Medicaid	$9.89
Rate for Payer: Cigna Medicare	$9.89
Rate for Payer: Employer Direct Commercial	$9.89
Rate for Payer: Humana Medicare/TRICARE	$9.89
Rate for Payer: Molina CHIP/Medicaid	$9.89
Rate for Payer: Molina Dual Medicare/Medicaid	$9.89
Rate for Payer: Molina Medicare	$9.89
Rate for Payer: Multiplan Auto	$86.45
Rate for Payer: Multiplan Commercial	$86.45
Rate for Payer: Multiplan Workers Comp	$86.45
Rate for Payer: Parkland Medicaid	$9.89
Rate for Payer: Scott and White EPO/PPO	$12.36
Rate for Payer: Scott and White Medicare	$9.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.89
Rate for Payer: Superior Health Plan EPO	$9.89
Rate for Payer: Superior Health Plan Medicare	$9.89
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.89
Rate for Payer: Universal American Medicare	$9.89
Rate for Payer: Wellcare Medicare	$9.89
Rate for Payer: Wellmed Medicare	$9.89

Vitamin D 25 Hydroxy Level

Facility

$521.00

Service Code	CPT 82306
Hospital Charge Code	1620104
Hospital Revenue Code	301
Rate for Payer: Cash Price	$458.48

Vitamin D 25 Hydroxy Level

Facility

$521.00

Service Code	CPT 82306
Hospital Charge Code	1620104
Hospital Revenue Code	301
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$338.65
Rate for Payer: Aetna Commercial	$31.08
Rate for Payer: Aetna Medicare	$44.40
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.60
Rate for Payer: Amerigroup Medicare	$29.60
Rate for Payer: BCBS of TX Blue Advantage	$48.84
Rate for Payer: BCBS of TX Blue Essentials	$58.61
Rate for Payer: BCBS of TX Medicare	$29.60
Rate for Payer: BCBS of TX PPO	$65.42
Rate for Payer: Cash Price	$458.48
Rate for Payer: Cash Price	$458.48
Rate for Payer: Cigna Medicaid	$29.60
Rate for Payer: Cigna Medicare	$29.60
Rate for Payer: Employer Direct Commercial	$29.60
Rate for Payer: Humana Medicare/TRICARE	$29.60
Rate for Payer: Molina CHIP/Medicaid	$29.60
Rate for Payer: Molina Dual Medicare/Medicaid	$29.60
Rate for Payer: Molina Medicare	$29.60
Rate for Payer: Multiplan Auto	$338.65
Rate for Payer: Multiplan Commercial	$338.65
Rate for Payer: Multiplan Workers Comp	$338.65
Rate for Payer: Parkland Medicaid	$29.60
Rate for Payer: Scott and White EPO/PPO	$37.00
Rate for Payer: Scott and White Medicare	$29.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.60
Rate for Payer: Superior Health Plan EPO	$29.60
Rate for Payer: Superior Health Plan Medicare	$29.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.60
Rate for Payer: Universal American Medicare	$29.60
Rate for Payer: Wellcare Medicare	$29.60
Rate for Payer: Wellmed Medicare	$29.60

Vitamin D, 25-Hydroxy SO

Facility

$521.00

Service Code	CPT 82306
Hospital Charge Code	7254595
Hospital Revenue Code	301
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$338.65
Rate for Payer: Aetna Commercial	$31.08
Rate for Payer: Aetna Medicare	$44.40
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.60
Rate for Payer: Amerigroup Medicare	$29.60
Rate for Payer: BCBS of TX Blue Advantage	$48.84
Rate for Payer: BCBS of TX Blue Essentials	$58.61
Rate for Payer: BCBS of TX Medicare	$29.60
Rate for Payer: BCBS of TX PPO	$65.42
Rate for Payer: Cash Price	$458.48
Rate for Payer: Cash Price	$458.48
Rate for Payer: Cigna Medicaid	$29.60
Rate for Payer: Cigna Medicare	$29.60
Rate for Payer: Employer Direct Commercial	$29.60
Rate for Payer: Humana Medicare/TRICARE	$29.60
Rate for Payer: Molina CHIP/Medicaid	$29.60
Rate for Payer: Molina Dual Medicare/Medicaid	$29.60
Rate for Payer: Molina Medicare	$29.60
Rate for Payer: Multiplan Auto	$338.65
Rate for Payer: Multiplan Commercial	$338.65
Rate for Payer: Multiplan Workers Comp	$338.65
Rate for Payer: Parkland Medicaid	$29.60
Rate for Payer: Scott and White EPO/PPO	$37.00
Rate for Payer: Scott and White Medicare	$29.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.60
Rate for Payer: Superior Health Plan EPO	$29.60
Rate for Payer: Superior Health Plan Medicare	$29.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.60
Rate for Payer: Universal American Medicare	$29.60
Rate for Payer: Wellcare Medicare	$29.60
Rate for Payer: Wellmed Medicare	$29.60

Vitamin D, 25-Hydroxy SO

Facility

$521.00

Service Code	CPT 82306
Hospital Charge Code	7254595
Hospital Revenue Code	301
Rate for Payer: Cash Price	$458.48

Vitamin E SO

Facility

$154.00

Service Code	CPT 84446
Hospital Charge Code	1701606
Hospital Revenue Code	301
Rate for Payer: Cash Price	$135.52

Vitamin E SO

Facility

$154.00

Service Code	CPT 84446
Hospital Charge Code	1701606
Hospital Revenue Code	301
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$100.10
Rate for Payer: Aetna Commercial	$14.89
Rate for Payer: Aetna Medicare	$21.27
Rate for Payer: Amerigroup CHIP/Medicaid	$5.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.18
Rate for Payer: Amerigroup Medicare	$14.18
Rate for Payer: BCBS of TX Blue Advantage	$23.40
Rate for Payer: BCBS of TX Blue Essentials	$28.08
Rate for Payer: BCBS of TX Medicare	$14.18
Rate for Payer: BCBS of TX PPO	$31.34
Rate for Payer: Cash Price	$135.52
Rate for Payer: Cash Price	$135.52
Rate for Payer: Cigna Medicaid	$14.18
Rate for Payer: Cigna Medicare	$14.18
Rate for Payer: Employer Direct Commercial	$14.18
Rate for Payer: Humana Medicare/TRICARE	$14.18
Rate for Payer: Molina CHIP/Medicaid	$14.18
Rate for Payer: Molina Dual Medicare/Medicaid	$14.18
Rate for Payer: Molina Medicare	$14.18
Rate for Payer: Multiplan Auto	$100.10
Rate for Payer: Multiplan Commercial	$100.10
Rate for Payer: Multiplan Workers Comp	$100.10
Rate for Payer: Parkland Medicaid	$14.18
Rate for Payer: Scott and White EPO/PPO	$17.72
Rate for Payer: Scott and White Medicare	$14.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.18
Rate for Payer: Superior Health Plan EPO	$14.18
Rate for Payer: Superior Health Plan Medicare	$14.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.18
Rate for Payer: Universal American Medicare	$14.18
Rate for Payer: Wellcare Medicare	$14.18
Rate for Payer: Wellmed Medicare	$14.18

vitoss 1.2cc

Facility

$4,059.04

Service Code	HCPCS C1762
Hospital Charge Code	8688547
Hospital Revenue Code	278
Min. Negotiated Rate	$1,014.76
Max. Negotiated Rate	$2,029.52
Rate for Payer: Aetna Commercial	$1,217.71
Rate for Payer: Cash Price	$3,571.96
Rate for Payer: Cigna Commercial	$1,014.76
Rate for Payer: Multiplan Auto	$2,029.52
Rate for Payer: Multiplan Commercial	$2,029.52
Rate for Payer: Multiplan Workers Comp	$2,029.52
Rate for Payer: Scott and White EPO/PPO	$2,029.52

Know your out-of-pocket cost for care.

All Charges