White Rock Medical Center

All Charges

Charge

Type

Setting

Price

vitoss 1.2cc

Facility

$4,059.04

Service Code	HCPCS C1762
Hospital Charge Code	8688547
Hospital Revenue Code	278
Min. Negotiated Rate	$365.31
Max. Negotiated Rate	$2,029.52
Rate for Payer: Aetna Commercial	$1,217.71
Rate for Payer: Amerigroup CHIP/Medicaid	$365.31
Rate for Payer: BCBS of TX Blue Advantage	$1,217.71
Rate for Payer: BCBS of TX Blue Essentials	$1,461.25
Rate for Payer: BCBS of TX PPO	$1,623.62
Rate for Payer: Cash Price	$3,571.96
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
Rate for Payer: Superior Health Plan EPO	$552.03

VITOSS 2.5

Facility

$6,955.78

Service Code	HCPCS C1713
Hospital Charge Code	132252
Hospital Revenue Code	278
Min. Negotiated Rate	$626.02
Max. Negotiated Rate	$3,477.89
Rate for Payer: Aetna Commercial	$2,086.73
Rate for Payer: Amerigroup CHIP/Medicaid	$626.02
Rate for Payer: BCBS of TX Blue Advantage	$2,086.73
Rate for Payer: BCBS of TX Blue Essentials	$2,504.08
Rate for Payer: BCBS of TX PPO	$2,782.31
Rate for Payer: Cash Price	$6,121.09
Rate for Payer: Multiplan Auto	$3,477.89
Rate for Payer: Multiplan Commercial	$3,477.89
Rate for Payer: Multiplan Workers Comp	$3,477.89
Rate for Payer: Scott and White EPO/PPO	$3,477.89
Rate for Payer: Superior Health Plan EPO	$945.99

VITOSS 2.5

Facility

$6,955.78

Service Code	HCPCS C1713
Hospital Charge Code	132252
Hospital Revenue Code	278
Min. Negotiated Rate	$1,738.94
Max. Negotiated Rate	$3,477.89
Rate for Payer: Aetna Commercial	$2,086.73
Rate for Payer: Cash Price	$6,121.09
Rate for Payer: Cigna Commercial	$1,738.94
Rate for Payer: Multiplan Auto	$3,477.89
Rate for Payer: Multiplan Commercial	$3,477.89
Rate for Payer: Multiplan Workers Comp	$3,477.89
Rate for Payer: Scott and White EPO/PPO	$3,477.89

VLV TRACH SPEAK -- DHF

Facility

$338.80

Service Code	HCPCS L8501
Hospital Charge Code	82075516
Hospital Revenue Code	274
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$169.40
Rate for Payer: Aetna Commercial	$101.64
Rate for Payer: Amerigroup CHIP/Medicaid	$30.49
Rate for Payer: BCBS of TX Blue Advantage	$101.64
Rate for Payer: BCBS of TX Blue Essentials	$121.97
Rate for Payer: BCBS of TX PPO	$135.52
Rate for Payer: Cash Price	$298.14
Rate for Payer: Multiplan Auto	$169.40
Rate for Payer: Multiplan Commercial	$169.40
Rate for Payer: Multiplan Workers Comp	$169.40
Rate for Payer: Scott and White EPO/PPO	$169.40
Rate for Payer: Superior Health Plan EPO	$46.08

VLV TRACH SPEAK -- DHF

Facility

$338.80

Service Code	HCPCS L8501
Hospital Charge Code	82075516
Hospital Revenue Code	274
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$169.40
Rate for Payer: Aetna Commercial	$101.64
Rate for Payer: Cash Price	$298.14
Rate for Payer: Cigna Commercial	$84.70
Rate for Payer: Multiplan Auto	$169.40
Rate for Payer: Multiplan Commercial	$169.40
Rate for Payer: Multiplan Workers Comp	$169.40
Rate for Payer: Scott and White EPO/PPO	$169.40

von Willebrand Factor (vWF) Ag SO

Facility

$111.00

Service Code	CPT 85246
Hospital Charge Code	1700996
Hospital Revenue Code	305
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$72.15
Rate for Payer: Aetna Commercial	$24.08
Rate for Payer: Aetna Medicare	$34.41
Rate for Payer: Amerigroup CHIP/Medicaid	$8.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.94
Rate for Payer: Amerigroup Medicare	$22.94
Rate for Payer: BCBS of TX Blue Advantage	$37.85
Rate for Payer: BCBS of TX Blue Essentials	$45.42
Rate for Payer: BCBS of TX Medicare	$22.94
Rate for Payer: BCBS of TX PPO	$50.70
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cash Price	$97.68
Rate for Payer: Cigna Medicaid	$22.94
Rate for Payer: Cigna Medicare	$22.94
Rate for Payer: Employer Direct Commercial	$22.94
Rate for Payer: Humana Medicare/TRICARE	$22.94
Rate for Payer: Molina CHIP/Medicaid	$22.94
Rate for Payer: Molina Dual Medicare/Medicaid	$22.94
Rate for Payer: Molina Medicare	$22.94
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Parkland Medicaid	$22.94
Rate for Payer: Scott and White EPO/PPO	$28.68
Rate for Payer: Scott and White Medicare	$22.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.94
Rate for Payer: Superior Health Plan EPO	$22.94
Rate for Payer: Superior Health Plan Medicare	$22.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.94
Rate for Payer: Universal American Medicare	$22.94
Rate for Payer: Wellcare Medicare	$22.94
Rate for Payer: Wellmed Medicare	$22.94

von Willebrand Factor (vWF) Ag SO

Facility

$111.00

Service Code	CPT 85246
Hospital Charge Code	1700996
Hospital Revenue Code	305
Rate for Payer: Cash Price	$97.68

Vulva/Perineum

Facility

$1,052.00

Service Code	CPT 56405
Hospital Charge Code	8682618
Hospital Revenue Code	450
Rate for Payer: Cash Price	$925.76

Vulva/Perineum

Facility

$1,052.00

Service Code	CPT 56405
Hospital Charge Code	8682618
Hospital Revenue Code	450
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$683.80
Rate for Payer: Aetna Commercial	$578.60
Rate for Payer: Aetna Medicare	$440.08
Rate for Payer: Amerigroup CHIP/Medicaid	$94.68
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$293.39
Rate for Payer: Amerigroup Medicare	$293.39
Rate for Payer: BCBS of TX Blue Advantage	$116.92
Rate for Payer: BCBS of TX Blue Essentials	$140.02
Rate for Payer: BCBS of TX Medicare	$293.39
Rate for Payer: BCBS of TX PPO	$176.43
Rate for Payer: Cash Price	$925.76
Rate for Payer: Cash Price	$925.76
Rate for Payer: Cash Price	$925.76
Rate for Payer: Cigna Commercial	$664.62
Rate for Payer: Cigna Medicaid	$75.58
Rate for Payer: Cigna Medicare	$293.39
Rate for Payer: Employer Direct Commercial	$293.39
Rate for Payer: Humana Medicare/TRICARE	$293.39
Rate for Payer: Molina CHIP/Medicaid	$75.58
Rate for Payer: Molina Dual Medicare/Medicaid	$293.39
Rate for Payer: Molina Medicare	$293.39
Rate for Payer: Multiplan Auto	$683.80
Rate for Payer: Multiplan Commercial	$683.80
Rate for Payer: Multiplan Workers Comp	$683.80
Rate for Payer: Parkland Medicaid	$75.58
Rate for Payer: Scott and White EPO/PPO	$5.25
Rate for Payer: Scott and White Medicare	$293.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$75.58
Rate for Payer: Superior Health Plan EPO	$293.39
Rate for Payer: Superior Health Plan Medicare	$293.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$293.39
Rate for Payer: Universal American Medicare	$293.39
Rate for Payer: Wellcare Medicare	$293.39
Rate for Payer: Wellmed Medicare	$293.39

vWF Activity SO

Facility

$244.00

Service Code	CPT 85245
Hospital Charge Code	1708452
Hospital Revenue Code	305
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$158.60
Rate for Payer: Aetna Commercial	$24.08
Rate for Payer: Aetna Medicare	$34.41
Rate for Payer: Amerigroup CHIP/Medicaid	$8.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.94
Rate for Payer: Amerigroup Medicare	$22.94
Rate for Payer: BCBS of TX Blue Advantage	$37.85
Rate for Payer: BCBS of TX Blue Essentials	$45.42
Rate for Payer: BCBS of TX Medicare	$22.94
Rate for Payer: BCBS of TX PPO	$50.70
Rate for Payer: Cash Price	$214.72
Rate for Payer: Cash Price	$214.72
Rate for Payer: Cigna Medicaid	$22.94
Rate for Payer: Cigna Medicare	$22.94
Rate for Payer: Employer Direct Commercial	$22.94
Rate for Payer: Humana Medicare/TRICARE	$22.94
Rate for Payer: Molina CHIP/Medicaid	$22.94
Rate for Payer: Molina Dual Medicare/Medicaid	$22.94
Rate for Payer: Molina Medicare	$22.94
Rate for Payer: Multiplan Auto	$158.60
Rate for Payer: Multiplan Commercial	$158.60
Rate for Payer: Multiplan Workers Comp	$158.60
Rate for Payer: Parkland Medicaid	$22.94
Rate for Payer: Scott and White EPO/PPO	$28.68
Rate for Payer: Scott and White Medicare	$22.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.94
Rate for Payer: Superior Health Plan EPO	$22.94
Rate for Payer: Superior Health Plan Medicare	$22.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.94
Rate for Payer: Universal American Medicare	$22.94
Rate for Payer: Wellcare Medicare	$22.94
Rate for Payer: Wellmed Medicare	$22.94

vWF Activity SO

Facility

$244.00

Service Code	CPT 85245
Hospital Charge Code	1708452
Hospital Revenue Code	305
Rate for Payer: Cash Price	$214.72

VZV Real Time PCR SO

Facility

$535.00

Service Code	CPT 87798
Hospital Charge Code	1709039
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$347.75
Rate for Payer: Aetna Commercial	$36.84
Rate for Payer: Aetna Medicare	$52.64
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$57.90
Rate for Payer: BCBS of TX Blue Essentials	$69.48
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$77.55
Rate for Payer: Cash Price	$470.80
Rate for Payer: Cash Price	$470.80
Rate for Payer: Cigna Medicaid	$35.09
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$35.09
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$347.75
Rate for Payer: Multiplan Commercial	$347.75
Rate for Payer: Multiplan Workers Comp	$347.75
Rate for Payer: Parkland Medicaid	$35.09
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.09
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

VZV Real Time PCR SO

Facility

$535.00

Service Code	CPT 87798
Hospital Charge Code	1709039
Hospital Revenue Code	306
Rate for Payer: Cash Price	$470.80

WAND ARTHRO BIPLR DISP2 -- DHF

Facility

$3,364.14

Hospital Charge Code	81779621
Hospital Revenue Code	272
Min. Negotiated Rate	$302.77
Max. Negotiated Rate	$2,186.69
Rate for Payer: Aetna Commercial	$1,850.28
Rate for Payer: Amerigroup CHIP/Medicaid	$302.77
Rate for Payer: BCBS of TX Blue Advantage	$1,009.24
Rate for Payer: BCBS of TX Blue Essentials	$1,211.09
Rate for Payer: BCBS of TX PPO	$1,345.66
Rate for Payer: Cash Price	$2,960.44
Rate for Payer: Multiplan Auto	$2,186.69
Rate for Payer: Multiplan Commercial	$2,186.69
Rate for Payer: Multiplan Workers Comp	$2,186.69
Rate for Payer: Scott and White EPO/PPO	$1,682.07
Rate for Payer: Superior Health Plan EPO	$457.52

WAND ARTHRO BIPLR DISP2 -- DHF

Facility

$3,364.14

Hospital Charge Code	81779621
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,960.44

WASHER CANCL -- DHF

Facility

$205.28

Service Code	HCPCS C1713
Hospital Charge Code	81370702
Hospital Revenue Code	278
Min. Negotiated Rate	$51.32
Max. Negotiated Rate	$102.64
Rate for Payer: Aetna Commercial	$61.58
Rate for Payer: Cash Price	$180.65
Rate for Payer: Cigna Commercial	$51.32
Rate for Payer: Multiplan Auto	$102.64
Rate for Payer: Multiplan Commercial	$102.64
Rate for Payer: Multiplan Workers Comp	$102.64
Rate for Payer: Scott and White EPO/PPO	$102.64

WASHER CANCL -- DHF

Facility

$205.28

Service Code	HCPCS C1713
Hospital Charge Code	81370702
Hospital Revenue Code	278
Min. Negotiated Rate	$18.48
Max. Negotiated Rate	$102.64
Rate for Payer: Aetna Commercial	$61.58
Rate for Payer: Amerigroup CHIP/Medicaid	$18.48
Rate for Payer: BCBS of TX Blue Advantage	$61.58
Rate for Payer: BCBS of TX Blue Essentials	$73.90
Rate for Payer: BCBS of TX PPO	$82.11
Rate for Payer: Cash Price	$180.65
Rate for Payer: Multiplan Auto	$102.64
Rate for Payer: Multiplan Commercial	$102.64
Rate for Payer: Multiplan Workers Comp	$102.64
Rate for Payer: Scott and White EPO/PPO	$102.64
Rate for Payer: Superior Health Plan EPO	$27.92

WASHER FOR 6.5/8.0 SCREWS

Facility

$266.99

Service Code	HCPCS C1713
Hospital Charge Code	126364
Hospital Revenue Code	278
Min. Negotiated Rate	$24.03
Max. Negotiated Rate	$133.50
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Amerigroup CHIP/Medicaid	$24.03
Rate for Payer: BCBS of TX Blue Advantage	$80.10
Rate for Payer: BCBS of TX Blue Essentials	$96.12
Rate for Payer: BCBS of TX PPO	$106.80
Rate for Payer: Cash Price	$234.95
Rate for Payer: Multiplan Auto	$133.50
Rate for Payer: Multiplan Commercial	$133.50
Rate for Payer: Multiplan Workers Comp	$133.50
Rate for Payer: Scott and White EPO/PPO	$133.50
Rate for Payer: Superior Health Plan EPO	$36.31

WASHER FOR 6.5/8.0 SCREWS

Facility

$266.99

Service Code	HCPCS C1713
Hospital Charge Code	126364
Hospital Revenue Code	278
Min. Negotiated Rate	$66.75
Max. Negotiated Rate	$133.50
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Cash Price	$234.95
Rate for Payer: Cigna Commercial	$66.75
Rate for Payer: Multiplan Auto	$133.50
Rate for Payer: Multiplan Commercial	$133.50
Rate for Payer: Multiplan Workers Comp	$133.50
Rate for Payer: Scott and White EPO/PPO	$133.50

WAX BONE 2.5GMS -- DHF

Facility

$211.71

Hospital Charge Code	81952509
Hospital Revenue Code	272
Rate for Payer: Cash Price	$186.30

WAX BONE 2.5GMS -- DHF

Facility

$211.71

Hospital Charge Code	81952509
Hospital Revenue Code	272
Min. Negotiated Rate	$19.05
Max. Negotiated Rate	$137.61
Rate for Payer: Aetna Commercial	$116.44
Rate for Payer: Amerigroup CHIP/Medicaid	$19.05
Rate for Payer: BCBS of TX Blue Advantage	$63.51
Rate for Payer: BCBS of TX Blue Essentials	$76.22
Rate for Payer: BCBS of TX PPO	$84.68
Rate for Payer: Cash Price	$186.30
Rate for Payer: Multiplan Auto	$137.61
Rate for Payer: Multiplan Commercial	$137.61
Rate for Payer: Multiplan Workers Comp	$137.61
Rate for Payer: Scott and White EPO/PPO	$105.86
Rate for Payer: Superior Health Plan EPO	$28.79

WC Apply Rigid Leg Cast Lt BCE

Facility

$874.00

Service Code	CPT 29445 LT
Hospital Charge Code	7150828
Hospital Revenue Code	761
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$568.10
Rate for Payer: Aetna Commercial	$480.70
Rate for Payer: Aetna Medicare	$368.42
Rate for Payer: Amerigroup CHIP/Medicaid	$78.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$245.61
Rate for Payer: Amerigroup Medicare	$245.61
Rate for Payer: BCBS of TX Blue Advantage	$103.66
Rate for Payer: BCBS of TX Blue Essentials	$124.14
Rate for Payer: BCBS of TX Medicare	$245.61
Rate for Payer: BCBS of TX PPO	$156.42
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cigna Commercial	$556.38
Rate for Payer: Cigna Medicaid	$49.56
Rate for Payer: Cigna Medicare	$245.61
Rate for Payer: Employer Direct Commercial	$245.61
Rate for Payer: Humana Medicare/TRICARE	$245.61
Rate for Payer: Molina CHIP/Medicaid	$49.56
Rate for Payer: Molina Dual Medicare/Medicaid	$245.61
Rate for Payer: Molina Medicare	$245.61
Rate for Payer: Multiplan Auto	$568.10
Rate for Payer: Multiplan Commercial	$568.10
Rate for Payer: Multiplan Workers Comp	$568.10
Rate for Payer: Parkland Medicaid	$49.56
Rate for Payer: Scott and White EPO/PPO	$4.39
Rate for Payer: Scott and White Medicare	$245.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.56
Rate for Payer: Superior Health Plan EPO	$245.61
Rate for Payer: Superior Health Plan Medicare	$245.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$245.61
Rate for Payer: Universal American Medicare	$245.61
Rate for Payer: Wellcare Medicare	$245.61
Rate for Payer: Wellmed Medicare	$245.61

WC Apply Rigid Leg Cast Lt BCE

Facility

$874.00

Service Code	CPT 29445 LT
Hospital Charge Code	7150828
Hospital Revenue Code	761
Rate for Payer: Cash Price	$769.12

WC Apply Rigid Leg Cast Rt BCE

Facility

$874.00

Service Code	CPT 29445 RT
Hospital Charge Code	7150827
Hospital Revenue Code	761
Rate for Payer: Cash Price	$769.12

WC Apply Rigid Leg Cast Rt BCE

Facility

$874.00

Service Code	CPT 29445 RT
Hospital Charge Code	7150827
Hospital Revenue Code	761
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$568.10
Rate for Payer: Aetna Commercial	$480.70
Rate for Payer: Aetna Medicare	$368.42
Rate for Payer: Amerigroup CHIP/Medicaid	$78.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$245.61
Rate for Payer: Amerigroup Medicare	$245.61
Rate for Payer: BCBS of TX Blue Advantage	$103.66
Rate for Payer: BCBS of TX Blue Essentials	$124.14
Rate for Payer: BCBS of TX Medicare	$245.61
Rate for Payer: BCBS of TX PPO	$156.42
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cash Price	$769.12
Rate for Payer: Cigna Commercial	$556.38
Rate for Payer: Cigna Medicaid	$49.56
Rate for Payer: Cigna Medicare	$245.61
Rate for Payer: Employer Direct Commercial	$245.61
Rate for Payer: Humana Medicare/TRICARE	$245.61
Rate for Payer: Molina CHIP/Medicaid	$49.56
Rate for Payer: Molina Dual Medicare/Medicaid	$245.61
Rate for Payer: Molina Medicare	$245.61
Rate for Payer: Multiplan Auto	$568.10
Rate for Payer: Multiplan Commercial	$568.10
Rate for Payer: Multiplan Workers Comp	$568.10
Rate for Payer: Parkland Medicaid	$49.56
Rate for Payer: Scott and White EPO/PPO	$4.39
Rate for Payer: Scott and White Medicare	$245.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$49.56
Rate for Payer: Superior Health Plan EPO	$245.61
Rate for Payer: Superior Health Plan Medicare	$245.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$245.61
Rate for Payer: Universal American Medicare	$245.61
Rate for Payer: Wellcare Medicare	$245.61
Rate for Payer: Wellmed Medicare	$245.61

Know your out-of-pocket cost for care.

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