White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Valproic Acid Level

Facility

$373.00

Service Code	HCPCS 80164
Hospital Charge Code	1602960
Hospital Revenue Code	300
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$268.56
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	$111.90
Rate for Payer: BCBS of TX Blue Essentials	$134.28
Rate for Payer: BCBS of TX Medicare	$13.54
Rate for Payer: BCBS of TX PPO	$149.20
Rate for Payer: Cash Price	$253.64
Rate for Payer: Cash Price	$253.64
Rate for Payer: Cigna Medicaid	$268.56
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	$268.56
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	$268.56
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	$268.56
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

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	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

VALVE, EX, DISPOSABLE, 0-2

Facility

$115.05

Hospital Charge Code	993316
Hospital Revenue Code	270
Min. Negotiated Rate	$10.35
Max. Negotiated Rate	$82.84
Rate for Payer: Amerigroup CHIP/Medicaid	$10.35
Rate for Payer: BCBS of TX Blue Advantage	$34.52
Rate for Payer: BCBS of TX Blue Essentials	$41.42
Rate for Payer: BCBS of TX PPO	$46.02
Rate for Payer: Cash Price	$78.23
Rate for Payer: Cigna Medicaid	$82.84
Rate for Payer: Molina CHIP/Medicaid	$82.84
Rate for Payer: Multiplan Auto	$74.78
Rate for Payer: Multiplan Commercial	$74.78
Rate for Payer: Multiplan Workers Comp	$74.78
Rate for Payer: Parkland Medicaid	$82.84
Rate for Payer: Scott and White EPO/PPO	$57.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$82.84
Rate for Payer: Superior Health Plan EPO	$15.65

VALVE, EX, DISPOSABLE, 0-2

Facility

$115.05

Hospital Charge Code	993316
Hospital Revenue Code	270
Rate for Payer: Cash Price	$78.23

VALVE PEEP 30MM DISP ADPT

Facility

$9.78

Hospital Charge Code	993614
Hospital Revenue Code	270
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$7.04
Rate for Payer: Amerigroup CHIP/Medicaid	$0.88
Rate for Payer: BCBS of TX Blue Advantage	$2.93
Rate for Payer: BCBS of TX Blue Essentials	$3.52
Rate for Payer: BCBS of TX PPO	$3.91
Rate for Payer: Cash Price	$6.65
Rate for Payer: Cigna Medicaid	$7.04
Rate for Payer: Molina CHIP/Medicaid	$7.04
Rate for Payer: Multiplan Auto	$6.36
Rate for Payer: Multiplan Commercial	$6.36
Rate for Payer: Multiplan Workers Comp	$6.36
Rate for Payer: Parkland Medicaid	$7.04
Rate for Payer: Scott and White EPO/PPO	$4.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.04
Rate for Payer: Superior Health Plan EPO	$1.33

VALVE PEEP 30MM DISP ADPT

Facility

$9.78

Hospital Charge Code	993614
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.65

VALVE URO ADULT LOPEZ

Facility

$45.40

Hospital Charge Code	81820557
Hospital Revenue Code	272
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$32.69
Rate for Payer: Amerigroup CHIP/Medicaid	$4.09
Rate for Payer: BCBS of TX Blue Advantage	$13.62
Rate for Payer: BCBS of TX Blue Essentials	$16.34
Rate for Payer: BCBS of TX PPO	$18.16
Rate for Payer: Cash Price	$30.87
Rate for Payer: Cigna Medicaid	$32.69
Rate for Payer: Molina CHIP/Medicaid	$32.69
Rate for Payer: Multiplan Auto	$29.51
Rate for Payer: Multiplan Commercial	$29.51
Rate for Payer: Multiplan Workers Comp	$29.51
Rate for Payer: Parkland Medicaid	$32.69
Rate for Payer: Scott and White EPO/PPO	$22.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.69
Rate for Payer: Superior Health Plan EPO	$6.17

VALVE URO ADULT LOPEZ

Facility

$45.40

Hospital Charge Code	81820557
Hospital Revenue Code	272
Rate for Payer: Cash Price	$30.87

vancomycin 1.25 g in 250 mL

Facility

$128.17

Service Code	HCPCS J3375
Hospital Charge Code	77869690
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

vancomycin 1.25 g in 250 mL

Facility

$128.17

Service Code	HCPCS J3375
Hospital Charge Code	77869690
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

vancomycin 1 g IV Inj

Facility

$128.17

Service Code	HCPCS J3373
Hospital Charge Code	77869305
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

vancomycin 1 g IV Inj

Facility

$128.17

Service Code	HCPCS J3373
Hospital Charge Code	77869305
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

vancomycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J3370
Hospital Charge Code	77870620
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

vancomycin 500 mg IV Inj

Facility

$128.17

Service Code	HCPCS J3370
Hospital Charge Code	77870620
Hospital Revenue Code	636
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.06
Rate for Payer: BCBS of TX Blue Essentials	$2.47
Rate for Payer: BCBS of TX PPO	$2.74
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

vancomycin 500 mg IV Inj

Facility

$128.17

Service Code	NDC 47781059891
Hospital Charge Code	1.49878E+11
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

vancomycin 500 mg IV Inj

Facility

$128.17

Service Code	NDC 47781059891
Hospital Charge Code	1.49878E+11
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

vancomycin 50 mg/mL Oral Liquid 300 mL

Facility

$483.93

Service Code	HCPCS J3490
Hospital Charge Code	77870571
Hospital Revenue Code	250
Rate for Payer: Cash Price	$329.07

vancomycin 50 mg/mL Oral Liquid 300 mL

Facility

$483.93

Service Code	HCPCS J3490
Hospital Charge Code	77870571
Hospital Revenue Code	250
Min. Negotiated Rate	$43.55
Max. Negotiated Rate	$348.43
Rate for Payer: Amerigroup CHIP/Medicaid	$43.55
Rate for Payer: BCBS of TX Blue Advantage	$145.18
Rate for Payer: BCBS of TX Blue Essentials	$174.21
Rate for Payer: BCBS of TX PPO	$193.57
Rate for Payer: Cash Price	$329.07
Rate for Payer: Cigna Medicaid	$348.43
Rate for Payer: Molina CHIP/Medicaid	$348.43
Rate for Payer: Multiplan Auto	$314.55
Rate for Payer: Multiplan Commercial	$314.55
Rate for Payer: Multiplan Workers Comp	$314.55
Rate for Payer: Parkland Medicaid	$348.43
Rate for Payer: Scott and White EPO/PPO	$241.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$348.43
Rate for Payer: Superior Health Plan EPO	$65.81

Vancomycin Level Trough

Facility

$404.00

Service Code	HCPCS 80202
Hospital Charge Code	1601525
Hospital Revenue Code	300
Rate for Payer: Cash Price	$274.72

Vancomycin Level Trough

Facility

$404.00

Service Code	HCPCS 80202
Hospital Charge Code	1601525
Hospital Revenue Code	300
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$290.88
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	$121.20
Rate for Payer: BCBS of TX Blue Essentials	$145.44
Rate for Payer: BCBS of TX Medicare	$13.54
Rate for Payer: BCBS of TX PPO	$161.60
Rate for Payer: Cash Price	$274.72
Rate for Payer: Cash Price	$274.72
Rate for Payer: Cigna Medicaid	$290.88
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	$290.88
Rate for Payer: Molina Dual Medicare/Medicaid	$13.54
Rate for Payer: Molina Medicare	$13.54
Rate for Payer: Multiplan Auto	$262.60
Rate for Payer: Multiplan Commercial	$262.60
Rate for Payer: Multiplan Workers Comp	$262.60
Rate for Payer: Parkland Medicaid	$290.88
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	$290.88
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

Vanillylmandelic Acid, 24-Hr U SO

Facility

$78.00

Service Code	HCPCS 84585
Hospital Charge Code	1702182
Hospital Revenue Code	301
Rate for Payer: Cash Price	$53.04

Vanillylmandelic Acid, 24-Hr U SO

Facility

$78.00

Service Code	HCPCS 84585
Hospital Charge Code	1702182
Hospital Revenue Code	301
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$56.16
Rate for Payer: Amerigroup CHIP/Medicaid	$6.05
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.50
Rate for Payer: Amerigroup Medicare	$15.50
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	$15.50
Rate for Payer: BCBS of TX PPO	$31.20
Rate for Payer: Cash Price	$53.04
Rate for Payer: Cash Price	$53.04
Rate for Payer: Cigna Medicaid	$56.16
Rate for Payer: Cigna Medicare	$15.50
Rate for Payer: Employer Direct Commercial	$15.50
Rate for Payer: Humana Medicare/TRICARE	$15.50
Rate for Payer: Molina CHIP/Medicaid	$56.16
Rate for Payer: Molina Dual Medicare/Medicaid	$15.50
Rate for Payer: Molina Medicare	$15.50
Rate for Payer: Multiplan Auto	$50.70
Rate for Payer: Multiplan Commercial	$50.70
Rate for Payer: Multiplan Workers Comp	$50.70
Rate for Payer: Parkland Medicaid	$56.16
Rate for Payer: Scott and White EPO/PPO	$19.38
Rate for Payer: Scott and White Medicare	$15.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.16
Rate for Payer: Superior Health Plan EPO	$15.50
Rate for Payer: Superior Health Plan Medicare	$15.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.50
Rate for Payer: Universal American Medicare	$15.50
Rate for Payer: Wellcare Medicare	$15.50
Rate for Payer: Wellmed Medicare	$15.50

Varicella Zoster Abs, IgG/IgM SO

Facility

$197.00

Service Code	HCPCS 86787
Hospital Charge Code	1700897
Hospital Revenue Code	302
Rate for Payer: Cash Price	$133.96

Varicella Zoster Abs, IgG/IgM SO

Facility

$197.00

Service Code	HCPCS 86787
Hospital Charge Code	1700897
Hospital Revenue Code	302
Min. Negotiated Rate	$5.02
Max. Negotiated Rate	$141.84
Rate for Payer: Amerigroup CHIP/Medicaid	$5.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.88
Rate for Payer: Amerigroup Medicare	$12.88
Rate for Payer: BCBS of TX Blue Advantage	$59.10
Rate for Payer: BCBS of TX Blue Essentials	$70.92
Rate for Payer: BCBS of TX Medicare	$12.88
Rate for Payer: BCBS of TX PPO	$78.80
Rate for Payer: Cash Price	$133.96
Rate for Payer: Cash Price	$133.96
Rate for Payer: Cigna Medicaid	$141.84
Rate for Payer: Cigna Medicare	$12.88
Rate for Payer: Employer Direct Commercial	$12.88
Rate for Payer: Humana Medicare/TRICARE	$12.88
Rate for Payer: Molina CHIP/Medicaid	$141.84
Rate for Payer: Molina Dual Medicare/Medicaid	$12.88
Rate for Payer: Molina Medicare	$12.88
Rate for Payer: Multiplan Auto	$128.05
Rate for Payer: Multiplan Commercial	$128.05
Rate for Payer: Multiplan Workers Comp	$128.05
Rate for Payer: Parkland Medicaid	$141.84
Rate for Payer: Scott and White EPO/PPO	$16.10
Rate for Payer: Scott and White Medicare	$12.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$141.84
Rate for Payer: Superior Health Plan EPO	$12.88
Rate for Payer: Superior Health Plan Medicare	$12.88
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.88
Rate for Payer: Universal American Medicare	$12.88
Rate for Payer: Wellcare Medicare	$12.88
Rate for Payer: Wellmed Medicare	$12.88

Know your out-of-pocket cost for care.

All Charges