White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
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

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

VASC EMB/OCC ARTERY

Facility

$24,099.00

Service Code	HCPCS 37242
Hospital Charge Code	4617242
Hospital Revenue Code	361
Min. Negotiated Rate	$5,195.63
Max. Negotiated Rate	$38,926.35
Rate for Payer: Amerigroup CHIP/Medicaid	$5,195.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Amerigroup Medicare	$18,415.17
Rate for Payer: BCBS of TX Blue Advantage	$16,547.16
Rate for Payer: BCBS of TX Blue Essentials	$19,816.96
Rate for Payer: BCBS of TX Medicare	$18,415.17
Rate for Payer: BCBS of TX PPO	$24,969.37
Rate for Payer: Cash Price	$16,387.32
Rate for Payer: Cash Price	$16,387.32
Rate for Payer: Cash Price	$16,387.32
Rate for Payer: Cigna Commercial	$38,926.35
Rate for Payer: Cigna Medicaid	$17,351.28
Rate for Payer: Cigna Medicare	$18,415.17
Rate for Payer: Employer Direct Commercial	$18,415.17
Rate for Payer: Humana Medicare/TRICARE	$18,415.17
Rate for Payer: Molina CHIP/Medicaid	$17,351.28
Rate for Payer: Molina Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Molina Medicare	$18,415.17
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$17,351.28
Rate for Payer: Scott and White EPO/PPO	$34,068.06
Rate for Payer: Scott and White Medicare	$18,415.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,351.28
Rate for Payer: Superior Health Plan EPO	$18,415.17
Rate for Payer: Superior Health Plan Medicare	$18,415.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,415.17
Rate for Payer: Universal American Medicare	$18,415.17
Rate for Payer: Wellcare Medicare	$18,415.17
Rate for Payer: Wellmed Medicare	$18,415.17

VASC EMB/OCC ARTERY

Facility

$24,099.00

Service Code	HCPCS 37242
Hospital Charge Code	4617242
Hospital Revenue Code	361
Rate for Payer: Cash Price	$16,387.32

VASC RMVL TUNNELED CV CATH BCE

Facility

$1,849.00

Service Code	HCPCS 36589
Hospital Charge Code	8750540
Hospital Revenue Code	361
Min. Negotiated Rate	$223.75
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$223.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$630.16
Rate for Payer: Amerigroup Medicare	$630.16
Rate for Payer: BCBS of TX Blue Advantage	$1,052.95
Rate for Payer: BCBS of TX Blue Essentials	$1,261.02
Rate for Payer: BCBS of TX Medicare	$630.16
Rate for Payer: BCBS of TX PPO	$1,588.89
Rate for Payer: Cash Price	$1,257.32
Rate for Payer: Cash Price	$1,257.32
Rate for Payer: Cash Price	$1,257.32
Rate for Payer: Cigna Commercial	$1,332.05
Rate for Payer: Cigna Medicaid	$1,331.28
Rate for Payer: Cigna Medicare	$630.16
Rate for Payer: Employer Direct Commercial	$630.16
Rate for Payer: Humana Medicare/TRICARE	$630.16
Rate for Payer: Molina CHIP/Medicaid	$1,331.28
Rate for Payer: Molina Dual Medicare/Medicaid	$630.16
Rate for Payer: Molina Medicare	$630.16
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,331.28
Rate for Payer: Scott and White EPO/PPO	$1,165.80
Rate for Payer: Scott and White Medicare	$630.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,331.28
Rate for Payer: Superior Health Plan EPO	$630.16
Rate for Payer: Superior Health Plan Medicare	$630.16
Rate for Payer: Universal American Dual Medicare/Medicaid	$630.16
Rate for Payer: Universal American Medicare	$630.16
Rate for Payer: Wellcare Medicare	$630.16
Rate for Payer: Wellmed Medicare	$630.16

VASC RMVL TUNNELED CV CATH BCE

Facility

$1,849.00

Service Code	HCPCS 36589
Hospital Charge Code	8750540
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,257.32

VASCU-GUARD PERIPHERAL VAS PATCH 0.8X8MM

Facility

$1,100.00

Service Code	HCPCS C1884
Hospital Charge Code	131744
Hospital Revenue Code	278
Min. Negotiated Rate	$275.00
Max. Negotiated Rate	$550.00
Rate for Payer: Cash Price	$748.00
Rate for Payer: Cigna Commercial	$275.00
Rate for Payer: Multiplan Auto	$550.00
Rate for Payer: Multiplan Commercial	$550.00
Rate for Payer: Multiplan Workers Comp	$550.00
Rate for Payer: Scott and White EPO/PPO	$550.00

VASCU-GUARD PERIPHERAL VAS PATCH 0.8X8MM

Facility

$1,100.00

Service Code	HCPCS C1884
Hospital Charge Code	131744
Hospital Revenue Code	278
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$792.00
Rate for Payer: Amerigroup CHIP/Medicaid	$99.00
Rate for Payer: BCBS of TX Blue Advantage	$330.00
Rate for Payer: BCBS of TX Blue Essentials	$396.00
Rate for Payer: BCBS of TX PPO	$440.00
Rate for Payer: Cash Price	$748.00
Rate for Payer: Cigna Medicaid	$792.00
Rate for Payer: Molina CHIP/Medicaid	$792.00
Rate for Payer: Multiplan Auto	$550.00
Rate for Payer: Multiplan Commercial	$550.00
Rate for Payer: Multiplan Workers Comp	$550.00
Rate for Payer: Parkland Medicaid	$792.00
Rate for Payer: Scott and White EPO/PPO	$550.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$792.00
Rate for Payer: Superior Health Plan EPO	$149.60

vasopressin 20 units/mL Solx

Facility

$128.17

Service Code	HCPCS J2598
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 J2598
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 Solx

Facility

$128.17

Service Code	HCPCS J2598
Hospital Charge Code	78398993
Hospital Revenue Code	636
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$4.71
Rate for Payer: BCBS of TX Blue Essentials	$5.66
Rate for Payer: BCBS of TX PPO	$6.27
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

vasopressin 20 units/mL Solx

Facility

$128.17

Service Code	HCPCS J2598
Hospital Charge Code	78875811
Hospital Revenue Code	636
Min. Negotiated Rate	$4.71
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$4.71
Rate for Payer: BCBS of TX Blue Essentials	$5.66
Rate for Payer: BCBS of TX PPO	$6.27
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

VAULT ALIF PEEK CAGE 32MM X 08MM X13MM

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	145335
Hospital Revenue Code	278
Min. Negotiated Rate	$9,036.25
Max. Negotiated Rate	$18,072.50
Rate for Payer: Cash Price	$24,578.60
Rate for Payer: Cigna Commercial	$9,036.25
Rate for Payer: Multiplan Auto	$18,072.50
Rate for Payer: Multiplan Commercial	$18,072.50
Rate for Payer: Multiplan Workers Comp	$18,072.50
Rate for Payer: Scott and White EPO/PPO	$18,072.50

VAULT ALIF PEEK CAGE 32MM X 08MM X13MM

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	145335
Hospital Revenue Code	278
Min. Negotiated Rate	$3,253.05
Max. Negotiated Rate	$26,024.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3,253.05
Rate for Payer: Cash Price	$24,578.60
Rate for Payer: Cigna Medicaid	$26,024.40
Rate for Payer: Molina CHIP/Medicaid	$26,024.40
Rate for Payer: Multiplan Auto	$18,072.50
Rate for Payer: Multiplan Commercial	$18,072.50
Rate for Payer: Multiplan Workers Comp	$18,072.50
Rate for Payer: Parkland Medicaid	$26,024.40
Rate for Payer: Scott and White EPO/PPO	$18,072.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,024.40
Rate for Payer: Superior Health Plan EPO	$4,915.72

VBG -Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation)

Facility

$371.00

Service Code	HCPCS 82803
Hospital Charge Code	4000493
Hospital Revenue Code	301
Rate for Payer: Cash Price	$252.28

VBG -Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation)

Facility

$371.00

Service Code	HCPCS 82803
Hospital Charge Code	4000493
Hospital Revenue Code	301
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$267.12
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.07
Rate for Payer: Amerigroup Medicare	$26.07
Rate for Payer: BCBS of TX Blue Advantage	$111.30
Rate for Payer: BCBS of TX Blue Essentials	$133.56
Rate for Payer: BCBS of TX Medicare	$26.07
Rate for Payer: BCBS of TX PPO	$148.40
Rate for Payer: Cash Price	$252.28
Rate for Payer: Cash Price	$252.28
Rate for Payer: Cigna Medicaid	$267.12
Rate for Payer: Cigna Medicare	$26.07
Rate for Payer: Employer Direct Commercial	$26.07
Rate for Payer: Humana Medicare/TRICARE	$26.07
Rate for Payer: Molina CHIP/Medicaid	$267.12
Rate for Payer: Molina Dual Medicare/Medicaid	$26.07
Rate for Payer: Molina Medicare	$26.07
Rate for Payer: Multiplan Auto	$241.15
Rate for Payer: Multiplan Commercial	$241.15
Rate for Payer: Multiplan Workers Comp	$241.15
Rate for Payer: Parkland Medicaid	$267.12
Rate for Payer: Scott and White EPO/PPO	$32.59
Rate for Payer: Scott and White Medicare	$26.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$267.12
Rate for Payer: Superior Health Plan EPO	$26.07
Rate for Payer: Superior Health Plan Medicare	$26.07
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.07
Rate for Payer: Universal American Medicare	$26.07
Rate for Payer: Wellcare Medicare	$26.07
Rate for Payer: Wellmed Medicare	$26.07

VEEG EA 12-26HR INTMT MNTR

Facility

$6,399.00

Service Code	HCPCS 95715
Hospital Charge Code	8568476
Hospital Revenue Code	740
Min. Negotiated Rate	$374.86
Max. Negotiated Rate	$4,607.28
Rate for Payer: Amerigroup CHIP/Medicaid	$575.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$1,919.70
Rate for Payer: BCBS of TX Blue Essentials	$2,303.64
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$2,559.60
Rate for Payer: Cash Price	$4,351.32
Rate for Payer: Cash Price	$4,351.32
Rate for Payer: Cash Price	$4,351.32
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$4,607.28
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$4,607.28
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
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: Parkland Medicaid	$4,607.28
Rate for Payer: Scott and White EPO/PPO	$3,199.50
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,607.28
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

VEEG EA 12-26HR INTMT MNTR

Facility

$6,399.00

Service Code	HCPCS 95715
Hospital Charge Code	8568476
Hospital Revenue Code	740
Rate for Payer: Cash Price	$4,351.32

VEEG EA 12-26 HR UNMNTR

Facility

$4,038.00

Service Code	HCPCS 95714
Hospital Charge Code	8568475
Hospital Revenue Code	740
Min. Negotiated Rate	$363.42
Max. Negotiated Rate	$2,907.36
Rate for Payer: Amerigroup CHIP/Medicaid	$363.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$374.86
Rate for Payer: Amerigroup Medicare	$374.86
Rate for Payer: BCBS of TX Blue Advantage	$1,211.40
Rate for Payer: BCBS of TX Blue Essentials	$1,453.68
Rate for Payer: BCBS of TX Medicare	$374.86
Rate for Payer: BCBS of TX PPO	$1,615.20
Rate for Payer: Cash Price	$2,745.84
Rate for Payer: Cash Price	$2,745.84
Rate for Payer: Cash Price	$2,745.84
Rate for Payer: Cigna Commercial	$792.38
Rate for Payer: Cigna Medicaid	$2,907.36
Rate for Payer: Cigna Medicare	$374.86
Rate for Payer: Employer Direct Commercial	$374.86
Rate for Payer: Humana Medicare/TRICARE	$374.86
Rate for Payer: Molina CHIP/Medicaid	$2,907.36
Rate for Payer: Molina Dual Medicare/Medicaid	$374.86
Rate for Payer: Molina Medicare	$374.86
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: Parkland Medicaid	$2,907.36
Rate for Payer: Scott and White EPO/PPO	$2,019.00
Rate for Payer: Scott and White Medicare	$374.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,907.36
Rate for Payer: Superior Health Plan EPO	$374.86
Rate for Payer: Superior Health Plan Medicare	$374.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$374.86
Rate for Payer: Universal American Medicare	$374.86
Rate for Payer: Wellcare Medicare	$374.86
Rate for Payer: Wellmed Medicare	$374.86

VEEG EA 12-26 HR UNMNTR

Facility

$4,038.00

Service Code	HCPCS 95714
Hospital Charge Code	8568475
Hospital Revenue Code	740
Rate for Payer: Cash Price	$2,745.84

VEIN LIGATION AND STRIPPING

Facility

$58,090.60

Service Code	MSDRG 263
Min. Negotiated Rate	$20,572.92
Max. Negotiated Rate	$58,090.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,167.84
Rate for Payer: Amerigroup Medicare	$27,167.84
Rate for Payer: BCBS of TX Medicare	$27,167.84
Rate for Payer: Cigna Commercial	$39,379.31
Rate for Payer: Cigna Medicare	$27,167.84
Rate for Payer: Employer Direct Commercial	$27,167.84
Rate for Payer: Humana Medicare/TRICARE	$27,167.84
Rate for Payer: Molina Dual Medicare/Medicaid	$27,167.84
Rate for Payer: Molina Medicare	$27,167.84
Rate for Payer: Multiplan Auto	$58,090.60
Rate for Payer: Multiplan Commercial	$58,090.60
Rate for Payer: Multiplan Workers Comp	$58,090.60
Rate for Payer: Scott and White EPO/PPO	$26,752.25
Rate for Payer: Scott and White Medicare	$27,167.84
Rate for Payer: Superior Health Plan EPO	$27,167.84
Rate for Payer: Superior Health Plan Medicare	$27,167.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,167.84
Rate for Payer: Universal American Medicare	$27,167.84
Rate for Payer: Wellcare Medicare	$27,167.84
Rate for Payer: Wellmed Medicare	$27,167.84

VEIN LIGATION & STRIPPING

Facility

$58,090.60

Service Code	MSDRG 263
Min. Negotiated Rate	$20,572.92
Max. Negotiated Rate	$58,090.60
Rate for Payer: BCBS of TX Blue Advantage	$20,572.92
Rate for Payer: BCBS of TX Blue Essentials	$24,685.11
Rate for Payer: BCBS of TX PPO	$27,428.97

venlafaxine 25 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77872286
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Know your out-of-pocket cost for care.

All Charges