White Rock Medical Center

All Charges

Charge

Type

Setting

Price

VENTRICULAR SHUNT PROCEDURES

Facility

$7,362.35

Service Code	APR-DRG 0222
Min. Negotiated Rate	$6,941.48
Max. Negotiated Rate	$7,362.35
Rate for Payer: Amerigroup CHIP/Medicaid	$6,941.48
Rate for Payer: Cigna Medicaid	$6,941.48
Rate for Payer: Molina CHIP/Medicaid	$6,941.48
Rate for Payer: Parkland Medicaid	$6,941.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,362.35

VENTRICULAR SHUNT PROCEDURES W CC

Facility

$40,489.00

Service Code	MSDRG 032
Min. Negotiated Rate	$18,646.25
Max. Negotiated Rate	$40,489.00
Rate for Payer: BCBS of TX Blue Advantage	$19,798.06
Rate for Payer: BCBS of TX Blue Essentials	$23,755.37
Rate for Payer: BCBS of TX PPO	$26,395.88

VENTRICULAR SHUNT PROCEDURES WITH CC

Facility

$40,489.00

Service Code	MSDRG 032
Min. Negotiated Rate	$18,646.25
Max. Negotiated Rate	$40,489.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,378.24
Rate for Payer: Amerigroup Medicare	$20,378.24
Rate for Payer: BCBS of TX Medicare	$20,378.24
Rate for Payer: Cigna Commercial	$27,447.28
Rate for Payer: Cigna Medicare	$20,378.24
Rate for Payer: Employer Direct Commercial	$20,378.24
Rate for Payer: Humana Medicare/TRICARE	$20,378.24
Rate for Payer: Molina Dual Medicare/Medicaid	$20,378.24
Rate for Payer: Molina Medicare	$20,378.24
Rate for Payer: Multiplan Auto	$40,489.00
Rate for Payer: Multiplan Commercial	$40,489.00
Rate for Payer: Multiplan Workers Comp	$40,489.00
Rate for Payer: Scott and White EPO/PPO	$18,646.25
Rate for Payer: Scott and White Medicare	$20,378.24
Rate for Payer: Superior Health Plan EPO	$20,378.24
Rate for Payer: Superior Health Plan Medicare	$20,378.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,378.24
Rate for Payer: Universal American Medicare	$20,378.24
Rate for Payer: Wellcare Medicare	$20,378.24
Rate for Payer: Wellmed Medicare	$20,378.24

VENTRICULAR SHUNT PROCEDURES WITH MCC

Facility

$85,129.50

Service Code	MSDRG 031
Min. Negotiated Rate	$35,972.94
Max. Negotiated Rate	$85,129.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$37,597.77
Rate for Payer: Amerigroup Medicare	$37,597.77
Rate for Payer: BCBS of TX Medicare	$37,597.77
Rate for Payer: Cigna Commercial	$57,708.84
Rate for Payer: Cigna Medicare	$37,597.77
Rate for Payer: Employer Direct Commercial	$37,597.77
Rate for Payer: Humana Medicare/TRICARE	$37,597.77
Rate for Payer: Molina Dual Medicare/Medicaid	$37,597.77
Rate for Payer: Molina Medicare	$37,597.77
Rate for Payer: Multiplan Auto	$85,129.50
Rate for Payer: Multiplan Commercial	$85,129.50
Rate for Payer: Multiplan Workers Comp	$85,129.50
Rate for Payer: Scott and White EPO/PPO	$39,204.38
Rate for Payer: Scott and White Medicare	$37,597.77
Rate for Payer: Superior Health Plan EPO	$37,597.77
Rate for Payer: Superior Health Plan Medicare	$37,597.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$37,597.77
Rate for Payer: Universal American Medicare	$37,597.77
Rate for Payer: Wellcare Medicare	$37,597.77
Rate for Payer: Wellmed Medicare	$37,597.77

VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC

Facility

$31,595.10

Service Code	MSDRG 033
Min. Negotiated Rate	$14,514.22
Max. Negotiated Rate	$31,595.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,947.53
Rate for Payer: Amerigroup Medicare	$16,947.53
Rate for Payer: BCBS of TX Medicare	$16,947.53
Rate for Payer: Cigna Commercial	$21,418.15
Rate for Payer: Cigna Medicare	$16,947.53
Rate for Payer: Employer Direct Commercial	$16,947.53
Rate for Payer: Humana Medicare/TRICARE	$16,947.53
Rate for Payer: Molina Dual Medicare/Medicaid	$16,947.53
Rate for Payer: Molina Medicare	$16,947.53
Rate for Payer: Multiplan Auto	$31,595.10
Rate for Payer: Multiplan Commercial	$31,595.10
Rate for Payer: Multiplan Workers Comp	$31,595.10
Rate for Payer: Scott and White EPO/PPO	$14,550.38
Rate for Payer: Scott and White Medicare	$16,947.53
Rate for Payer: Superior Health Plan EPO	$16,947.53
Rate for Payer: Superior Health Plan Medicare	$16,947.53
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,947.53
Rate for Payer: Universal American Medicare	$16,947.53
Rate for Payer: Wellcare Medicare	$16,947.53
Rate for Payer: Wellmed Medicare	$16,947.53

VENTRICULAR SHUNT PROCEDURES W MCC

Facility

$85,129.50

Service Code	MSDRG 031
Min. Negotiated Rate	$35,972.94
Max. Negotiated Rate	$85,129.50
Rate for Payer: BCBS of TX Blue Advantage	$35,972.94
Rate for Payer: BCBS of TX Blue Essentials	$43,163.35
Rate for Payer: BCBS of TX PPO	$47,961.13

VENTRICULAR SHUNT PROCEDURES W/O CC/MCC

Facility

$31,595.10

Service Code	MSDRG 033
Min. Negotiated Rate	$14,514.22
Max. Negotiated Rate	$31,595.10
Rate for Payer: BCBS of TX Blue Advantage	$14,514.22
Rate for Payer: BCBS of TX Blue Essentials	$17,415.38
Rate for Payer: BCBS of TX PPO	$19,351.17

verapamil 120 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77872755
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

verapamil 120 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77872755
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

verapamil 240 mg/24 hours ER Cap

Facility

$8.00

Service Code	HCPCS j3490
Hospital Charge Code	77873238
Hospital Revenue Code	140
Rate for Payer: Cash Price	$5.44

verapamil 2.5 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	456
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

verapamil 2.5 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	456
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

VERIFY All clean test indicator

Facility

$8.19

Hospital Charge Code	993936
Hospital Revenue Code	270
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$5.90
Rate for Payer: Amerigroup CHIP/Medicaid	$0.74
Rate for Payer: BCBS of TX Blue Advantage	$2.46
Rate for Payer: BCBS of TX Blue Essentials	$2.95
Rate for Payer: BCBS of TX PPO	$3.28
Rate for Payer: Cash Price	$5.57
Rate for Payer: Cigna Medicaid	$5.90
Rate for Payer: Molina CHIP/Medicaid	$5.90
Rate for Payer: Multiplan Auto	$5.32
Rate for Payer: Multiplan Commercial	$5.32
Rate for Payer: Multiplan Workers Comp	$5.32
Rate for Payer: Parkland Medicaid	$5.90
Rate for Payer: Scott and White EPO/PPO	$4.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.90
Rate for Payer: Superior Health Plan EPO	$1.11

VERIFY All clean test indicator

Facility

$8.19

Hospital Charge Code	993936
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.57

VERIFY SixCess 270'F 4 minute steam indicator strip,long

Facility

$0.54

Hospital Charge Code	992933
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.37

VERIFY SixCess 270'F 4 minute steam indicator strip,long

Facility

$0.54

Hospital Charge Code	992933
Hospital Revenue Code	272
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.39
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.16
Rate for Payer: BCBS of TX Blue Essentials	$0.19
Rate for Payer: BCBS of TX PPO	$0.22
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna Medicaid	$0.39
Rate for Payer: Molina CHIP/Medicaid	$0.39
Rate for Payer: Multiplan Auto	$0.35
Rate for Payer: Multiplan Commercial	$0.35
Rate for Payer: Multiplan Workers Comp	$0.35
Rate for Payer: Parkland Medicaid	$0.39
Rate for Payer: Scott and White EPO/PPO	$0.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.39
Rate for Payer: Superior Health Plan EPO	$0.07

VERITAS 2X8 SQ CM -- DHF

Facility

$223.00

Service Code	HCPCS C9354
Hospital Charge Code	40269995
Hospital Revenue Code	278
Min. Negotiated Rate	$55.75
Max. Negotiated Rate	$111.50
Rate for Payer: Cash Price	$151.64
Rate for Payer: Cigna Commercial	$55.75
Rate for Payer: Multiplan Auto	$111.50
Rate for Payer: Multiplan Commercial	$111.50
Rate for Payer: Multiplan Workers Comp	$111.50
Rate for Payer: Scott and White EPO/PPO	$111.50

VERITAS 2X8 SQ CM -- DHF

Facility

$223.00

Service Code	HCPCS C9354
Hospital Charge Code	40269995
Hospital Revenue Code	278
Min. Negotiated Rate	$20.07
Max. Negotiated Rate	$160.56
Rate for Payer: Amerigroup CHIP/Medicaid	$20.07
Rate for Payer: BCBS of TX Blue Advantage	$66.90
Rate for Payer: BCBS of TX Blue Essentials	$80.28
Rate for Payer: BCBS of TX PPO	$89.20
Rate for Payer: Cash Price	$151.64
Rate for Payer: Cigna Medicaid	$160.56
Rate for Payer: Molina CHIP/Medicaid	$160.56
Rate for Payer: Multiplan Auto	$111.50
Rate for Payer: Multiplan Commercial	$111.50
Rate for Payer: Multiplan Workers Comp	$111.50
Rate for Payer: Parkland Medicaid	$160.56
Rate for Payer: Scott and White EPO/PPO	$111.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$160.56
Rate for Payer: Superior Health Plan EPO	$30.33

VERSA GRAFT

Facility

$8,012.05

Hospital Charge Code	992737
Hospital Revenue Code	270
Min. Negotiated Rate	$721.08
Max. Negotiated Rate	$5,768.68
Rate for Payer: Amerigroup CHIP/Medicaid	$721.08
Rate for Payer: BCBS of TX Blue Advantage	$2,403.61
Rate for Payer: BCBS of TX Blue Essentials	$2,884.34
Rate for Payer: BCBS of TX PPO	$3,204.82
Rate for Payer: Cash Price	$5,448.19
Rate for Payer: Cigna Medicaid	$5,768.68
Rate for Payer: Molina CHIP/Medicaid	$5,768.68
Rate for Payer: Multiplan Auto	$5,207.83
Rate for Payer: Multiplan Commercial	$5,207.83
Rate for Payer: Multiplan Workers Comp	$5,207.83
Rate for Payer: Parkland Medicaid	$5,768.68
Rate for Payer: Scott and White EPO/PPO	$4,006.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,768.68
Rate for Payer: Superior Health Plan EPO	$1,089.64

VERSA GRAFT

Facility

$8,012.05

Hospital Charge Code	992737
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5,448.19

VERSALOK NEEDLE

Facility

$2,814.80

Hospital Charge Code	992662
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,914.06

VERSALOK NEEDLE

Facility

$2,814.80

Hospital Charge Code	992662
Hospital Revenue Code	272
Min. Negotiated Rate	$253.33
Max. Negotiated Rate	$2,026.66
Rate for Payer: Amerigroup CHIP/Medicaid	$253.33
Rate for Payer: BCBS of TX Blue Advantage	$844.44
Rate for Payer: BCBS of TX Blue Essentials	$1,013.33
Rate for Payer: BCBS of TX PPO	$1,125.92
Rate for Payer: Cash Price	$1,914.06
Rate for Payer: Cigna Medicaid	$2,026.66
Rate for Payer: Molina CHIP/Medicaid	$2,026.66
Rate for Payer: Multiplan Auto	$1,829.62
Rate for Payer: Multiplan Commercial	$1,829.62
Rate for Payer: Multiplan Workers Comp	$1,829.62
Rate for Payer: Parkland Medicaid	$2,026.66
Rate for Payer: Scott and White EPO/PPO	$1,407.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,026.66
Rate for Payer: Superior Health Plan EPO	$382.81

VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES

Facility

$25,887.99

Service Code	APR-DRG 3104
Min. Negotiated Rate	$24,408.10
Max. Negotiated Rate	$25,887.99
Rate for Payer: Amerigroup CHIP/Medicaid	$24,408.10
Rate for Payer: Cigna Medicaid	$24,408.10
Rate for Payer: Molina CHIP/Medicaid	$24,408.10
Rate for Payer: Parkland Medicaid	$24,408.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,887.99

VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES

Facility

$8,938.25

Service Code	APR-DRG 3102
Min. Negotiated Rate	$8,427.29
Max. Negotiated Rate	$8,938.25
Rate for Payer: Amerigroup CHIP/Medicaid	$8,427.29
Rate for Payer: Cigna Medicaid	$8,427.29
Rate for Payer: Molina CHIP/Medicaid	$8,427.29
Rate for Payer: Parkland Medicaid	$8,427.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,938.25

VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES

Facility

$5,680.84

Service Code	APR-DRG 3101
Min. Negotiated Rate	$5,356.10
Max. Negotiated Rate	$5,680.84
Rate for Payer: Amerigroup CHIP/Medicaid	$5,356.10
Rate for Payer: Cigna Medicaid	$5,356.10
Rate for Payer: Molina CHIP/Medicaid	$5,356.10
Rate for Payer: Parkland Medicaid	$5,356.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,680.84

Know your out-of-pocket cost for care.

All Charges