White Rock Medical Center

All Charges

Charge

Type

Setting

Price

VERTIGO AND OTHER LABYRINTH DISORDERS

Facility

$2,410.24

Service Code	APR-DRG 1111
Min. Negotiated Rate	$2,272.46
Max. Negotiated Rate	$2,410.24
Rate for Payer: Amerigroup CHIP/Medicaid	$2,272.46
Rate for Payer: Cigna Medicaid	$2,272.46
Rate for Payer: Molina CHIP/Medicaid	$2,272.46
Rate for Payer: Parkland Medicaid	$2,272.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,410.24

VEST, CHEST WRAP SINGLE PATIENT 103/104 ADULT MED

Facility

$125.30

Hospital Charge Code	993540
Hospital Revenue Code	270
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$90.22
Rate for Payer: Amerigroup CHIP/Medicaid	$11.28
Rate for Payer: BCBS of TX Blue Advantage	$37.59
Rate for Payer: BCBS of TX Blue Essentials	$45.11
Rate for Payer: BCBS of TX PPO	$50.12
Rate for Payer: Cash Price	$85.20
Rate for Payer: Cigna Medicaid	$90.22
Rate for Payer: Molina CHIP/Medicaid	$90.22
Rate for Payer: Multiplan Auto	$81.44
Rate for Payer: Multiplan Commercial	$81.44
Rate for Payer: Multiplan Workers Comp	$81.44
Rate for Payer: Parkland Medicaid	$90.22
Rate for Payer: Scott and White EPO/PPO	$62.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.22
Rate for Payer: Superior Health Plan EPO	$17.04

VEST, CHEST WRAP SINGLE PATIENT 103/104 ADULT MED

Facility

$125.30

Hospital Charge Code	993540
Hospital Revenue Code	270
Rate for Payer: Cash Price	$85.20

VEST PT LG DISP WRP

Facility

$125.30

Hospital Charge Code	993470
Hospital Revenue Code	270
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$90.22
Rate for Payer: Amerigroup CHIP/Medicaid	$11.28
Rate for Payer: BCBS of TX Blue Advantage	$37.59
Rate for Payer: BCBS of TX Blue Essentials	$45.11
Rate for Payer: BCBS of TX PPO	$50.12
Rate for Payer: Cash Price	$85.20
Rate for Payer: Cigna Medicaid	$90.22
Rate for Payer: Molina CHIP/Medicaid	$90.22
Rate for Payer: Multiplan Auto	$81.44
Rate for Payer: Multiplan Commercial	$81.44
Rate for Payer: Multiplan Workers Comp	$81.44
Rate for Payer: Parkland Medicaid	$90.22
Rate for Payer: Scott and White EPO/PPO	$62.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$90.22
Rate for Payer: Superior Health Plan EPO	$17.04

VEST PT LG DISP WRP

Facility

$125.30

Hospital Charge Code	993470
Hospital Revenue Code	270
Rate for Payer: Cash Price	$85.20

VG0108 VASCUGUARD

Facility

$544.80

Service Code	HCPCS C1760
Hospital Charge Code	992504
Hospital Revenue Code	278
Min. Negotiated Rate	$136.20
Max. Negotiated Rate	$272.40
Rate for Payer: Cash Price	$370.46
Rate for Payer: Cigna Commercial	$136.20
Rate for Payer: Multiplan Auto	$272.40
Rate for Payer: Multiplan Commercial	$272.40
Rate for Payer: Multiplan Workers Comp	$272.40
Rate for Payer: Scott and White EPO/PPO	$272.40

VG0108 VASCUGUARD

Facility

$544.80

Service Code	HCPCS C1760
Hospital Charge Code	992504
Hospital Revenue Code	278
Min. Negotiated Rate	$49.03
Max. Negotiated Rate	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$49.03
Rate for Payer: BCBS of TX Blue Advantage	$163.44
Rate for Payer: BCBS of TX Blue Essentials	$196.13
Rate for Payer: BCBS of TX PPO	$217.92
Rate for Payer: Cash Price	$370.46
Rate for Payer: Cigna Medicaid	$392.26
Rate for Payer: Molina CHIP/Medicaid	$392.26
Rate for Payer: Multiplan Auto	$272.40
Rate for Payer: Multiplan Commercial	$272.40
Rate for Payer: Multiplan Workers Comp	$272.40
Rate for Payer: Parkland Medicaid	$392.26
Rate for Payer: Scott and White EPO/PPO	$272.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$392.26
Rate for Payer: Superior Health Plan EPO	$74.09

Viabahn Endoprosthesis with HEPARIN Bioactive Surface REF# VBHR130502AC-Code # C1874

Facility

$23,849.39

Service Code	HCPCS 37205
Hospital Charge Code	991390
Hospital Revenue Code	278
Min. Negotiated Rate	$5,962.35
Max. Negotiated Rate	$11,924.69
Rate for Payer: Cash Price	$16,217.59
Rate for Payer: Cigna Commercial	$5,962.35
Rate for Payer: Multiplan Auto	$11,924.69
Rate for Payer: Multiplan Commercial	$11,924.69
Rate for Payer: Multiplan Workers Comp	$11,924.69
Rate for Payer: Scott and White EPO/PPO	$11,924.69

Viabahn Endoprosthesis with HEPARIN Bioactive Surface REF# VBHR130502AC-Code # C1874

Facility

$23,849.39

Service Code	HCPCS 37205
Hospital Charge Code	991390
Hospital Revenue Code	278
Min. Negotiated Rate	$2,146.45
Max. Negotiated Rate	$17,171.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2,146.45
Rate for Payer: BCBS of TX Blue Advantage	$7,154.82
Rate for Payer: BCBS of TX Blue Essentials	$8,585.78
Rate for Payer: BCBS of TX PPO	$9,539.76
Rate for Payer: Cash Price	$16,217.59
Rate for Payer: Cigna Medicaid	$17,171.56
Rate for Payer: Molina CHIP/Medicaid	$17,171.56
Rate for Payer: Multiplan Auto	$11,924.69
Rate for Payer: Multiplan Commercial	$11,924.69
Rate for Payer: Multiplan Workers Comp	$11,924.69
Rate for Payer: Parkland Medicaid	$17,171.56
Rate for Payer: Scott and White EPO/PPO	$11,924.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,171.56
Rate for Payer: Superior Health Plan EPO	$3,243.52

ViaValve Safty IV Catheter Safety Straight Gauge 1-1/4' Ea, 50 EA/BX

Facility

$9.31

Hospital Charge Code	993455
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.33

ViaValve Safty IV Catheter Safety Straight Gauge 1-1/4' Ea, 50 EA/BX

Facility

$9.31

Hospital Charge Code	993455
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.79
Rate for Payer: BCBS of TX Blue Essentials	$3.35
Rate for Payer: BCBS of TX PPO	$3.72
Rate for Payer: Cash Price	$6.33
Rate for Payer: Cigna Medicaid	$6.70
Rate for Payer: Molina CHIP/Medicaid	$6.70
Rate for Payer: Multiplan Auto	$6.05
Rate for Payer: Multiplan Commercial	$6.05
Rate for Payer: Multiplan Workers Comp	$6.05
Rate for Payer: Parkland Medicaid	$6.70
Rate for Payer: Scott and White EPO/PPO	$4.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.70
Rate for Payer: Superior Health Plan EPO	$1.27

VICRYL MESH

Facility

$1,138.55

Service Code	HCPCS C1781
Hospital Charge Code	992346
Hospital Revenue Code	272
Rate for Payer: Cash Price	$774.21

VICRYL MESH

Facility

$1,138.55

Service Code	HCPCS C1781
Hospital Charge Code	992346
Hospital Revenue Code	272
Min. Negotiated Rate	$102.47
Max. Negotiated Rate	$819.76
Rate for Payer: Amerigroup CHIP/Medicaid	$102.47
Rate for Payer: BCBS of TX Blue Advantage	$341.56
Rate for Payer: BCBS of TX Blue Essentials	$409.88
Rate for Payer: BCBS of TX PPO	$455.42
Rate for Payer: Cash Price	$774.21
Rate for Payer: Cigna Medicaid	$819.76
Rate for Payer: Molina CHIP/Medicaid	$819.76
Rate for Payer: Multiplan Auto	$740.06
Rate for Payer: Multiplan Commercial	$740.06
Rate for Payer: Multiplan Workers Comp	$740.06
Rate for Payer: Parkland Medicaid	$819.76
Rate for Payer: Scott and White EPO/PPO	$569.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$819.76
Rate for Payer: Superior Health Plan EPO	$154.84

Viral Culture, General SO

Facility

$287.00

Service Code	HCPCS 87252
Hospital Charge Code	7009356
Hospital Revenue Code	306
Rate for Payer: Cash Price	$195.16

Viral Culture, General SO

Facility

$287.00

Service Code	HCPCS 87252
Hospital Charge Code	7009356
Hospital Revenue Code	306
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$206.64
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	$86.10
Rate for Payer: BCBS of TX Blue Essentials	$103.32
Rate for Payer: BCBS of TX Medicare	$26.07
Rate for Payer: BCBS of TX PPO	$114.80
Rate for Payer: Cash Price	$195.16
Rate for Payer: Cash Price	$195.16
Rate for Payer: Cigna Medicaid	$206.64
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	$206.64
Rate for Payer: Molina Dual Medicare/Medicaid	$26.07
Rate for Payer: Molina Medicare	$26.07
Rate for Payer: Multiplan Auto	$186.55
Rate for Payer: Multiplan Commercial	$186.55
Rate for Payer: Multiplan Workers Comp	$186.55
Rate for Payer: Parkland Medicaid	$206.64
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	$206.64
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

VIRAL ILLNESS

Facility

$4,963.05

Service Code	APR-DRG 7233
Min. Negotiated Rate	$4,679.34
Max. Negotiated Rate	$4,963.05
Rate for Payer: Amerigroup CHIP/Medicaid	$4,679.34
Rate for Payer: Cigna Medicaid	$4,679.34
Rate for Payer: Molina CHIP/Medicaid	$4,679.34
Rate for Payer: Parkland Medicaid	$4,679.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,963.05

VIRAL ILLNESS

Facility

$2,370.26

Service Code	APR-DRG 7232
Min. Negotiated Rate	$2,234.76
Max. Negotiated Rate	$2,370.26
Rate for Payer: Amerigroup CHIP/Medicaid	$2,234.76
Rate for Payer: Cigna Medicaid	$2,234.76
Rate for Payer: Molina CHIP/Medicaid	$2,234.76
Rate for Payer: Parkland Medicaid	$2,234.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,370.26

VIRAL ILLNESS

Facility

$29,089.19

Service Code	APR-DRG 7234
Min. Negotiated Rate	$27,426.31
Max. Negotiated Rate	$29,089.19
Rate for Payer: Amerigroup CHIP/Medicaid	$27,426.31
Rate for Payer: Cigna Medicaid	$27,426.31
Rate for Payer: Molina CHIP/Medicaid	$27,426.31
Rate for Payer: Parkland Medicaid	$27,426.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,089.19

VIRAL ILLNESS

Facility

$1,647.56

Service Code	APR-DRG 7231
Min. Negotiated Rate	$1,553.38
Max. Negotiated Rate	$1,647.56
Rate for Payer: Amerigroup CHIP/Medicaid	$1,553.38
Rate for Payer: Cigna Medicaid	$1,553.38
Rate for Payer: Molina CHIP/Medicaid	$1,553.38
Rate for Payer: Parkland Medicaid	$1,553.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,647.56

VIRAL ILLNESS WITH MCC

Facility

$31,783.20

Service Code	MSDRG 865
Min. Negotiated Rate	$11,886.92
Max. Negotiated Rate	$31,783.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,741.15
Rate for Payer: Amerigroup Medicare	$15,741.15
Rate for Payer: BCBS of TX Medicare	$15,741.15
Rate for Payer: Cigna Commercial	$19,298.10
Rate for Payer: Cigna Medicare	$15,741.15
Rate for Payer: Employer Direct Commercial	$15,741.15
Rate for Payer: Humana Medicare/TRICARE	$15,741.15
Rate for Payer: Molina Dual Medicare/Medicaid	$15,741.15
Rate for Payer: Molina Medicare	$15,741.15
Rate for Payer: Multiplan Auto	$31,783.20
Rate for Payer: Multiplan Commercial	$31,783.20
Rate for Payer: Multiplan Workers Comp	$31,783.20
Rate for Payer: Scott and White EPO/PPO	$14,637.00
Rate for Payer: Scott and White Medicare	$15,741.15
Rate for Payer: Superior Health Plan EPO	$15,741.15
Rate for Payer: Superior Health Plan Medicare	$15,741.15
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,741.15
Rate for Payer: Universal American Medicare	$15,741.15
Rate for Payer: Wellcare Medicare	$15,741.15
Rate for Payer: Wellmed Medicare	$15,741.15

VIRAL ILLNESS WITHOUT MCC

Facility

$17,094.30

Service Code	MSDRG 866
Min. Negotiated Rate	$7,055.44
Max. Negotiated Rate	$17,094.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,133.39
Rate for Payer: Amerigroup Medicare	$11,133.39
Rate for Payer: BCBS of TX Medicare	$11,133.39
Rate for Payer: Cigna Commercial	$11,200.45
Rate for Payer: Cigna Medicare	$11,133.39
Rate for Payer: Employer Direct Commercial	$11,133.39
Rate for Payer: Humana Medicare/TRICARE	$11,133.39
Rate for Payer: Molina Dual Medicare/Medicaid	$11,133.39
Rate for Payer: Molina Medicare	$11,133.39
Rate for Payer: Multiplan Auto	$17,094.30
Rate for Payer: Multiplan Commercial	$17,094.30
Rate for Payer: Multiplan Workers Comp	$17,094.30
Rate for Payer: Scott and White EPO/PPO	$7,872.38
Rate for Payer: Scott and White Medicare	$11,133.39
Rate for Payer: Superior Health Plan EPO	$11,133.39
Rate for Payer: Superior Health Plan Medicare	$11,133.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,133.39
Rate for Payer: Universal American Medicare	$11,133.39
Rate for Payer: Wellcare Medicare	$11,133.39
Rate for Payer: Wellmed Medicare	$11,133.39

VIRAL ILLNESS W MCC

Facility

$31,783.20

Service Code	MSDRG 865
Min. Negotiated Rate	$11,886.92
Max. Negotiated Rate	$31,783.20
Rate for Payer: BCBS of TX Blue Advantage	$11,886.92
Rate for Payer: BCBS of TX Blue Essentials	$14,262.92
Rate for Payer: BCBS of TX PPO	$15,848.31

VIRAL ILLNESS W/O MCC

Facility

$17,094.30

Service Code	MSDRG 866
Min. Negotiated Rate	$7,055.44
Max. Negotiated Rate	$17,094.30
Rate for Payer: BCBS of TX Blue Advantage	$7,055.44
Rate for Payer: BCBS of TX Blue Essentials	$8,465.71
Rate for Payer: BCBS of TX PPO	$9,406.71

VIRAL MENINGITIS

Facility

$3,298.52

Service Code	APR-DRG 0512
Min. Negotiated Rate	$3,109.96
Max. Negotiated Rate	$3,298.52
Rate for Payer: Amerigroup CHIP/Medicaid	$3,109.96
Rate for Payer: Cigna Medicaid	$3,109.96
Rate for Payer: Molina CHIP/Medicaid	$3,109.96
Rate for Payer: Parkland Medicaid	$3,109.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,298.52

VIRAL MENINGITIS

Facility

$2,025.88

Service Code	APR-DRG 0511
Min. Negotiated Rate	$1,910.07
Max. Negotiated Rate	$2,025.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,910.07
Rate for Payer: Cigna Medicaid	$1,910.07
Rate for Payer: Molina CHIP/Medicaid	$1,910.07
Rate for Payer: Parkland Medicaid	$1,910.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,025.88

Know your out-of-pocket cost for care.

All Charges