White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Vitamin B6, Plasma SO

Facility

$272.00

Service Code	HCPCS 84207
Hospital Charge Code	1706134
Hospital Revenue Code	301
Rate for Payer: Cash Price	$184.96

Vitamin C SO

Facility

$133.00

Service Code	HCPCS 82180
Hospital Charge Code	1705961
Hospital Revenue Code	301
Rate for Payer: Cash Price	$90.44

Vitamin C SO

Facility

$133.00

Service Code	HCPCS 82180
Hospital Charge Code	1705961
Hospital Revenue Code	301
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$95.76
Rate for Payer: Amerigroup CHIP/Medicaid	$3.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.89
Rate for Payer: Amerigroup Medicare	$9.89
Rate for Payer: BCBS of TX Blue Advantage	$39.90
Rate for Payer: BCBS of TX Blue Essentials	$47.88
Rate for Payer: BCBS of TX Medicare	$9.89
Rate for Payer: BCBS of TX PPO	$53.20
Rate for Payer: Cash Price	$90.44
Rate for Payer: Cash Price	$90.44
Rate for Payer: Cigna Medicaid	$95.76
Rate for Payer: Cigna Medicare	$9.89
Rate for Payer: Employer Direct Commercial	$9.89
Rate for Payer: Humana Medicare/TRICARE	$9.89
Rate for Payer: Molina CHIP/Medicaid	$95.76
Rate for Payer: Molina Dual Medicare/Medicaid	$9.89
Rate for Payer: Molina Medicare	$9.89
Rate for Payer: Multiplan Auto	$86.45
Rate for Payer: Multiplan Commercial	$86.45
Rate for Payer: Multiplan Workers Comp	$86.45
Rate for Payer: Parkland Medicaid	$95.76
Rate for Payer: Scott and White EPO/PPO	$12.36
Rate for Payer: Scott and White Medicare	$9.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$95.76
Rate for Payer: Superior Health Plan EPO	$9.89
Rate for Payer: Superior Health Plan Medicare	$9.89
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.89
Rate for Payer: Universal American Medicare	$9.89
Rate for Payer: Wellcare Medicare	$9.89
Rate for Payer: Wellmed Medicare	$9.89

Vitamin D, 25-Hydroxy

Facility

$521.00

Service Code	HCPCS 82306
Hospital Charge Code	7254595
Hospital Revenue Code	301
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$375.12
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29.60
Rate for Payer: Amerigroup Medicare	$29.60
Rate for Payer: BCBS of TX Blue Advantage	$156.30
Rate for Payer: BCBS of TX Blue Essentials	$187.56
Rate for Payer: BCBS of TX Medicare	$29.60
Rate for Payer: BCBS of TX PPO	$208.40
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cash Price	$354.28
Rate for Payer: Cigna Medicaid	$375.12
Rate for Payer: Cigna Medicare	$29.60
Rate for Payer: Employer Direct Commercial	$29.60
Rate for Payer: Humana Medicare/TRICARE	$29.60
Rate for Payer: Molina CHIP/Medicaid	$375.12
Rate for Payer: Molina Dual Medicare/Medicaid	$29.60
Rate for Payer: Molina Medicare	$29.60
Rate for Payer: Multiplan Auto	$338.65
Rate for Payer: Multiplan Commercial	$338.65
Rate for Payer: Multiplan Workers Comp	$338.65
Rate for Payer: Parkland Medicaid	$375.12
Rate for Payer: Scott and White EPO/PPO	$37.00
Rate for Payer: Scott and White Medicare	$29.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.12
Rate for Payer: Superior Health Plan EPO	$29.60
Rate for Payer: Superior Health Plan Medicare	$29.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$29.60
Rate for Payer: Universal American Medicare	$29.60
Rate for Payer: Wellcare Medicare	$29.60
Rate for Payer: Wellmed Medicare	$29.60

Vitamin D, 25-Hydroxy

Facility

$521.00

Service Code	HCPCS 82306
Hospital Charge Code	7254595
Hospital Revenue Code	301
Rate for Payer: Cash Price	$354.28

Vitamin E SO

Facility

$154.00

Service Code	HCPCS 84446
Hospital Charge Code	1701606
Hospital Revenue Code	301
Rate for Payer: Cash Price	$104.72

Vitamin E SO

Facility

$154.00

Service Code	HCPCS 84446
Hospital Charge Code	1701606
Hospital Revenue Code	301
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$110.88
Rate for Payer: Amerigroup CHIP/Medicaid	$5.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.18
Rate for Payer: Amerigroup Medicare	$14.18
Rate for Payer: BCBS of TX Blue Advantage	$46.20
Rate for Payer: BCBS of TX Blue Essentials	$55.44
Rate for Payer: BCBS of TX Medicare	$14.18
Rate for Payer: BCBS of TX PPO	$61.60
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cigna Medicaid	$110.88
Rate for Payer: Cigna Medicare	$14.18
Rate for Payer: Employer Direct Commercial	$14.18
Rate for Payer: Humana Medicare/TRICARE	$14.18
Rate for Payer: Molina CHIP/Medicaid	$110.88
Rate for Payer: Molina Dual Medicare/Medicaid	$14.18
Rate for Payer: Molina Medicare	$14.18
Rate for Payer: Multiplan Auto	$100.10
Rate for Payer: Multiplan Commercial	$100.10
Rate for Payer: Multiplan Workers Comp	$100.10
Rate for Payer: Parkland Medicaid	$110.88
Rate for Payer: Scott and White EPO/PPO	$17.73
Rate for Payer: Scott and White Medicare	$14.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.88
Rate for Payer: Superior Health Plan EPO	$14.18
Rate for Payer: Superior Health Plan Medicare	$14.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.18
Rate for Payer: Universal American Medicare	$14.18
Rate for Payer: Wellcare Medicare	$14.18
Rate for Payer: Wellmed Medicare	$14.18

Vitamin K1 SO

Facility

$303.71

Service Code	HCPCS 84597
Hospital Charge Code	1709856
Hospital Revenue Code	301
Rate for Payer: Cash Price	$206.52

Vitamin K1 SO

Facility

$303.71

Service Code	HCPCS 84597
Hospital Charge Code	1709856
Hospital Revenue Code	301
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$218.67
Rate for Payer: Amerigroup CHIP/Medicaid	$5.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.72
Rate for Payer: Amerigroup Medicare	$13.72
Rate for Payer: BCBS of TX Blue Advantage	$91.11
Rate for Payer: BCBS of TX Blue Essentials	$109.34
Rate for Payer: BCBS of TX Medicare	$13.72
Rate for Payer: BCBS of TX PPO	$121.48
Rate for Payer: Cash Price	$206.52
Rate for Payer: Cash Price	$206.52
Rate for Payer: Cigna Medicaid	$218.67
Rate for Payer: Cigna Medicare	$13.72
Rate for Payer: Employer Direct Commercial	$13.72
Rate for Payer: Humana Medicare/TRICARE	$13.72
Rate for Payer: Molina CHIP/Medicaid	$218.67
Rate for Payer: Molina Dual Medicare/Medicaid	$13.72
Rate for Payer: Molina Medicare	$13.72
Rate for Payer: Multiplan Auto	$197.41
Rate for Payer: Multiplan Commercial	$197.41
Rate for Payer: Multiplan Workers Comp	$197.41
Rate for Payer: Parkland Medicaid	$218.67
Rate for Payer: Scott and White EPO/PPO	$17.15
Rate for Payer: Scott and White Medicare	$13.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$218.67
Rate for Payer: Superior Health Plan EPO	$13.72
Rate for Payer: Superior Health Plan Medicare	$13.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.72
Rate for Payer: Universal American Medicare	$13.72
Rate for Payer: Wellcare Medicare	$13.72
Rate for Payer: Wellmed Medicare	$13.72

VITOSS

Facility

$8,500.00

Service Code	HCPCS C1713
Hospital Charge Code	992135
Hospital Revenue Code	278
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$6,120.00
Rate for Payer: Amerigroup CHIP/Medicaid	$765.00
Rate for Payer: BCBS of TX Blue Advantage	$2,550.00
Rate for Payer: BCBS of TX Blue Essentials	$3,060.00
Rate for Payer: BCBS of TX PPO	$3,400.00
Rate for Payer: Cash Price	$5,780.00
Rate for Payer: Cigna Medicaid	$6,120.00
Rate for Payer: Molina CHIP/Medicaid	$6,120.00
Rate for Payer: Multiplan Auto	$4,250.00
Rate for Payer: Multiplan Commercial	$4,250.00
Rate for Payer: Multiplan Workers Comp	$4,250.00
Rate for Payer: Parkland Medicaid	$6,120.00
Rate for Payer: Scott and White EPO/PPO	$4,250.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,120.00
Rate for Payer: Superior Health Plan EPO	$1,156.00

VITOSS

Facility

$8,500.00

Service Code	HCPCS C1713
Hospital Charge Code	992135
Hospital Revenue Code	278
Min. Negotiated Rate	$2,125.00
Max. Negotiated Rate	$4,250.00
Rate for Payer: Cash Price	$5,780.00
Rate for Payer: Cigna Commercial	$2,125.00
Rate for Payer: Multiplan Auto	$4,250.00
Rate for Payer: Multiplan Commercial	$4,250.00
Rate for Payer: Multiplan Workers Comp	$4,250.00
Rate for Payer: Scott and White EPO/PPO	$4,250.00

VITROS BETA HUMAN CHORLONIC GONADOTROPIN CALIBRATOR

Facility

$400.10

Hospital Charge Code	993701
Hospital Revenue Code	270
Rate for Payer: Cash Price	$272.07

VITROS BETA HUMAN CHORLONIC GONADOTROPIN CALIBRATOR

Facility

$400.10

Hospital Charge Code	993701
Hospital Revenue Code	270
Min. Negotiated Rate	$36.01
Max. Negotiated Rate	$288.07
Rate for Payer: Amerigroup CHIP/Medicaid	$36.01
Rate for Payer: BCBS of TX Blue Advantage	$120.03
Rate for Payer: BCBS of TX Blue Essentials	$144.04
Rate for Payer: BCBS of TX PPO	$160.04
Rate for Payer: Cash Price	$272.07
Rate for Payer: Cigna Medicaid	$288.07
Rate for Payer: Molina CHIP/Medicaid	$288.07
Rate for Payer: Multiplan Auto	$260.06
Rate for Payer: Multiplan Commercial	$260.06
Rate for Payer: Multiplan Workers Comp	$260.06
Rate for Payer: Parkland Medicaid	$288.07
Rate for Payer: Scott and White EPO/PPO	$200.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$288.07
Rate for Payer: Superior Health Plan EPO	$54.41

VITROS KIT 7 CALIBATOR 6 X 3ML 2SETS/BX

Facility

$398.00

Hospital Charge Code	993699
Hospital Revenue Code	270
Min. Negotiated Rate	$35.82
Max. Negotiated Rate	$286.56
Rate for Payer: Amerigroup CHIP/Medicaid	$35.82
Rate for Payer: BCBS of TX Blue Advantage	$119.40
Rate for Payer: BCBS of TX Blue Essentials	$143.28
Rate for Payer: BCBS of TX PPO	$159.20
Rate for Payer: Cash Price	$270.64
Rate for Payer: Cigna Medicaid	$286.56
Rate for Payer: Molina CHIP/Medicaid	$286.56
Rate for Payer: Multiplan Auto	$258.70
Rate for Payer: Multiplan Commercial	$258.70
Rate for Payer: Multiplan Workers Comp	$258.70
Rate for Payer: Parkland Medicaid	$286.56
Rate for Payer: Scott and White EPO/PPO	$199.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$286.56
Rate for Payer: Superior Health Plan EPO	$54.13

VITROS KIT 7 CALIBATOR 6 X 3ML 2SETS/BX

Facility

$398.00

Hospital Charge Code	993699
Hospital Revenue Code	270
Rate for Payer: Cash Price	$270.64

VITROS MICROSLIDE ALB: ALBUMIN REAGENT 250 COUNT

Facility

$9.97

Hospital Charge Code	993703
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.78

VITROS MICROSLIDE ALB: ALBUMIN REAGENT 250 COUNT

Facility

$9.97

Hospital Charge Code	993703
Hospital Revenue Code	270
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$7.18
Rate for Payer: Amerigroup CHIP/Medicaid	$0.90
Rate for Payer: BCBS of TX Blue Advantage	$2.99
Rate for Payer: BCBS of TX Blue Essentials	$3.59
Rate for Payer: BCBS of TX PPO	$3.99
Rate for Payer: Cash Price	$6.78
Rate for Payer: Cigna Medicaid	$7.18
Rate for Payer: Molina CHIP/Medicaid	$7.18
Rate for Payer: Multiplan Auto	$6.48
Rate for Payer: Multiplan Commercial	$6.48
Rate for Payer: Multiplan Workers Comp	$6.48
Rate for Payer: Parkland Medicaid	$7.18
Rate for Payer: Scott and White EPO/PPO	$4.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.18
Rate for Payer: Superior Health Plan EPO	$1.36

Vitros microslide ammonla reagent 90 Count 90 / Pk

Facility

$23.98

Hospital Charge Code	993840
Hospital Revenue Code	272
Rate for Payer: Cash Price	$16.31

Vitros microslide ammonla reagent 90 Count 90 / Pk

Facility

$23.98

Hospital Charge Code	993840
Hospital Revenue Code	272
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$17.27
Rate for Payer: Amerigroup CHIP/Medicaid	$2.16
Rate for Payer: BCBS of TX Blue Advantage	$7.19
Rate for Payer: BCBS of TX Blue Essentials	$8.63
Rate for Payer: BCBS of TX PPO	$9.59
Rate for Payer: Cash Price	$16.31
Rate for Payer: Cigna Medicaid	$17.27
Rate for Payer: Molina CHIP/Medicaid	$17.27
Rate for Payer: Multiplan Auto	$15.59
Rate for Payer: Multiplan Commercial	$15.59
Rate for Payer: Multiplan Workers Comp	$15.59
Rate for Payer: Parkland Medicaid	$17.27
Rate for Payer: Scott and White EPO/PPO	$11.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17.27
Rate for Payer: Superior Health Plan EPO	$3.26

VITROS MICROSLIDE B-HCG II TOTAL REAGENT TEST

Facility

$72.37

Hospital Charge Code	993700
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.21

VITROS MICROSLIDE B-HCG II TOTAL REAGENT TEST

Facility

$72.37

Hospital Charge Code	993700
Hospital Revenue Code	270
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$52.11
Rate for Payer: Amerigroup CHIP/Medicaid	$6.51
Rate for Payer: BCBS of TX Blue Advantage	$21.71
Rate for Payer: BCBS of TX Blue Essentials	$26.05
Rate for Payer: BCBS of TX PPO	$28.95
Rate for Payer: Cash Price	$49.21
Rate for Payer: Cigna Medicaid	$52.11
Rate for Payer: Molina CHIP/Medicaid	$52.11
Rate for Payer: Multiplan Auto	$47.04
Rate for Payer: Multiplan Commercial	$47.04
Rate for Payer: Multiplan Workers Comp	$47.04
Rate for Payer: Parkland Medicaid	$52.11
Rate for Payer: Scott and White EPO/PPO	$36.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.11
Rate for Payer: Superior Health Plan EPO	$9.84

VITROS MICROSLIDE POTASSIUM REAGENT TEST 5 X 50 COUNT

Facility

$49.84

Hospital Charge Code	993702
Hospital Revenue Code	270
Min. Negotiated Rate	$4.49
Max. Negotiated Rate	$35.88
Rate for Payer: Amerigroup CHIP/Medicaid	$4.49
Rate for Payer: BCBS of TX Blue Advantage	$14.95
Rate for Payer: BCBS of TX Blue Essentials	$17.94
Rate for Payer: BCBS of TX PPO	$19.94
Rate for Payer: Cash Price	$33.89
Rate for Payer: Cigna Medicaid	$35.88
Rate for Payer: Molina CHIP/Medicaid	$35.88
Rate for Payer: Multiplan Auto	$32.40
Rate for Payer: Multiplan Commercial	$32.40
Rate for Payer: Multiplan Workers Comp	$32.40
Rate for Payer: Parkland Medicaid	$35.88
Rate for Payer: Scott and White EPO/PPO	$24.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.88
Rate for Payer: Superior Health Plan EPO	$6.78

VITROS MICROSLIDE POTASSIUM REAGENT TEST 5 X 50 COUNT

Facility

$49.84

Hospital Charge Code	993702
Hospital Revenue Code	270
Rate for Payer: Cash Price	$33.89

VITROS MICROWELL TROPONIN I ES REAGENT TEST

Facility

$16,723.32

Hospital Charge Code	993713
Hospital Revenue Code	270
Min. Negotiated Rate	$1,505.10
Max. Negotiated Rate	$12,040.79
Rate for Payer: Amerigroup CHIP/Medicaid	$1,505.10
Rate for Payer: BCBS of TX Blue Advantage	$5,017.00
Rate for Payer: BCBS of TX Blue Essentials	$6,020.40
Rate for Payer: BCBS of TX PPO	$6,689.33
Rate for Payer: Cash Price	$11,371.86
Rate for Payer: Cigna Medicaid	$12,040.79
Rate for Payer: Molina CHIP/Medicaid	$12,040.79
Rate for Payer: Multiplan Auto	$10,870.16
Rate for Payer: Multiplan Commercial	$10,870.16
Rate for Payer: Multiplan Workers Comp	$10,870.16
Rate for Payer: Parkland Medicaid	$12,040.79
Rate for Payer: Scott and White EPO/PPO	$8,361.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,040.79
Rate for Payer: Superior Health Plan EPO	$2,274.37

VITROS MICROWELL TROPONIN I ES REAGENT TEST

Facility

$16,723.32

Hospital Charge Code	993713
Hospital Revenue Code	270
Rate for Payer: Cash Price	$11,371.86

Know your out-of-pocket cost for care.

All Charges