White Rock Medical Center

All Charges

Charge

Type

Setting

Price

V-LOC 90 Absorbable Wound Closure Device, Undyed, Size 3-0, 18' Long, P-12 Needle

Facility

$193.36

Hospital Charge Code	993737
Hospital Revenue Code	272
Rate for Payer: Cash Price	$131.48

V-LOC 90 Absorbable Wound Closure Device, Undyed, Size 3-0, 18' Long, P-12 Needle

Facility

$193.36

Hospital Charge Code	993737
Hospital Revenue Code	272
Min. Negotiated Rate	$17.40
Max. Negotiated Rate	$139.22
Rate for Payer: Amerigroup CHIP/Medicaid	$17.40
Rate for Payer: BCBS of TX Blue Advantage	$58.01
Rate for Payer: BCBS of TX Blue Essentials	$69.61
Rate for Payer: BCBS of TX PPO	$77.34
Rate for Payer: Cash Price	$131.48
Rate for Payer: Cigna Medicaid	$139.22
Rate for Payer: Molina CHIP/Medicaid	$139.22
Rate for Payer: Multiplan Auto	$125.68
Rate for Payer: Multiplan Commercial	$125.68
Rate for Payer: Multiplan Workers Comp	$125.68
Rate for Payer: Parkland Medicaid	$139.22
Rate for Payer: Scott and White EPO/PPO	$96.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$139.22
Rate for Payer: Superior Health Plan EPO	$26.30

V-LOC 90 SUTURE 3-0 18' GLYCOLIDE BARBED P-12

Facility

$292.91

Hospital Charge Code	992706
Hospital Revenue Code	272
Min. Negotiated Rate	$26.36
Max. Negotiated Rate	$210.90
Rate for Payer: Amerigroup CHIP/Medicaid	$26.36
Rate for Payer: BCBS of TX Blue Advantage	$87.87
Rate for Payer: BCBS of TX Blue Essentials	$105.45
Rate for Payer: BCBS of TX PPO	$117.16
Rate for Payer: Cash Price	$199.18
Rate for Payer: Cigna Medicaid	$210.90
Rate for Payer: Molina CHIP/Medicaid	$210.90
Rate for Payer: Multiplan Auto	$190.39
Rate for Payer: Multiplan Commercial	$190.39
Rate for Payer: Multiplan Workers Comp	$190.39
Rate for Payer: Parkland Medicaid	$210.90
Rate for Payer: Scott and White EPO/PPO	$146.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$210.90
Rate for Payer: Superior Health Plan EPO	$39.84

V-LOC 90 SUTURE 3-0 18' GLYCOLIDE BARBED P-12

Facility

$292.91

Hospital Charge Code	992706
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.18

V-LOC 90 SUTURE 3-0 18' GLYCOLIDE BARBED P-14

Facility

$292.91

Hospital Charge Code	992707
Hospital Revenue Code	272
Min. Negotiated Rate	$26.36
Max. Negotiated Rate	$210.90
Rate for Payer: Amerigroup CHIP/Medicaid	$26.36
Rate for Payer: BCBS of TX Blue Advantage	$87.87
Rate for Payer: BCBS of TX Blue Essentials	$105.45
Rate for Payer: BCBS of TX PPO	$117.16
Rate for Payer: Cash Price	$199.18
Rate for Payer: Cigna Medicaid	$210.90
Rate for Payer: Molina CHIP/Medicaid	$210.90
Rate for Payer: Multiplan Auto	$190.39
Rate for Payer: Multiplan Commercial	$190.39
Rate for Payer: Multiplan Workers Comp	$190.39
Rate for Payer: Parkland Medicaid	$210.90
Rate for Payer: Scott and White EPO/PPO	$146.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$210.90
Rate for Payer: Superior Health Plan EPO	$39.84

V-LOC 90 SUTURE 3-0 18' GLYCOLIDE BARBED P-14

Facility

$292.91

Hospital Charge Code	992707
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.18

VLV TRACH SPEAK -- DHF

Facility

$338.80

Hospital Charge Code	82075516
Hospital Revenue Code	274
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$169.40
Rate for Payer: Cash Price	$230.38
Rate for Payer: Cigna Commercial	$84.70
Rate for Payer: Multiplan Auto	$169.40
Rate for Payer: Multiplan Commercial	$169.40
Rate for Payer: Multiplan Workers Comp	$169.40
Rate for Payer: Scott and White EPO/PPO	$169.40

VLV TRACH SPEAK -- DHF

Facility

$338.80

Hospital Charge Code	82075516
Hospital Revenue Code	274
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$243.94
Rate for Payer: Amerigroup CHIP/Medicaid	$30.49
Rate for Payer: BCBS of TX Blue Advantage	$101.64
Rate for Payer: BCBS of TX Blue Essentials	$121.97
Rate for Payer: BCBS of TX PPO	$135.52
Rate for Payer: Cash Price	$230.38
Rate for Payer: Cigna Medicaid	$243.94
Rate for Payer: Molina CHIP/Medicaid	$243.94
Rate for Payer: Multiplan Auto	$169.40
Rate for Payer: Multiplan Commercial	$169.40
Rate for Payer: Multiplan Workers Comp	$169.40
Rate for Payer: Parkland Medicaid	$243.94
Rate for Payer: Scott and White EPO/PPO	$169.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$243.94
Rate for Payer: Superior Health Plan EPO	$46.08

Voltage-Gated Calcium Channel

Facility

$347.13

Service Code	HCPCS 86596
Hospital Charge Code	4203467
Hospital Revenue Code	302
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$249.93
Rate for Payer: Amerigroup CHIP/Medicaid	$7.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.05
Rate for Payer: Amerigroup Medicare	$12.05
Rate for Payer: BCBS of TX Blue Advantage	$104.14
Rate for Payer: BCBS of TX Blue Essentials	$124.97
Rate for Payer: BCBS of TX Medicare	$12.05
Rate for Payer: BCBS of TX PPO	$138.85
Rate for Payer: Cash Price	$236.05
Rate for Payer: Cash Price	$236.05
Rate for Payer: Cigna Medicaid	$249.93
Rate for Payer: Cigna Medicare	$12.05
Rate for Payer: Employer Direct Commercial	$12.05
Rate for Payer: Humana Medicare/TRICARE	$12.05
Rate for Payer: Molina CHIP/Medicaid	$249.93
Rate for Payer: Molina Dual Medicare/Medicaid	$12.05
Rate for Payer: Molina Medicare	$12.05
Rate for Payer: Multiplan Auto	$225.63
Rate for Payer: Multiplan Commercial	$225.63
Rate for Payer: Multiplan Workers Comp	$225.63
Rate for Payer: Parkland Medicaid	$249.93
Rate for Payer: Scott and White EPO/PPO	$15.06
Rate for Payer: Scott and White Medicare	$12.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$249.93
Rate for Payer: Superior Health Plan EPO	$12.05
Rate for Payer: Superior Health Plan Medicare	$12.05
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.05
Rate for Payer: Universal American Medicare	$12.05
Rate for Payer: Wellcare Medicare	$12.05
Rate for Payer: Wellmed Medicare	$12.05

Voltage-Gated Calcium Channel

Facility

$347.13

Service Code	HCPCS 86596
Hospital Charge Code	4203467
Hospital Revenue Code	302
Rate for Payer: Cash Price	$236.05

von Willebrand Factor (vWF) Ag SO

Facility

$111.00

Service Code	HCPCS 85246
Hospital Charge Code	1700996
Hospital Revenue Code	305
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$79.92
Rate for Payer: Amerigroup CHIP/Medicaid	$8.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.94
Rate for Payer: Amerigroup Medicare	$22.94
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX Medicare	$22.94
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Cigna Medicare	$22.94
Rate for Payer: Employer Direct Commercial	$22.94
Rate for Payer: Humana Medicare/TRICARE	$22.94
Rate for Payer: Molina CHIP/Medicaid	$79.92
Rate for Payer: Molina Dual Medicare/Medicaid	$22.94
Rate for Payer: Molina Medicare	$22.94
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$28.68
Rate for Payer: Scott and White Medicare	$22.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$22.94
Rate for Payer: Superior Health Plan Medicare	$22.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.94
Rate for Payer: Universal American Medicare	$22.94
Rate for Payer: Wellcare Medicare	$22.94
Rate for Payer: Wellmed Medicare	$22.94

von Willebrand Factor (vWF) Ag SO

Facility

$111.00

Service Code	HCPCS 85246
Hospital Charge Code	1700996
Hospital Revenue Code	305
Rate for Payer: Cash Price	$75.48

Voriconazole, Quant

Facility

$500.00

Service Code	HCPCS 80285
Hospital Charge Code	4203471
Hospital Revenue Code	301
Rate for Payer: Cash Price	$340.00

Voriconazole, Quant

Facility

$500.00

Service Code	HCPCS 80285
Hospital Charge Code	4203471
Hospital Revenue Code	301
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$360.00
Rate for Payer: Amerigroup CHIP/Medicaid	$10.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27.11
Rate for Payer: Amerigroup Medicare	$27.11
Rate for Payer: BCBS of TX Blue Advantage	$150.00
Rate for Payer: BCBS of TX Blue Essentials	$180.00
Rate for Payer: BCBS of TX Medicare	$27.11
Rate for Payer: BCBS of TX PPO	$200.00
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cigna Medicaid	$360.00
Rate for Payer: Cigna Medicare	$27.11
Rate for Payer: Employer Direct Commercial	$27.11
Rate for Payer: Humana Medicare/TRICARE	$27.11
Rate for Payer: Molina CHIP/Medicaid	$360.00
Rate for Payer: Molina Dual Medicare/Medicaid	$27.11
Rate for Payer: Molina Medicare	$27.11
Rate for Payer: Multiplan Auto	$325.00
Rate for Payer: Multiplan Commercial	$325.00
Rate for Payer: Multiplan Workers Comp	$325.00
Rate for Payer: Parkland Medicaid	$360.00
Rate for Payer: Scott and White EPO/PPO	$33.89
Rate for Payer: Scott and White Medicare	$27.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$360.00
Rate for Payer: Superior Health Plan EPO	$27.11
Rate for Payer: Superior Health Plan Medicare	$27.11
Rate for Payer: Universal American Dual Medicare/Medicaid	$27.11
Rate for Payer: Universal American Medicare	$27.11
Rate for Payer: Wellcare Medicare	$27.11
Rate for Payer: Wellmed Medicare	$27.11

vWF Activity SO

Facility

$244.00

Service Code	HCPCS 85245
Hospital Charge Code	1708452
Hospital Revenue Code	305
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$175.68
Rate for Payer: Amerigroup CHIP/Medicaid	$8.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.94
Rate for Payer: Amerigroup Medicare	$22.94
Rate for Payer: BCBS of TX Blue Advantage	$73.20
Rate for Payer: BCBS of TX Blue Essentials	$87.84
Rate for Payer: BCBS of TX Medicare	$22.94
Rate for Payer: BCBS of TX PPO	$97.60
Rate for Payer: Cash Price	$165.92
Rate for Payer: Cash Price	$165.92
Rate for Payer: Cigna Medicaid	$175.68
Rate for Payer: Cigna Medicare	$22.94
Rate for Payer: Employer Direct Commercial	$22.94
Rate for Payer: Humana Medicare/TRICARE	$22.94
Rate for Payer: Molina CHIP/Medicaid	$175.68
Rate for Payer: Molina Dual Medicare/Medicaid	$22.94
Rate for Payer: Molina Medicare	$22.94
Rate for Payer: Multiplan Auto	$158.60
Rate for Payer: Multiplan Commercial	$158.60
Rate for Payer: Multiplan Workers Comp	$158.60
Rate for Payer: Parkland Medicaid	$175.68
Rate for Payer: Scott and White EPO/PPO	$28.68
Rate for Payer: Scott and White Medicare	$22.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$175.68
Rate for Payer: Superior Health Plan EPO	$22.94
Rate for Payer: Superior Health Plan Medicare	$22.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.94
Rate for Payer: Universal American Medicare	$22.94
Rate for Payer: Wellcare Medicare	$22.94
Rate for Payer: Wellmed Medicare	$22.94

vWF Activity SO

Facility

$244.00

Service Code	HCPCS 85245
Hospital Charge Code	1708452
Hospital Revenue Code	305
Rate for Payer: Cash Price	$165.92

WALKER, NEXTEP CONTOUR 2, LARGE

Facility

$152.50

Hospital Charge Code	993916
Hospital Revenue Code	274
Min. Negotiated Rate	$38.12
Max. Negotiated Rate	$76.25
Rate for Payer: Cash Price	$103.70
Rate for Payer: Cigna Commercial	$38.12
Rate for Payer: Multiplan Auto	$76.25
Rate for Payer: Multiplan Commercial	$76.25
Rate for Payer: Multiplan Workers Comp	$76.25
Rate for Payer: Scott and White EPO/PPO	$76.25

WALKER, NEXTEP CONTOUR 2, LARGE

Facility

$152.50

Hospital Charge Code	993916
Hospital Revenue Code	274
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$109.80
Rate for Payer: Amerigroup CHIP/Medicaid	$13.72
Rate for Payer: BCBS of TX Blue Advantage	$45.75
Rate for Payer: BCBS of TX Blue Essentials	$54.90
Rate for Payer: BCBS of TX PPO	$61.00
Rate for Payer: Cash Price	$103.70
Rate for Payer: Cigna Medicaid	$109.80
Rate for Payer: Molina CHIP/Medicaid	$109.80
Rate for Payer: Multiplan Auto	$76.25
Rate for Payer: Multiplan Commercial	$76.25
Rate for Payer: Multiplan Workers Comp	$76.25
Rate for Payer: Parkland Medicaid	$109.80
Rate for Payer: Scott and White EPO/PPO	$76.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.80
Rate for Payer: Superior Health Plan EPO	$20.74

WALKER, NEXTEP CONTOUR 2, MEDIUM

Facility

$152.50

Hospital Charge Code	993915
Hospital Revenue Code	274
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$109.80
Rate for Payer: Amerigroup CHIP/Medicaid	$13.72
Rate for Payer: BCBS of TX Blue Advantage	$45.75
Rate for Payer: BCBS of TX Blue Essentials	$54.90
Rate for Payer: BCBS of TX PPO	$61.00
Rate for Payer: Cash Price	$103.70
Rate for Payer: Cigna Medicaid	$109.80
Rate for Payer: Molina CHIP/Medicaid	$109.80
Rate for Payer: Multiplan Auto	$76.25
Rate for Payer: Multiplan Commercial	$76.25
Rate for Payer: Multiplan Workers Comp	$76.25
Rate for Payer: Parkland Medicaid	$109.80
Rate for Payer: Scott and White EPO/PPO	$76.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$109.80
Rate for Payer: Superior Health Plan EPO	$20.74

WALKER, NEXTEP CONTOUR 2, MEDIUM

Facility

$152.50

Hospital Charge Code	993915
Hospital Revenue Code	274
Min. Negotiated Rate	$38.12
Max. Negotiated Rate	$76.25
Rate for Payer: Cash Price	$103.70
Rate for Payer: Cigna Commercial	$38.12
Rate for Payer: Multiplan Auto	$76.25
Rate for Payer: Multiplan Commercial	$76.25
Rate for Payer: Multiplan Workers Comp	$76.25
Rate for Payer: Scott and White EPO/PPO	$76.25

WALKER, SHORT, NONSKID, MD, EA

Facility

$363.56

Hospital Charge Code	993079
Hospital Revenue Code	270
Rate for Payer: Cash Price	$247.22

WALKER, SHORT, NONSKID, MD, EA

Facility

$363.56

Hospital Charge Code	993079
Hospital Revenue Code	270
Min. Negotiated Rate	$32.72
Max. Negotiated Rate	$261.76
Rate for Payer: Amerigroup CHIP/Medicaid	$32.72
Rate for Payer: BCBS of TX Blue Advantage	$109.07
Rate for Payer: BCBS of TX Blue Essentials	$130.88
Rate for Payer: BCBS of TX PPO	$145.42
Rate for Payer: Cash Price	$247.22
Rate for Payer: Cigna Medicaid	$261.76
Rate for Payer: Molina CHIP/Medicaid	$261.76
Rate for Payer: Multiplan Auto	$236.31
Rate for Payer: Multiplan Commercial	$236.31
Rate for Payer: Multiplan Workers Comp	$236.31
Rate for Payer: Parkland Medicaid	$261.76
Rate for Payer: Scott and White EPO/PPO	$181.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$261.76
Rate for Payer: Superior Health Plan EPO	$49.44

WAND, ARTHO BIPOLAR 90 DEGREE W/SUCTION-EDGE

Facility

$762.22

Hospital Charge Code	992646
Hospital Revenue Code	272
Rate for Payer: Cash Price	$518.31

WAND, ARTHO BIPOLAR 90 DEGREE W/SUCTION-EDGE

Facility

$762.22

Hospital Charge Code	992646
Hospital Revenue Code	272
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$548.80
Rate for Payer: Amerigroup CHIP/Medicaid	$68.60
Rate for Payer: BCBS of TX Blue Advantage	$228.67
Rate for Payer: BCBS of TX Blue Essentials	$274.40
Rate for Payer: BCBS of TX PPO	$304.89
Rate for Payer: Cash Price	$518.31
Rate for Payer: Cigna Medicaid	$548.80
Rate for Payer: Molina CHIP/Medicaid	$548.80
Rate for Payer: Multiplan Auto	$495.44
Rate for Payer: Multiplan Commercial	$495.44
Rate for Payer: Multiplan Workers Comp	$495.44
Rate for Payer: Parkland Medicaid	$548.80
Rate for Payer: Scott and White EPO/PPO	$381.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$548.80
Rate for Payer: Superior Health Plan EPO	$103.66

WAND ARTHRO BIPLR DISP2

Facility

$3,364.14

Hospital Charge Code	81779621
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,287.62

Know your out-of-pocket cost for care.

All Charges