White Rock Medical Center

All Charges

Charge

Type

Setting

Price

.TR Interpretation

Facility

$386.00

Service Code	CPT 86078
Hospital Charge Code	1600002
Hospital Revenue Code	300
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$52.71
Rate for Payer: Aetna Medicare	$234.31
Rate for Payer: Amerigroup CHIP/Medicaid	$20.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.13
Rate for Payer: Cash Price	$339.68
Rate for Payer: Cash Price	$339.68
Rate for Payer: Cash Price	$339.68
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$250.90
Rate for Payer: Multiplan Commercial	$250.90
Rate for Payer: Multiplan Workers Comp	$250.90
Rate for Payer: Scott and White EPO/PPO	$59.24
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

.TR Interpretation

Facility

$386.00

Service Code	CPT 86078
Hospital Charge Code	1600002
Hospital Revenue Code	300
Rate for Payer: Cash Price	$339.68

TRLUML BALO ANGIOP S&I ADDL ART

Facility

$10,885.00

Service Code	CPT 37247
Hospital Charge Code	2351114
Hospital Revenue Code	360
Min. Negotiated Rate	$979.65
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$5,986.75
Rate for Payer: Amerigroup CHIP/Medicaid	$979.65
Rate for Payer: Cash Price	$9,578.80
Rate for Payer: Cash Price	$9,578.80
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: Scott and White EPO/PPO	$5,442.50
Rate for Payer: Superior Health Plan EPO	$1,480.36

TRLUML BALO ANGIOP S&I ADDL ART

Facility

$10,885.00

Service Code	CPT 37247
Hospital Charge Code	2351114
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,578.80

TRLUML BALO ANGIOP S&I ADDL VEIN

Facility

$5,591.00

Service Code	CPT 37249
Hospital Charge Code	2351116
Hospital Revenue Code	360
Min. Negotiated Rate	$503.19
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,075.05
Rate for Payer: Amerigroup CHIP/Medicaid	$503.19
Rate for Payer: Cash Price	$4,920.08
Rate for Payer: Cash Price	$4,920.08
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: Scott and White EPO/PPO	$2,795.50
Rate for Payer: Superior Health Plan EPO	$760.38

TRLUML BALO ANGIOP S&I ADDL VEIN

Facility

$5,591.00

Service Code	CPT 37249
Hospital Charge Code	2351116
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,920.08

TRLUML BALO ANGIOP S&I INT ART

Facility

$13,299.00

Service Code	CPT 37246
Hospital Charge Code	2351113
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,703.12

TRLUML BALO ANGIOP S&I INT ART

Facility

$13,299.00

Service Code	CPT 37246
Hospital Charge Code	2351113
Hospital Revenue Code	360
Min. Negotiated Rate	$2,300.22
Max. Negotiated Rate	$12,483.85
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$7,840.86
Rate for Payer: Amerigroup CHIP/Medicaid	$2,300.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Amerigroup Medicare	$5,227.24
Rate for Payer: BCBS of TX Blue Advantage	$8,273.03
Rate for Payer: BCBS of TX Blue Essentials	$9,907.82
Rate for Payer: BCBS of TX Medicare	$5,227.24
Rate for Payer: BCBS of TX PPO	$12,483.85
Rate for Payer: Cash Price	$11,703.12
Rate for Payer: Cash Price	$11,703.12
Rate for Payer: Cigna Commercial	$11,841.22
Rate for Payer: Cigna Medicaid	$2,300.22
Rate for Payer: Cigna Medicare	$5,227.24
Rate for Payer: Employer Direct Commercial	$5,227.24
Rate for Payer: Humana Medicare/TRICARE	$5,227.24
Rate for Payer: Molina CHIP/Medicaid	$2,300.22
Rate for Payer: Molina Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Molina Medicare	$5,227.24
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	$2,300.22
Rate for Payer: Scott and White EPO/PPO	$9,670.39
Rate for Payer: Scott and White Medicare	$5,227.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,300.22
Rate for Payer: Superior Health Plan EPO	$5,227.24
Rate for Payer: Superior Health Plan Medicare	$5,227.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Universal American Medicare	$5,227.24
Rate for Payer: Wellcare Medicare	$5,227.24
Rate for Payer: Wellmed Medicare	$5,227.24

TRLUML BALO ANGIOP S&I INT VEIN

Facility

$9,216.00

Service Code	CPT 37248
Hospital Charge Code	2351115
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,110.08

TRLUML BALO ANGIOP S&I INT VEIN

Facility

$9,216.00

Service Code	CPT 37248
Hospital Charge Code	2351115
Hospital Revenue Code	360
Min. Negotiated Rate	$1,764.89
Max. Negotiated Rate	$12,483.85
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$7,840.86
Rate for Payer: Amerigroup CHIP/Medicaid	$1,764.89
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Amerigroup Medicare	$5,227.24
Rate for Payer: BCBS of TX Blue Advantage	$8,273.03
Rate for Payer: BCBS of TX Blue Essentials	$9,907.82
Rate for Payer: BCBS of TX Medicare	$5,227.24
Rate for Payer: BCBS of TX PPO	$12,483.85
Rate for Payer: Cash Price	$8,110.08
Rate for Payer: Cash Price	$8,110.08
Rate for Payer: Cigna Commercial	$11,841.22
Rate for Payer: Cigna Medicaid	$1,764.89
Rate for Payer: Cigna Medicare	$5,227.24
Rate for Payer: Employer Direct Commercial	$5,227.24
Rate for Payer: Humana Medicare/TRICARE	$5,227.24
Rate for Payer: Molina CHIP/Medicaid	$1,764.89
Rate for Payer: Molina Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Molina Medicare	$5,227.24
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	$1,764.89
Rate for Payer: Scott and White EPO/PPO	$9,670.39
Rate for Payer: Scott and White Medicare	$5,227.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,764.89
Rate for Payer: Superior Health Plan EPO	$5,227.24
Rate for Payer: Superior Health Plan Medicare	$5,227.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,227.24
Rate for Payer: Universal American Medicare	$5,227.24
Rate for Payer: Wellcare Medicare	$5,227.24
Rate for Payer: Wellmed Medicare	$5,227.24

TRNSCTH EMBOLIZATN

Facility

$4,048.00

Service Code	CPT 75894
Hospital Charge Code	4616005
Hospital Revenue Code	323
Rate for Payer: Cash Price	$3,562.24

TRNSCTH EMBOLIZATN

Facility

$4,048.00

Service Code	CPT 75894
Hospital Charge Code	4616005
Hospital Revenue Code	323
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$2,631.20
Rate for Payer: Aetna Commercial	$1,034.91
Rate for Payer: Amerigroup CHIP/Medicaid	$364.32
Rate for Payer: BCBS of TX Blue Advantage	$122.50
Rate for Payer: BCBS of TX Blue Essentials	$147.00
Rate for Payer: BCBS of TX PPO	$164.07
Rate for Payer: Cash Price	$3,562.24
Rate for Payer: Cash Price	$3,562.24
Rate for Payer: Multiplan Auto	$2,631.20
Rate for Payer: Multiplan Commercial	$2,631.20
Rate for Payer: Multiplan Workers Comp	$2,631.20
Rate for Payer: Scott and White EPO/PPO	$2,024.00
Rate for Payer: Superior Health Plan EPO	$550.53

TRNSDU DOME -- DHF

Facility

$1,351.37

Hospital Charge Code	81776700
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1,189.21

TRNSDU DOME -- DHF

Facility

$1,351.37

Hospital Charge Code	81776700
Hospital Revenue Code	270
Min. Negotiated Rate	$121.62
Max. Negotiated Rate	$878.39
Rate for Payer: Aetna Commercial	$743.25
Rate for Payer: Amerigroup CHIP/Medicaid	$121.62
Rate for Payer: BCBS of TX Blue Advantage	$405.41
Rate for Payer: BCBS of TX Blue Essentials	$486.49
Rate for Payer: BCBS of TX PPO	$540.55
Rate for Payer: Cash Price	$1,189.21
Rate for Payer: Multiplan Auto	$878.39
Rate for Payer: Multiplan Commercial	$878.39
Rate for Payer: Multiplan Workers Comp	$878.39
Rate for Payer: Scott and White EPO/PPO	$675.68
Rate for Payer: Superior Health Plan EPO	$183.79

TROCAR, BLADELESS 12 X 150MM W/OPTIVIEW TECHNOLOGY -- DHF

Facility

$921.79

Hospital Charge Code	80828171
Hospital Revenue Code	272
Min. Negotiated Rate	$82.96
Max. Negotiated Rate	$599.16
Rate for Payer: Aetna Commercial	$506.98
Rate for Payer: Amerigroup CHIP/Medicaid	$82.96
Rate for Payer: BCBS of TX Blue Advantage	$276.54
Rate for Payer: BCBS of TX Blue Essentials	$331.84
Rate for Payer: BCBS of TX PPO	$368.72
Rate for Payer: Cash Price	$811.18
Rate for Payer: Multiplan Auto	$599.16
Rate for Payer: Multiplan Commercial	$599.16
Rate for Payer: Multiplan Workers Comp	$599.16
Rate for Payer: Scott and White EPO/PPO	$460.89
Rate for Payer: Superior Health Plan EPO	$125.36

TROCAR, ENDO BLADELESS W/STABILITY SLV 5MM X 150MM -- DHF

Facility

$624.98

Hospital Charge Code	80828155
Hospital Revenue Code	272
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$406.24
Rate for Payer: Aetna Commercial	$343.74
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.49
Rate for Payer: BCBS of TX Blue Essentials	$224.99
Rate for Payer: BCBS of TX PPO	$249.99
Rate for Payer: Cash Price	$549.98
Rate for Payer: Multiplan Auto	$406.24
Rate for Payer: Multiplan Commercial	$406.24
Rate for Payer: Multiplan Workers Comp	$406.24
Rate for Payer: Scott and White EPO/PPO	$312.49
Rate for Payer: Superior Health Plan EPO	$85.00

TROCAR, ENDOPATH BLADELESS 15MM X 100MM L -- DHF

Facility

$921.79

Hospital Charge Code	80828171
Hospital Revenue Code	272
Min. Negotiated Rate	$82.96
Max. Negotiated Rate	$599.16
Rate for Payer: Aetna Commercial	$506.98
Rate for Payer: Amerigroup CHIP/Medicaid	$82.96
Rate for Payer: BCBS of TX Blue Advantage	$276.54
Rate for Payer: BCBS of TX Blue Essentials	$331.84
Rate for Payer: BCBS of TX PPO	$368.72
Rate for Payer: Cash Price	$811.18
Rate for Payer: Multiplan Auto	$599.16
Rate for Payer: Multiplan Commercial	$599.16
Rate for Payer: Multiplan Workers Comp	$599.16
Rate for Payer: Scott and White EPO/PPO	$460.89
Rate for Payer: Superior Health Plan EPO	$125.36

TROCAR, ENDOPATH BLADELESS 15MM X 100MM L -- DHF

Facility

$921.79

Hospital Charge Code	80828171
Hospital Revenue Code	272
Rate for Payer: Cash Price	$811.18

TROCAR, ENDOPATH W/BLADE BLUNT TIP 12MM X 100MM L -- DHF

Facility

$624.98

Hospital Charge Code	80828155
Hospital Revenue Code	272
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$406.24
Rate for Payer: Aetna Commercial	$343.74
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.49
Rate for Payer: BCBS of TX Blue Essentials	$224.99
Rate for Payer: BCBS of TX PPO	$249.99
Rate for Payer: Cash Price	$549.98
Rate for Payer: Multiplan Auto	$406.24
Rate for Payer: Multiplan Commercial	$406.24
Rate for Payer: Multiplan Workers Comp	$406.24
Rate for Payer: Scott and White EPO/PPO	$312.49
Rate for Payer: Superior Health Plan EPO	$85.00

TROCAR, ENDOPATH W/BLADE BLUNT TIP 12MM X 100MM L -- DHF

Facility

$624.98

Hospital Charge Code	80828155
Hospital Revenue Code	272
Rate for Payer: Cash Price	$549.98

TROCAR Kii FIRST ENTRY 5X100 CFF03

Facility

$408.60

Hospital Charge Code	81713703
Hospital Revenue Code	272
Min. Negotiated Rate	$36.77
Max. Negotiated Rate	$265.59
Rate for Payer: Aetna Commercial	$224.73
Rate for Payer: Amerigroup CHIP/Medicaid	$36.77
Rate for Payer: BCBS of TX Blue Advantage	$122.58
Rate for Payer: BCBS of TX Blue Essentials	$147.10
Rate for Payer: BCBS of TX PPO	$163.44
Rate for Payer: Cash Price	$359.57
Rate for Payer: Multiplan Auto	$265.59
Rate for Payer: Multiplan Commercial	$265.59
Rate for Payer: Multiplan Workers Comp	$265.59
Rate for Payer: Scott and White EPO/PPO	$204.30
Rate for Payer: Superior Health Plan EPO	$55.57

TROCAR Kii FIRST ENTRY 5X100 CFF03

Facility

$408.60

Hospital Charge Code	81713703
Hospital Revenue Code	272
Rate for Payer: Cash Price	$359.57

TROCAR, OPTICAL 5/11MM W/VERSAPORT TROCAR SLV DISP -- DHF

Facility

$1,645.09

Hospital Charge Code	81771909
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,447.68

TROCAR, OPTICAL 5/11MM W/VERSAPORT TROCAR SLV DISP -- DHF

Facility

$1,645.09

Hospital Charge Code	81771909
Hospital Revenue Code	272
Min. Negotiated Rate	$148.06
Max. Negotiated Rate	$1,069.31
Rate for Payer: Aetna Commercial	$904.80
Rate for Payer: Amerigroup CHIP/Medicaid	$148.06
Rate for Payer: BCBS of TX Blue Advantage	$493.53
Rate for Payer: BCBS of TX Blue Essentials	$592.23
Rate for Payer: BCBS of TX PPO	$658.04
Rate for Payer: Cash Price	$1,447.68
Rate for Payer: Multiplan Auto	$1,069.31
Rate for Payer: Multiplan Commercial	$1,069.31
Rate for Payer: Multiplan Workers Comp	$1,069.31
Rate for Payer: Scott and White EPO/PPO	$822.54
Rate for Payer: Superior Health Plan EPO	$223.73

trocar versaone optical

Facility

$92.03

Hospital Charge Code	8688549
Hospital Revenue Code	272
Rate for Payer: Cash Price	$80.99

Know your out-of-pocket cost for care.

All Charges