White Rock Medical Center

All Charges

Charge

Type

Setting

Price

TRNSCTH EMBOLIZATN

Facility

$4,048.00

Service Code	HCPCS 75894
Hospital Charge Code	4616005
Hospital Revenue Code	323
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$2,914.56
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	$2,752.64
Rate for Payer: Cash Price	$2,752.64
Rate for Payer: Cigna Medicaid	$2,914.56
Rate for Payer: Molina CHIP/Medicaid	$2,914.56
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: Parkland Medicaid	$2,914.56
Rate for Payer: Scott and White EPO/PPO	$2,024.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,914.56
Rate for Payer: Superior Health Plan EPO	$550.53

TRNSCTH EMBOLIZATN

Facility

$4,048.00

Service Code	HCPCS 75894
Hospital Charge Code	4616005
Hospital Revenue Code	323
Rate for Payer: Cash Price	$2,752.64

TRNSDU DOME -- DHF

Facility

$1,351.37

Hospital Charge Code	81776700
Hospital Revenue Code	270
Rate for Payer: Cash Price	$918.93

TRNSDU DOME -- DHF

Facility

$1,351.37

Hospital Charge Code	81776700
Hospital Revenue Code	270
Min. Negotiated Rate	$121.62
Max. Negotiated Rate	$972.99
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	$918.93
Rate for Payer: Cigna Medicaid	$972.99
Rate for Payer: Molina CHIP/Medicaid	$972.99
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: Parkland Medicaid	$972.99
Rate for Payer: Scott and White EPO/PPO	$675.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$972.99
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	$663.69
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	$626.82
Rate for Payer: Cigna Medicaid	$663.69
Rate for Payer: Molina CHIP/Medicaid	$663.69
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: Parkland Medicaid	$663.69
Rate for Payer: Scott and White EPO/PPO	$460.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$663.69
Rate for Payer: Superior Health Plan EPO	$125.36

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

Facility

$921.79

Hospital Charge Code	80828171
Hospital Revenue Code	272
Rate for Payer: Cash Price	$626.82

TROCAR ENDO 100X12MM EPTH XCL BLNT TIP H12LP

Facility

$55.38

Hospital Charge Code	993744
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.66

TROCAR ENDO 100X12MM EPTH XCL BLNT TIP H12LP

Facility

$55.38

Hospital Charge Code	993744
Hospital Revenue Code	272
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$39.87
Rate for Payer: Amerigroup CHIP/Medicaid	$4.98
Rate for Payer: BCBS of TX Blue Advantage	$16.61
Rate for Payer: BCBS of TX Blue Essentials	$19.94
Rate for Payer: BCBS of TX PPO	$22.15
Rate for Payer: Cash Price	$37.66
Rate for Payer: Cigna Medicaid	$39.87
Rate for Payer: Molina CHIP/Medicaid	$39.87
Rate for Payer: Multiplan Auto	$36.00
Rate for Payer: Multiplan Commercial	$36.00
Rate for Payer: Multiplan Workers Comp	$36.00
Rate for Payer: Parkland Medicaid	$39.87
Rate for Payer: Scott and White EPO/PPO	$27.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.87
Rate for Payer: Superior Health Plan EPO	$7.53

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

Facility

$624.98

Hospital Charge Code	80828155
Hospital Revenue Code	272
Rate for Payer: Cash Price	$424.99

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	$449.99
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	$424.99
Rate for Payer: Cigna Medicaid	$449.99
Rate for Payer: Molina CHIP/Medicaid	$449.99
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: Parkland Medicaid	$449.99
Rate for Payer: Scott and White EPO/PPO	$312.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$449.99
Rate for Payer: Superior Health Plan EPO	$85.00

TROCAR, ENDOPATH XCEL, BLADELESS, 12MM

Facility

$110.77

Hospital Charge Code	992806
Hospital Revenue Code	272
Min. Negotiated Rate	$9.97
Max. Negotiated Rate	$79.75
Rate for Payer: Amerigroup CHIP/Medicaid	$9.97
Rate for Payer: BCBS of TX Blue Advantage	$33.23
Rate for Payer: BCBS of TX Blue Essentials	$39.88
Rate for Payer: BCBS of TX PPO	$44.31
Rate for Payer: Cash Price	$75.32
Rate for Payer: Cigna Medicaid	$79.75
Rate for Payer: Molina CHIP/Medicaid	$79.75
Rate for Payer: Multiplan Auto	$72.00
Rate for Payer: Multiplan Commercial	$72.00
Rate for Payer: Multiplan Workers Comp	$72.00
Rate for Payer: Parkland Medicaid	$79.75
Rate for Payer: Scott and White EPO/PPO	$55.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.75
Rate for Payer: Superior Health Plan EPO	$15.06

TROCAR, ENDOPATH XCEL, BLADELESS, 12MM

Facility

$110.77

Hospital Charge Code	992806
Hospital Revenue Code	272
Rate for Payer: Cash Price	$75.32

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	$294.19
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	$277.85
Rate for Payer: Cigna Medicaid	$294.19
Rate for Payer: Molina CHIP/Medicaid	$294.19
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: Parkland Medicaid	$294.19
Rate for Payer: Scott and White EPO/PPO	$204.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$294.19
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	$277.85

TROCAR LAPSCP 100X15MM EPTH XCL BLDLS

Facility

$231.17

Hospital Charge Code	992871
Hospital Revenue Code	272
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$166.44
Rate for Payer: Amerigroup CHIP/Medicaid	$20.81
Rate for Payer: BCBS of TX Blue Advantage	$69.35
Rate for Payer: BCBS of TX Blue Essentials	$83.22
Rate for Payer: BCBS of TX PPO	$92.47
Rate for Payer: Cash Price	$157.20
Rate for Payer: Cigna Medicaid	$166.44
Rate for Payer: Molina CHIP/Medicaid	$166.44
Rate for Payer: Multiplan Auto	$150.26
Rate for Payer: Multiplan Commercial	$150.26
Rate for Payer: Multiplan Workers Comp	$150.26
Rate for Payer: Parkland Medicaid	$166.44
Rate for Payer: Scott and White EPO/PPO	$115.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$166.44
Rate for Payer: Superior Health Plan EPO	$31.44

TROCAR LAPSCP 100X15MM EPTH XCL BLDLS

Facility

$231.17

Hospital Charge Code	992871
Hospital Revenue Code	272
Rate for Payer: Cash Price	$157.20

TROCAR LAPSCP FRST ENTRY KII FIOS 100X5MM

Facility

$249.70

Hospital Charge Code	992594
Hospital Revenue Code	270
Min. Negotiated Rate	$22.47
Max. Negotiated Rate	$179.78
Rate for Payer: Amerigroup CHIP/Medicaid	$22.47
Rate for Payer: BCBS of TX Blue Advantage	$74.91
Rate for Payer: BCBS of TX Blue Essentials	$89.89
Rate for Payer: BCBS of TX PPO	$99.88
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cigna Medicaid	$179.78
Rate for Payer: Molina CHIP/Medicaid	$179.78
Rate for Payer: Multiplan Auto	$162.31
Rate for Payer: Multiplan Commercial	$162.31
Rate for Payer: Multiplan Workers Comp	$162.31
Rate for Payer: Parkland Medicaid	$179.78
Rate for Payer: Scott and White EPO/PPO	$124.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.78
Rate for Payer: Superior Health Plan EPO	$33.96

TROCAR LAPSCP FRST ENTRY KII FIOS 100X5MM

Facility

$249.70

Hospital Charge Code	992594
Hospital Revenue Code	270
Rate for Payer: Cash Price	$169.80

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	$1,184.46
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	$1,118.66
Rate for Payer: Cigna Medicaid	$1,184.46
Rate for Payer: Molina CHIP/Medicaid	$1,184.46
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: Parkland Medicaid	$1,184.46
Rate for Payer: Scott and White EPO/PPO	$822.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,184.46
Rate for Payer: Superior Health Plan EPO	$223.73

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	$1,118.66

TROCAR TITAM 5MM STNDRD

Facility

$272.40

Hospital Charge Code	146659
Hospital Revenue Code	272
Min. Negotiated Rate	$24.52
Max. Negotiated Rate	$196.13
Rate for Payer: Amerigroup CHIP/Medicaid	$24.52
Rate for Payer: BCBS of TX Blue Advantage	$81.72
Rate for Payer: BCBS of TX Blue Essentials	$98.06
Rate for Payer: BCBS of TX PPO	$108.96
Rate for Payer: Cash Price	$185.23
Rate for Payer: Cigna Medicaid	$196.13
Rate for Payer: Molina CHIP/Medicaid	$196.13
Rate for Payer: Multiplan Auto	$177.06
Rate for Payer: Multiplan Commercial	$177.06
Rate for Payer: Multiplan Workers Comp	$177.06
Rate for Payer: Parkland Medicaid	$196.13
Rate for Payer: Scott and White EPO/PPO	$136.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$196.13
Rate for Payer: Superior Health Plan EPO	$37.05

TROCAR TITAM 5MM STNDRD

Facility

$272.40

Hospital Charge Code	146659
Hospital Revenue Code	272
Rate for Payer: Cash Price	$185.23

TROCAR VERSAONE 5MM UNIVERSAL STD

Facility

$41.71

Hospital Charge Code	992838
Hospital Revenue Code	272
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$30.03
Rate for Payer: Amerigroup CHIP/Medicaid	$3.75
Rate for Payer: BCBS of TX Blue Advantage	$12.51
Rate for Payer: BCBS of TX Blue Essentials	$15.02
Rate for Payer: BCBS of TX PPO	$16.68
Rate for Payer: Cash Price	$28.36
Rate for Payer: Cigna Medicaid	$30.03
Rate for Payer: Molina CHIP/Medicaid	$30.03
Rate for Payer: Multiplan Auto	$27.11
Rate for Payer: Multiplan Commercial	$27.11
Rate for Payer: Multiplan Workers Comp	$27.11
Rate for Payer: Parkland Medicaid	$30.03
Rate for Payer: Scott and White EPO/PPO	$20.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.03
Rate for Payer: Superior Health Plan EPO	$5.67

TROCAR VERSAONE 5MM UNIVERSAL STD

Facility

$41.71

Hospital Charge Code	992838
Hospital Revenue Code	272
Rate for Payer: Cash Price	$28.36

trocar versaone optical

Facility

$92.03

Hospital Charge Code	8688549
Hospital Revenue Code	272
Rate for Payer: Cash Price	$62.58

Know your out-of-pocket cost for care.

All Charges