White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Drainage of finger abscess simple

Facility

$10,000.00

Service Code	CPT 26010
Hospital Charge Code	36026010
Hospital Revenue Code	360
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$74.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$147.44
Rate for Payer: BCBS of TX Blue Essentials	$176.58
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$222.49
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$74.34
Rate for Payer: Cigna Medicare	$183.09
Rate for Payer: Employer Direct Commercial	$183.09
Rate for Payer: Humana Medicare/TRICARE	$183.09
Rate for Payer: Molina CHIP/Medicaid	$74.34
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
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	$74.34
Rate for Payer: Scott and White EPO/PPO	$4.04
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$74.34
Rate for Payer: Superior Health Plan EPO	$183.09
Rate for Payer: Superior Health Plan Medicare	$183.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$183.09
Rate for Payer: Universal American Medicare	$183.09
Rate for Payer: Wellcare Medicare	$183.09
Rate for Payer: Wellmed Medicare	$183.09

Drainage of palmar bursa; single, bursa

Facility

$10,000.00

Service Code	CPT 26025
Hospital Charge Code	36026025
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
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	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

DRAIN, PENROSE X-RAY 12'''' X 1/2'''' STERILE LATEX -- DHF

Facility

$41.57

Hospital Charge Code	81821159
Hospital Revenue Code	272
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$27.02
Rate for Payer: Aetna Commercial	$22.86
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$36.58
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Scott and White EPO/PPO	$20.78
Rate for Payer: Superior Health Plan EPO	$5.65

DRAIN, PENROSE X-RAY 12'''' X 1/4'''' LATEX STERILE -- DHF

Facility

$41.57

Hospital Charge Code	81821159
Hospital Revenue Code	272
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$27.02
Rate for Payer: Aetna Commercial	$22.86
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$36.58
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Scott and White EPO/PPO	$20.78
Rate for Payer: Superior Health Plan EPO	$5.65

DRAIN, SILICONE ROUND 3/4 FLUT 19FR & 3/16'''' TROCAR -- DHF

Facility

$83.23

Hospital Charge Code	81820649
Hospital Revenue Code	272
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$54.10
Rate for Payer: Aetna Commercial	$45.78
Rate for Payer: Amerigroup CHIP/Medicaid	$7.49
Rate for Payer: BCBS of TX Blue Advantage	$24.97
Rate for Payer: BCBS of TX Blue Essentials	$29.96
Rate for Payer: BCBS of TX PPO	$33.29
Rate for Payer: Cash Price	$73.24
Rate for Payer: Multiplan Auto	$54.10
Rate for Payer: Multiplan Commercial	$54.10
Rate for Payer: Multiplan Workers Comp	$54.10
Rate for Payer: Scott and White EPO/PPO	$41.62
Rate for Payer: Superior Health Plan EPO	$11.32

DRAIN, SILICONE ROUND HUBLESS 15FR & 3/16'''' TROCAR -- DHF

Facility

$83.23

Hospital Charge Code	81820649
Hospital Revenue Code	272
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$54.10
Rate for Payer: Aetna Commercial	$45.78
Rate for Payer: Amerigroup CHIP/Medicaid	$7.49
Rate for Payer: BCBS of TX Blue Advantage	$24.97
Rate for Payer: BCBS of TX Blue Essentials	$29.96
Rate for Payer: BCBS of TX PPO	$33.29
Rate for Payer: Cash Price	$73.24
Rate for Payer: Multiplan Auto	$54.10
Rate for Payer: Multiplan Commercial	$54.10
Rate for Payer: Multiplan Workers Comp	$54.10
Rate for Payer: Scott and White EPO/PPO	$41.62
Rate for Payer: Superior Health Plan EPO	$11.32

DRAIN, SILICONE ROUND HUBLESS 15FR & 3/16'''' TROCAR -- DHF

Facility

$83.23

Hospital Charge Code	81820649
Hospital Revenue Code	272
Rate for Payer: Cash Price	$73.24

drape arm dv xi

Facility

$236.08

Hospital Charge Code	8690509
Hospital Revenue Code	270
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$153.45
Rate for Payer: Aetna Commercial	$129.84
Rate for Payer: Amerigroup CHIP/Medicaid	$21.25
Rate for Payer: BCBS of TX Blue Advantage	$70.82
Rate for Payer: BCBS of TX Blue Essentials	$84.99
Rate for Payer: BCBS of TX PPO	$94.43
Rate for Payer: Cash Price	$207.75
Rate for Payer: Multiplan Auto	$153.45
Rate for Payer: Multiplan Commercial	$153.45
Rate for Payer: Multiplan Workers Comp	$153.45
Rate for Payer: Scott and White EPO/PPO	$118.04
Rate for Payer: Superior Health Plan EPO	$32.11

drape arm dv xi

Facility

$236.08

Hospital Charge Code	8690509
Hospital Revenue Code	270
Rate for Payer: Cash Price	$207.75

DRAPE C-ARMOR

Facility

$205.25

Hospital Charge Code	8514475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$180.62

DRAPE C-ARMOR

Facility

$205.25

Hospital Charge Code	8514475
Hospital Revenue Code	272
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$133.41
Rate for Payer: Aetna Commercial	$112.89
Rate for Payer: Amerigroup CHIP/Medicaid	$18.47
Rate for Payer: BCBS of TX Blue Advantage	$61.58
Rate for Payer: BCBS of TX Blue Essentials	$73.89
Rate for Payer: BCBS of TX PPO	$82.10
Rate for Payer: Cash Price	$180.62
Rate for Payer: Multiplan Auto	$133.41
Rate for Payer: Multiplan Commercial	$133.41
Rate for Payer: Multiplan Workers Comp	$133.41
Rate for Payer: Scott and White EPO/PPO	$102.62
Rate for Payer: Superior Health Plan EPO	$27.91

DRAPE COLUMN DV XI

Facility

$81.72

Hospital Charge Code	8690514
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$53.12
Rate for Payer: Aetna Commercial	$44.95
Rate for Payer: Amerigroup CHIP/Medicaid	$7.35
Rate for Payer: BCBS of TX Blue Advantage	$24.52
Rate for Payer: BCBS of TX Blue Essentials	$29.42
Rate for Payer: BCBS of TX PPO	$32.69
Rate for Payer: Cash Price	$71.91
Rate for Payer: Multiplan Auto	$53.12
Rate for Payer: Multiplan Commercial	$53.12
Rate for Payer: Multiplan Workers Comp	$53.12
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan EPO	$11.11

DRAPE COLUMN DV XI

Facility

$81.72

Hospital Charge Code	8690514
Hospital Revenue Code	272
Rate for Payer: Cash Price	$71.91

DRAPE, POUCH INSTRUMENT 7'''' X 11 3/4'''' -- DHF

Facility

$147.62

Hospital Charge Code	81623902
Hospital Revenue Code	272
Rate for Payer: Cash Price	$129.91

DRAPE, POUCH INSTRUMENT 7'''' X 11 3/4'''' -- DHF

Facility

$147.62

Hospital Charge Code	81623902
Hospital Revenue Code	272
Min. Negotiated Rate	$13.29
Max. Negotiated Rate	$95.95
Rate for Payer: Aetna Commercial	$81.19
Rate for Payer: Amerigroup CHIP/Medicaid	$13.29
Rate for Payer: BCBS of TX Blue Advantage	$44.29
Rate for Payer: BCBS of TX Blue Essentials	$53.14
Rate for Payer: BCBS of TX PPO	$59.05
Rate for Payer: Cash Price	$129.91
Rate for Payer: Multiplan Auto	$95.95
Rate for Payer: Multiplan Commercial	$95.95
Rate for Payer: Multiplan Workers Comp	$95.95
Rate for Payer: Scott and White EPO/PPO	$73.81
Rate for Payer: Superior Health Plan EPO	$20.08

drape robot rosa unit

Facility

$227.00

Hospital Charge Code	8702505
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$147.55
Rate for Payer: Aetna Commercial	$124.85
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$199.76
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan EPO	$30.87

drape robot rosa unit

Facility

$227.00

Hospital Charge Code	8702505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$199.76

DRAPE, SKIN PREP 23'''' X 17'''' -- DHF

Facility

$28.58

Hospital Charge Code	81621138
Hospital Revenue Code	272
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$18.58
Rate for Payer: Aetna Commercial	$15.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2.57
Rate for Payer: BCBS of TX Blue Advantage	$8.57
Rate for Payer: BCBS of TX Blue Essentials	$10.29
Rate for Payer: BCBS of TX PPO	$11.43
Rate for Payer: Cash Price	$25.15
Rate for Payer: Multiplan Auto	$18.58
Rate for Payer: Multiplan Commercial	$18.58
Rate for Payer: Multiplan Workers Comp	$18.58
Rate for Payer: Scott and White EPO/PPO	$14.29
Rate for Payer: Superior Health Plan EPO	$3.89

DRAPE, SKIN PREP 23'''' X 17'''' -- DHF

Facility

$28.58

Hospital Charge Code	81621138
Hospital Revenue Code	272
Rate for Payer: Cash Price	$25.15

DRAPE, SKIN PREP 23'''' X 33'''' -- DHF

Facility

$744.93

Hospital Charge Code	81622300
Hospital Revenue Code	272
Rate for Payer: Cash Price	$655.54

DRAPE, SKIN PREP 23'''' X 33'''' -- DHF

Facility

$744.93

Hospital Charge Code	81622300
Hospital Revenue Code	272
Min. Negotiated Rate	$67.04
Max. Negotiated Rate	$484.20
Rate for Payer: Aetna Commercial	$409.71
Rate for Payer: Amerigroup CHIP/Medicaid	$67.04
Rate for Payer: BCBS of TX Blue Advantage	$223.48
Rate for Payer: BCBS of TX Blue Essentials	$268.17
Rate for Payer: BCBS of TX PPO	$297.97
Rate for Payer: Cash Price	$655.54
Rate for Payer: Multiplan Auto	$484.20
Rate for Payer: Multiplan Commercial	$484.20
Rate for Payer: Multiplan Workers Comp	$484.20
Rate for Payer: Scott and White EPO/PPO	$372.46
Rate for Payer: Superior Health Plan EPO	$101.31

DRAPE, SKIN PREP ISOLATION 129 1/2'''' X 99 1/2'''' -- DHF

Facility

$266.40

Hospital Charge Code	81623704
Hospital Revenue Code	272
Min. Negotiated Rate	$23.98
Max. Negotiated Rate	$173.16
Rate for Payer: Aetna Commercial	$146.52
Rate for Payer: Amerigroup CHIP/Medicaid	$23.98
Rate for Payer: BCBS of TX Blue Advantage	$79.92
Rate for Payer: BCBS of TX Blue Essentials	$95.90
Rate for Payer: BCBS of TX PPO	$106.56
Rate for Payer: Cash Price	$234.43
Rate for Payer: Multiplan Auto	$173.16
Rate for Payer: Multiplan Commercial	$173.16
Rate for Payer: Multiplan Workers Comp	$173.16
Rate for Payer: Scott and White EPO/PPO	$133.20
Rate for Payer: Superior Health Plan EPO	$36.23

DRAPE, SLUSH WARMER 52'''' X 66'''' -- DHF

Facility

$266.40

Hospital Charge Code	81623704
Hospital Revenue Code	272
Min. Negotiated Rate	$23.98
Max. Negotiated Rate	$173.16
Rate for Payer: Aetna Commercial	$146.52
Rate for Payer: Amerigroup CHIP/Medicaid	$23.98
Rate for Payer: BCBS of TX Blue Advantage	$79.92
Rate for Payer: BCBS of TX Blue Essentials	$95.90
Rate for Payer: BCBS of TX PPO	$106.56
Rate for Payer: Cash Price	$234.43
Rate for Payer: Multiplan Auto	$173.16
Rate for Payer: Multiplan Commercial	$173.16
Rate for Payer: Multiplan Workers Comp	$173.16
Rate for Payer: Scott and White EPO/PPO	$133.20
Rate for Payer: Superior Health Plan EPO	$36.23

DRAPE, SLUSH WARMER 52'''' X 66'''' -- DHF

Facility

$266.40

Hospital Charge Code	81623704
Hospital Revenue Code	272
Rate for Payer: Cash Price	$234.43

DRAPE, UNDER BUTTOCKS W/FLUID COLL POUCH 40'''' X 44'''' -- DHF

Facility

$82.27

Hospital Charge Code	81622953
Hospital Revenue Code	272
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$53.48
Rate for Payer: Aetna Commercial	$45.25
Rate for Payer: Amerigroup CHIP/Medicaid	$7.40
Rate for Payer: BCBS of TX Blue Advantage	$24.68
Rate for Payer: BCBS of TX Blue Essentials	$29.62
Rate for Payer: BCBS of TX PPO	$32.91
Rate for Payer: Cash Price	$72.40
Rate for Payer: Multiplan Auto	$53.48
Rate for Payer: Multiplan Commercial	$53.48
Rate for Payer: Multiplan Workers Comp	$53.48
Rate for Payer: Scott and White EPO/PPO	$41.14
Rate for Payer: Superior Health Plan EPO	$11.19

Know your out-of-pocket cost for care.

All Charges