White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$82.27

Hospital Charge Code	81622953
Hospital Revenue Code	272
Rate for Payer: Cash Price	$72.40

DRAPE, U-SHAPED 47 1/8'''' X 51 1/6'''' -- DHF

Facility

$713.18

Hospital Charge Code	81623852
Hospital Revenue Code	272
Min. Negotiated Rate	$64.19
Max. Negotiated Rate	$463.57
Rate for Payer: Aetna Commercial	$392.25
Rate for Payer: Amerigroup CHIP/Medicaid	$64.19
Rate for Payer: BCBS of TX Blue Advantage	$213.95
Rate for Payer: BCBS of TX Blue Essentials	$256.74
Rate for Payer: BCBS of TX PPO	$285.27
Rate for Payer: Cash Price	$627.60
Rate for Payer: Multiplan Auto	$463.57
Rate for Payer: Multiplan Commercial	$463.57
Rate for Payer: Multiplan Workers Comp	$463.57
Rate for Payer: Scott and White EPO/PPO	$356.59
Rate for Payer: Superior Health Plan EPO	$96.99

DRAPE, U-SHAPED 76'''' X 120'''' W/SPLIT & TUBE HOLDERS -- DHF

Facility

$713.18

Hospital Charge Code	81623852
Hospital Revenue Code	272
Min. Negotiated Rate	$64.19
Max. Negotiated Rate	$463.57
Rate for Payer: Aetna Commercial	$392.25
Rate for Payer: Amerigroup CHIP/Medicaid	$64.19
Rate for Payer: BCBS of TX Blue Advantage	$213.95
Rate for Payer: BCBS of TX Blue Essentials	$256.74
Rate for Payer: BCBS of TX PPO	$285.27
Rate for Payer: Cash Price	$627.60
Rate for Payer: Multiplan Auto	$463.57
Rate for Payer: Multiplan Commercial	$463.57
Rate for Payer: Multiplan Workers Comp	$463.57
Rate for Payer: Scott and White EPO/PPO	$356.59
Rate for Payer: Superior Health Plan EPO	$96.99

DRAPE, U-SHAPED 76'''' X 120'''' W/SPLIT & TUBE HOLDERS -- DHF

Facility

$713.18

Hospital Charge Code	81623852
Hospital Revenue Code	272
Rate for Payer: Cash Price	$627.60

DRESSING, 3'' X 3'' STERILE 1'S -- DHF

Facility

$45.82

Hospital Charge Code	80243504
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna Commercial	$25.20
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$40.32
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan EPO	$6.23

DRESSING, 3'' X 3'' STERILE 1'S -- DHF

Facility

$45.82

Hospital Charge Code	80243504
Hospital Revenue Code	270
Rate for Payer: Cash Price	$40.32

DRESSING, 3'''' X 8'''' STERILE 3'S -- DHF

Facility

$147.62

Hospital Charge Code	80246556
Hospital Revenue Code	270
Rate for Payer: Cash Price	$129.91

DRESSING, 3'''' X 8'''' STERILE 3'S -- DHF

Facility

$147.62

Hospital Charge Code	80246556
Hospital Revenue Code	270
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

DRESSING, ADHESIVE 'PRIMAPORE 10' 11 3/4'''' X 4'''' STR -- DHF

Facility

$96.69

Hospital Charge Code	80243306
Hospital Revenue Code	272
Min. Negotiated Rate	$8.70
Max. Negotiated Rate	$62.85
Rate for Payer: Aetna Commercial	$53.18
Rate for Payer: Amerigroup CHIP/Medicaid	$8.70
Rate for Payer: BCBS of TX Blue Advantage	$29.01
Rate for Payer: BCBS of TX Blue Essentials	$34.81
Rate for Payer: BCBS of TX PPO	$38.68
Rate for Payer: Cash Price	$85.09
Rate for Payer: Multiplan Auto	$62.85
Rate for Payer: Multiplan Commercial	$62.85
Rate for Payer: Multiplan Workers Comp	$62.85
Rate for Payer: Scott and White EPO/PPO	$48.34
Rate for Payer: Superior Health Plan EPO	$13.15

dressing aquacel adv

Facility

$32.42

Hospital Charge Code	8720599
Hospital Revenue Code	270
Rate for Payer: Cash Price	$28.53

dressing aquacel adv

Facility

$32.42

Hospital Charge Code	8720599
Hospital Revenue Code	270
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$21.07
Rate for Payer: Aetna Commercial	$17.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2.92
Rate for Payer: BCBS of TX Blue Advantage	$9.73
Rate for Payer: BCBS of TX Blue Essentials	$11.67
Rate for Payer: BCBS of TX PPO	$12.97
Rate for Payer: Cash Price	$28.53
Rate for Payer: Multiplan Auto	$21.07
Rate for Payer: Multiplan Commercial	$21.07
Rate for Payer: Multiplan Workers Comp	$21.07
Rate for Payer: Scott and White EPO/PPO	$16.21
Rate for Payer: Superior Health Plan EPO	$4.41

DRESSING AQUACEL HYDROCOLLOIDAL

Facility

$129.98

Service Code	HCPCS A6237
Hospital Charge Code	8428489
Hospital Revenue Code	272
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$84.49
Rate for Payer: Aetna Commercial	$71.49
Rate for Payer: Amerigroup CHIP/Medicaid	$11.70
Rate for Payer: BCBS of TX Blue Advantage	$13.33
Rate for Payer: BCBS of TX Blue Essentials	$15.99
Rate for Payer: BCBS of TX PPO	$17.74
Rate for Payer: Cash Price	$114.38
Rate for Payer: Cash Price	$114.38
Rate for Payer: Multiplan Auto	$84.49
Rate for Payer: Multiplan Commercial	$84.49
Rate for Payer: Multiplan Workers Comp	$84.49
Rate for Payer: Scott and White EPO/PPO	$64.99
Rate for Payer: Superior Health Plan EPO	$17.68

DRESSING AQUACEL HYDROCOLLOIDAL

Facility

$129.98

Service Code	HCPCS A6237
Hospital Charge Code	8428489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$114.38

DRESSING, CALCIUM ALGINATE SILVER 4''''X4.75'''' STER -- DHF

Facility

$183.92

Hospital Charge Code	80249642
Hospital Revenue Code	270
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$119.55
Rate for Payer: Aetna Commercial	$101.16
Rate for Payer: Amerigroup CHIP/Medicaid	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$55.18
Rate for Payer: BCBS of TX Blue Essentials	$66.21
Rate for Payer: BCBS of TX PPO	$73.57
Rate for Payer: Cash Price	$161.85
Rate for Payer: Multiplan Auto	$119.55
Rate for Payer: Multiplan Commercial	$119.55
Rate for Payer: Multiplan Workers Comp	$119.55
Rate for Payer: Scott and White EPO/PPO	$91.96
Rate for Payer: Superior Health Plan EPO	$25.01

DRESSING, CALCIUM ALGINATE SILVER 4''''X4.75'''' STER -- DHF

Facility

$183.92

Hospital Charge Code	80249642
Hospital Revenue Code	270
Rate for Payer: Cash Price	$161.85

DRESSING, CLOSURE SKIN 1/2'''' X 4'''' -- DHF

Facility

$55.15

Hospital Charge Code	81850554
Hospital Revenue Code	272
Rate for Payer: Cash Price	$48.53

DRESSING, CLOSURE SKIN 1/2'''' X 4'''' -- DHF

Facility

$55.15

Hospital Charge Code	81850554
Hospital Revenue Code	272
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$35.85
Rate for Payer: Aetna Commercial	$30.33
Rate for Payer: Amerigroup CHIP/Medicaid	$4.96
Rate for Payer: BCBS of TX Blue Advantage	$16.54
Rate for Payer: BCBS of TX Blue Essentials	$19.85
Rate for Payer: BCBS of TX PPO	$22.06
Rate for Payer: Cash Price	$48.53
Rate for Payer: Multiplan Auto	$35.85
Rate for Payer: Multiplan Commercial	$35.85
Rate for Payer: Multiplan Workers Comp	$35.85
Rate for Payer: Scott and White EPO/PPO	$27.58
Rate for Payer: Superior Health Plan EPO	$7.50

DRESSING, COMBINE 4'''' X 7 7/8'''' STERILE -- DHF

Facility

$9.12

Hospital Charge Code	80243058
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.03

DRESSING, COMBINE 4'''' X 7 7/8'''' STERILE -- DHF

Facility

$9.12

Hospital Charge Code	80243058
Hospital Revenue Code	270
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$5.93
Rate for Payer: Aetna Commercial	$5.02
Rate for Payer: Amerigroup CHIP/Medicaid	$0.82
Rate for Payer: BCBS of TX Blue Advantage	$2.74
Rate for Payer: BCBS of TX Blue Essentials	$3.28
Rate for Payer: BCBS of TX PPO	$3.65
Rate for Payer: Cash Price	$8.03
Rate for Payer: Multiplan Auto	$5.93
Rate for Payer: Multiplan Commercial	$5.93
Rate for Payer: Multiplan Workers Comp	$5.93
Rate for Payer: Scott and White EPO/PPO	$4.56
Rate for Payer: Superior Health Plan EPO	$1.24

Dressing/Debridement Burns, Small

Facility

$413.00

Service Code	CPT 16020
Hospital Charge Code	7150819
Hospital Revenue Code	761
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$440.32
Rate for Payer: Aetna Commercial	$227.15
Rate for Payer: Aetna Medicare	$274.64
Rate for Payer: Amerigroup CHIP/Medicaid	$37.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$183.09
Rate for Payer: Amerigroup Medicare	$183.09
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$183.09
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cash Price	$363.44
Rate for Payer: Cigna Commercial	$414.75
Rate for Payer: Cigna Medicaid	$44.31
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	$44.31
Rate for Payer: Molina Dual Medicare/Medicaid	$183.09
Rate for Payer: Molina Medicare	$183.09
Rate for Payer: Multiplan Auto	$268.45
Rate for Payer: Multiplan Commercial	$268.45
Rate for Payer: Multiplan Workers Comp	$268.45
Rate for Payer: Parkland Medicaid	$44.31
Rate for Payer: Scott and White EPO/PPO	$3.27
Rate for Payer: Scott and White Medicare	$183.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$44.31
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

DRESSING, ENDOFORM 2X2 529312

Facility

$47.71

Service Code	HCPCS A6021
Hospital Charge Code	8570491
Hospital Revenue Code	272
Rate for Payer: Cash Price	$41.98

DRESSING, ENDOFORM 2X2 529312

Facility

$47.71

Service Code	HCPCS A6021
Hospital Charge Code	8570491
Hospital Revenue Code	272
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$47.13
Rate for Payer: Aetna Commercial	$26.24
Rate for Payer: Amerigroup CHIP/Medicaid	$4.29
Rate for Payer: BCBS of TX Blue Advantage	$35.41
Rate for Payer: BCBS of TX Blue Essentials	$42.49
Rate for Payer: BCBS of TX PPO	$47.13
Rate for Payer: Cash Price	$41.98
Rate for Payer: Cash Price	$41.98
Rate for Payer: Multiplan Auto	$31.01
Rate for Payer: Multiplan Commercial	$31.01
Rate for Payer: Multiplan Workers Comp	$31.01
Rate for Payer: Scott and White EPO/PPO	$23.86
Rate for Payer: Superior Health Plan EPO	$6.49

DRESSING EX-IO ADHESIVE

Facility

$81.72

Hospital Charge Code	8612539
Hospital Revenue Code	272
Rate for Payer: Cash Price	$71.91

DRESSING EX-IO ADHESIVE

Facility

$81.72

Hospital Charge Code	8612539
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

DRESSING, GAUZE 12-PLY 4'''' X 4'''' (10'S) STERILE TRAY -- DHF

Facility

$36.69

Hospital Charge Code	80245152
Hospital Revenue Code	272
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$23.85
Rate for Payer: Aetna Commercial	$20.18
Rate for Payer: Amerigroup CHIP/Medicaid	$3.30
Rate for Payer: BCBS of TX Blue Advantage	$11.01
Rate for Payer: BCBS of TX Blue Essentials	$13.21
Rate for Payer: BCBS of TX PPO	$14.68
Rate for Payer: Cash Price	$32.29
Rate for Payer: Multiplan Auto	$23.85
Rate for Payer: Multiplan Commercial	$23.85
Rate for Payer: Multiplan Workers Comp	$23.85
Rate for Payer: Scott and White EPO/PPO	$18.34
Rate for Payer: Superior Health Plan EPO	$4.99

Know your out-of-pocket cost for care.

All Charges