White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRESSING, GAUZE 12-PLY 4'''' X 4'''' (2'S) STER -- DHF

Facility

$14.01

Hospital Charge Code	80245251
Hospital Revenue Code	272
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$9.11
Rate for Payer: Aetna Commercial	$7.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1.26
Rate for Payer: BCBS of TX Blue Advantage	$4.20
Rate for Payer: BCBS of TX Blue Essentials	$5.04
Rate for Payer: BCBS of TX PPO	$5.60
Rate for Payer: Cash Price	$12.33
Rate for Payer: Multiplan Auto	$9.11
Rate for Payer: Multiplan Commercial	$9.11
Rate for Payer: Multiplan Workers Comp	$9.11
Rate for Payer: Scott and White EPO/PPO	$7.00
Rate for Payer: Superior Health Plan EPO	$1.91

DRESSING, GAUZE 12-PLY 4'''' X 4'''' (2'S) STER -- DHF

Facility

$14.01

Hospital Charge Code	80245251
Hospital Revenue Code	272
Rate for Payer: Cash Price	$12.33

DRESSING, GAUZE 8-PLY 2'''' X 2'''' (2'S) STER -- DHF

Facility

$4.69

Hospital Charge Code	80244957
Hospital Revenue Code	272
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$3.05
Rate for Payer: Aetna Commercial	$2.58
Rate for Payer: Amerigroup CHIP/Medicaid	$0.42
Rate for Payer: BCBS of TX Blue Advantage	$1.41
Rate for Payer: BCBS of TX Blue Essentials	$1.69
Rate for Payer: BCBS of TX PPO	$1.88
Rate for Payer: Cash Price	$4.13
Rate for Payer: Multiplan Auto	$3.05
Rate for Payer: Multiplan Commercial	$3.05
Rate for Payer: Multiplan Workers Comp	$3.05
Rate for Payer: Scott and White EPO/PPO	$2.34
Rate for Payer: Superior Health Plan EPO	$0.64

DRESSING, GAUZE 8-PLY 2'''' X 2'''' (2'S) STER -- DHF

Facility

$4.69

Hospital Charge Code	80244957
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.13

DRESSING, GAUZE DRAIN 6-PLY 4'''' X 4'''' (2'S) STER -- DHF

Facility

$41.57

Hospital Charge Code	80248305
Hospital Revenue Code	270
Rate for Payer: Cash Price	$36.58

DRESSING, GAUZE DRAIN 6-PLY 4'''' X 4'''' (2'S) STER -- DHF

Facility

$41.57

Hospital Charge Code	80248305
Hospital Revenue Code	270
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

DRESSING, GAUZE PETROLATUM XEROFORM LTX FR 1'''' X 8'''' -- DHF

Facility

$50.69

Hospital Charge Code	80246705
Hospital Revenue Code	270
Rate for Payer: Cash Price	$44.61

DRESSING, GAUZE PETROLATUM XEROFORM LTX FR 1'''' X 8'''' -- DHF

Facility

$50.69

Hospital Charge Code	80246705
Hospital Revenue Code	270
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$32.95
Rate for Payer: Aetna Commercial	$27.88
Rate for Payer: Amerigroup CHIP/Medicaid	$4.56
Rate for Payer: BCBS of TX Blue Advantage	$15.21
Rate for Payer: BCBS of TX Blue Essentials	$18.25
Rate for Payer: BCBS of TX PPO	$20.28
Rate for Payer: Cash Price	$44.61
Rate for Payer: Multiplan Auto	$32.95
Rate for Payer: Multiplan Commercial	$32.95
Rate for Payer: Multiplan Workers Comp	$32.95
Rate for Payer: Scott and White EPO/PPO	$25.34
Rate for Payer: Superior Health Plan EPO	$6.89

DRESSING, GAUZE WOVEN 6'''' X 6 3/4'''' (5'S) STERILE -- DHF

Facility

$64.05

Hospital Charge Code	80244551
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$41.63
Rate for Payer: Aetna Commercial	$35.23
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$19.22
Rate for Payer: BCBS of TX Blue Essentials	$23.06
Rate for Payer: BCBS of TX PPO	$25.62
Rate for Payer: Cash Price	$56.36
Rate for Payer: Multiplan Auto	$41.63
Rate for Payer: Multiplan Commercial	$41.63
Rate for Payer: Multiplan Workers Comp	$41.63
Rate for Payer: Scott and White EPO/PPO	$32.02
Rate for Payer: Superior Health Plan EPO	$8.71

DRESSING, GAUZE WOVEN 6'''' X 6 3/4'''' (5'S) STERILE -- DHF

Facility

$64.05

Hospital Charge Code	80244551
Hospital Revenue Code	270
Rate for Payer: Cash Price	$56.36

DRESSING, GAUZE X-RAY 16-PLY 4'''' X 4'''' 10'S STERILE -- DHF

Facility

$36.69

Hospital Charge Code	80245152
Hospital Revenue Code	272
Rate for Payer: Cash Price	$32.29

DRESSING, GAUZE X-RAY 16-PLY 4'''' X 4'''' 10'S STERILE -- 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

Dressing island medpor 3.6x12

Facility

$4.35

Hospital Charge Code	8602526
Hospital Revenue Code	272
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: Amerigroup CHIP/Medicaid	$0.39
Rate for Payer: BCBS of TX Blue Advantage	$1.30
Rate for Payer: BCBS of TX Blue Essentials	$1.57
Rate for Payer: BCBS of TX PPO	$1.74
Rate for Payer: Cash Price	$3.83
Rate for Payer: Multiplan Auto	$2.83
Rate for Payer: Multiplan Commercial	$2.83
Rate for Payer: Multiplan Workers Comp	$2.83
Rate for Payer: Scott and White EPO/PPO	$2.18
Rate for Payer: Superior Health Plan EPO	$0.59

Dressing island medpor 3.6x12

Facility

$4.35

Hospital Charge Code	8602526
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.83

Dressing island mepore 3.6x10

Facility

$2.76

Hospital Charge Code	8602527
Hospital Revenue Code	272
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.79
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Amerigroup CHIP/Medicaid	$0.25
Rate for Payer: BCBS of TX Blue Advantage	$0.83
Rate for Payer: BCBS of TX Blue Essentials	$0.99
Rate for Payer: BCBS of TX PPO	$1.10
Rate for Payer: Cash Price	$2.43
Rate for Payer: Multiplan Auto	$1.79
Rate for Payer: Multiplan Commercial	$1.79
Rate for Payer: Multiplan Workers Comp	$1.79
Rate for Payer: Scott and White EPO/PPO	$1.38
Rate for Payer: Superior Health Plan EPO	$0.38

Dressing island mepore 3.6x10

Facility

$2.76

Hospital Charge Code	8602527
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.43

Dressing island mepore 3.6x6

Facility

$1.95

Hospital Charge Code	8602523
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.72

Dressing island mepore 3.6x6

Facility

$1.95

Hospital Charge Code	8602523
Hospital Revenue Code	272
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.27
Rate for Payer: Aetna Commercial	$1.07
Rate for Payer: Amerigroup CHIP/Medicaid	$0.18
Rate for Payer: BCBS of TX Blue Advantage	$0.59
Rate for Payer: BCBS of TX Blue Essentials	$0.70
Rate for Payer: BCBS of TX PPO	$0.78
Rate for Payer: Cash Price	$1.72
Rate for Payer: Multiplan Auto	$1.27
Rate for Payer: Multiplan Commercial	$1.27
Rate for Payer: Multiplan Workers Comp	$1.27
Rate for Payer: Scott and White EPO/PPO	$0.98
Rate for Payer: Superior Health Plan EPO	$0.27

DRESSING MEPILEX 6X6

Facility

$104.19

Hospital Charge Code	8598509
Hospital Revenue Code	270
Rate for Payer: Cash Price	$91.69

DRESSING MEPILEX 6X6

Facility

$104.19

Hospital Charge Code	8598509
Hospital Revenue Code	270
Min. Negotiated Rate	$9.38
Max. Negotiated Rate	$67.72
Rate for Payer: Aetna Commercial	$57.30
Rate for Payer: Amerigroup CHIP/Medicaid	$9.38
Rate for Payer: BCBS of TX Blue Advantage	$31.26
Rate for Payer: BCBS of TX Blue Essentials	$37.51
Rate for Payer: BCBS of TX PPO	$41.68
Rate for Payer: Cash Price	$91.69
Rate for Payer: Multiplan Auto	$67.72
Rate for Payer: Multiplan Commercial	$67.72
Rate for Payer: Multiplan Workers Comp	$67.72
Rate for Payer: Scott and White EPO/PPO	$52.10
Rate for Payer: Superior Health Plan EPO	$14.17

DRESSING MEPITEL AG 7.5 X 10CM

Facility

$49.62

Hospital Charge Code	8598516
Hospital Revenue Code	270
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$32.25
Rate for Payer: Aetna Commercial	$27.29
Rate for Payer: Amerigroup CHIP/Medicaid	$4.47
Rate for Payer: BCBS of TX Blue Advantage	$14.89
Rate for Payer: BCBS of TX Blue Essentials	$17.86
Rate for Payer: BCBS of TX PPO	$19.85
Rate for Payer: Cash Price	$43.67
Rate for Payer: Multiplan Auto	$32.25
Rate for Payer: Multiplan Commercial	$32.25
Rate for Payer: Multiplan Workers Comp	$32.25
Rate for Payer: Scott and White EPO/PPO	$24.81
Rate for Payer: Superior Health Plan EPO	$6.75

DRESSING MEPITEL AG 7.5 X 10CM

Facility

$49.62

Hospital Charge Code	8598516
Hospital Revenue Code	270
Rate for Payer: Cash Price	$43.67

DRESSING, NON-ADHERENT 3'''' X 8'''' STERILE -- DHF

Facility

$9.12

Hospital Charge Code	80249279
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.03

DRESSING, NON-ADHERENT 3'''' X 8'''' STERILE -- DHF

Facility

$9.12

Hospital Charge Code	80249279
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, NON-ADHERENT ISLAND MELOLIN 4 X 3 1/8'''' -- 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

Know your out-of-pocket cost for care.

All Charges