White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRS BIND ELASTIC TUBLAR -- DHF

Facility

$136.73

Hospital Charge Code	80243678
Hospital Revenue Code	270
Rate for Payer: Cash Price	$120.32

DRS COBAN 6IN -- DHF

Facility

$96.69

Hospital Charge Code	80243876
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

DRS COBAN 6IN -- DHF

Facility

$96.69

Hospital Charge Code	80243876
Hospital Revenue Code	272
Rate for Payer: Cash Price	$85.09

drs collagen gel 1 0z

Facility

$19.16

Hospital Charge Code	131596
Hospital Revenue Code	270
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$12.45
Rate for Payer: Aetna Commercial	$10.54
Rate for Payer: Amerigroup CHIP/Medicaid	$1.72
Rate for Payer: BCBS of TX Blue Advantage	$5.75
Rate for Payer: BCBS of TX Blue Essentials	$6.90
Rate for Payer: BCBS of TX PPO	$7.66
Rate for Payer: Cash Price	$16.86
Rate for Payer: Multiplan Auto	$12.45
Rate for Payer: Multiplan Commercial	$12.45
Rate for Payer: Multiplan Workers Comp	$12.45
Rate for Payer: Scott and White EPO/PPO	$9.58
Rate for Payer: Superior Health Plan EPO	$2.61

drs collagen gel 1 0z

Facility

$19.16

Hospital Charge Code	131596
Hospital Revenue Code	270
Rate for Payer: Cash Price	$16.86

DRS DEBRID BURN -- DHF

Facility

$408.60

Hospital Charge Code	80243900
Hospital Revenue Code	270
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

DRS DEBRID BURN -- DHF

Facility

$408.60

Hospital Charge Code	80243900
Hospital Revenue Code	270
Rate for Payer: Cash Price	$359.57

drs drawtex hydro-wound

Facility

$33.82

Hospital Charge Code	120686
Hospital Revenue Code	270
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$21.98
Rate for Payer: Aetna Commercial	$18.60
Rate for Payer: Amerigroup CHIP/Medicaid	$3.04
Rate for Payer: BCBS of TX Blue Advantage	$10.15
Rate for Payer: BCBS of TX Blue Essentials	$12.18
Rate for Payer: BCBS of TX PPO	$13.53
Rate for Payer: Cash Price	$29.76
Rate for Payer: Multiplan Auto	$21.98
Rate for Payer: Multiplan Commercial	$21.98
Rate for Payer: Multiplan Workers Comp	$21.98
Rate for Payer: Scott and White EPO/PPO	$16.91
Rate for Payer: Superior Health Plan EPO	$4.60

drs drawtex hydro-wound

Facility

$33.82

Hospital Charge Code	120686
Hospital Revenue Code	270
Rate for Payer: Cash Price	$29.76

DRS DUODERM 80241169 -- DHF

Facility

$64.05

Hospital Charge Code	80241169
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

DRS DUODERM 80241169 -- DHF

Facility

$64.05

Hospital Charge Code	80241169
Hospital Revenue Code	270
Rate for Payer: Cash Price	$56.36

DRS DUODERM 80241185 -- DHF

Facility

$119.61

Hospital Charge Code	80241185
Hospital Revenue Code	270
Rate for Payer: Cash Price	$105.26

DRS DUODERM 80241185 -- DHF

Facility

$119.61

Hospital Charge Code	80241185
Hospital Revenue Code	270
Min. Negotiated Rate	$10.76
Max. Negotiated Rate	$77.75
Rate for Payer: Aetna Commercial	$65.79
Rate for Payer: Amerigroup CHIP/Medicaid	$10.76
Rate for Payer: BCBS of TX Blue Advantage	$35.88
Rate for Payer: BCBS of TX Blue Essentials	$43.06
Rate for Payer: BCBS of TX PPO	$47.84
Rate for Payer: Cash Price	$105.26
Rate for Payer: Multiplan Auto	$77.75
Rate for Payer: Multiplan Commercial	$77.75
Rate for Payer: Multiplan Workers Comp	$77.75
Rate for Payer: Scott and White EPO/PPO	$59.80
Rate for Payer: Superior Health Plan EPO	$16.27

DRS EYE PD -- DHF

Facility

$9.12

Hospital Charge Code	80244254
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.03

DRS EYE PD -- DHF

Facility

$9.12

Hospital Charge Code	80244254
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

DRS EYE SHIELD -- DHF

Facility

$82.27

Hospital Charge Code	80244353
Hospital Revenue Code	270
Rate for Payer: Cash Price	$72.40

DRS EYE SHIELD -- DHF

Facility

$82.27

Hospital Charge Code	80244353
Hospital Revenue Code	270
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

DRS FACIAL WRAP -- DHF

Facility

$98.84

Hospital Charge Code	80244429
Hospital Revenue Code	270
Rate for Payer: Cash Price	$86.98

DRS FACIAL WRAP -- DHF

Facility

$98.84

Hospital Charge Code	80244429
Hospital Revenue Code	270
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$64.25
Rate for Payer: Aetna Commercial	$54.36
Rate for Payer: Amerigroup CHIP/Medicaid	$8.90
Rate for Payer: BCBS of TX Blue Advantage	$29.65
Rate for Payer: BCBS of TX Blue Essentials	$35.58
Rate for Payer: BCBS of TX PPO	$39.54
Rate for Payer: Cash Price	$86.98
Rate for Payer: Multiplan Auto	$64.25
Rate for Payer: Multiplan Commercial	$64.25
Rate for Payer: Multiplan Workers Comp	$64.25
Rate for Payer: Scott and White EPO/PPO	$49.42
Rate for Payer: Superior Health Plan EPO	$13.44

DRSG TRANSP FLM 48SQ > -- DHF

Facility

$24.25

Hospital Charge Code	81822728
Hospital Revenue Code	272
Rate for Payer: Cash Price	$21.34

DRSG TRANSP FLM 48SQ > -- DHF

Facility

$24.25

Hospital Charge Code	81822728
Hospital Revenue Code	272
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$15.76
Rate for Payer: Aetna Commercial	$13.34
Rate for Payer: Amerigroup CHIP/Medicaid	$2.18
Rate for Payer: BCBS of TX Blue Advantage	$7.28
Rate for Payer: BCBS of TX Blue Essentials	$8.73
Rate for Payer: BCBS of TX PPO	$9.70
Rate for Payer: Cash Price	$21.34
Rate for Payer: Multiplan Auto	$15.76
Rate for Payer: Multiplan Commercial	$15.76
Rate for Payer: Multiplan Workers Comp	$15.76
Rate for Payer: Scott and White EPO/PPO	$12.12
Rate for Payer: Superior Health Plan EPO	$3.30

drs hydrofera blue 4"x5"

Facility

$27.88

Hospital Charge Code	8720626
Hospital Revenue Code	270
Rate for Payer: Cash Price	$24.53

drs hydrofera blue 4"x5"

Facility

$27.88

Hospital Charge Code	8720626
Hospital Revenue Code	270
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$18.12
Rate for Payer: Aetna Commercial	$15.33
Rate for Payer: Amerigroup CHIP/Medicaid	$2.51
Rate for Payer: BCBS of TX Blue Advantage	$8.36
Rate for Payer: BCBS of TX Blue Essentials	$10.04
Rate for Payer: BCBS of TX PPO	$11.15
Rate for Payer: Cash Price	$24.53
Rate for Payer: Multiplan Auto	$18.12
Rate for Payer: Multiplan Commercial	$18.12
Rate for Payer: Multiplan Workers Comp	$18.12
Rate for Payer: Scott and White EPO/PPO	$13.94
Rate for Payer: Superior Health Plan EPO	$3.79

DRS INTERCEED 3X4 -- DHF

Facility

$1,005.30

Service Code	HCPCS C1765
Hospital Charge Code	80245533
Hospital Revenue Code	278
Min. Negotiated Rate	$251.32
Max. Negotiated Rate	$502.65
Rate for Payer: Aetna Commercial	$301.59
Rate for Payer: Cash Price	$884.66
Rate for Payer: Cigna Commercial	$251.32
Rate for Payer: Multiplan Auto	$502.65
Rate for Payer: Multiplan Commercial	$502.65
Rate for Payer: Multiplan Workers Comp	$502.65
Rate for Payer: Scott and White EPO/PPO	$502.65

DRS INTERCEED 3X4 -- DHF

Facility

$1,005.30

Service Code	HCPCS C1765
Hospital Charge Code	80245533
Hospital Revenue Code	278
Min. Negotiated Rate	$90.48
Max. Negotiated Rate	$502.65
Rate for Payer: Aetna Commercial	$301.59
Rate for Payer: Amerigroup CHIP/Medicaid	$90.48
Rate for Payer: Cash Price	$884.66
Rate for Payer: Multiplan Auto	$502.65
Rate for Payer: Multiplan Commercial	$502.65
Rate for Payer: Multiplan Workers Comp	$502.65
Rate for Payer: Scott and White EPO/PPO	$502.65
Rate for Payer: Superior Health Plan EPO	$136.72

Know your out-of-pocket cost for care.

All Charges