White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRAPE, ABDOMINAL, MAJOR, ST, 8/CS

Facility

$191.09

Hospital Charge Code	993764
Hospital Revenue Code	272
Rate for Payer: Cash Price	$129.94

DRAPE, ABDOMINAL, MAJOR, ST, 8/CS

Facility

$191.09

Hospital Charge Code	993764
Hospital Revenue Code	272
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$137.58
Rate for Payer: Amerigroup CHIP/Medicaid	$17.20
Rate for Payer: BCBS of TX Blue Advantage	$57.33
Rate for Payer: BCBS of TX Blue Essentials	$68.79
Rate for Payer: BCBS of TX PPO	$76.44
Rate for Payer: Cash Price	$129.94
Rate for Payer: Cigna Medicaid	$137.58
Rate for Payer: Molina CHIP/Medicaid	$137.58
Rate for Payer: Multiplan Auto	$124.21
Rate for Payer: Multiplan Commercial	$124.21
Rate for Payer: Multiplan Workers Comp	$124.21
Rate for Payer: Parkland Medicaid	$137.58
Rate for Payer: Scott and White EPO/PPO	$95.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$137.58
Rate for Payer: Superior Health Plan EPO	$25.99

drape arm dv xi

Facility

$236.08

Hospital Charge Code	8690509
Hospital Revenue Code	270
Rate for Payer: Cash Price	$160.53

drape arm dv xi

Facility

$236.08

Hospital Charge Code	8690509
Hospital Revenue Code	270
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$169.98
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	$160.53
Rate for Payer: Cigna Medicaid	$169.98
Rate for Payer: Molina CHIP/Medicaid	$169.98
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: Parkland Medicaid	$169.98
Rate for Payer: Scott and White EPO/PPO	$118.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$169.98
Rate for Payer: Superior Health Plan EPO	$32.11

DRAPE C-ARMOR

Facility

$205.25

Hospital Charge Code	8514475
Hospital Revenue Code	272
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$147.78
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	$139.57
Rate for Payer: Cigna Medicaid	$147.78
Rate for Payer: Molina CHIP/Medicaid	$147.78
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: Parkland Medicaid	$147.78
Rate for Payer: Scott and White EPO/PPO	$102.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$147.78
Rate for Payer: Superior Health Plan EPO	$27.91

DRAPE C-ARMOR

Facility

$205.25

Hospital Charge Code	8514475
Hospital Revenue Code	272
Rate for Payer: Cash Price	$139.57

DRAPE, C-ARMOR, 42X74

Facility

$205.25

Hospital Charge Code	992753
Hospital Revenue Code	272
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$147.78
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	$139.57
Rate for Payer: Cigna Medicaid	$147.78
Rate for Payer: Molina CHIP/Medicaid	$147.78
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: Parkland Medicaid	$147.78
Rate for Payer: Scott and White EPO/PPO	$102.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$147.78
Rate for Payer: Superior Health Plan EPO	$27.91

DRAPE, C-ARMOR, 42X74

Facility

$205.25

Hospital Charge Code	992753
Hospital Revenue Code	272
Rate for Payer: Cash Price	$139.57

DRAPE COLUMN DV XI

Facility

$81.72

Hospital Charge Code	8690514
Hospital Revenue Code	272
Rate for Payer: Cash Price	$55.57

DRAPE COLUMN DV XI

Facility

$81.72

Hospital Charge Code	8690514
Hospital Revenue Code	272
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$58.84
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	$55.57
Rate for Payer: Cigna Medicaid	$58.84
Rate for Payer: Molina CHIP/Medicaid	$58.84
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: Parkland Medicaid	$58.84
Rate for Payer: Scott and White EPO/PPO	$40.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58.84
Rate for Payer: Superior Health Plan EPO	$11.11

DRAPE, MINI C-ARM, 54X63

Facility

$39.41

Hospital Charge Code	992746
Hospital Revenue Code	272
Rate for Payer: Cash Price	$26.80

DRAPE, MINI C-ARM, 54X63

Facility

$39.41

Hospital Charge Code	992746
Hospital Revenue Code	272
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$28.38
Rate for Payer: Amerigroup CHIP/Medicaid	$3.55
Rate for Payer: BCBS of TX Blue Advantage	$11.82
Rate for Payer: BCBS of TX Blue Essentials	$14.19
Rate for Payer: BCBS of TX PPO	$15.76
Rate for Payer: Cash Price	$26.80
Rate for Payer: Cigna Medicaid	$28.38
Rate for Payer: Molina CHIP/Medicaid	$28.38
Rate for Payer: Multiplan Auto	$25.62
Rate for Payer: Multiplan Commercial	$25.62
Rate for Payer: Multiplan Workers Comp	$25.62
Rate for Payer: Parkland Medicaid	$28.38
Rate for Payer: Scott and White EPO/PPO	$19.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.38
Rate for Payer: Superior Health Plan EPO	$5.36

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	$106.29
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	$100.38
Rate for Payer: Cigna Medicaid	$106.29
Rate for Payer: Molina CHIP/Medicaid	$106.29
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: Parkland Medicaid	$106.29
Rate for Payer: Scott and White EPO/PPO	$73.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106.29
Rate for Payer: Superior Health Plan EPO	$20.08

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	$100.38

DRAPE, RNF, 53X77', ST, 20/CS

Facility

$9.72

Hospital Charge Code	992776
Hospital Revenue Code	272
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$7.00
Rate for Payer: Amerigroup CHIP/Medicaid	$0.87
Rate for Payer: BCBS of TX Blue Advantage	$2.92
Rate for Payer: BCBS of TX Blue Essentials	$3.50
Rate for Payer: BCBS of TX PPO	$3.89
Rate for Payer: Cash Price	$6.61
Rate for Payer: Cigna Medicaid	$7.00
Rate for Payer: Molina CHIP/Medicaid	$7.00
Rate for Payer: Multiplan Auto	$6.32
Rate for Payer: Multiplan Commercial	$6.32
Rate for Payer: Multiplan Workers Comp	$6.32
Rate for Payer: Parkland Medicaid	$7.00
Rate for Payer: Scott and White EPO/PPO	$4.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.00
Rate for Payer: Superior Health Plan EPO	$1.32

DRAPE, RNF, 53X77', ST, 20/CS

Facility

$9.72

Hospital Charge Code	992776
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.61

drape robot rosa unit

Facility

$227.00

Hospital Charge Code	8702505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

drape robot rosa unit

Facility

$227.00

Hospital Charge Code	8702505
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$163.44
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	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Molina CHIP/Medicaid	$163.44
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: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$30.87

DRAPES, EXTREMILY DRAPE, 89' X 128'

Facility

$48.12

Hospital Charge Code	993778
Hospital Revenue Code	272
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$34.65
Rate for Payer: Amerigroup CHIP/Medicaid	$4.33
Rate for Payer: BCBS of TX Blue Advantage	$14.44
Rate for Payer: BCBS of TX Blue Essentials	$17.32
Rate for Payer: BCBS of TX PPO	$19.25
Rate for Payer: Cash Price	$32.72
Rate for Payer: Cigna Medicaid	$34.65
Rate for Payer: Molina CHIP/Medicaid	$34.65
Rate for Payer: Multiplan Auto	$31.28
Rate for Payer: Multiplan Commercial	$31.28
Rate for Payer: Multiplan Workers Comp	$31.28
Rate for Payer: Parkland Medicaid	$34.65
Rate for Payer: Scott and White EPO/PPO	$24.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.65
Rate for Payer: Superior Health Plan EPO	$6.54

DRAPES, EXTREMILY DRAPE, 89' X 128'

Facility

$48.12

Hospital Charge Code	993778
Hospital Revenue Code	272
Rate for Payer: Cash Price	$32.72

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	$20.58
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	$19.43
Rate for Payer: Cigna Medicaid	$20.58
Rate for Payer: Molina CHIP/Medicaid	$20.58
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: Parkland Medicaid	$20.58
Rate for Payer: Scott and White EPO/PPO	$14.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.58
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	$19.43

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	$536.35
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	$506.55
Rate for Payer: Cigna Medicaid	$536.35
Rate for Payer: Molina CHIP/Medicaid	$536.35
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: Parkland Medicaid	$536.35
Rate for Payer: Scott and White EPO/PPO	$372.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$536.35
Rate for Payer: Superior Health Plan EPO	$101.31

DRAPE, SKIN PREP 23' X 33 -- DHF

Facility

$744.93

Hospital Charge Code	81622300
Hospital Revenue Code	272
Rate for Payer: Cash Price	$506.55

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	$191.81
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	$181.15
Rate for Payer: Cigna Medicaid	$191.81
Rate for Payer: Molina CHIP/Medicaid	$191.81
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: Parkland Medicaid	$191.81
Rate for Payer: Scott and White EPO/PPO	$133.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$191.81
Rate for Payer: Superior Health Plan EPO	$36.23

Know your out-of-pocket cost for care.

All Charges