White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRAIN SILICONE ROUND 3/4 FLUT 19FR & 3/16 TROCAR

Facility

$40.86

Hospital Charge Code	993684
Hospital Revenue Code	270
Rate for Payer: Cash Price	$27.78

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

Facility

$83.23

Hospital Charge Code	81820649
Hospital Revenue Code	272
Rate for Payer: Cash Price	$56.60

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	$59.93
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	$56.60
Rate for Payer: Cigna Medicaid	$59.93
Rate for Payer: Molina CHIP/Medicaid	$59.93
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: Parkland Medicaid	$59.93
Rate for Payer: Scott and White EPO/PPO	$41.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.93
Rate for Payer: Superior Health Plan EPO	$11.32

DRAPE 38X16IN ABD MAJ ABS REINF FEN

Facility

$47.77

Hospital Charge Code	992829
Hospital Revenue Code	272
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$34.39
Rate for Payer: Amerigroup CHIP/Medicaid	$4.30
Rate for Payer: BCBS of TX Blue Advantage	$14.33
Rate for Payer: BCBS of TX Blue Essentials	$17.20
Rate for Payer: BCBS of TX PPO	$19.11
Rate for Payer: Cash Price	$32.48
Rate for Payer: Cigna Medicaid	$34.39
Rate for Payer: Molina CHIP/Medicaid	$34.39
Rate for Payer: Multiplan Auto	$31.05
Rate for Payer: Multiplan Commercial	$31.05
Rate for Payer: Multiplan Workers Comp	$31.05
Rate for Payer: Parkland Medicaid	$34.39
Rate for Payer: Scott and White EPO/PPO	$23.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.39
Rate for Payer: Superior Health Plan EPO	$6.50

DRAPE 38X16IN ABD MAJ ABS REINF FEN

Facility

$47.77

Hospital Charge Code	992829
Hospital Revenue Code	272
Rate for Payer: Cash Price	$32.48

DRAPE 76X54IN SHLDR U IMPRV PRXM

Facility

$20.60

Hospital Charge Code	993743
Hospital Revenue Code	272
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$14.83
Rate for Payer: Amerigroup CHIP/Medicaid	$1.85
Rate for Payer: BCBS of TX Blue Advantage	$6.18
Rate for Payer: BCBS of TX Blue Essentials	$7.42
Rate for Payer: BCBS of TX PPO	$8.24
Rate for Payer: Cash Price	$14.01
Rate for Payer: Cigna Medicaid	$14.83
Rate for Payer: Molina CHIP/Medicaid	$14.83
Rate for Payer: Multiplan Auto	$13.39
Rate for Payer: Multiplan Commercial	$13.39
Rate for Payer: Multiplan Workers Comp	$13.39
Rate for Payer: Parkland Medicaid	$14.83
Rate for Payer: Scott and White EPO/PPO	$10.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.83
Rate for Payer: Superior Health Plan EPO	$2.80

DRAPE 76X54IN SHLDR U IMPRV PRXM

Facility

$20.60

Hospital Charge Code	993743
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14.01

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, ABDOMINAL, MAJOR, ST, 8/CS

Facility

$191.09

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

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
Rate for Payer: Cash Price	$6.61

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 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

drape robot rosa unit

Facility

$227.00

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

Know your out-of-pocket cost for care.

All Charges