White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRAPES, EXTREMILY DRAPE, 89' X 128'

Facility

$48.12

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

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

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
Rate for Payer: Cash Price	$181.15

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

DRAPE, STERLU, U-DRAPE

Facility

$16.56

Hospital Charge Code	993769
Hospital Revenue Code	272
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$11.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1.49
Rate for Payer: BCBS of TX Blue Advantage	$4.97
Rate for Payer: BCBS of TX Blue Essentials	$5.96
Rate for Payer: BCBS of TX PPO	$6.62
Rate for Payer: Cash Price	$11.26
Rate for Payer: Cigna Medicaid	$11.92
Rate for Payer: Molina CHIP/Medicaid	$11.92
Rate for Payer: Multiplan Auto	$10.76
Rate for Payer: Multiplan Commercial	$10.76
Rate for Payer: Multiplan Workers Comp	$10.76
Rate for Payer: Parkland Medicaid	$11.92
Rate for Payer: Scott and White EPO/PPO	$8.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.92
Rate for Payer: Superior Health Plan EPO	$2.25

DRAPE, STERLU, U-DRAPE

Facility

$16.56

Hospital Charge Code	993769
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.26

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

Facility

$82.27

Hospital Charge Code	81622953
Hospital Revenue Code	272
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$59.23
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	$55.94
Rate for Payer: Cigna Medicaid	$59.23
Rate for Payer: Molina CHIP/Medicaid	$59.23
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: Parkland Medicaid	$59.23
Rate for Payer: Scott and White EPO/PPO	$41.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.23
Rate for Payer: Superior Health Plan EPO	$11.19

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	$55.94

DRAPE, U, POLY, 48X52, INVISISHIELD

Facility

$25.01

Hospital Charge Code	993012
Hospital Revenue Code	270
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$18.01
Rate for Payer: Amerigroup CHIP/Medicaid	$2.25
Rate for Payer: BCBS of TX Blue Advantage	$7.50
Rate for Payer: BCBS of TX Blue Essentials	$9.00
Rate for Payer: BCBS of TX PPO	$10.00
Rate for Payer: Cash Price	$17.01
Rate for Payer: Cigna Medicaid	$18.01
Rate for Payer: Molina CHIP/Medicaid	$18.01
Rate for Payer: Multiplan Auto	$16.26
Rate for Payer: Multiplan Commercial	$16.26
Rate for Payer: Multiplan Workers Comp	$16.26
Rate for Payer: Parkland Medicaid	$18.01
Rate for Payer: Scott and White EPO/PPO	$12.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.01
Rate for Payer: Superior Health Plan EPO	$3.40

DRAPE, U, POLY, 48X52, INVISISHIELD

Facility

$25.01

Hospital Charge Code	993012
Hospital Revenue Code	270
Rate for Payer: Cash Price	$17.01

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	$513.49
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	$484.96
Rate for Payer: Cigna Medicaid	$513.49
Rate for Payer: Molina CHIP/Medicaid	$513.49
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: Parkland Medicaid	$513.49
Rate for Payer: Scott and White EPO/PPO	$356.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$513.49
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	$484.96

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

Facility

$45.82

Hospital Charge Code	80243504
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.16

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	$32.99
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	$31.16
Rate for Payer: Cigna Medicaid	$32.99
Rate for Payer: Molina CHIP/Medicaid	$32.99
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: Parkland Medicaid	$32.99
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.99
Rate for Payer: Superior Health Plan EPO	$6.23

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

Facility

$147.62

Hospital Charge Code	80246556
Hospital Revenue Code	270
Rate for Payer: Cash Price	$100.38

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	$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

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	$69.62
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	$65.75
Rate for Payer: Cigna Medicaid	$69.62
Rate for Payer: Molina CHIP/Medicaid	$69.62
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: Parkland Medicaid	$69.62
Rate for Payer: Scott and White EPO/PPO	$48.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.62
Rate for Payer: Superior Health Plan EPO	$13.15

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

Facility

$96.69

Hospital Charge Code	80243306
Hospital Revenue Code	272
Rate for Payer: Cash Price	$65.75

DRESSING ANTI-MICROBIAL SILVERLON ADHESIVE 4X6

Facility

$60.34

Hospital Charge Code	131599
Hospital Revenue Code	272
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$43.44
Rate for Payer: Amerigroup CHIP/Medicaid	$5.43
Rate for Payer: BCBS of TX Blue Advantage	$18.10
Rate for Payer: BCBS of TX Blue Essentials	$21.72
Rate for Payer: BCBS of TX PPO	$24.14
Rate for Payer: Cash Price	$41.03
Rate for Payer: Cigna Medicaid	$43.44
Rate for Payer: Molina CHIP/Medicaid	$43.44
Rate for Payer: Multiplan Auto	$39.22
Rate for Payer: Multiplan Commercial	$39.22
Rate for Payer: Multiplan Workers Comp	$39.22
Rate for Payer: Parkland Medicaid	$43.44
Rate for Payer: Scott and White EPO/PPO	$30.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.44
Rate for Payer: Superior Health Plan EPO	$8.21

DRESSING ANTI-MICROBIAL SILVERLON ADHESIVE 4X6

Facility

$60.34

Hospital Charge Code	131599
Hospital Revenue Code	272
Rate for Payer: Cash Price	$41.03

dressing aquacel adv

Facility

$32.42

Hospital Charge Code	8720599
Hospital Revenue Code	270
Rate for Payer: Cash Price	$22.05

Know your out-of-pocket cost for care.

All Charges