White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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, STERLU, U-DRAPE

Facility

$16.56

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

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, 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, 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, U, POLY, 48X52, INVISISHIELD

Facility

$25.01

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

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-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
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 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 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
Rate for Payer: Cash Price	$65.75

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 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

dressing aquacel adv

Facility

$32.42

Hospital Charge Code	8720599
Hospital Revenue Code	270
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$23.34
Rate for Payer: Amerigroup CHIP/Medicaid	$2.92
Rate for Payer: BCBS of TX Blue Advantage	$9.73
Rate for Payer: BCBS of TX Blue Essentials	$11.67
Rate for Payer: BCBS of TX PPO	$12.97
Rate for Payer: Cash Price	$22.05
Rate for Payer: Cigna Medicaid	$23.34
Rate for Payer: Molina CHIP/Medicaid	$23.34
Rate for Payer: Multiplan Auto	$21.07
Rate for Payer: Multiplan Commercial	$21.07
Rate for Payer: Multiplan Workers Comp	$21.07
Rate for Payer: Parkland Medicaid	$23.34
Rate for Payer: Scott and White EPO/PPO	$16.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.34
Rate for Payer: Superior Health Plan EPO	$4.41

DRESSING AQUACEL HYDROCOLLOIDAL

Facility

$129.98

Hospital Charge Code	8428489
Hospital Revenue Code	272
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$93.59
Rate for Payer: Amerigroup CHIP/Medicaid	$11.70
Rate for Payer: BCBS of TX Blue Advantage	$38.99
Rate for Payer: BCBS of TX Blue Essentials	$46.79
Rate for Payer: BCBS of TX PPO	$51.99
Rate for Payer: Cash Price	$88.39
Rate for Payer: Cigna Medicaid	$93.59
Rate for Payer: Molina CHIP/Medicaid	$93.59
Rate for Payer: Multiplan Auto	$84.49
Rate for Payer: Multiplan Commercial	$84.49
Rate for Payer: Multiplan Workers Comp	$84.49
Rate for Payer: Parkland Medicaid	$93.59
Rate for Payer: Scott and White EPO/PPO	$64.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$93.59
Rate for Payer: Superior Health Plan EPO	$17.68

DRESSING AQUACEL HYDROCOLLOIDAL

Facility

$129.98

Hospital Charge Code	8428489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$88.39

DRESSING, BIOPATCH, 1'DISK, CHG, 4MM CENTER

Facility

$51.78

Hospital Charge Code	993766
Hospital Revenue Code	270
Rate for Payer: Cash Price	$35.21

DRESSING, BIOPATCH, 1'DISK, CHG, 4MM CENTER

Facility

$51.78

Hospital Charge Code	993766
Hospital Revenue Code	270
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$37.28
Rate for Payer: Amerigroup CHIP/Medicaid	$4.66
Rate for Payer: BCBS of TX Blue Advantage	$15.53
Rate for Payer: BCBS of TX Blue Essentials	$18.64
Rate for Payer: BCBS of TX PPO	$20.71
Rate for Payer: Cash Price	$35.21
Rate for Payer: Cigna Medicaid	$37.28
Rate for Payer: Molina CHIP/Medicaid	$37.28
Rate for Payer: Multiplan Auto	$33.66
Rate for Payer: Multiplan Commercial	$33.66
Rate for Payer: Multiplan Workers Comp	$33.66
Rate for Payer: Parkland Medicaid	$37.28
Rate for Payer: Scott and White EPO/PPO	$25.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.28
Rate for Payer: Superior Health Plan EPO	$7.04

DRESSING, BIOPATCH, 1' DISK, CHG, 4MM CENTER

Facility

$25.64

Hospital Charge Code	993836
Hospital Revenue Code	272
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$18.46
Rate for Payer: Amerigroup CHIP/Medicaid	$2.31
Rate for Payer: BCBS of TX Blue Advantage	$7.69
Rate for Payer: BCBS of TX Blue Essentials	$9.23
Rate for Payer: BCBS of TX PPO	$10.26
Rate for Payer: Cash Price	$17.44
Rate for Payer: Cigna Medicaid	$18.46
Rate for Payer: Molina CHIP/Medicaid	$18.46
Rate for Payer: Multiplan Auto	$16.67
Rate for Payer: Multiplan Commercial	$16.67
Rate for Payer: Multiplan Workers Comp	$16.67
Rate for Payer: Parkland Medicaid	$18.46
Rate for Payer: Scott and White EPO/PPO	$12.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.46
Rate for Payer: Superior Health Plan EPO	$3.49

DRESSING, BIOPATCH, 1' DISK, CHG, 4MM CENTER

Facility

$25.64

Hospital Charge Code	993836
Hospital Revenue Code	272
Rate for Payer: Cash Price	$17.44

Know your out-of-pocket cost for care.

All Charges