White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRESSING, CALCIUM ALGINATE SILVER 4'X4.75 STER -- DHF

Facility

$183.92

Hospital Charge Code	80249642
Hospital Revenue Code	270
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$132.42
Rate for Payer: Amerigroup CHIP/Medicaid	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$55.18
Rate for Payer: BCBS of TX Blue Essentials	$66.21
Rate for Payer: BCBS of TX PPO	$73.57
Rate for Payer: Cash Price	$125.07
Rate for Payer: Cigna Medicaid	$132.42
Rate for Payer: Molina CHIP/Medicaid	$132.42
Rate for Payer: Multiplan Auto	$119.55
Rate for Payer: Multiplan Commercial	$119.55
Rate for Payer: Multiplan Workers Comp	$119.55
Rate for Payer: Parkland Medicaid	$132.42
Rate for Payer: Scott and White EPO/PPO	$91.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.42
Rate for Payer: Superior Health Plan EPO	$25.01

DRESSING, CALCIUM ALGINATE SILVER 4'X4.75 STER -- DHF

Facility

$183.92

Hospital Charge Code	80249642
Hospital Revenue Code	270
Rate for Payer: Cash Price	$125.07

DRESSING, CLOSURE SKIN 1/2' X 4 -- DHF

Facility

$55.15

Hospital Charge Code	81850554
Hospital Revenue Code	272
Rate for Payer: Cash Price	$37.50

DRESSING, CLOSURE SKIN 1/2' X 4 -- DHF

Facility

$55.15

Hospital Charge Code	81850554
Hospital Revenue Code	272
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$39.71
Rate for Payer: Amerigroup CHIP/Medicaid	$4.96
Rate for Payer: BCBS of TX Blue Advantage	$16.55
Rate for Payer: BCBS of TX Blue Essentials	$19.85
Rate for Payer: BCBS of TX PPO	$22.06
Rate for Payer: Cash Price	$37.50
Rate for Payer: Cigna Medicaid	$39.71
Rate for Payer: Molina CHIP/Medicaid	$39.71
Rate for Payer: Multiplan Auto	$35.85
Rate for Payer: Multiplan Commercial	$35.85
Rate for Payer: Multiplan Workers Comp	$35.85
Rate for Payer: Parkland Medicaid	$39.71
Rate for Payer: Scott and White EPO/PPO	$27.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39.71
Rate for Payer: Superior Health Plan EPO	$7.50

DRESSING, COMBINE 4' X 7 7/8 STERILE -- DHF

Facility

$9.12

Hospital Charge Code	80243058
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.20

DRESSING, COMBINE 4' X 7 7/8 STERILE -- DHF

Facility

$9.12

Hospital Charge Code	80243058
Hospital Revenue Code	270
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$6.57
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	$6.20
Rate for Payer: Cigna Medicaid	$6.57
Rate for Payer: Molina CHIP/Medicaid	$6.57
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: Parkland Medicaid	$6.57
Rate for Payer: Scott and White EPO/PPO	$4.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.57
Rate for Payer: Superior Health Plan EPO	$1.24

DRESSING EA-IO STABILIZER ADHESIVE

Facility

$40.86

Hospital Charge Code	993659
Hospital Revenue Code	270
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$29.42
Rate for Payer: Amerigroup CHIP/Medicaid	$3.68
Rate for Payer: BCBS of TX Blue Advantage	$12.26
Rate for Payer: BCBS of TX Blue Essentials	$14.71
Rate for Payer: BCBS of TX PPO	$16.34
Rate for Payer: Cash Price	$27.78
Rate for Payer: Cigna Medicaid	$29.42
Rate for Payer: Molina CHIP/Medicaid	$29.42
Rate for Payer: Multiplan Auto	$26.56
Rate for Payer: Multiplan Commercial	$26.56
Rate for Payer: Multiplan Workers Comp	$26.56
Rate for Payer: Parkland Medicaid	$29.42
Rate for Payer: Scott and White EPO/PPO	$20.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.42
Rate for Payer: Superior Health Plan EPO	$5.56

DRESSING EA-IO STABILIZER ADHESIVE

Facility

$40.86

Hospital Charge Code	993659
Hospital Revenue Code	270
Rate for Payer: Cash Price	$27.78

DRESSING, ENDOFORM 2X2 529312

Facility

$47.71

Hospital Charge Code	8570491
Hospital Revenue Code	272
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$34.35
Rate for Payer: Amerigroup CHIP/Medicaid	$4.29
Rate for Payer: BCBS of TX Blue Advantage	$14.31
Rate for Payer: BCBS of TX Blue Essentials	$17.18
Rate for Payer: BCBS of TX PPO	$19.08
Rate for Payer: Cash Price	$32.44
Rate for Payer: Cigna Medicaid	$34.35
Rate for Payer: Molina CHIP/Medicaid	$34.35
Rate for Payer: Multiplan Auto	$31.01
Rate for Payer: Multiplan Commercial	$31.01
Rate for Payer: Multiplan Workers Comp	$31.01
Rate for Payer: Parkland Medicaid	$34.35
Rate for Payer: Scott and White EPO/PPO	$23.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.35
Rate for Payer: Superior Health Plan EPO	$6.49

DRESSING, ENDOFORM 2X2 529312

Facility

$47.71

Hospital Charge Code	8570491
Hospital Revenue Code	272
Rate for Payer: Cash Price	$32.44

DRESSING EX-IO ADHESIVE

Facility

$81.72

Hospital Charge Code	8612539
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

DRESSING EX-IO ADHESIVE

Facility

$81.72

Hospital Charge Code	8612539
Hospital Revenue Code	272
Rate for Payer: Cash Price	$55.57

DRESSING, GAUZE 12-PLY 4' X 4 (10'S) STERILE TRAY -- DHF

Facility

$36.69

Hospital Charge Code	80245152
Hospital Revenue Code	272
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$26.42
Rate for Payer: Amerigroup CHIP/Medicaid	$3.30
Rate for Payer: BCBS of TX Blue Advantage	$11.01
Rate for Payer: BCBS of TX Blue Essentials	$13.21
Rate for Payer: BCBS of TX PPO	$14.68
Rate for Payer: Cash Price	$24.95
Rate for Payer: Cigna Medicaid	$26.42
Rate for Payer: Molina CHIP/Medicaid	$26.42
Rate for Payer: Multiplan Auto	$23.85
Rate for Payer: Multiplan Commercial	$23.85
Rate for Payer: Multiplan Workers Comp	$23.85
Rate for Payer: Parkland Medicaid	$26.42
Rate for Payer: Scott and White EPO/PPO	$18.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.42
Rate for Payer: Superior Health Plan EPO	$4.99

DRESSING, GAUZE 12-PLY 4' X 4 (10'S) STERILE TRAY -- DHF

Facility

$36.69

Hospital Charge Code	80245152
Hospital Revenue Code	272
Rate for Payer: Cash Price	$24.95

DRESSING, GAUZE 12-PLY 4' X 4 (2'S) STER -- DHF

Facility

$14.01

Hospital Charge Code	80245251
Hospital Revenue Code	272
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$10.09
Rate for Payer: Amerigroup CHIP/Medicaid	$1.26
Rate for Payer: BCBS of TX Blue Advantage	$4.20
Rate for Payer: BCBS of TX Blue Essentials	$5.04
Rate for Payer: BCBS of TX PPO	$5.60
Rate for Payer: Cash Price	$9.53
Rate for Payer: Cigna Medicaid	$10.09
Rate for Payer: Molina CHIP/Medicaid	$10.09
Rate for Payer: Multiplan Auto	$9.11
Rate for Payer: Multiplan Commercial	$9.11
Rate for Payer: Multiplan Workers Comp	$9.11
Rate for Payer: Parkland Medicaid	$10.09
Rate for Payer: Scott and White EPO/PPO	$7.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.09
Rate for Payer: Superior Health Plan EPO	$1.91

DRESSING, GAUZE 12-PLY 4' X 4 (2'S) STER -- DHF

Facility

$14.01

Hospital Charge Code	80245251
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.53

DRESSING, GAUZE 8-PLY 2' X 2 (2'S) STER -- DHF

Facility

$4.69

Hospital Charge Code	80244957
Hospital Revenue Code	272
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$3.38
Rate for Payer: Amerigroup CHIP/Medicaid	$0.42
Rate for Payer: BCBS of TX Blue Advantage	$1.41
Rate for Payer: BCBS of TX Blue Essentials	$1.69
Rate for Payer: BCBS of TX PPO	$1.88
Rate for Payer: Cash Price	$3.19
Rate for Payer: Cigna Medicaid	$3.38
Rate for Payer: Molina CHIP/Medicaid	$3.38
Rate for Payer: Multiplan Auto	$3.05
Rate for Payer: Multiplan Commercial	$3.05
Rate for Payer: Multiplan Workers Comp	$3.05
Rate for Payer: Parkland Medicaid	$3.38
Rate for Payer: Scott and White EPO/PPO	$2.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.38
Rate for Payer: Superior Health Plan EPO	$0.64

DRESSING, GAUZE 8-PLY 2' X 2 (2'S) STER -- DHF

Facility

$4.69

Hospital Charge Code	80244957
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.19

DRESSING, GAUZE DRAIN 6-PLY 4' X 4 (2'S) STER -- DHF

Facility

$41.57

Hospital Charge Code	80248305
Hospital Revenue Code	270
Rate for Payer: Cash Price	$28.27

DRESSING, GAUZE DRAIN 6-PLY 4' X 4 (2'S) STER -- DHF

Facility

$41.57

Hospital Charge Code	80248305
Hospital Revenue Code	270
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$29.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.74
Rate for Payer: BCBS of TX Blue Advantage	$12.47
Rate for Payer: BCBS of TX Blue Essentials	$14.97
Rate for Payer: BCBS of TX PPO	$16.63
Rate for Payer: Cash Price	$28.27
Rate for Payer: Cigna Medicaid	$29.93
Rate for Payer: Molina CHIP/Medicaid	$29.93
Rate for Payer: Multiplan Auto	$27.02
Rate for Payer: Multiplan Commercial	$27.02
Rate for Payer: Multiplan Workers Comp	$27.02
Rate for Payer: Parkland Medicaid	$29.93
Rate for Payer: Scott and White EPO/PPO	$20.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29.93
Rate for Payer: Superior Health Plan EPO	$5.65

DRESSING, GAUZE PETROLATUM XEROFORM LTX FR 1' X 8 -- DHF

Facility

$50.69

Hospital Charge Code	80246705
Hospital Revenue Code	270
Rate for Payer: Cash Price	$34.47

DRESSING, GAUZE PETROLATUM XEROFORM LTX FR 1' X 8 -- DHF

Facility

$50.69

Hospital Charge Code	80246705
Hospital Revenue Code	270
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$36.50
Rate for Payer: Amerigroup CHIP/Medicaid	$4.56
Rate for Payer: BCBS of TX Blue Advantage	$15.21
Rate for Payer: BCBS of TX Blue Essentials	$18.25
Rate for Payer: BCBS of TX PPO	$20.28
Rate for Payer: Cash Price	$34.47
Rate for Payer: Cigna Medicaid	$36.50
Rate for Payer: Molina CHIP/Medicaid	$36.50
Rate for Payer: Multiplan Auto	$32.95
Rate for Payer: Multiplan Commercial	$32.95
Rate for Payer: Multiplan Workers Comp	$32.95
Rate for Payer: Parkland Medicaid	$36.50
Rate for Payer: Scott and White EPO/PPO	$25.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$36.50
Rate for Payer: Superior Health Plan EPO	$6.89

DRESSING, GAUZE WOVEN 6' X 6 3/4 (5'S) STERILE -- DHF

Facility

$64.05

Hospital Charge Code	80244551
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$46.12
Rate for Payer: Amerigroup CHIP/Medicaid	$5.76
Rate for Payer: BCBS of TX Blue Advantage	$19.21
Rate for Payer: BCBS of TX Blue Essentials	$23.06
Rate for Payer: BCBS of TX PPO	$25.62
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cigna Medicaid	$46.12
Rate for Payer: Molina CHIP/Medicaid	$46.12
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: Parkland Medicaid	$46.12
Rate for Payer: Scott and White EPO/PPO	$32.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46.12
Rate for Payer: Superior Health Plan EPO	$8.71

DRESSING, GAUZE WOVEN 6' X 6 3/4 (5'S) STERILE -- DHF

Facility

$64.05

Hospital Charge Code	80244551
Hospital Revenue Code	270
Rate for Payer: Cash Price	$43.55

DRESSING HDRCLD 35X9CM AQCL AG HDRFB

Facility

$157.72

Hospital Charge Code	120680
Hospital Revenue Code	272
Min. Negotiated Rate	$14.19
Max. Negotiated Rate	$113.56
Rate for Payer: Amerigroup CHIP/Medicaid	$14.19
Rate for Payer: BCBS of TX Blue Advantage	$47.32
Rate for Payer: BCBS of TX Blue Essentials	$56.78
Rate for Payer: BCBS of TX PPO	$63.09
Rate for Payer: Cash Price	$107.25
Rate for Payer: Cigna Medicaid	$113.56
Rate for Payer: Molina CHIP/Medicaid	$113.56
Rate for Payer: Multiplan Auto	$102.52
Rate for Payer: Multiplan Commercial	$102.52
Rate for Payer: Multiplan Workers Comp	$102.52
Rate for Payer: Parkland Medicaid	$113.56
Rate for Payer: Scott and White EPO/PPO	$78.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$113.56
Rate for Payer: Superior Health Plan EPO	$21.45

Know your out-of-pocket cost for care.

All Charges