White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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
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, 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, 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, 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 EA-IO STABILIZER ADHESIVE

Facility

$40.86

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

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, 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
Rate for Payer: Cash Price	$9.53

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 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

Know your out-of-pocket cost for care.

All Charges