White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
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 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 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

DRESSING HDRCLD 35X9CM AQCL AG HDRFB

Facility

$157.72

Hospital Charge Code	120680
Hospital Revenue Code	272
Rate for Payer: Cash Price	$107.25

Dressing island medpor 3.6x12

Facility

$4.35

Hospital Charge Code	8602526
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.96

Dressing island medpor 3.6x12

Facility

$4.35

Hospital Charge Code	8602526
Hospital Revenue Code	272
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$3.13
Rate for Payer: Amerigroup CHIP/Medicaid	$0.39
Rate for Payer: BCBS of TX Blue Advantage	$1.30
Rate for Payer: BCBS of TX Blue Essentials	$1.57
Rate for Payer: BCBS of TX PPO	$1.74
Rate for Payer: Cash Price	$2.96
Rate for Payer: Cigna Medicaid	$3.13
Rate for Payer: Molina CHIP/Medicaid	$3.13
Rate for Payer: Multiplan Auto	$2.83
Rate for Payer: Multiplan Commercial	$2.83
Rate for Payer: Multiplan Workers Comp	$2.83
Rate for Payer: Parkland Medicaid	$3.13
Rate for Payer: Scott and White EPO/PPO	$2.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.13
Rate for Payer: Superior Health Plan EPO	$0.59

Dressing island mepore 3.6x10

Facility

$2.76

Hospital Charge Code	8602527
Hospital Revenue Code	272
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.99
Rate for Payer: Amerigroup CHIP/Medicaid	$0.25
Rate for Payer: BCBS of TX Blue Advantage	$0.83
Rate for Payer: BCBS of TX Blue Essentials	$0.99
Rate for Payer: BCBS of TX PPO	$1.10
Rate for Payer: Cash Price	$1.88
Rate for Payer: Cigna Medicaid	$1.99
Rate for Payer: Molina CHIP/Medicaid	$1.99
Rate for Payer: Multiplan Auto	$1.79
Rate for Payer: Multiplan Commercial	$1.79
Rate for Payer: Multiplan Workers Comp	$1.79
Rate for Payer: Parkland Medicaid	$1.99
Rate for Payer: Scott and White EPO/PPO	$1.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.99
Rate for Payer: Superior Health Plan EPO	$0.38

Dressing island mepore 3.6x10

Facility

$2.76

Hospital Charge Code	8602527
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.88

Dressing island mepore 3.6x6

Facility

$1.95

Hospital Charge Code	8602523
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.33

Dressing island mepore 3.6x6

Facility

$1.95

Hospital Charge Code	8602523
Hospital Revenue Code	272
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.40
Rate for Payer: Amerigroup CHIP/Medicaid	$0.18
Rate for Payer: BCBS of TX Blue Advantage	$0.59
Rate for Payer: BCBS of TX Blue Essentials	$0.70
Rate for Payer: BCBS of TX PPO	$0.78
Rate for Payer: Cash Price	$1.33
Rate for Payer: Cigna Medicaid	$1.40
Rate for Payer: Molina CHIP/Medicaid	$1.40
Rate for Payer: Multiplan Auto	$1.27
Rate for Payer: Multiplan Commercial	$1.27
Rate for Payer: Multiplan Workers Comp	$1.27
Rate for Payer: Parkland Medicaid	$1.40
Rate for Payer: Scott and White EPO/PPO	$0.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.40
Rate for Payer: Superior Health Plan EPO	$0.27

DRESSING LG VAC FOM

Facility

$219.62

Hospital Charge Code	993510
Hospital Revenue Code	270
Min. Negotiated Rate	$19.77
Max. Negotiated Rate	$158.13
Rate for Payer: Amerigroup CHIP/Medicaid	$19.77
Rate for Payer: BCBS of TX Blue Advantage	$65.89
Rate for Payer: BCBS of TX Blue Essentials	$79.06
Rate for Payer: BCBS of TX PPO	$87.85
Rate for Payer: Cash Price	$149.34
Rate for Payer: Cigna Medicaid	$158.13
Rate for Payer: Molina CHIP/Medicaid	$158.13
Rate for Payer: Multiplan Auto	$142.75
Rate for Payer: Multiplan Commercial	$142.75
Rate for Payer: Multiplan Workers Comp	$142.75
Rate for Payer: Parkland Medicaid	$158.13
Rate for Payer: Scott and White EPO/PPO	$109.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$158.13
Rate for Payer: Superior Health Plan EPO	$29.87

DRESSING LG VAC FOM

Facility

$219.62

Hospital Charge Code	993510
Hospital Revenue Code	270
Rate for Payer: Cash Price	$149.34

DRESSING MED VAC GFM FOM M827505210S

Facility

$181.95

Hospital Charge Code	993509
Hospital Revenue Code	270
Rate for Payer: Cash Price	$123.73

DRESSING MED VAC GFM FOM M827505210S

Facility

$181.95

Hospital Charge Code	993509
Hospital Revenue Code	270
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$131.00
Rate for Payer: Amerigroup CHIP/Medicaid	$16.38
Rate for Payer: BCBS of TX Blue Advantage	$54.59
Rate for Payer: BCBS of TX Blue Essentials	$65.50
Rate for Payer: BCBS of TX PPO	$72.78
Rate for Payer: Cash Price	$123.73
Rate for Payer: Cigna Medicaid	$131.00
Rate for Payer: Molina CHIP/Medicaid	$131.00
Rate for Payer: Multiplan Auto	$118.27
Rate for Payer: Multiplan Commercial	$118.27
Rate for Payer: Multiplan Workers Comp	$118.27
Rate for Payer: Parkland Medicaid	$131.00
Rate for Payer: Scott and White EPO/PPO	$90.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$131.00
Rate for Payer: Superior Health Plan EPO	$24.75

DRESSING MEPILEX 6X6

Facility

$104.19

Hospital Charge Code	8598509
Hospital Revenue Code	270
Min. Negotiated Rate	$9.38
Max. Negotiated Rate	$75.02
Rate for Payer: Amerigroup CHIP/Medicaid	$9.38
Rate for Payer: BCBS of TX Blue Advantage	$31.26
Rate for Payer: BCBS of TX Blue Essentials	$37.51
Rate for Payer: BCBS of TX PPO	$41.68
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cigna Medicaid	$75.02
Rate for Payer: Molina CHIP/Medicaid	$75.02
Rate for Payer: Multiplan Auto	$67.72
Rate for Payer: Multiplan Commercial	$67.72
Rate for Payer: Multiplan Workers Comp	$67.72
Rate for Payer: Parkland Medicaid	$75.02
Rate for Payer: Scott and White EPO/PPO	$52.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$75.02
Rate for Payer: Superior Health Plan EPO	$14.17

DRESSING MEPILEX 6X6

Facility

$104.19

Hospital Charge Code	8598509
Hospital Revenue Code	270
Rate for Payer: Cash Price	$70.85

DRESSING MEPITEL AG 7.5 X 10CM

Facility

$49.62

Hospital Charge Code	8598516
Hospital Revenue Code	270
Rate for Payer: Cash Price	$33.74

DRESSING MEPITEL AG 7.5 X 10CM

Facility

$49.62

Hospital Charge Code	8598516
Hospital Revenue Code	270
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$35.73
Rate for Payer: Amerigroup CHIP/Medicaid	$4.47
Rate for Payer: BCBS of TX Blue Advantage	$14.89
Rate for Payer: BCBS of TX Blue Essentials	$17.86
Rate for Payer: BCBS of TX PPO	$19.85
Rate for Payer: Cash Price	$33.74
Rate for Payer: Cigna Medicaid	$35.73
Rate for Payer: Molina CHIP/Medicaid	$35.73
Rate for Payer: Multiplan Auto	$32.25
Rate for Payer: Multiplan Commercial	$32.25
Rate for Payer: Multiplan Workers Comp	$32.25
Rate for Payer: Parkland Medicaid	$35.73
Rate for Payer: Scott and White EPO/PPO	$24.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35.73
Rate for Payer: Superior Health Plan EPO	$6.75

DRESSING, NON-ADHERENT 3' X 8 STERILE -- DHF

Facility

$9.12

Hospital Charge Code	80249279
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, NON-ADHERENT 3' X 8 STERILE -- DHF

Facility

$9.12

Hospital Charge Code	80249279
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.20

DRESSING, PRIMAPORE, 4'X3.125'

Facility

$2.31

Hospital Charge Code	992821
Hospital Revenue Code	272
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$1.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.21
Rate for Payer: BCBS of TX Blue Advantage	$0.69
Rate for Payer: BCBS of TX Blue Essentials	$0.83
Rate for Payer: BCBS of TX PPO	$0.92
Rate for Payer: Cash Price	$1.57
Rate for Payer: Cigna Medicaid	$1.66
Rate for Payer: Molina CHIP/Medicaid	$1.66
Rate for Payer: Multiplan Auto	$1.50
Rate for Payer: Multiplan Commercial	$1.50
Rate for Payer: Multiplan Workers Comp	$1.50
Rate for Payer: Parkland Medicaid	$1.66
Rate for Payer: Scott and White EPO/PPO	$1.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.66
Rate for Payer: Superior Health Plan EPO	$0.31

Know your out-of-pocket cost for care.

All Charges