White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

DRESSING, PRIMAPORE, 6'X3.125'

Facility

$2.15

Hospital Charge Code	992917
Hospital Revenue Code	272
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$1.55
Rate for Payer: Amerigroup CHIP/Medicaid	$0.19
Rate for Payer: BCBS of TX Blue Advantage	$0.65
Rate for Payer: BCBS of TX Blue Essentials	$0.77
Rate for Payer: BCBS of TX PPO	$0.86
Rate for Payer: Cash Price	$1.46
Rate for Payer: Cigna Medicaid	$1.55
Rate for Payer: Molina CHIP/Medicaid	$1.55
Rate for Payer: Multiplan Auto	$1.40
Rate for Payer: Multiplan Commercial	$1.40
Rate for Payer: Multiplan Workers Comp	$1.40
Rate for Payer: Parkland Medicaid	$1.55
Rate for Payer: Scott and White EPO/PPO	$1.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.55
Rate for Payer: Superior Health Plan EPO	$0.29

DRESSING, PRIMAPORE, 6'X3.125'

Facility

$2.15

Hospital Charge Code	992917
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.46

DRESSING SM VAC GRANUFORM FOM

Facility

$144.30

Hospital Charge Code	993508
Hospital Revenue Code	270
Rate for Payer: Cash Price	$98.12

DRESSING SM VAC GRANUFORM FOM

Facility

$144.30

Hospital Charge Code	993508
Hospital Revenue Code	270
Min. Negotiated Rate	$12.99
Max. Negotiated Rate	$103.90
Rate for Payer: Amerigroup CHIP/Medicaid	$12.99
Rate for Payer: BCBS of TX Blue Advantage	$43.29
Rate for Payer: BCBS of TX Blue Essentials	$51.95
Rate for Payer: BCBS of TX PPO	$57.72
Rate for Payer: Cash Price	$98.12
Rate for Payer: Cigna Medicaid	$103.90
Rate for Payer: Molina CHIP/Medicaid	$103.90
Rate for Payer: Multiplan Auto	$93.80
Rate for Payer: Multiplan Commercial	$93.80
Rate for Payer: Multiplan Workers Comp	$93.80
Rate for Payer: Parkland Medicaid	$103.90
Rate for Payer: Scott and White EPO/PPO	$72.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$103.90
Rate for Payer: Superior Health Plan EPO	$19.62

DRESSING, TEGADERM, TRNS, FILM, 2.375X2

Facility

$1.20

Hospital Charge Code	992869
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.82

DRESSING, TEGADERM, TRNS, FILM, 2.375X2

Facility

$1.20

Hospital Charge Code	992869
Hospital Revenue Code	272
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.86
Rate for Payer: Amerigroup CHIP/Medicaid	$0.11
Rate for Payer: BCBS of TX Blue Advantage	$0.36
Rate for Payer: BCBS of TX Blue Essentials	$0.43
Rate for Payer: BCBS of TX PPO	$0.48
Rate for Payer: Cash Price	$0.82
Rate for Payer: Cigna Medicaid	$0.86
Rate for Payer: Molina CHIP/Medicaid	$0.86
Rate for Payer: Multiplan Auto	$0.78
Rate for Payer: Multiplan Commercial	$0.78
Rate for Payer: Multiplan Workers Comp	$0.78
Rate for Payer: Parkland Medicaid	$0.86
Rate for Payer: Scott and White EPO/PPO	$0.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.86
Rate for Payer: Superior Health Plan EPO	$0.16

DRESSING, TRANSPARENT TEGADERM REGULAR 4'X4-3/4 -- DHF

Facility

$6.57

Hospital Charge Code	80249295
Hospital Revenue Code	270
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$4.73
Rate for Payer: Amerigroup CHIP/Medicaid	$0.59
Rate for Payer: BCBS of TX Blue Advantage	$1.97
Rate for Payer: BCBS of TX Blue Essentials	$2.37
Rate for Payer: BCBS of TX PPO	$2.63
Rate for Payer: Cash Price	$4.47
Rate for Payer: Cigna Medicaid	$4.73
Rate for Payer: Molina CHIP/Medicaid	$4.73
Rate for Payer: Multiplan Auto	$4.27
Rate for Payer: Multiplan Commercial	$4.27
Rate for Payer: Multiplan Workers Comp	$4.27
Rate for Payer: Parkland Medicaid	$4.73
Rate for Payer: Scott and White EPO/PPO	$3.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.73
Rate for Payer: Superior Health Plan EPO	$0.89

DRESSING, TRANSPARENT TEGADERM REGULAR 4'X4-3/4 -- DHF

Facility

$6.57

Hospital Charge Code	80249295
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.47

DRESSING, TRANSPARENT WOUND W/CLR WINDOW 10CMX12CM -- DHF

Facility

$73.38

Hospital Charge Code	80248859
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.90

DRESSING, TRANSPARENT WOUND W/CLR WINDOW 10CMX12CM -- DHF

Facility

$73.38

Hospital Charge Code	80248859
Hospital Revenue Code	270
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$52.83
Rate for Payer: Amerigroup CHIP/Medicaid	$6.60
Rate for Payer: BCBS of TX Blue Advantage	$22.01
Rate for Payer: BCBS of TX Blue Essentials	$26.42
Rate for Payer: BCBS of TX PPO	$29.35
Rate for Payer: Cash Price	$49.90
Rate for Payer: Cigna Medicaid	$52.83
Rate for Payer: Molina CHIP/Medicaid	$52.83
Rate for Payer: Multiplan Auto	$47.70
Rate for Payer: Multiplan Commercial	$47.70
Rate for Payer: Multiplan Workers Comp	$47.70
Rate for Payer: Parkland Medicaid	$52.83
Rate for Payer: Scott and White EPO/PPO	$36.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$52.83
Rate for Payer: Superior Health Plan EPO	$9.98

DRESSING WOUND EXUFIBER 17.5 X 8

Facility

$33.87

Hospital Charge Code	8598510
Hospital Revenue Code	272
Rate for Payer: Cash Price	$23.03

DRESSING WOUND EXUFIBER 17.5 X 8

Facility

$33.87

Hospital Charge Code	8598510
Hospital Revenue Code	272
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$24.39
Rate for Payer: Amerigroup CHIP/Medicaid	$3.05
Rate for Payer: BCBS of TX Blue Advantage	$10.16
Rate for Payer: BCBS of TX Blue Essentials	$12.19
Rate for Payer: BCBS of TX PPO	$13.55
Rate for Payer: Cash Price	$23.03
Rate for Payer: Cigna Medicaid	$24.39
Rate for Payer: Molina CHIP/Medicaid	$24.39
Rate for Payer: Multiplan Auto	$22.02
Rate for Payer: Multiplan Commercial	$22.02
Rate for Payer: Multiplan Workers Comp	$22.02
Rate for Payer: Parkland Medicaid	$24.39
Rate for Payer: Scott and White EPO/PPO	$16.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24.39
Rate for Payer: Superior Health Plan EPO	$4.61

DRESSING WOUND EXUFIBER 4X5

Facility

$28.28

Hospital Charge Code	8568965
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19.23

DRESSING WOUND EXUFIBER 4X5

Facility

$28.28

Hospital Charge Code	8568965
Hospital Revenue Code	272
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$20.36
Rate for Payer: Amerigroup CHIP/Medicaid	$2.55
Rate for Payer: BCBS of TX Blue Advantage	$8.48
Rate for Payer: BCBS of TX Blue Essentials	$10.18
Rate for Payer: BCBS of TX PPO	$11.31
Rate for Payer: Cash Price	$19.23
Rate for Payer: Cigna Medicaid	$20.36
Rate for Payer: Molina CHIP/Medicaid	$20.36
Rate for Payer: Multiplan Auto	$18.38
Rate for Payer: Multiplan Commercial	$18.38
Rate for Payer: Multiplan Workers Comp	$18.38
Rate for Payer: Parkland Medicaid	$20.36
Rate for Payer: Scott and White EPO/PPO	$14.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20.36
Rate for Payer: Superior Health Plan EPO	$3.85

DRESSING, XEROFORM 1 X 8' OVERWRAP PK STERILE -- DHF

Facility

$4.69

Hospital Charge Code	80249261
Hospital Revenue Code	270
Rate for Payer: Cash Price	$3.19

DRESSING, XEROFORM 1 X 8' OVERWRAP PK STERILE -- DHF

Facility

$4.69

Hospital Charge Code	80249261
Hospital Revenue Code	270
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

DRILL

Facility

$386.35

Hospital Charge Code	993465
Hospital Revenue Code	272
Rate for Payer: Cash Price	$262.72

DRILL

Facility

$386.35

Hospital Charge Code	993465
Hospital Revenue Code	272
Min. Negotiated Rate	$34.77
Max. Negotiated Rate	$278.17
Rate for Payer: Amerigroup CHIP/Medicaid	$34.77
Rate for Payer: BCBS of TX Blue Advantage	$115.91
Rate for Payer: BCBS of TX Blue Essentials	$139.09
Rate for Payer: BCBS of TX PPO	$154.54
Rate for Payer: Cash Price	$262.72
Rate for Payer: Cigna Medicaid	$278.17
Rate for Payer: Molina CHIP/Medicaid	$278.17
Rate for Payer: Multiplan Auto	$251.13
Rate for Payer: Multiplan Commercial	$251.13
Rate for Payer: Multiplan Workers Comp	$251.13
Rate for Payer: Parkland Medicaid	$278.17
Rate for Payer: Scott and White EPO/PPO	$193.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$278.17
Rate for Payer: Superior Health Plan EPO	$52.54

DRILL 10MM CANNULATED

Facility

$1,475.50

Hospital Charge Code	146533
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,003.34

DRILL 10MM CANNULATED

Facility

$1,475.50

Hospital Charge Code	146533
Hospital Revenue Code	272
Min. Negotiated Rate	$132.79
Max. Negotiated Rate	$1,062.36
Rate for Payer: Amerigroup CHIP/Medicaid	$132.79
Rate for Payer: BCBS of TX Blue Advantage	$442.65
Rate for Payer: BCBS of TX Blue Essentials	$531.18
Rate for Payer: BCBS of TX PPO	$590.20
Rate for Payer: Cash Price	$1,003.34
Rate for Payer: Cigna Medicaid	$1,062.36
Rate for Payer: Molina CHIP/Medicaid	$1,062.36
Rate for Payer: Multiplan Auto	$959.08
Rate for Payer: Multiplan Commercial	$959.08
Rate for Payer: Multiplan Workers Comp	$959.08
Rate for Payer: Parkland Medicaid	$1,062.36
Rate for Payer: Scott and White EPO/PPO	$737.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,062.36
Rate for Payer: Superior Health Plan EPO	$200.67

DRILL 3.2 X 300

Facility

$998.80

Hospital Charge Code	993246
Hospital Revenue Code	272
Rate for Payer: Cash Price	$679.18

DRILL 3.2 X 300

Facility

$998.80

Hospital Charge Code	993246
Hospital Revenue Code	272
Min. Negotiated Rate	$89.89
Max. Negotiated Rate	$719.14
Rate for Payer: Amerigroup CHIP/Medicaid	$89.89
Rate for Payer: BCBS of TX Blue Advantage	$299.64
Rate for Payer: BCBS of TX Blue Essentials	$359.57
Rate for Payer: BCBS of TX PPO	$399.52
Rate for Payer: Cash Price	$679.18
Rate for Payer: Cigna Medicaid	$719.14
Rate for Payer: Molina CHIP/Medicaid	$719.14
Rate for Payer: Multiplan Auto	$649.22
Rate for Payer: Multiplan Commercial	$649.22
Rate for Payer: Multiplan Workers Comp	$649.22
Rate for Payer: Parkland Medicaid	$719.14
Rate for Payer: Scott and White EPO/PPO	$499.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$719.14
Rate for Payer: Superior Health Plan EPO	$135.84

DRILL 4.2 X 170MM

Facility

$1,071.44

Hospital Charge Code	146686
Hospital Revenue Code	272
Min. Negotiated Rate	$96.43
Max. Negotiated Rate	$771.44
Rate for Payer: Amerigroup CHIP/Medicaid	$96.43
Rate for Payer: BCBS of TX Blue Advantage	$321.43
Rate for Payer: BCBS of TX Blue Essentials	$385.72
Rate for Payer: BCBS of TX PPO	$428.58
Rate for Payer: Cash Price	$728.58
Rate for Payer: Cigna Medicaid	$771.44
Rate for Payer: Molina CHIP/Medicaid	$771.44
Rate for Payer: Multiplan Auto	$696.44
Rate for Payer: Multiplan Commercial	$696.44
Rate for Payer: Multiplan Workers Comp	$696.44
Rate for Payer: Parkland Medicaid	$771.44
Rate for Payer: Scott and White EPO/PPO	$535.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$771.44
Rate for Payer: Superior Health Plan EPO	$145.72

DRILL 4.2 X 170MM

Facility

$1,071.44

Hospital Charge Code	146686
Hospital Revenue Code	272
Rate for Payer: Cash Price	$728.58

Know your out-of-pocket cost for care.

All Charges