White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DRS PET/VS 3X9 -- DHF

Facility

$82.27

Hospital Charge Code	80246853
Hospital Revenue Code	270
Rate for Payer: Cash Price	$55.94

DRS PET/XM 1X8 -- DHF

Facility

$45.82

Hospital Charge Code	80247000
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.16

DRS PET/XM 1X8 -- DHF

Facility

$45.82

Hospital Charge Code	80247000
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

DRS PET/XM 5X9 -- DHF

Facility

$64.05

Hospital Charge Code	80247109
Hospital Revenue Code	270
Rate for Payer: Cash Price	$43.55

DRS PET/XM 5X9 -- DHF

Facility

$64.05

Hospital Charge Code	80247109
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

DRS PK IODO 1IN -- DHF

Facility

$266.40

Hospital Charge Code	80247406
Hospital Revenue Code	270
Rate for Payer: Cash Price	$181.15

DRS PK IODO 1IN -- DHF

Facility

$266.40

Hospital Charge Code	80247406
Hospital Revenue Code	270
Min. Negotiated Rate	$23.98
Max. Negotiated Rate	$191.81
Rate for Payer: Amerigroup CHIP/Medicaid	$23.98
Rate for Payer: BCBS of TX Blue Advantage	$79.92
Rate for Payer: BCBS of TX Blue Essentials	$95.90
Rate for Payer: BCBS of TX PPO	$106.56
Rate for Payer: Cash Price	$181.15
Rate for Payer: Cigna Medicaid	$191.81
Rate for Payer: Molina CHIP/Medicaid	$191.81
Rate for Payer: Multiplan Auto	$173.16
Rate for Payer: Multiplan Commercial	$173.16
Rate for Payer: Multiplan Workers Comp	$173.16
Rate for Payer: Parkland Medicaid	$191.81
Rate for Payer: Scott and White EPO/PPO	$133.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$191.81
Rate for Payer: Superior Health Plan EPO	$36.23

DRS PK IODO 2IN -- DHF

Facility

$354.16

Hospital Charge Code	80247455
Hospital Revenue Code	270
Rate for Payer: Cash Price	$240.83

DRS PK IODO 2IN -- DHF

Facility

$354.16

Hospital Charge Code	80247455
Hospital Revenue Code	270
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$255.00
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.25
Rate for Payer: BCBS of TX Blue Essentials	$127.50
Rate for Payer: BCBS of TX PPO	$141.66
Rate for Payer: Cash Price	$240.83
Rate for Payer: Cigna Medicaid	$255.00
Rate for Payer: Molina CHIP/Medicaid	$255.00
Rate for Payer: Multiplan Auto	$230.20
Rate for Payer: Multiplan Commercial	$230.20
Rate for Payer: Multiplan Workers Comp	$230.20
Rate for Payer: Parkland Medicaid	$255.00
Rate for Payer: Scott and White EPO/PPO	$177.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$255.00
Rate for Payer: Superior Health Plan EPO	$48.17

DRS PK NU-GZ A/S -- DHF

Facility

$220.53

Hospital Charge Code	80247505
Hospital Revenue Code	272
Rate for Payer: Cash Price	$149.96

DRS PK NU-GZ A/S -- DHF

Facility

$220.53

Hospital Charge Code	80247505
Hospital Revenue Code	272
Min. Negotiated Rate	$19.85
Max. Negotiated Rate	$158.78
Rate for Payer: Amerigroup CHIP/Medicaid	$19.85
Rate for Payer: BCBS of TX Blue Advantage	$66.16
Rate for Payer: BCBS of TX Blue Essentials	$79.39
Rate for Payer: BCBS of TX PPO	$88.21
Rate for Payer: Cash Price	$149.96
Rate for Payer: Cigna Medicaid	$158.78
Rate for Payer: Molina CHIP/Medicaid	$158.78
Rate for Payer: Multiplan Auto	$143.34
Rate for Payer: Multiplan Commercial	$143.34
Rate for Payer: Multiplan Workers Comp	$143.34
Rate for Payer: Parkland Medicaid	$158.78
Rate for Payer: Scott and White EPO/PPO	$110.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$158.78
Rate for Payer: Superior Health Plan EPO	$29.99

DRS PRESS LG -- DHF

Facility

$188.33

Hospital Charge Code	80247802
Hospital Revenue Code	272
Rate for Payer: Cash Price	$128.06

DRS PRESS LG -- DHF

Facility

$188.33

Hospital Charge Code	80247802
Hospital Revenue Code	272
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$135.60
Rate for Payer: Amerigroup CHIP/Medicaid	$16.95
Rate for Payer: BCBS of TX Blue Advantage	$56.50
Rate for Payer: BCBS of TX Blue Essentials	$67.80
Rate for Payer: BCBS of TX PPO	$75.33
Rate for Payer: Cash Price	$128.06
Rate for Payer: Cigna Medicaid	$135.60
Rate for Payer: Molina CHIP/Medicaid	$135.60
Rate for Payer: Multiplan Auto	$122.41
Rate for Payer: Multiplan Commercial	$122.41
Rate for Payer: Multiplan Workers Comp	$122.41
Rate for Payer: Parkland Medicaid	$135.60
Rate for Payer: Scott and White EPO/PPO	$94.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.60
Rate for Payer: Superior Health Plan EPO	$25.61

drs prisma collagen

Facility

$38.50

Hospital Charge Code	120401
Hospital Revenue Code	272
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$27.72
Rate for Payer: Amerigroup CHIP/Medicaid	$3.46
Rate for Payer: BCBS of TX Blue Advantage	$11.55
Rate for Payer: BCBS of TX Blue Essentials	$13.86
Rate for Payer: BCBS of TX PPO	$15.40
Rate for Payer: Cash Price	$26.18
Rate for Payer: Cigna Medicaid	$27.72
Rate for Payer: Molina CHIP/Medicaid	$27.72
Rate for Payer: Multiplan Auto	$25.02
Rate for Payer: Multiplan Commercial	$25.02
Rate for Payer: Multiplan Workers Comp	$25.02
Rate for Payer: Parkland Medicaid	$27.72
Rate for Payer: Scott and White EPO/PPO	$19.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.72
Rate for Payer: Superior Health Plan EPO	$5.24

drs prisma collagen

Facility

$38.50

Hospital Charge Code	120401
Hospital Revenue Code	272
Rate for Payer: Cash Price	$26.18

drs prisma collagen -wound

Facility

$38.50

Hospital Charge Code	120817
Hospital Revenue Code	270
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$27.72
Rate for Payer: Amerigroup CHIP/Medicaid	$3.46
Rate for Payer: BCBS of TX Blue Advantage	$11.55
Rate for Payer: BCBS of TX Blue Essentials	$13.86
Rate for Payer: BCBS of TX PPO	$15.40
Rate for Payer: Cash Price	$26.18
Rate for Payer: Cigna Medicaid	$27.72
Rate for Payer: Molina CHIP/Medicaid	$27.72
Rate for Payer: Multiplan Auto	$25.02
Rate for Payer: Multiplan Commercial	$25.02
Rate for Payer: Multiplan Workers Comp	$25.02
Rate for Payer: Parkland Medicaid	$27.72
Rate for Payer: Scott and White EPO/PPO	$19.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.72
Rate for Payer: Superior Health Plan EPO	$5.24

drs prisma collagen -wound

Facility

$38.50

Hospital Charge Code	120817
Hospital Revenue Code	270
Rate for Payer: Cash Price	$26.18

DRSSG, TGDRM, TRNSP, FRAME, W/TAB, 4X4.75

Facility

$3.53

Hospital Charge Code	992822
Hospital Revenue Code	272
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$2.54
Rate for Payer: Amerigroup CHIP/Medicaid	$0.32
Rate for Payer: BCBS of TX Blue Advantage	$1.06
Rate for Payer: BCBS of TX Blue Essentials	$1.27
Rate for Payer: BCBS of TX PPO	$1.41
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cigna Medicaid	$2.54
Rate for Payer: Molina CHIP/Medicaid	$2.54
Rate for Payer: Multiplan Auto	$2.29
Rate for Payer: Multiplan Commercial	$2.29
Rate for Payer: Multiplan Workers Comp	$2.29
Rate for Payer: Parkland Medicaid	$2.54
Rate for Payer: Scott and White EPO/PPO	$1.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.54
Rate for Payer: Superior Health Plan EPO	$0.48

DRSSG, TGDRM, TRNSP, FRAME, W/TAB, 4X4.75

Facility

$3.53

Hospital Charge Code	992822
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.40

DRS SORB 2X2 -- DHF

Facility

$101.36

Hospital Charge Code	80248057
Hospital Revenue Code	270
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$72.98
Rate for Payer: Amerigroup CHIP/Medicaid	$9.12
Rate for Payer: BCBS of TX Blue Advantage	$30.41
Rate for Payer: BCBS of TX Blue Essentials	$36.49
Rate for Payer: BCBS of TX PPO	$40.54
Rate for Payer: Cash Price	$68.92
Rate for Payer: Cigna Medicaid	$72.98
Rate for Payer: Molina CHIP/Medicaid	$72.98
Rate for Payer: Multiplan Auto	$65.88
Rate for Payer: Multiplan Commercial	$65.88
Rate for Payer: Multiplan Workers Comp	$65.88
Rate for Payer: Parkland Medicaid	$72.98
Rate for Payer: Scott and White EPO/PPO	$50.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$72.98
Rate for Payer: Superior Health Plan EPO	$13.78

DRS SORB 2X2 -- DHF

Facility

$101.36

Hospital Charge Code	80248057
Hospital Revenue Code	270
Rate for Payer: Cash Price	$68.92

DRS SORB 4X4 -- DHF

Facility

$87.80

Hospital Charge Code	80248107
Hospital Revenue Code	270
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$63.22
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$59.70
Rate for Payer: Cigna Medicaid	$63.22
Rate for Payer: Molina CHIP/Medicaid	$63.22
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Parkland Medicaid	$63.22
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.22
Rate for Payer: Superior Health Plan EPO	$11.94

DRS SORB 4X4 -- DHF

Facility

$87.80

Hospital Charge Code	80248107
Hospital Revenue Code	270
Rate for Payer: Cash Price	$59.70

DRS SORB A/S -- DHF

Facility

$96.69

Hospital Charge Code	80248040
Hospital Revenue Code	270
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

DRS SORB A/S -- DHF

Facility

$96.69

Hospital Charge Code	80248040
Hospital Revenue Code	270
Rate for Payer: Cash Price	$65.75

Know your out-of-pocket cost for care.

All Charges