White Rock Medical Center

All Charges

Charge

Type

Setting

Price

GAUZE, NW, DELUXE, 2'X2', 4PLY, NS, LF

Facility

$0.05

Hospital Charge Code	992962
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.03

GAUZE, PACKING IODOFORM 1/2'X 5YD STERILE -- DHF

Facility

$247.86

Hospital Charge Code	80247307
Hospital Revenue Code	270
Rate for Payer: Cash Price	$168.54

GAUZE, PACKING IODOFORM 1/2'X 5YD STERILE -- DHF

Facility

$247.86

Hospital Charge Code	80247307
Hospital Revenue Code	270
Min. Negotiated Rate	$22.31
Max. Negotiated Rate	$178.46
Rate for Payer: Amerigroup CHIP/Medicaid	$22.31
Rate for Payer: BCBS of TX Blue Advantage	$74.36
Rate for Payer: BCBS of TX Blue Essentials	$89.23
Rate for Payer: BCBS of TX PPO	$99.14
Rate for Payer: Cash Price	$168.54
Rate for Payer: Cigna Medicaid	$178.46
Rate for Payer: Molina CHIP/Medicaid	$178.46
Rate for Payer: Multiplan Auto	$161.11
Rate for Payer: Multiplan Commercial	$161.11
Rate for Payer: Multiplan Workers Comp	$161.11
Rate for Payer: Parkland Medicaid	$178.46
Rate for Payer: Scott and White EPO/PPO	$123.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$178.46
Rate for Payer: Superior Health Plan EPO	$33.71

GAUZE, PACKING IODOFORM 1/4' X 5 YD STERILE -- DHF

Facility

$234.19

Hospital Charge Code	80247356
Hospital Revenue Code	270
Min. Negotiated Rate	$21.08
Max. Negotiated Rate	$168.62
Rate for Payer: Amerigroup CHIP/Medicaid	$21.08
Rate for Payer: BCBS of TX Blue Advantage	$70.26
Rate for Payer: BCBS of TX Blue Essentials	$84.31
Rate for Payer: BCBS of TX PPO	$93.68
Rate for Payer: Cash Price	$159.25
Rate for Payer: Cigna Medicaid	$168.62
Rate for Payer: Molina CHIP/Medicaid	$168.62
Rate for Payer: Multiplan Auto	$152.22
Rate for Payer: Multiplan Commercial	$152.22
Rate for Payer: Multiplan Workers Comp	$152.22
Rate for Payer: Parkland Medicaid	$168.62
Rate for Payer: Scott and White EPO/PPO	$117.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$168.62
Rate for Payer: Superior Health Plan EPO	$31.85

GAUZE, PACKING IODOFORM 1/4' X 5 YD STERILE -- DHF

Facility

$234.19

Hospital Charge Code	80247356
Hospital Revenue Code	270
Rate for Payer: Cash Price	$159.25

GAUZE, SPONGE, 4'X4', 12PLY, WOVEN, NS, LS

Facility

$0.27

Hospital Charge Code	992963
Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.19
Rate for Payer: Amerigroup CHIP/Medicaid	$0.02
Rate for Payer: BCBS of TX Blue Advantage	$0.08
Rate for Payer: BCBS of TX Blue Essentials	$0.10
Rate for Payer: BCBS of TX PPO	$0.11
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna Medicaid	$0.19
Rate for Payer: Molina CHIP/Medicaid	$0.19
Rate for Payer: Multiplan Auto	$0.18
Rate for Payer: Multiplan Commercial	$0.18
Rate for Payer: Multiplan Workers Comp	$0.18
Rate for Payer: Parkland Medicaid	$0.19
Rate for Payer: Scott and White EPO/PPO	$0.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.19
Rate for Payer: Superior Health Plan EPO	$0.04

GAUZE, SPONGE, 4'X4', 12PLY, WOVEN, NS, LS

Facility

$0.27

Hospital Charge Code	992963
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.18

GAUZE, SPONGE, 4X4, 4PLY, NS, NW, LF

Facility

$0.06

Hospital Charge Code	992918
Hospital Revenue Code	272
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Amerigroup CHIP/Medicaid	$0.01
Rate for Payer: BCBS of TX Blue Advantage	$0.02
Rate for Payer: BCBS of TX Blue Essentials	$0.02
Rate for Payer: BCBS of TX PPO	$0.02
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna Medicaid	$0.04
Rate for Payer: Molina CHIP/Medicaid	$0.04
Rate for Payer: Multiplan Auto	$0.04
Rate for Payer: Multiplan Commercial	$0.04
Rate for Payer: Multiplan Workers Comp	$0.04
Rate for Payer: Parkland Medicaid	$0.04
Rate for Payer: Scott and White EPO/PPO	$0.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.04
Rate for Payer: Superior Health Plan EPO	$0.01

GAUZE, SPONGE, 4X4, 4PLY, NS, NW, LF

Facility

$0.06

Hospital Charge Code	992918
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.04

GDE NDL BX COMP -- DHF

Facility

$42.70

Hospital Charge Code	80730294
Hospital Revenue Code	272
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$30.74
Rate for Payer: Amerigroup CHIP/Medicaid	$3.84
Rate for Payer: BCBS of TX Blue Advantage	$12.81
Rate for Payer: BCBS of TX Blue Essentials	$15.37
Rate for Payer: BCBS of TX PPO	$17.08
Rate for Payer: Cash Price	$29.04
Rate for Payer: Cigna Medicaid	$30.74
Rate for Payer: Molina CHIP/Medicaid	$30.74
Rate for Payer: Multiplan Auto	$27.75
Rate for Payer: Multiplan Commercial	$27.75
Rate for Payer: Multiplan Workers Comp	$27.75
Rate for Payer: Parkland Medicaid	$30.74
Rate for Payer: Scott and White EPO/PPO	$21.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.74
Rate for Payer: Superior Health Plan EPO	$5.81

GDE NDL BX COMP -- DHF

Facility

$42.70

Hospital Charge Code	80730294
Hospital Revenue Code	272
Rate for Payer: Cash Price	$29.04

GDE PINS -- DHF

Facility

$522.19

Hospital Charge Code	81327009
Hospital Revenue Code	272
Rate for Payer: Cash Price	$355.09

GDE PINS -- DHF

Facility

$522.19

Hospital Charge Code	81327009
Hospital Revenue Code	272
Min. Negotiated Rate	$47.00
Max. Negotiated Rate	$375.98
Rate for Payer: Amerigroup CHIP/Medicaid	$47.00
Rate for Payer: BCBS of TX Blue Advantage	$156.66
Rate for Payer: BCBS of TX Blue Essentials	$187.99
Rate for Payer: BCBS of TX PPO	$208.88
Rate for Payer: Cash Price	$355.09
Rate for Payer: Cigna Medicaid	$375.98
Rate for Payer: Molina CHIP/Medicaid	$375.98
Rate for Payer: Multiplan Auto	$339.42
Rate for Payer: Multiplan Commercial	$339.42
Rate for Payer: Multiplan Workers Comp	$339.42
Rate for Payer: Parkland Medicaid	$375.98
Rate for Payer: Scott and White EPO/PPO	$261.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$375.98
Rate for Payer: Superior Health Plan EPO	$71.02

gel adhesive tensive conductive

Facility

$13.17

Hospital Charge Code	144857
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.96

gel adhesive tensive conductive

Facility

$13.17

Hospital Charge Code	144857
Hospital Revenue Code	272
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$9.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1.19
Rate for Payer: BCBS of TX Blue Advantage	$3.95
Rate for Payer: BCBS of TX Blue Essentials	$4.74
Rate for Payer: BCBS of TX PPO	$5.27
Rate for Payer: Cash Price	$8.96
Rate for Payer: Cigna Medicaid	$9.48
Rate for Payer: Molina CHIP/Medicaid	$9.48
Rate for Payer: Multiplan Auto	$8.56
Rate for Payer: Multiplan Commercial	$8.56
Rate for Payer: Multiplan Workers Comp	$8.56
Rate for Payer: Parkland Medicaid	$9.48
Rate for Payer: Scott and White EPO/PPO	$6.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.48
Rate for Payer: Superior Health Plan EPO	$1.79

GEL DRML WND 10 -- DHF

Facility

$331.23

Hospital Charge Code	80322860
Hospital Revenue Code	270
Rate for Payer: Cash Price	$225.24

GEL DRML WND 10 -- DHF

Facility

$331.23

Hospital Charge Code	80322860
Hospital Revenue Code	270
Min. Negotiated Rate	$29.81
Max. Negotiated Rate	$238.49
Rate for Payer: Amerigroup CHIP/Medicaid	$29.81
Rate for Payer: BCBS of TX Blue Advantage	$99.37
Rate for Payer: BCBS of TX Blue Essentials	$119.24
Rate for Payer: BCBS of TX PPO	$132.49
Rate for Payer: Cash Price	$225.24
Rate for Payer: Cigna Medicaid	$238.49
Rate for Payer: Molina CHIP/Medicaid	$238.49
Rate for Payer: Multiplan Auto	$215.30
Rate for Payer: Multiplan Commercial	$215.30
Rate for Payer: Multiplan Workers Comp	$215.30
Rate for Payer: Parkland Medicaid	$238.49
Rate for Payer: Scott and White EPO/PPO	$165.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$238.49
Rate for Payer: Superior Health Plan EPO	$45.05

GEL DRML WND 2 -- DHF

Facility

$60.46

Hospital Charge Code	80322845
Hospital Revenue Code	270
Rate for Payer: Cash Price	$41.11

GEL DRML WND 2 -- DHF

Facility

$60.46

Hospital Charge Code	80322845
Hospital Revenue Code	270
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$43.53
Rate for Payer: Amerigroup CHIP/Medicaid	$5.44
Rate for Payer: BCBS of TX Blue Advantage	$18.14
Rate for Payer: BCBS of TX Blue Essentials	$21.77
Rate for Payer: BCBS of TX PPO	$24.18
Rate for Payer: Cash Price	$41.11
Rate for Payer: Cigna Medicaid	$43.53
Rate for Payer: Molina CHIP/Medicaid	$43.53
Rate for Payer: Multiplan Auto	$39.30
Rate for Payer: Multiplan Commercial	$39.30
Rate for Payer: Multiplan Workers Comp	$39.30
Rate for Payer: Parkland Medicaid	$43.53
Rate for Payer: Scott and White EPO/PPO	$30.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.53
Rate for Payer: Superior Health Plan EPO	$8.22

GEL, ULTRASOUND SCANNING, SINGLES

Facility

$1.74

Hospital Charge Code	992899
Hospital Revenue Code	272
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$1.25
Rate for Payer: Amerigroup CHIP/Medicaid	$0.16
Rate for Payer: BCBS of TX Blue Advantage	$0.52
Rate for Payer: BCBS of TX Blue Essentials	$0.63
Rate for Payer: BCBS of TX PPO	$0.70
Rate for Payer: Cash Price	$1.18
Rate for Payer: Cigna Medicaid	$1.25
Rate for Payer: Molina CHIP/Medicaid	$1.25
Rate for Payer: Multiplan Auto	$1.13
Rate for Payer: Multiplan Commercial	$1.13
Rate for Payer: Multiplan Workers Comp	$1.13
Rate for Payer: Parkland Medicaid	$1.25
Rate for Payer: Scott and White EPO/PPO	$0.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.25
Rate for Payer: Superior Health Plan EPO	$0.24

GEL, ULTRASOUND SCANNING, SINGLES

Facility

$1.74

Hospital Charge Code	992899
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1.18

GEL WOUND DRESSING MEDIHONEY FLIP TOP TUBE 1.5OZ

Facility

$56.09

Hospital Charge Code	993268
Hospital Revenue Code	270
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$40.38
Rate for Payer: Amerigroup CHIP/Medicaid	$5.05
Rate for Payer: BCBS of TX Blue Advantage	$16.83
Rate for Payer: BCBS of TX Blue Essentials	$20.19
Rate for Payer: BCBS of TX PPO	$22.44
Rate for Payer: Cash Price	$38.14
Rate for Payer: Cigna Medicaid	$40.38
Rate for Payer: Molina CHIP/Medicaid	$40.38
Rate for Payer: Multiplan Auto	$36.46
Rate for Payer: Multiplan Commercial	$36.46
Rate for Payer: Multiplan Workers Comp	$36.46
Rate for Payer: Parkland Medicaid	$40.38
Rate for Payer: Scott and White EPO/PPO	$28.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.38
Rate for Payer: Superior Health Plan EPO	$7.63

GEL WOUND DRESSING MEDIHONEY FLIP TOP TUBE 1.5OZ

Facility

$56.09

Hospital Charge Code	993268
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.14

GEL WOUND MEDIHONEY TB -- DHF

Facility

$62.95

Hospital Charge Code	80383227
Hospital Revenue Code	272
Rate for Payer: Cash Price	$42.81

GEL WOUND MEDIHONEY TB -- DHF

Facility

$62.95

Hospital Charge Code	80383227
Hospital Revenue Code	272
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$45.32
Rate for Payer: Amerigroup CHIP/Medicaid	$5.67
Rate for Payer: BCBS of TX Blue Advantage	$18.89
Rate for Payer: BCBS of TX Blue Essentials	$22.66
Rate for Payer: BCBS of TX PPO	$25.18
Rate for Payer: Cash Price	$42.81
Rate for Payer: Cigna Medicaid	$45.32
Rate for Payer: Molina CHIP/Medicaid	$45.32
Rate for Payer: Multiplan Auto	$40.92
Rate for Payer: Multiplan Commercial	$40.92
Rate for Payer: Multiplan Workers Comp	$40.92
Rate for Payer: Parkland Medicaid	$45.32
Rate for Payer: Scott and White EPO/PPO	$31.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$45.32
Rate for Payer: Superior Health Plan EPO	$8.56

Know your out-of-pocket cost for care.

All Charges