White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PACK NEEDLE HIP ACCESS

Facility

$342.04

Hospital Charge Code	8692541
Hospital Revenue Code	272
Rate for Payer: Cash Price	$301.00

PACK NEEDLE HIP ACCESS

Facility

$342.04

Hospital Charge Code	8692541
Hospital Revenue Code	272
Min. Negotiated Rate	$30.78
Max. Negotiated Rate	$222.33
Rate for Payer: Aetna Commercial	$188.12
Rate for Payer: Amerigroup CHIP/Medicaid	$30.78
Rate for Payer: BCBS of TX Blue Advantage	$102.61
Rate for Payer: BCBS of TX Blue Essentials	$123.13
Rate for Payer: BCBS of TX PPO	$136.82
Rate for Payer: Cash Price	$301.00
Rate for Payer: Multiplan Auto	$222.33
Rate for Payer: Multiplan Commercial	$222.33
Rate for Payer: Multiplan Workers Comp	$222.33
Rate for Payer: Scott and White EPO/PPO	$171.02
Rate for Payer: Superior Health Plan EPO	$46.52

PACK ORTHOPEDIC

Facility

$67.24

Hospital Charge Code	8514473
Hospital Revenue Code	272
Rate for Payer: Cash Price	$59.17

PACK ORTHOPEDIC

Facility

$67.24

Hospital Charge Code	8514473
Hospital Revenue Code	272
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$43.71
Rate for Payer: Aetna Commercial	$36.98
Rate for Payer: Amerigroup CHIP/Medicaid	$6.05
Rate for Payer: BCBS of TX Blue Advantage	$20.17
Rate for Payer: BCBS of TX Blue Essentials	$24.21
Rate for Payer: BCBS of TX PPO	$26.90
Rate for Payer: Cash Price	$59.17
Rate for Payer: Multiplan Auto	$43.71
Rate for Payer: Multiplan Commercial	$43.71
Rate for Payer: Multiplan Workers Comp	$43.71
Rate for Payer: Scott and White EPO/PPO	$33.62
Rate for Payer: Superior Health Plan EPO	$9.14

PACK UNIVERSAL DRAPE STERILE

Facility

$56.16

Hospital Charge Code	8692537
Hospital Revenue Code	270
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$36.50
Rate for Payer: Aetna Commercial	$30.89
Rate for Payer: Amerigroup CHIP/Medicaid	$5.05
Rate for Payer: BCBS of TX Blue Advantage	$16.85
Rate for Payer: BCBS of TX Blue Essentials	$20.22
Rate for Payer: BCBS of TX PPO	$22.46
Rate for Payer: Cash Price	$49.42
Rate for Payer: Multiplan Auto	$36.50
Rate for Payer: Multiplan Commercial	$36.50
Rate for Payer: Multiplan Workers Comp	$36.50
Rate for Payer: Scott and White EPO/PPO	$28.08
Rate for Payer: Superior Health Plan EPO	$7.64

PACK UNIVERSAL DRAPE STERILE

Facility

$56.16

Hospital Charge Code	8692537
Hospital Revenue Code	270
Rate for Payer: Cash Price	$49.42

pad boot insert

Facility

$935.24

Hospital Charge Code	102867
Hospital Revenue Code	270
Min. Negotiated Rate	$84.17
Max. Negotiated Rate	$607.91
Rate for Payer: Aetna Commercial	$514.38
Rate for Payer: Amerigroup CHIP/Medicaid	$84.17
Rate for Payer: BCBS of TX Blue Advantage	$280.57
Rate for Payer: BCBS of TX Blue Essentials	$336.69
Rate for Payer: BCBS of TX PPO	$374.10
Rate for Payer: Cash Price	$823.01
Rate for Payer: Multiplan Auto	$607.91
Rate for Payer: Multiplan Commercial	$607.91
Rate for Payer: Multiplan Workers Comp	$607.91
Rate for Payer: Scott and White EPO/PPO	$467.62
Rate for Payer: Superior Health Plan EPO	$127.19

pad boot insert

Facility

$935.24

Hospital Charge Code	102867
Hospital Revenue Code	270
Rate for Payer: Cash Price	$823.01

PADDING, CAST COTTON EXTRA THICK 3'''' X 4 YDS STER -- DHF

Facility

$78.04

Hospital Charge Code	81030009
Hospital Revenue Code	270
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$50.73
Rate for Payer: Aetna Commercial	$42.92
Rate for Payer: Amerigroup CHIP/Medicaid	$7.02
Rate for Payer: BCBS of TX Blue Advantage	$23.41
Rate for Payer: BCBS of TX Blue Essentials	$28.09
Rate for Payer: BCBS of TX PPO	$31.22
Rate for Payer: Cash Price	$68.68
Rate for Payer: Multiplan Auto	$50.73
Rate for Payer: Multiplan Commercial	$50.73
Rate for Payer: Multiplan Workers Comp	$50.73
Rate for Payer: Scott and White EPO/PPO	$39.02
Rate for Payer: Superior Health Plan EPO	$10.61

PADDING, CAST COTTON EXTRA THICK 4'''' X 4 YDS STER -- DHF

Facility

$78.04

Hospital Charge Code	81030009
Hospital Revenue Code	270
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$50.73
Rate for Payer: Aetna Commercial	$42.92
Rate for Payer: Amerigroup CHIP/Medicaid	$7.02
Rate for Payer: BCBS of TX Blue Advantage	$23.41
Rate for Payer: BCBS of TX Blue Essentials	$28.09
Rate for Payer: BCBS of TX PPO	$31.22
Rate for Payer: Cash Price	$68.68
Rate for Payer: Multiplan Auto	$50.73
Rate for Payer: Multiplan Commercial	$50.73
Rate for Payer: Multiplan Workers Comp	$50.73
Rate for Payer: Scott and White EPO/PPO	$39.02
Rate for Payer: Superior Health Plan EPO	$10.61

PADDING, CAST COTTON EXTRA THICK 6'''' X 4 YDS STER -- DHF

Facility

$78.04

Hospital Charge Code	81030009
Hospital Revenue Code	270
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$50.73
Rate for Payer: Aetna Commercial	$42.92
Rate for Payer: Amerigroup CHIP/Medicaid	$7.02
Rate for Payer: BCBS of TX Blue Advantage	$23.41
Rate for Payer: BCBS of TX Blue Essentials	$28.09
Rate for Payer: BCBS of TX PPO	$31.22
Rate for Payer: Cash Price	$68.68
Rate for Payer: Multiplan Auto	$50.73
Rate for Payer: Multiplan Commercial	$50.73
Rate for Payer: Multiplan Workers Comp	$50.73
Rate for Payer: Scott and White EPO/PPO	$39.02
Rate for Payer: Superior Health Plan EPO	$10.61

PADDING, CAST COTTON EXTRA THICK 6'''' X 4 YDS STER -- DHF

Facility

$78.04

Hospital Charge Code	81030009
Hospital Revenue Code	270
Rate for Payer: Cash Price	$68.68

PADDING, CAST COTTON WEBRIL II 4'''' X 4 YDS STERILE -- DHF

Facility

$23.04

Hospital Charge Code	81030116
Hospital Revenue Code	270
Rate for Payer: Cash Price	$20.28

PADDING, CAST COTTON WEBRIL II 4'''' X 4 YDS STERILE -- DHF

Facility

$23.04

Hospital Charge Code	81030116
Hospital Revenue Code	270
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$14.98
Rate for Payer: Aetna Commercial	$12.67
Rate for Payer: Amerigroup CHIP/Medicaid	$2.07
Rate for Payer: BCBS of TX Blue Advantage	$6.91
Rate for Payer: BCBS of TX Blue Essentials	$8.29
Rate for Payer: BCBS of TX PPO	$9.22
Rate for Payer: Cash Price	$20.28
Rate for Payer: Multiplan Auto	$14.98
Rate for Payer: Multiplan Commercial	$14.98
Rate for Payer: Multiplan Workers Comp	$14.98
Rate for Payer: Scott and White EPO/PPO	$11.52
Rate for Payer: Superior Health Plan EPO	$3.13

PAD, DRI-FLOOR FLUID ABSORB 33'''' X 40'''' -- DHF

Facility

$70.32

Hospital Charge Code	80333925
Hospital Revenue Code	272
Rate for Payer: Cash Price	$61.88

PAD, DRI-FLOOR FLUID ABSORB 33'''' X 40'''' -- DHF

Facility

$70.32

Hospital Charge Code	80333925
Hospital Revenue Code	272
Min. Negotiated Rate	$6.33
Max. Negotiated Rate	$45.71
Rate for Payer: Aetna Commercial	$38.68
Rate for Payer: Amerigroup CHIP/Medicaid	$6.33
Rate for Payer: BCBS of TX Blue Advantage	$21.10
Rate for Payer: BCBS of TX Blue Essentials	$25.32
Rate for Payer: BCBS of TX PPO	$28.13
Rate for Payer: Cash Price	$61.88
Rate for Payer: Multiplan Auto	$45.71
Rate for Payer: Multiplan Commercial	$45.71
Rate for Payer: Multiplan Workers Comp	$45.71
Rate for Payer: Scott and White EPO/PPO	$35.16
Rate for Payer: Superior Health Plan EPO	$9.56

PAD DUO TRACK

Facility

$323.48

Hospital Charge Code	8570494
Hospital Revenue Code	272
Rate for Payer: Cash Price	$284.66

PAD DUO TRACK

Facility

$323.48

Hospital Charge Code	8570494
Hospital Revenue Code	272
Min. Negotiated Rate	$29.11
Max. Negotiated Rate	$210.26
Rate for Payer: Aetna Commercial	$177.91
Rate for Payer: Amerigroup CHIP/Medicaid	$29.11
Rate for Payer: BCBS of TX Blue Advantage	$97.04
Rate for Payer: BCBS of TX Blue Essentials	$116.45
Rate for Payer: BCBS of TX PPO	$129.39
Rate for Payer: Cash Price	$284.66
Rate for Payer: Multiplan Auto	$210.26
Rate for Payer: Multiplan Commercial	$210.26
Rate for Payer: Multiplan Workers Comp	$210.26
Rate for Payer: Scott and White EPO/PPO	$161.74
Rate for Payer: Superior Health Plan EPO	$43.99

PAD, KNEE POSITIONING UNIVERSAL STERILE DISP -- DHF

Facility

$201.20

Hospital Charge Code	81760555
Hospital Revenue Code	270
Min. Negotiated Rate	$18.11
Max. Negotiated Rate	$130.78
Rate for Payer: Aetna Commercial	$110.66
Rate for Payer: Amerigroup CHIP/Medicaid	$18.11
Rate for Payer: BCBS of TX Blue Advantage	$60.36
Rate for Payer: BCBS of TX Blue Essentials	$72.43
Rate for Payer: BCBS of TX PPO	$80.48
Rate for Payer: Cash Price	$177.06
Rate for Payer: Multiplan Auto	$130.78
Rate for Payer: Multiplan Commercial	$130.78
Rate for Payer: Multiplan Workers Comp	$130.78
Rate for Payer: Scott and White EPO/PPO	$100.60
Rate for Payer: Superior Health Plan EPO	$27.36

PAD, MATRIX KNEE FOAM STERILE DISP. -- DHF

Facility

$201.20

Hospital Charge Code	81760555
Hospital Revenue Code	270
Rate for Payer: Cash Price	$177.06

PAD, MATRIX KNEE FOAM STERILE DISP. -- DHF

Facility

$201.20

Hospital Charge Code	81760555
Hospital Revenue Code	270
Min. Negotiated Rate	$18.11
Max. Negotiated Rate	$130.78
Rate for Payer: Aetna Commercial	$110.66
Rate for Payer: Amerigroup CHIP/Medicaid	$18.11
Rate for Payer: BCBS of TX Blue Advantage	$60.36
Rate for Payer: BCBS of TX Blue Essentials	$72.43
Rate for Payer: BCBS of TX PPO	$80.48
Rate for Payer: Cash Price	$177.06
Rate for Payer: Multiplan Auto	$130.78
Rate for Payer: Multiplan Commercial	$130.78
Rate for Payer: Multiplan Workers Comp	$130.78
Rate for Payer: Scott and White EPO/PPO	$100.60
Rate for Payer: Superior Health Plan EPO	$27.36

pad perineal supine

Facility

$526.64

Hospital Charge Code	102886
Hospital Revenue Code	270
Min. Negotiated Rate	$47.40
Max. Negotiated Rate	$342.32
Rate for Payer: Aetna Commercial	$289.65
Rate for Payer: Amerigroup CHIP/Medicaid	$47.40
Rate for Payer: BCBS of TX Blue Advantage	$157.99
Rate for Payer: BCBS of TX Blue Essentials	$189.59
Rate for Payer: BCBS of TX PPO	$210.66
Rate for Payer: Cash Price	$463.44
Rate for Payer: Multiplan Auto	$342.32
Rate for Payer: Multiplan Commercial	$342.32
Rate for Payer: Multiplan Workers Comp	$342.32
Rate for Payer: Scott and White EPO/PPO	$263.32
Rate for Payer: Superior Health Plan EPO	$71.62

pad perineal supine

Facility

$526.64

Hospital Charge Code	102886
Hospital Revenue Code	270
Rate for Payer: Cash Price	$463.44

PAD PINK W/ARM PROTECTOR

Facility

$404.06

Hospital Charge Code	8538536
Hospital Revenue Code	272
Min. Negotiated Rate	$36.37
Max. Negotiated Rate	$262.64
Rate for Payer: Aetna Commercial	$222.23
Rate for Payer: Amerigroup CHIP/Medicaid	$36.37
Rate for Payer: BCBS of TX Blue Advantage	$121.22
Rate for Payer: BCBS of TX Blue Essentials	$145.46
Rate for Payer: BCBS of TX PPO	$161.62
Rate for Payer: Cash Price	$355.57
Rate for Payer: Multiplan Auto	$262.64
Rate for Payer: Multiplan Commercial	$262.64
Rate for Payer: Multiplan Workers Comp	$262.64
Rate for Payer: Scott and White EPO/PPO	$202.03
Rate for Payer: Superior Health Plan EPO	$54.95

PAD PINK W/ARM PROTECTOR

Facility

$404.06

Hospital Charge Code	8538536
Hospital Revenue Code	272
Rate for Payer: Cash Price	$355.57

Know your out-of-pocket cost for care.

All Charges