White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MASK, FACE AIR CUSHION PREMIUM W/O HOOK RING ADULT

Facility

$7.08

Hospital Charge Code	993621
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.81

MASK FACE FULL CPAP/BIPAP LARGE DISP

Facility

$18.05

Hospital Charge Code	993520
Hospital Revenue Code	270
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$13.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1.62
Rate for Payer: BCBS of TX Blue Advantage	$5.42
Rate for Payer: BCBS of TX Blue Essentials	$6.50
Rate for Payer: BCBS of TX PPO	$7.22
Rate for Payer: Cash Price	$12.27
Rate for Payer: Cigna Medicaid	$13.00
Rate for Payer: Molina CHIP/Medicaid	$13.00
Rate for Payer: Multiplan Auto	$11.73
Rate for Payer: Multiplan Commercial	$11.73
Rate for Payer: Multiplan Workers Comp	$11.73
Rate for Payer: Parkland Medicaid	$13.00
Rate for Payer: Scott and White EPO/PPO	$9.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.00
Rate for Payer: Superior Health Plan EPO	$2.45

MASK FACE FULL CPAP/BIPAP LARGE DISP

Facility

$18.05

Hospital Charge Code	993520
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.27

MASK FACE FULL CPAP/BIPAP SMALL DISPOSABLE

Facility

$18.05

Hospital Charge Code	993521
Hospital Revenue Code	270
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$13.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1.62
Rate for Payer: BCBS of TX Blue Advantage	$5.42
Rate for Payer: BCBS of TX Blue Essentials	$6.50
Rate for Payer: BCBS of TX PPO	$7.22
Rate for Payer: Cash Price	$12.27
Rate for Payer: Cigna Medicaid	$13.00
Rate for Payer: Molina CHIP/Medicaid	$13.00
Rate for Payer: Multiplan Auto	$11.73
Rate for Payer: Multiplan Commercial	$11.73
Rate for Payer: Multiplan Workers Comp	$11.73
Rate for Payer: Parkland Medicaid	$13.00
Rate for Payer: Scott and White EPO/PPO	$9.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.00
Rate for Payer: Superior Health Plan EPO	$2.45

MASK FACE FULL CPAP/BIPAP SMALL DISPOSABLE

Facility

$18.05

Hospital Charge Code	993521
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.27

MASK, FACE FULL NON-VENTED LARGE SINGLE USE

Facility

$98.89

Hospital Charge Code	993624
Hospital Revenue Code	270
Rate for Payer: Cash Price	$67.25

MASK, FACE FULL NON-VENTED LARGE SINGLE USE

Facility

$98.89

Hospital Charge Code	993624
Hospital Revenue Code	270
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$71.20
Rate for Payer: Amerigroup CHIP/Medicaid	$8.90
Rate for Payer: BCBS of TX Blue Advantage	$29.67
Rate for Payer: BCBS of TX Blue Essentials	$35.60
Rate for Payer: BCBS of TX PPO	$39.56
Rate for Payer: Cash Price	$67.25
Rate for Payer: Cigna Medicaid	$71.20
Rate for Payer: Molina CHIP/Medicaid	$71.20
Rate for Payer: Multiplan Auto	$64.28
Rate for Payer: Multiplan Commercial	$64.28
Rate for Payer: Multiplan Workers Comp	$64.28
Rate for Payer: Parkland Medicaid	$71.20
Rate for Payer: Scott and White EPO/PPO	$49.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$71.20
Rate for Payer: Superior Health Plan EPO	$13.45

MASK, FACE FULL NON-VENTED MEDIUM SINGLE USE

Facility

$98.89

Hospital Charge Code	993625
Hospital Revenue Code	270
Rate for Payer: Cash Price	$67.25

MASK, FACE FULL NON-VENTED MEDIUM SINGLE USE

Facility

$98.89

Hospital Charge Code	993625
Hospital Revenue Code	270
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$71.20
Rate for Payer: Amerigroup CHIP/Medicaid	$8.90
Rate for Payer: BCBS of TX Blue Advantage	$29.67
Rate for Payer: BCBS of TX Blue Essentials	$35.60
Rate for Payer: BCBS of TX PPO	$39.56
Rate for Payer: Cash Price	$67.25
Rate for Payer: Cigna Medicaid	$71.20
Rate for Payer: Molina CHIP/Medicaid	$71.20
Rate for Payer: Multiplan Auto	$64.28
Rate for Payer: Multiplan Commercial	$64.28
Rate for Payer: Multiplan Workers Comp	$64.28
Rate for Payer: Parkland Medicaid	$71.20
Rate for Payer: Scott and White EPO/PPO	$49.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$71.20
Rate for Payer: Superior Health Plan EPO	$13.45

MASK, FACE FULL NON-VENTED SMALL SINGLE USE

Facility

$98.89

Hospital Charge Code	993626
Hospital Revenue Code	270
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$71.20
Rate for Payer: Amerigroup CHIP/Medicaid	$8.90
Rate for Payer: BCBS of TX Blue Advantage	$29.67
Rate for Payer: BCBS of TX Blue Essentials	$35.60
Rate for Payer: BCBS of TX PPO	$39.56
Rate for Payer: Cash Price	$67.25
Rate for Payer: Cigna Medicaid	$71.20
Rate for Payer: Molina CHIP/Medicaid	$71.20
Rate for Payer: Multiplan Auto	$64.28
Rate for Payer: Multiplan Commercial	$64.28
Rate for Payer: Multiplan Workers Comp	$64.28
Rate for Payer: Parkland Medicaid	$71.20
Rate for Payer: Scott and White EPO/PPO	$49.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$71.20
Rate for Payer: Superior Health Plan EPO	$13.45

MASK, FACE FULL NON-VENTED SMALL SINGLE USE

Facility

$98.89

Hospital Charge Code	993626
Hospital Revenue Code	270
Rate for Payer: Cash Price	$67.25

MASK, FACE, W/ANTIASPHYXIATION VLVE, LRG

Facility

$116.62

Hospital Charge Code	993348
Hospital Revenue Code	270
Rate for Payer: Cash Price	$79.30

MASK, FACE, W/ANTIASPHYXIATION VLVE, LRG

Facility

$116.62

Hospital Charge Code	993348
Hospital Revenue Code	270
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$83.97
Rate for Payer: Amerigroup CHIP/Medicaid	$10.50
Rate for Payer: BCBS of TX Blue Advantage	$34.99
Rate for Payer: BCBS of TX Blue Essentials	$41.98
Rate for Payer: BCBS of TX PPO	$46.65
Rate for Payer: Cash Price	$79.30
Rate for Payer: Cigna Medicaid	$83.97
Rate for Payer: Molina CHIP/Medicaid	$83.97
Rate for Payer: Multiplan Auto	$75.80
Rate for Payer: Multiplan Commercial	$75.80
Rate for Payer: Multiplan Workers Comp	$75.80
Rate for Payer: Parkland Medicaid	$83.97
Rate for Payer: Scott and White EPO/PPO	$58.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.97
Rate for Payer: Superior Health Plan EPO	$15.86

MASK, FACE, W/ANTIASPHYXIATION VLVE, MED

Facility

$116.62

Hospital Charge Code	993313
Hospital Revenue Code	270
Rate for Payer: Cash Price	$79.30

MASK, FACE, W/ANTIASPHYXIATION VLVE, MED

Facility

$116.62

Hospital Charge Code	993313
Hospital Revenue Code	270
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$83.97
Rate for Payer: Amerigroup CHIP/Medicaid	$10.50
Rate for Payer: BCBS of TX Blue Advantage	$34.99
Rate for Payer: BCBS of TX Blue Essentials	$41.98
Rate for Payer: BCBS of TX PPO	$46.65
Rate for Payer: Cash Price	$79.30
Rate for Payer: Cigna Medicaid	$83.97
Rate for Payer: Molina CHIP/Medicaid	$83.97
Rate for Payer: Multiplan Auto	$75.80
Rate for Payer: Multiplan Commercial	$75.80
Rate for Payer: Multiplan Workers Comp	$75.80
Rate for Payer: Parkland Medicaid	$83.97
Rate for Payer: Scott and White EPO/PPO	$58.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.97
Rate for Payer: Superior Health Plan EPO	$15.86

MASK, FACE, W/ANTIASPHYXIATION VLVE, SM

Facility

$116.62

Hospital Charge Code	993314
Hospital Revenue Code	270
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$83.97
Rate for Payer: Amerigroup CHIP/Medicaid	$10.50
Rate for Payer: BCBS of TX Blue Advantage	$34.99
Rate for Payer: BCBS of TX Blue Essentials	$41.98
Rate for Payer: BCBS of TX PPO	$46.65
Rate for Payer: Cash Price	$79.30
Rate for Payer: Cigna Medicaid	$83.97
Rate for Payer: Molina CHIP/Medicaid	$83.97
Rate for Payer: Multiplan Auto	$75.80
Rate for Payer: Multiplan Commercial	$75.80
Rate for Payer: Multiplan Workers Comp	$75.80
Rate for Payer: Parkland Medicaid	$83.97
Rate for Payer: Scott and White EPO/PPO	$58.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$83.97
Rate for Payer: Superior Health Plan EPO	$15.86

MASK, FACE, W/ANTIASPHYXIATION VLVE, SM

Facility

$116.62

Hospital Charge Code	993314
Hospital Revenue Code	270
Rate for Payer: Cash Price	$79.30

MASK, LARGEADULT, SZ6, UNSCENTED, 50/CS

Facility

$6.06

Hospital Charge Code	993057
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.12

MASK, LARGEADULT, SZ6, UNSCENTED, 50/CS

Facility

$6.06

Hospital Charge Code	993057
Hospital Revenue Code	270
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$4.36
Rate for Payer: Amerigroup CHIP/Medicaid	$0.55
Rate for Payer: BCBS of TX Blue Advantage	$1.82
Rate for Payer: BCBS of TX Blue Essentials	$2.18
Rate for Payer: BCBS of TX PPO	$2.42
Rate for Payer: Cash Price	$4.12
Rate for Payer: Cigna Medicaid	$4.36
Rate for Payer: Molina CHIP/Medicaid	$4.36
Rate for Payer: Multiplan Auto	$3.94
Rate for Payer: Multiplan Commercial	$3.94
Rate for Payer: Multiplan Workers Comp	$3.94
Rate for Payer: Parkland Medicaid	$4.36
Rate for Payer: Scott and White EPO/PPO	$3.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.36
Rate for Payer: Superior Health Plan EPO	$0.82

MASK, LARYNGEAL SUP AIRWAY STRL SZ 5

Facility

$133.84

Hospital Charge Code	993723
Hospital Revenue Code	272
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$96.36
Rate for Payer: Amerigroup CHIP/Medicaid	$12.05
Rate for Payer: BCBS of TX Blue Advantage	$40.15
Rate for Payer: BCBS of TX Blue Essentials	$48.18
Rate for Payer: BCBS of TX PPO	$53.54
Rate for Payer: Cash Price	$91.01
Rate for Payer: Cigna Medicaid	$96.36
Rate for Payer: Molina CHIP/Medicaid	$96.36
Rate for Payer: Multiplan Auto	$87.00
Rate for Payer: Multiplan Commercial	$87.00
Rate for Payer: Multiplan Workers Comp	$87.00
Rate for Payer: Parkland Medicaid	$96.36
Rate for Payer: Scott and White EPO/PPO	$66.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$96.36
Rate for Payer: Superior Health Plan EPO	$18.20

MASK, LARYNGEAL SUP AIRWAY STRL SZ 5

Facility

$133.84

Hospital Charge Code	993723
Hospital Revenue Code	272
Rate for Payer: Cash Price	$91.01

MASK, LOOP, YELLOW, LVL 1

Facility

$0.60

Hospital Charge Code	992991
Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.43
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.18
Rate for Payer: BCBS of TX Blue Essentials	$0.22
Rate for Payer: BCBS of TX PPO	$0.24
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna Medicaid	$0.43
Rate for Payer: Molina CHIP/Medicaid	$0.43
Rate for Payer: Multiplan Auto	$0.39
Rate for Payer: Multiplan Commercial	$0.39
Rate for Payer: Multiplan Workers Comp	$0.39
Rate for Payer: Parkland Medicaid	$0.43
Rate for Payer: Scott and White EPO/PPO	$0.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.43
Rate for Payer: Superior Health Plan EPO	$0.08

MASK, LOOP, YELLOW, LVL 1

Facility

$0.60

Hospital Charge Code	992991
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.41

MASK OX HIGH/MED CONCENT W/7FT TUBING NON-REB

Facility

$6.09

Hospital Charge Code	993051
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.14

MASK OX HIGH/MED CONCENT W/7FT TUBING NON-REB

Facility

$6.09

Hospital Charge Code	993051
Hospital Revenue Code	270
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$4.38
Rate for Payer: Amerigroup CHIP/Medicaid	$0.55
Rate for Payer: BCBS of TX Blue Advantage	$1.83
Rate for Payer: BCBS of TX Blue Essentials	$2.19
Rate for Payer: BCBS of TX PPO	$2.44
Rate for Payer: Cash Price	$4.14
Rate for Payer: Cigna Medicaid	$4.38
Rate for Payer: Molina CHIP/Medicaid	$4.38
Rate for Payer: Multiplan Auto	$3.96
Rate for Payer: Multiplan Commercial	$3.96
Rate for Payer: Multiplan Workers Comp	$3.96
Rate for Payer: Parkland Medicaid	$4.38
Rate for Payer: Scott and White EPO/PPO	$3.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.38
Rate for Payer: Superior Health Plan EPO	$0.83

Know your out-of-pocket cost for care.

All Charges