White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PACK UNIVERSAL DRAPE STERILE

Facility

$56.16

Hospital Charge Code	8692537
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.19

PACK UNIVERSAL DRAPE STERILE

Facility

$56.16

Hospital Charge Code	8692537
Hospital Revenue Code	270
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$40.44
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	$38.19
Rate for Payer: Cigna Medicaid	$40.44
Rate for Payer: Molina CHIP/Medicaid	$40.44
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: Parkland Medicaid	$40.44
Rate for Payer: Scott and White EPO/PPO	$28.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.44
Rate for Payer: Superior Health Plan EPO	$7.64

PAD, ABDOMINAL, 5'X9, STERILE, LF, 1/PK

Facility

$0.56

Hospital Charge Code	992868
Hospital Revenue Code	272
Rate for Payer: Cash Price	$0.38

PAD, ABDOMINAL, 5'X9, STERILE, LF, 1/PK

Facility

$0.56

Hospital Charge Code	992868
Hospital Revenue Code	272
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.40
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.17
Rate for Payer: BCBS of TX Blue Essentials	$0.20
Rate for Payer: BCBS of TX PPO	$0.22
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna Medicaid	$0.40
Rate for Payer: Molina CHIP/Medicaid	$0.40
Rate for Payer: Multiplan Auto	$0.36
Rate for Payer: Multiplan Commercial	$0.36
Rate for Payer: Multiplan Workers Comp	$0.36
Rate for Payer: Parkland Medicaid	$0.40
Rate for Payer: Scott and White EPO/PPO	$0.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.40
Rate for Payer: Superior Health Plan EPO	$0.08

pad boot insert

Facility

$935.24

Hospital Charge Code	102867
Hospital Revenue Code	270
Rate for Payer: Cash Price	$635.96

pad boot insert

Facility

$935.24

Hospital Charge Code	102867
Hospital Revenue Code	270
Min. Negotiated Rate	$84.17
Max. Negotiated Rate	$673.37
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	$635.96
Rate for Payer: Cigna Medicaid	$673.37
Rate for Payer: Molina CHIP/Medicaid	$673.37
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: Parkland Medicaid	$673.37
Rate for Payer: Scott and White EPO/PPO	$467.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$673.37
Rate for Payer: Superior Health Plan EPO	$127.19

PAD DEFIB, RADIOLUCENT, ZOLL COMPTBL, ADLT/CHLD 10KG

Facility

$180.77

Hospital Charge Code	993042
Hospital Revenue Code	270
Min. Negotiated Rate	$16.27
Max. Negotiated Rate	$130.15
Rate for Payer: Amerigroup CHIP/Medicaid	$16.27
Rate for Payer: BCBS of TX Blue Advantage	$54.23
Rate for Payer: BCBS of TX Blue Essentials	$65.08
Rate for Payer: BCBS of TX PPO	$72.31
Rate for Payer: Cash Price	$122.92
Rate for Payer: Cigna Medicaid	$130.15
Rate for Payer: Molina CHIP/Medicaid	$130.15
Rate for Payer: Multiplan Auto	$117.50
Rate for Payer: Multiplan Commercial	$117.50
Rate for Payer: Multiplan Workers Comp	$117.50
Rate for Payer: Parkland Medicaid	$130.15
Rate for Payer: Scott and White EPO/PPO	$90.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$130.15
Rate for Payer: Superior Health Plan EPO	$24.58

PAD DEFIB, RADIOLUCENT, ZOLL COMPTBL, ADLT/CHLD 10KG

Facility

$180.77

Hospital Charge Code	993042
Hospital Revenue Code	270
Rate for Payer: Cash Price	$122.92

PADDING, CAST, 4', 12/BG

Facility

$3.33

Hospital Charge Code	992835
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.26

PADDING, CAST, 4', 12/BG

Facility

$3.33

Hospital Charge Code	992835
Hospital Revenue Code	272
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$2.40
Rate for Payer: Amerigroup CHIP/Medicaid	$0.30
Rate for Payer: BCBS of TX Blue Advantage	$1.00
Rate for Payer: BCBS of TX Blue Essentials	$1.20
Rate for Payer: BCBS of TX PPO	$1.33
Rate for Payer: Cash Price	$2.26
Rate for Payer: Cigna Medicaid	$2.40
Rate for Payer: Molina CHIP/Medicaid	$2.40
Rate for Payer: Multiplan Auto	$2.16
Rate for Payer: Multiplan Commercial	$2.16
Rate for Payer: Multiplan Workers Comp	$2.16
Rate for Payer: Parkland Medicaid	$2.40
Rate for Payer: Scott and White EPO/PPO	$1.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.40
Rate for Payer: Superior Health Plan EPO	$0.45

PADDING, CAST, 6'

Facility

$4.63

Hospital Charge Code	992836
Hospital Revenue Code	272
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$3.33
Rate for Payer: Amerigroup CHIP/Medicaid	$0.42
Rate for Payer: BCBS of TX Blue Advantage	$1.39
Rate for Payer: BCBS of TX Blue Essentials	$1.67
Rate for Payer: BCBS of TX PPO	$1.85
Rate for Payer: Cash Price	$3.15
Rate for Payer: Cigna Medicaid	$3.33
Rate for Payer: Molina CHIP/Medicaid	$3.33
Rate for Payer: Multiplan Auto	$3.01
Rate for Payer: Multiplan Commercial	$3.01
Rate for Payer: Multiplan Workers Comp	$3.01
Rate for Payer: Parkland Medicaid	$3.33
Rate for Payer: Scott and White EPO/PPO	$2.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.33
Rate for Payer: Superior Health Plan EPO	$0.63

PADDING, CAST, 6'

Facility

$4.63

Hospital Charge Code	992836
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.15

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	$56.19
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	$53.07
Rate for Payer: Cigna Medicaid	$56.19
Rate for Payer: Molina CHIP/Medicaid	$56.19
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: Parkland Medicaid	$56.19
Rate for Payer: Scott and White EPO/PPO	$39.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56.19
Rate for Payer: Superior Health Plan EPO	$10.61

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

Facility

$78.04

Hospital Charge Code	81030009
Hospital Revenue Code	270
Rate for Payer: Cash Price	$53.07

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	$15.67

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	$16.59
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	$15.67
Rate for Payer: Cigna Medicaid	$16.59
Rate for Payer: Molina CHIP/Medicaid	$16.59
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: Parkland Medicaid	$16.59
Rate for Payer: Scott and White EPO/PPO	$11.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.59
Rate for Payer: Superior Health Plan EPO	$3.13

PADDING, UNDERCAST, COTTON, 4' X 4YD STERILE

Facility

$22.29

Hospital Charge Code	993818
Hospital Revenue Code	272
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$16.05
Rate for Payer: Amerigroup CHIP/Medicaid	$2.01
Rate for Payer: BCBS of TX Blue Advantage	$6.69
Rate for Payer: BCBS of TX Blue Essentials	$8.02
Rate for Payer: BCBS of TX PPO	$8.92
Rate for Payer: Cash Price	$15.16
Rate for Payer: Cigna Medicaid	$16.05
Rate for Payer: Molina CHIP/Medicaid	$16.05
Rate for Payer: Multiplan Auto	$14.49
Rate for Payer: Multiplan Commercial	$14.49
Rate for Payer: Multiplan Workers Comp	$14.49
Rate for Payer: Parkland Medicaid	$16.05
Rate for Payer: Scott and White EPO/PPO	$11.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.05
Rate for Payer: Superior Health Plan EPO	$3.03

PADDING, UNDERCAST, COTTON, 4' X 4YD STERILE

Facility

$22.29

Hospital Charge Code	993818
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.16

PADDING, UNDERCAST, COTTON, 6'X4YD STERILE

Facility

$290.38

Hospital Charge Code	992971
Hospital Revenue Code	270
Rate for Payer: Cash Price	$197.46

PADDING, UNDERCAST, COTTON, 6'X4YD STERILE

Facility

$290.38

Hospital Charge Code	992971
Hospital Revenue Code	270
Min. Negotiated Rate	$26.13
Max. Negotiated Rate	$209.07
Rate for Payer: Amerigroup CHIP/Medicaid	$26.13
Rate for Payer: BCBS of TX Blue Advantage	$87.11
Rate for Payer: BCBS of TX Blue Essentials	$104.54
Rate for Payer: BCBS of TX PPO	$116.15
Rate for Payer: Cash Price	$197.46
Rate for Payer: Cigna Medicaid	$209.07
Rate for Payer: Molina CHIP/Medicaid	$209.07
Rate for Payer: Multiplan Auto	$188.75
Rate for Payer: Multiplan Commercial	$188.75
Rate for Payer: Multiplan Workers Comp	$188.75
Rate for Payer: Parkland Medicaid	$209.07
Rate for Payer: Scott and White EPO/PPO	$145.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$209.07
Rate for Payer: Superior Health Plan EPO	$39.49

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	$47.82

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	$50.63
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	$47.82
Rate for Payer: Cigna Medicaid	$50.63
Rate for Payer: Molina CHIP/Medicaid	$50.63
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: Parkland Medicaid	$50.63
Rate for Payer: Scott and White EPO/PPO	$35.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.63
Rate for Payer: Superior Health Plan EPO	$9.56

PAD DUO TRACK

Facility

$323.48

Hospital Charge Code	8570494
Hospital Revenue Code	272
Min. Negotiated Rate	$29.11
Max. Negotiated Rate	$232.91
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	$219.97
Rate for Payer: Cigna Medicaid	$232.91
Rate for Payer: Molina CHIP/Medicaid	$232.91
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: Parkland Medicaid	$232.91
Rate for Payer: Scott and White EPO/PPO	$161.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$232.91
Rate for Payer: Superior Health Plan EPO	$43.99

PAD DUO TRACK

Facility

$323.48

Hospital Charge Code	8570494
Hospital Revenue Code	272
Rate for Payer: Cash Price	$219.97

PAD, KNEE POSITIONING UNIVERSAL STERILE DISP -- DHF

Facility

$201.20

Hospital Charge Code	81760555
Hospital Revenue Code	270
Rate for Payer: Cash Price	$136.82

Know your out-of-pocket cost for care.

All Charges