White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
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, 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, 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, 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, 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

PADDING, UNDERCAST, COTTON, 6'X4YD STERILE

Facility

$290.38

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

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
Rate for Payer: Cash Price	$219.97

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, KNEE POSITIONING UNIVERSAL STERILE DISP -- DHF

Facility

$201.20

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

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	$144.86
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	$136.82
Rate for Payer: Cigna Medicaid	$144.86
Rate for Payer: Molina CHIP/Medicaid	$144.86
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: Parkland Medicaid	$144.86
Rate for Payer: Scott and White EPO/PPO	$100.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$144.86
Rate for Payer: Superior Health Plan EPO	$27.36

PAD MATRIX KNEE FOAM STERILE DISP.

Facility

$344.28

Hospital Charge Code	993634
Hospital Revenue Code	270
Min. Negotiated Rate	$30.99
Max. Negotiated Rate	$247.88
Rate for Payer: Amerigroup CHIP/Medicaid	$30.99
Rate for Payer: BCBS of TX Blue Advantage	$103.28
Rate for Payer: BCBS of TX Blue Essentials	$123.94
Rate for Payer: BCBS of TX PPO	$137.71
Rate for Payer: Cash Price	$234.11
Rate for Payer: Cigna Medicaid	$247.88
Rate for Payer: Molina CHIP/Medicaid	$247.88
Rate for Payer: Multiplan Auto	$223.78
Rate for Payer: Multiplan Commercial	$223.78
Rate for Payer: Multiplan Workers Comp	$223.78
Rate for Payer: Parkland Medicaid	$247.88
Rate for Payer: Scott and White EPO/PPO	$172.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$247.88
Rate for Payer: Superior Health Plan EPO	$46.82

PAD MATRIX KNEE FOAM STERILE DISP.

Facility

$344.28

Hospital Charge Code	993634
Hospital Revenue Code	270
Rate for Payer: Cash Price	$234.11

PAD NASAL FOR SLEEP COMFORT W/CPAP MASK LARGE

Facility

$45.17

Hospital Charge Code	993525
Hospital Revenue Code	270
Min. Negotiated Rate	$4.07
Max. Negotiated Rate	$32.52
Rate for Payer: Amerigroup CHIP/Medicaid	$4.07
Rate for Payer: BCBS of TX Blue Advantage	$13.55
Rate for Payer: BCBS of TX Blue Essentials	$16.26
Rate for Payer: BCBS of TX PPO	$18.07
Rate for Payer: Cash Price	$30.72
Rate for Payer: Cigna Medicaid	$32.52
Rate for Payer: Molina CHIP/Medicaid	$32.52
Rate for Payer: Multiplan Auto	$29.36
Rate for Payer: Multiplan Commercial	$29.36
Rate for Payer: Multiplan Workers Comp	$29.36
Rate for Payer: Parkland Medicaid	$32.52
Rate for Payer: Scott and White EPO/PPO	$22.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.52
Rate for Payer: Superior Health Plan EPO	$6.14

PAD NASAL FOR SLEEP COMFORT W/CPAP MASK LARGE

Facility

$45.17

Hospital Charge Code	993525
Hospital Revenue Code	270
Rate for Payer: Cash Price	$30.72

PAD, NASAL FOR SLEEP COMFORT W/CPAP MASK SMALL

Facility

$45.17

Hospital Charge Code	993545
Hospital Revenue Code	270
Rate for Payer: Cash Price	$30.72

PAD, NASAL FOR SLEEP COMFORT W/CPAP MASK SMALL

Facility

$45.17

Hospital Charge Code	993545
Hospital Revenue Code	270
Min. Negotiated Rate	$4.07
Max. Negotiated Rate	$32.52
Rate for Payer: Amerigroup CHIP/Medicaid	$4.07
Rate for Payer: BCBS of TX Blue Advantage	$13.55
Rate for Payer: BCBS of TX Blue Essentials	$16.26
Rate for Payer: BCBS of TX PPO	$18.07
Rate for Payer: Cash Price	$30.72
Rate for Payer: Cigna Medicaid	$32.52
Rate for Payer: Molina CHIP/Medicaid	$32.52
Rate for Payer: Multiplan Auto	$29.36
Rate for Payer: Multiplan Commercial	$29.36
Rate for Payer: Multiplan Workers Comp	$29.36
Rate for Payer: Parkland Medicaid	$32.52
Rate for Payer: Scott and White EPO/PPO	$22.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.52
Rate for Payer: Superior Health Plan EPO	$6.14

pad perineal supine

Facility

$526.64

Hospital Charge Code	102886
Hospital Revenue Code	270
Rate for Payer: Cash Price	$358.12

pad perineal supine

Facility

$526.64

Hospital Charge Code	102886
Hospital Revenue Code	270
Min. Negotiated Rate	$47.40
Max. Negotiated Rate	$379.18
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	$358.12
Rate for Payer: Cigna Medicaid	$379.18
Rate for Payer: Molina CHIP/Medicaid	$379.18
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: Parkland Medicaid	$379.18
Rate for Payer: Scott and White EPO/PPO	$263.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$379.18
Rate for Payer: Superior Health Plan EPO	$71.62

PAD PINK W/ARM PROTECTOR

Facility

$404.06

Hospital Charge Code	8538536
Hospital Revenue Code	272
Rate for Payer: Cash Price	$274.76

PAD PINK W/ARM PROTECTOR

Facility

$404.06

Hospital Charge Code	8538536
Hospital Revenue Code	272
Min. Negotiated Rate	$36.37
Max. Negotiated Rate	$290.92
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	$274.76
Rate for Payer: Cigna Medicaid	$290.92
Rate for Payer: Molina CHIP/Medicaid	$290.92
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: Parkland Medicaid	$290.92
Rate for Payer: Scott and White EPO/PPO	$202.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$290.92
Rate for Payer: Superior Health Plan EPO	$54.95

PAD POLISH SUPER WHITE 24'

Facility

$14.86

Hospital Charge Code	993275
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.10

Know your out-of-pocket cost for care.

All Charges