White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$30.72

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 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
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 perineal supine

Facility

$526.64

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

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

PAD POLISH SUPER WHITE 24'

Facility

$14.86

Hospital Charge Code	993275
Hospital Revenue Code	270
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$10.70
Rate for Payer: Amerigroup CHIP/Medicaid	$1.34
Rate for Payer: BCBS of TX Blue Advantage	$4.46
Rate for Payer: BCBS of TX Blue Essentials	$5.35
Rate for Payer: BCBS of TX PPO	$5.94
Rate for Payer: Cash Price	$10.10
Rate for Payer: Cigna Medicaid	$10.70
Rate for Payer: Molina CHIP/Medicaid	$10.70
Rate for Payer: Multiplan Auto	$9.66
Rate for Payer: Multiplan Commercial	$9.66
Rate for Payer: Multiplan Workers Comp	$9.66
Rate for Payer: Parkland Medicaid	$10.70
Rate for Payer: Scott and White EPO/PPO	$7.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.70
Rate for Payer: Superior Health Plan EPO	$2.02

PAD, PREP, ALCOHOL, MEDIUM, STRL, BULK

Facility

$0.06

Hospital Charge Code	992990
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.04

PAD, PREP, ALCOHOL, MEDIUM, STRL, BULK

Facility

$0.06

Hospital Charge Code	992990
Hospital Revenue Code	270
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

PAD, PREP, ALCOHOL, STRL, MEDIUM, 2-PLY

Facility

$0.14

Hospital Charge Code	993084
Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.10
Rate for Payer: Amerigroup CHIP/Medicaid	$0.01
Rate for Payer: BCBS of TX Blue Advantage	$0.04
Rate for Payer: BCBS of TX Blue Essentials	$0.05
Rate for Payer: BCBS of TX PPO	$0.06
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna Medicaid	$0.10
Rate for Payer: Molina CHIP/Medicaid	$0.10
Rate for Payer: Multiplan Auto	$0.09
Rate for Payer: Multiplan Commercial	$0.09
Rate for Payer: Multiplan Workers Comp	$0.09
Rate for Payer: Parkland Medicaid	$0.10
Rate for Payer: Scott and White EPO/PPO	$0.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.10
Rate for Payer: Superior Health Plan EPO	$0.02

PAD, PREP, ALCOHOL, STRL, MEDIUM, 2-PLY

Facility

$0.14

Hospital Charge Code	993084
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.10

PAD, SANITARY, 11 IN, MAXI, N-STRL, IND WRAP

Facility

$0.51

Hospital Charge Code	993969
Hospital Revenue Code	271
Rate for Payer: Cash Price	$0.35

PAD, SANITARY, 11 IN, MAXI, N-STRL, IND WRAP

Facility

$0.51

Hospital Charge Code	993969
Hospital Revenue Code	271
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.37
Rate for Payer: Amerigroup CHIP/Medicaid	$0.05
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.18
Rate for Payer: BCBS of TX PPO	$0.20
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna Medicaid	$0.37
Rate for Payer: Molina CHIP/Medicaid	$0.37
Rate for Payer: Multiplan Auto	$0.33
Rate for Payer: Multiplan Commercial	$0.33
Rate for Payer: Multiplan Workers Comp	$0.33
Rate for Payer: Parkland Medicaid	$0.37
Rate for Payer: Scott and White EPO/PPO	$0.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.37
Rate for Payer: Superior Health Plan EPO	$0.07

PAD, SANITARY, 9 IN, MAXI, ADH, STRL, IND BOX

Facility

$1.59

Hospital Charge Code	993214
Hospital Revenue Code	270
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$1.14
Rate for Payer: Amerigroup CHIP/Medicaid	$0.14
Rate for Payer: BCBS of TX Blue Advantage	$0.48
Rate for Payer: BCBS of TX Blue Essentials	$0.57
Rate for Payer: BCBS of TX PPO	$0.64
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna Medicaid	$1.14
Rate for Payer: Molina CHIP/Medicaid	$1.14
Rate for Payer: Multiplan Auto	$1.03
Rate for Payer: Multiplan Commercial	$1.03
Rate for Payer: Multiplan Workers Comp	$1.03
Rate for Payer: Parkland Medicaid	$1.14
Rate for Payer: Scott and White EPO/PPO	$0.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.14
Rate for Payer: Superior Health Plan EPO	$0.22

PAD, SANITARY, 9 IN, MAXI, ADH, STRL, IND BOX

Facility

$1.59

Hospital Charge Code	993214
Hospital Revenue Code	270
Rate for Payer: Cash Price	$1.08

PAD, TIP CLEANER ELECTRO SURGICAL LARGE STERILE -- DHF

Facility

$183.92

Hospital Charge Code	80322159
Hospital Revenue Code	270
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$132.42
Rate for Payer: Amerigroup CHIP/Medicaid	$16.55
Rate for Payer: BCBS of TX Blue Advantage	$55.18
Rate for Payer: BCBS of TX Blue Essentials	$66.21
Rate for Payer: BCBS of TX PPO	$73.57
Rate for Payer: Cash Price	$125.07
Rate for Payer: Cigna Medicaid	$132.42
Rate for Payer: Molina CHIP/Medicaid	$132.42
Rate for Payer: Multiplan Auto	$119.55
Rate for Payer: Multiplan Commercial	$119.55
Rate for Payer: Multiplan Workers Comp	$119.55
Rate for Payer: Parkland Medicaid	$132.42
Rate for Payer: Scott and White EPO/PPO	$91.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$132.42
Rate for Payer: Superior Health Plan EPO	$25.01

PAD, TIP CLEANER ELECTRO SURGICAL LARGE STERILE -- DHF

Facility

$183.92

Hospital Charge Code	80322159
Hospital Revenue Code	270
Rate for Payer: Cash Price	$125.07

PAIN DSTRJ NULYT AGT GNCLR NRV BCE

Facility

$6,240.55

Service Code	HCPCS 64624
Hospital Charge Code	6100006
Hospital Revenue Code	761
Rate for Payer: Cash Price	$4,243.57

PAIN DSTRJ NULYT AGT GNCLR NRV BCE

Facility

$6,240.55

Service Code	HCPCS 64624
Hospital Charge Code	6100006
Hospital Revenue Code	761
Min. Negotiated Rate	$532.18
Max. Negotiated Rate	$4,493.20
Rate for Payer: Amerigroup CHIP/Medicaid	$561.65
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Amerigroup Medicare	$1,961.62
Rate for Payer: BCBS of TX Blue Advantage	$532.18
Rate for Payer: BCBS of TX Blue Essentials	$637.34
Rate for Payer: BCBS of TX Medicare	$1,961.62
Rate for Payer: BCBS of TX PPO	$803.05
Rate for Payer: Cash Price	$4,243.57
Rate for Payer: Cash Price	$4,243.57
Rate for Payer: Cash Price	$4,243.57
Rate for Payer: Cigna Commercial	$4,146.52
Rate for Payer: Cigna Medicaid	$4,493.20
Rate for Payer: Cigna Medicare	$1,961.62
Rate for Payer: Employer Direct Commercial	$1,961.62
Rate for Payer: Humana Medicare/TRICARE	$1,961.62
Rate for Payer: Molina CHIP/Medicaid	$4,493.20
Rate for Payer: Molina Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Molina Medicare	$1,961.62
Rate for Payer: Multiplan Auto	$4,056.36
Rate for Payer: Multiplan Commercial	$4,056.36
Rate for Payer: Multiplan Workers Comp	$4,056.36
Rate for Payer: Parkland Medicaid	$4,493.20
Rate for Payer: Scott and White EPO/PPO	$3,120.28
Rate for Payer: Scott and White Medicare	$1,961.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,493.20
Rate for Payer: Superior Health Plan EPO	$1,961.62
Rate for Payer: Superior Health Plan Medicare	$1,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,961.62
Rate for Payer: Universal American Medicare	$1,961.62
Rate for Payer: Wellcare Medicare	$1,961.62
Rate for Payer: Wellmed Medicare	$1,961.62

Know your out-of-pocket cost for care.

All Charges