White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BANDAGE, CONFORMING GAUZE 3-PLY 4'X 4.1 YD STERILE -- DHF

Facility

$78.04

Hospital Charge Code	80241102
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

BANDAGE, ELASTIC CMPRSS SELF-CLSR 3'X5 YD

Facility

$3.96

Hospital Charge Code	993756
Hospital Revenue Code	271
Rate for Payer: Cash Price	$2.69

BANDAGE, ELASTIC CMPRSS SELF-CLSR 3'X5 YD

Facility

$3.96

Hospital Charge Code	993756
Hospital Revenue Code	271
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$2.85
Rate for Payer: Amerigroup CHIP/Medicaid	$0.36
Rate for Payer: BCBS of TX Blue Advantage	$1.19
Rate for Payer: BCBS of TX Blue Essentials	$1.43
Rate for Payer: BCBS of TX PPO	$1.58
Rate for Payer: Cash Price	$2.69
Rate for Payer: Cigna Medicaid	$2.85
Rate for Payer: Molina CHIP/Medicaid	$2.85
Rate for Payer: Multiplan Auto	$2.57
Rate for Payer: Multiplan Commercial	$2.57
Rate for Payer: Multiplan Workers Comp	$2.57
Rate for Payer: Parkland Medicaid	$2.85
Rate for Payer: Scott and White EPO/PPO	$1.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.85
Rate for Payer: Superior Health Plan EPO	$0.54

BANDAGE, ELASTIC CMPRSS SELF-CLSR 4'X5 YD

Facility

$6.58

Hospital Charge Code	993831
Hospital Revenue Code	271
Rate for Payer: Cash Price	$4.47

BANDAGE, ELASTIC CMPRSS SELF-CLSR 4'X5 YD

Facility

$6.58

Hospital Charge Code	993831
Hospital Revenue Code	271
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$4.74
Rate for Payer: Amerigroup CHIP/Medicaid	$0.59
Rate for Payer: BCBS of TX Blue Advantage	$1.97
Rate for Payer: BCBS of TX Blue Essentials	$2.37
Rate for Payer: BCBS of TX PPO	$2.63
Rate for Payer: Cash Price	$4.47
Rate for Payer: Cigna Medicaid	$4.74
Rate for Payer: Molina CHIP/Medicaid	$4.74
Rate for Payer: Multiplan Auto	$4.28
Rate for Payer: Multiplan Commercial	$4.28
Rate for Payer: Multiplan Workers Comp	$4.28
Rate for Payer: Parkland Medicaid	$4.74
Rate for Payer: Scott and White EPO/PPO	$3.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.74
Rate for Payer: Superior Health Plan EPO	$0.89

BANDAGE, ELASTIC, ESMARK, STERILE, 4'X9', LF

Facility

$12.05

Hospital Charge Code	992804
Hospital Revenue Code	272
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$8.68
Rate for Payer: Amerigroup CHIP/Medicaid	$1.08
Rate for Payer: BCBS of TX Blue Advantage	$3.62
Rate for Payer: BCBS of TX Blue Essentials	$4.34
Rate for Payer: BCBS of TX PPO	$4.82
Rate for Payer: Cash Price	$8.19
Rate for Payer: Cigna Medicaid	$8.68
Rate for Payer: Molina CHIP/Medicaid	$8.68
Rate for Payer: Multiplan Auto	$7.83
Rate for Payer: Multiplan Commercial	$7.83
Rate for Payer: Multiplan Workers Comp	$7.83
Rate for Payer: Parkland Medicaid	$8.68
Rate for Payer: Scott and White EPO/PPO	$6.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.68
Rate for Payer: Superior Health Plan EPO	$1.64

BANDAGE, ELASTIC, ESMARK, STERILE, 4'X9', LF

Facility

$12.05

Hospital Charge Code	992804
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.19

BANDAGE, ELASTIC, ESMARK, STERILE, 6'X9', LF

Facility

$16.84

Hospital Charge Code	992805
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.45

BANDAGE, ELASTIC, ESMARK, STERILE, 6'X9', LF

Facility

$16.84

Hospital Charge Code	992805
Hospital Revenue Code	272
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$12.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1.52
Rate for Payer: BCBS of TX Blue Advantage	$5.05
Rate for Payer: BCBS of TX Blue Essentials	$6.06
Rate for Payer: BCBS of TX PPO	$6.74
Rate for Payer: Cash Price	$11.45
Rate for Payer: Cigna Medicaid	$12.12
Rate for Payer: Molina CHIP/Medicaid	$12.12
Rate for Payer: Multiplan Auto	$10.95
Rate for Payer: Multiplan Commercial	$10.95
Rate for Payer: Multiplan Workers Comp	$10.95
Rate for Payer: Parkland Medicaid	$12.12
Rate for Payer: Scott and White EPO/PPO	$8.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.12
Rate for Payer: Superior Health Plan EPO	$2.29

BANDAGE, ELASTIC LTX FREE W/VELCRO CLOS STR 3'X5YD -- DHF

Facility

$48.15

Hospital Charge Code	80240419
Hospital Revenue Code	270
Min. Negotiated Rate	$4.33
Max. Negotiated Rate	$34.67
Rate for Payer: Amerigroup CHIP/Medicaid	$4.33
Rate for Payer: BCBS of TX Blue Advantage	$14.45
Rate for Payer: BCBS of TX Blue Essentials	$17.33
Rate for Payer: BCBS of TX PPO	$19.26
Rate for Payer: Cash Price	$32.74
Rate for Payer: Cigna Medicaid	$34.67
Rate for Payer: Molina CHIP/Medicaid	$34.67
Rate for Payer: Multiplan Auto	$31.30
Rate for Payer: Multiplan Commercial	$31.30
Rate for Payer: Multiplan Workers Comp	$31.30
Rate for Payer: Parkland Medicaid	$34.67
Rate for Payer: Scott and White EPO/PPO	$24.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$34.67
Rate for Payer: Superior Health Plan EPO	$6.55

BANDAGE, ELASTIC LTX FREE W/VELCRO CLOS STR 3'X5YD -- DHF

Facility

$48.15

Hospital Charge Code	80240419
Hospital Revenue Code	270
Rate for Payer: Cash Price	$32.74

BANDAGE, ELASTIC, MATRIX, 2'X5YD, LF, HOOK&LP

Facility

$9.84

Hospital Charge Code	993069
Hospital Revenue Code	272
Rate for Payer: Cash Price	$6.69

BANDAGE, ELASTIC, MATRIX, 2'X5YD, LF, HOOK&LP

Facility

$9.84

Hospital Charge Code	993069
Hospital Revenue Code	272
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$7.08
Rate for Payer: Amerigroup CHIP/Medicaid	$0.89
Rate for Payer: BCBS of TX Blue Advantage	$2.95
Rate for Payer: BCBS of TX Blue Essentials	$3.54
Rate for Payer: BCBS of TX PPO	$3.94
Rate for Payer: Cash Price	$6.69
Rate for Payer: Cigna Medicaid	$7.08
Rate for Payer: Molina CHIP/Medicaid	$7.08
Rate for Payer: Multiplan Auto	$6.40
Rate for Payer: Multiplan Commercial	$6.40
Rate for Payer: Multiplan Workers Comp	$6.40
Rate for Payer: Parkland Medicaid	$7.08
Rate for Payer: Scott and White EPO/PPO	$4.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.08
Rate for Payer: Superior Health Plan EPO	$1.34

BANDAGE, ELASTIC, MATRIX, 3'X5YD, LF, HOOK&LP

Facility

$7.92

Hospital Charge Code	993070
Hospital Revenue Code	272
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$5.70
Rate for Payer: Amerigroup CHIP/Medicaid	$0.71
Rate for Payer: BCBS of TX Blue Advantage	$2.38
Rate for Payer: BCBS of TX Blue Essentials	$2.85
Rate for Payer: BCBS of TX PPO	$3.17
Rate for Payer: Cash Price	$5.39
Rate for Payer: Cigna Medicaid	$5.70
Rate for Payer: Molina CHIP/Medicaid	$5.70
Rate for Payer: Multiplan Auto	$5.15
Rate for Payer: Multiplan Commercial	$5.15
Rate for Payer: Multiplan Workers Comp	$5.15
Rate for Payer: Parkland Medicaid	$5.70
Rate for Payer: Scott and White EPO/PPO	$3.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.70
Rate for Payer: Superior Health Plan EPO	$1.08

BANDAGE, ELASTIC, MATRIX, 3'X5YD, LF, HOOK&LP

Facility

$7.92

Hospital Charge Code	993070
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.39

BANDAGE, ELASTIC, MATRIX, 6'X5YD, LF, HOOK&LP

Facility

$4.89

Hospital Charge Code	992851
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.33

BANDAGE, ELASTIC, MATRIX, 6'X5YD, LF, HOOK&LP

Facility

$4.89

Hospital Charge Code	992851
Hospital Revenue Code	272
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$3.52
Rate for Payer: Amerigroup CHIP/Medicaid	$0.44
Rate for Payer: BCBS of TX Blue Advantage	$1.47
Rate for Payer: BCBS of TX Blue Essentials	$1.76
Rate for Payer: BCBS of TX PPO	$1.96
Rate for Payer: Cash Price	$3.33
Rate for Payer: Cigna Medicaid	$3.52
Rate for Payer: Molina CHIP/Medicaid	$3.52
Rate for Payer: Multiplan Auto	$3.18
Rate for Payer: Multiplan Commercial	$3.18
Rate for Payer: Multiplan Workers Comp	$3.18
Rate for Payer: Parkland Medicaid	$3.52
Rate for Payer: Scott and White EPO/PPO	$2.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.52
Rate for Payer: Superior Health Plan EPO	$0.67

BANDAGE, ELASTIC, STERILE, 4' X 5.5 YD

Facility

$15.50

Hospital Charge Code	993763
Hospital Revenue Code	272
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$11.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1.40
Rate for Payer: BCBS of TX Blue Advantage	$4.65
Rate for Payer: BCBS of TX Blue Essentials	$5.58
Rate for Payer: BCBS of TX PPO	$6.20
Rate for Payer: Cash Price	$10.54
Rate for Payer: Cigna Medicaid	$11.16
Rate for Payer: Molina CHIP/Medicaid	$11.16
Rate for Payer: Multiplan Auto	$10.07
Rate for Payer: Multiplan Commercial	$10.07
Rate for Payer: Multiplan Workers Comp	$10.07
Rate for Payer: Parkland Medicaid	$11.16
Rate for Payer: Scott and White EPO/PPO	$7.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.16
Rate for Payer: Superior Health Plan EPO	$2.11

BANDAGE, ELASTIC, STERILE, 4' X 5.5 YD

Facility

$15.50

Hospital Charge Code	993763
Hospital Revenue Code	272
Rate for Payer: Cash Price	$10.54

BANDAGE, GAUZE, 4.5'X4.1 YD, STERILE, LF

Facility

$3.72

Hospital Charge Code	992747
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2.53

BANDAGE, GAUZE, 4.5'X4.1 YD, STERILE, LF

Facility

$3.72

Hospital Charge Code	992747
Hospital Revenue Code	272
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$2.68
Rate for Payer: Amerigroup CHIP/Medicaid	$0.33
Rate for Payer: BCBS of TX Blue Advantage	$1.12
Rate for Payer: BCBS of TX Blue Essentials	$1.34
Rate for Payer: BCBS of TX PPO	$1.49
Rate for Payer: Cash Price	$2.53
Rate for Payer: Cigna Medicaid	$2.68
Rate for Payer: Molina CHIP/Medicaid	$2.68
Rate for Payer: Multiplan Auto	$2.42
Rate for Payer: Multiplan Commercial	$2.42
Rate for Payer: Multiplan Workers Comp	$2.42
Rate for Payer: Parkland Medicaid	$2.68
Rate for Payer: Scott and White EPO/PPO	$1.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.68
Rate for Payer: Superior Health Plan EPO	$0.51

BANDAGE, GAUZE ROLL 4 1/2' X 147 STERILE -- DHF

Facility

$82.27

Hospital Charge Code	80240955
Hospital Revenue Code	270
Rate for Payer: Cash Price	$55.94

BANDAGE, GAUZE ROLL 4 1/2' X 147 STERILE -- DHF

Facility

$82.27

Hospital Charge Code	80240955
Hospital Revenue Code	270
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$59.23
Rate for Payer: Amerigroup CHIP/Medicaid	$7.40
Rate for Payer: BCBS of TX Blue Advantage	$24.68
Rate for Payer: BCBS of TX Blue Essentials	$29.62
Rate for Payer: BCBS of TX PPO	$32.91
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cigna Medicaid	$59.23
Rate for Payer: Molina CHIP/Medicaid	$59.23
Rate for Payer: Multiplan Auto	$53.48
Rate for Payer: Multiplan Commercial	$53.48
Rate for Payer: Multiplan Workers Comp	$53.48
Rate for Payer: Parkland Medicaid	$59.23
Rate for Payer: Scott and White EPO/PPO	$41.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.23
Rate for Payer: Superior Health Plan EPO	$11.19

BANDAGE, SELF-ADHERENT ELASTIC WRAP LF 4'X5YD STRL -- DHF

Facility

$45.82

Hospital Charge Code	80240310
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.16

BANDAGE, SELF-ADHERENT ELASTIC WRAP LF 4'X5YD STRL -- DHF

Facility

$45.82

Hospital Charge Code	80240310
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$32.99
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$31.16
Rate for Payer: Cigna Medicaid	$32.99
Rate for Payer: Molina CHIP/Medicaid	$32.99
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Parkland Medicaid	$32.99
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.99
Rate for Payer: Superior Health Plan EPO	$6.23

Know your out-of-pocket cost for care.

All Charges