White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SUT PASSER -- DHF

Facility

$166.75

Hospital Charge Code	81774010
Hospital Revenue Code	272
Min. Negotiated Rate	$15.01
Max. Negotiated Rate	$108.39
Rate for Payer: Aetna Commercial	$91.71
Rate for Payer: Amerigroup CHIP/Medicaid	$15.01
Rate for Payer: BCBS of TX Blue Advantage	$50.02
Rate for Payer: BCBS of TX Blue Essentials	$60.03
Rate for Payer: BCBS of TX PPO	$66.70
Rate for Payer: Cash Price	$146.74
Rate for Payer: Multiplan Auto	$108.39
Rate for Payer: Multiplan Commercial	$108.39
Rate for Payer: Multiplan Workers Comp	$108.39
Rate for Payer: Scott and White EPO/PPO	$83.38
Rate for Payer: Superior Health Plan EPO	$22.68

SUT RETREIVER -- DHF

Facility

$92.16

Hospital Charge Code	81774051
Hospital Revenue Code	272
Rate for Payer: Cash Price	$81.10

SUT RETREIVER -- DHF

Facility

$92.16

Hospital Charge Code	81774051
Hospital Revenue Code	272
Min. Negotiated Rate	$8.29
Max. Negotiated Rate	$59.90
Rate for Payer: Aetna Commercial	$50.69
Rate for Payer: Amerigroup CHIP/Medicaid	$8.29
Rate for Payer: BCBS of TX Blue Advantage	$27.65
Rate for Payer: BCBS of TX Blue Essentials	$33.18
Rate for Payer: BCBS of TX PPO	$36.86
Rate for Payer: Cash Price	$81.10
Rate for Payer: Multiplan Auto	$59.90
Rate for Payer: Multiplan Commercial	$59.90
Rate for Payer: Multiplan Workers Comp	$59.90
Rate for Payer: Scott and White EPO/PPO	$46.08
Rate for Payer: Superior Health Plan EPO	$12.53

SUT SPEC AS -- DHF

Facility

$735.24

Hospital Charge Code	81945578
Hospital Revenue Code	272
Rate for Payer: Cash Price	$647.01

SUT SPEC AS -- DHF

Facility

$735.24

Hospital Charge Code	81945578
Hospital Revenue Code	272
Min. Negotiated Rate	$66.17
Max. Negotiated Rate	$477.91
Rate for Payer: Aetna Commercial	$404.38
Rate for Payer: Amerigroup CHIP/Medicaid	$66.17
Rate for Payer: BCBS of TX Blue Advantage	$220.57
Rate for Payer: BCBS of TX Blue Essentials	$264.69
Rate for Payer: BCBS of TX PPO	$294.10
Rate for Payer: Cash Price	$647.01
Rate for Payer: Multiplan Auto	$477.91
Rate for Payer: Multiplan Commercial	$477.91
Rate for Payer: Multiplan Workers Comp	$477.91
Rate for Payer: Scott and White EPO/PPO	$367.62
Rate for Payer: Superior Health Plan EPO	$99.99

SUT STAPLE REM -- DHF

Facility

$138.28

Hospital Charge Code	81945651
Hospital Revenue Code	272
Rate for Payer: Cash Price	$121.69

SUT STAPLE REM -- DHF

Facility

$138.28

Hospital Charge Code	81945651
Hospital Revenue Code	272
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$89.88
Rate for Payer: Aetna Commercial	$76.05
Rate for Payer: Amerigroup CHIP/Medicaid	$12.45
Rate for Payer: BCBS of TX Blue Advantage	$41.48
Rate for Payer: BCBS of TX Blue Essentials	$49.78
Rate for Payer: BCBS of TX PPO	$55.31
Rate for Payer: Cash Price	$121.69
Rate for Payer: Multiplan Auto	$89.88
Rate for Payer: Multiplan Commercial	$89.88
Rate for Payer: Multiplan Workers Comp	$89.88
Rate for Payer: Scott and White EPO/PPO	$69.14
Rate for Payer: Superior Health Plan EPO	$18.81

SUT STP END HERN -- DHF

Facility

$1,254.78

Hospital Charge Code	81945800
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,104.21

SUT STP END HERN -- DHF

Facility

$1,254.78

Hospital Charge Code	81945800
Hospital Revenue Code	272
Min. Negotiated Rate	$112.93
Max. Negotiated Rate	$815.61
Rate for Payer: Aetna Commercial	$690.13
Rate for Payer: Amerigroup CHIP/Medicaid	$112.93
Rate for Payer: BCBS of TX Blue Advantage	$376.43
Rate for Payer: BCBS of TX Blue Essentials	$451.72
Rate for Payer: BCBS of TX PPO	$501.91
Rate for Payer: Cash Price	$1,104.21
Rate for Payer: Multiplan Auto	$815.61
Rate for Payer: Multiplan Commercial	$815.61
Rate for Payer: Multiplan Workers Comp	$815.61
Rate for Payer: Scott and White EPO/PPO	$627.39
Rate for Payer: Superior Health Plan EPO	$170.65

SUTURE 3-0VLOC 90ABSORB V-20 6" VLOCM0604

Facility

$138.29

Hospital Charge Code	135489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$121.70

SUTURE 3-0VLOC 90ABSORB V-20 6" VLOCM0604

Facility

$138.29

Hospital Charge Code	135489
Hospital Revenue Code	272
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$89.89
Rate for Payer: Aetna Commercial	$76.06
Rate for Payer: Amerigroup CHIP/Medicaid	$12.45
Rate for Payer: BCBS of TX Blue Advantage	$41.49
Rate for Payer: BCBS of TX Blue Essentials	$49.78
Rate for Payer: BCBS of TX PPO	$55.32
Rate for Payer: Cash Price	$121.70
Rate for Payer: Multiplan Auto	$89.89
Rate for Payer: Multiplan Commercial	$89.89
Rate for Payer: Multiplan Workers Comp	$89.89
Rate for Payer: Scott and White EPO/PPO	$69.14
Rate for Payer: Superior Health Plan EPO	$18.81

SUTURE ANCHOR 4.5MM POPLOCK W/ HIFI

Facility

$2,848.01

Service Code	HCPCS C1713
Hospital Charge Code	140698
Hospital Revenue Code	278
Min. Negotiated Rate	$256.32
Max. Negotiated Rate	$1,424.00
Rate for Payer: Aetna Commercial	$854.40
Rate for Payer: Amerigroup CHIP/Medicaid	$256.32
Rate for Payer: BCBS of TX Blue Advantage	$854.40
Rate for Payer: BCBS of TX Blue Essentials	$1,025.28
Rate for Payer: BCBS of TX PPO	$1,139.20
Rate for Payer: Cash Price	$2,506.25
Rate for Payer: Multiplan Auto	$1,424.00
Rate for Payer: Multiplan Commercial	$1,424.00
Rate for Payer: Multiplan Workers Comp	$1,424.00
Rate for Payer: Scott and White EPO/PPO	$1,424.00
Rate for Payer: Superior Health Plan EPO	$387.33

SUTURE ANCHOR 4.5MM POPLOCK W/ HIFI

Facility

$2,848.01

Service Code	HCPCS C1713
Hospital Charge Code	140698
Hospital Revenue Code	278
Min. Negotiated Rate	$712.00
Max. Negotiated Rate	$1,424.00
Rate for Payer: Aetna Commercial	$854.40
Rate for Payer: Cash Price	$2,506.25
Rate for Payer: Cigna Commercial	$712.00
Rate for Payer: Multiplan Auto	$1,424.00
Rate for Payer: Multiplan Commercial	$1,424.00
Rate for Payer: Multiplan Workers Comp	$1,424.00
Rate for Payer: Scott and White EPO/PPO	$1,424.00

SUTURE, CINCH OVERSTITCH SINGLE-USE -- DHF

Facility

$429.03

Hospital Charge Code	81954034
Hospital Revenue Code	272
Min. Negotiated Rate	$38.61
Max. Negotiated Rate	$278.87
Rate for Payer: Aetna Commercial	$235.97
Rate for Payer: Amerigroup CHIP/Medicaid	$38.61
Rate for Payer: BCBS of TX Blue Advantage	$128.71
Rate for Payer: BCBS of TX Blue Essentials	$154.45
Rate for Payer: BCBS of TX PPO	$171.61
Rate for Payer: Cash Price	$377.55
Rate for Payer: Multiplan Auto	$278.87
Rate for Payer: Multiplan Commercial	$278.87
Rate for Payer: Multiplan Workers Comp	$278.87
Rate for Payer: Scott and White EPO/PPO	$214.52
Rate for Payer: Superior Health Plan EPO	$58.35

SUTURE, CINCH OVERSTITCH SINGLE-USE -- DHF

Facility

$429.03

Hospital Charge Code	81954034
Hospital Revenue Code	272
Rate for Payer: Cash Price	$377.55

SUTURE, COATED VCYL UND BR 4-0 NEURO 8-18'''' CR RB-1 -- DHF

Facility

$202.44

Hospital Charge Code	81944704
Hospital Revenue Code	272
Min. Negotiated Rate	$18.22
Max. Negotiated Rate	$131.59
Rate for Payer: Aetna Commercial	$111.34
Rate for Payer: Amerigroup CHIP/Medicaid	$18.22
Rate for Payer: BCBS of TX Blue Advantage	$60.73
Rate for Payer: BCBS of TX Blue Essentials	$72.88
Rate for Payer: BCBS of TX PPO	$80.98
Rate for Payer: Cash Price	$178.15
Rate for Payer: Multiplan Auto	$131.59
Rate for Payer: Multiplan Commercial	$131.59
Rate for Payer: Multiplan Workers Comp	$131.59
Rate for Payer: Scott and White EPO/PPO	$101.22
Rate for Payer: Superior Health Plan EPO	$27.53

SUTURE, COATED VICRYL UND BR 0 OB GYN 36'''' CT-1 -- DHF

Facility

$147.62

Hospital Charge Code	81944456
Hospital Revenue Code	272
Min. Negotiated Rate	$13.29
Max. Negotiated Rate	$95.95
Rate for Payer: Aetna Commercial	$81.19
Rate for Payer: Amerigroup CHIP/Medicaid	$13.29
Rate for Payer: BCBS of TX Blue Advantage	$44.29
Rate for Payer: BCBS of TX Blue Essentials	$53.14
Rate for Payer: BCBS of TX PPO	$59.05
Rate for Payer: Cash Price	$129.91
Rate for Payer: Multiplan Auto	$95.95
Rate for Payer: Multiplan Commercial	$95.95
Rate for Payer: Multiplan Workers Comp	$95.95
Rate for Payer: Scott and White EPO/PPO	$73.81
Rate for Payer: Superior Health Plan EPO	$20.08

SUTURE, COATED VICRYL UND BR 0 SUTUPAK 6-18'''' SS -- DHF

Facility

$257.57

Hospital Charge Code	81944902
Hospital Revenue Code	272
Min. Negotiated Rate	$23.18
Max. Negotiated Rate	$167.42
Rate for Payer: Aetna Commercial	$141.66
Rate for Payer: Amerigroup CHIP/Medicaid	$23.18
Rate for Payer: BCBS of TX Blue Advantage	$77.27
Rate for Payer: BCBS of TX Blue Essentials	$92.73
Rate for Payer: BCBS of TX PPO	$103.03
Rate for Payer: Cash Price	$226.66
Rate for Payer: Multiplan Auto	$167.42
Rate for Payer: Multiplan Commercial	$167.42
Rate for Payer: Multiplan Workers Comp	$167.42
Rate for Payer: Scott and White EPO/PPO	$128.78
Rate for Payer: Superior Health Plan EPO	$35.03

SUTURE, COATED VICRYL UND BR 1 ORTHO 27'''' OS-6 -- DHF

Facility

$202.44

Hospital Charge Code	81944704
Hospital Revenue Code	272
Min. Negotiated Rate	$18.22
Max. Negotiated Rate	$131.59
Rate for Payer: Aetna Commercial	$111.34
Rate for Payer: Amerigroup CHIP/Medicaid	$18.22
Rate for Payer: BCBS of TX Blue Advantage	$60.73
Rate for Payer: BCBS of TX Blue Essentials	$72.88
Rate for Payer: BCBS of TX PPO	$80.98
Rate for Payer: Cash Price	$178.15
Rate for Payer: Multiplan Auto	$131.59
Rate for Payer: Multiplan Commercial	$131.59
Rate for Payer: Multiplan Workers Comp	$131.59
Rate for Payer: Scott and White EPO/PPO	$101.22
Rate for Payer: Superior Health Plan EPO	$27.53

SUTURE, COATED VICRYL UND BR 2-0 CLOS 8-18 CR/CT-1 -- DHF

Facility

$106.03

Hospital Charge Code	81941858
Hospital Revenue Code	272
Min. Negotiated Rate	$9.54
Max. Negotiated Rate	$68.92
Rate for Payer: Aetna Commercial	$58.32
Rate for Payer: Amerigroup CHIP/Medicaid	$9.54
Rate for Payer: BCBS of TX Blue Advantage	$31.81
Rate for Payer: BCBS of TX Blue Essentials	$38.17
Rate for Payer: BCBS of TX PPO	$42.41
Rate for Payer: Cash Price	$93.31
Rate for Payer: Multiplan Auto	$68.92
Rate for Payer: Multiplan Commercial	$68.92
Rate for Payer: Multiplan Workers Comp	$68.92
Rate for Payer: Scott and White EPO/PPO	$53.02
Rate for Payer: Superior Health Plan EPO	$14.42

SUTURE, COATED VICRYL UND BR 2-0 CLOSURE 27'''' CT-1 -- DHF

Facility

$147.62

Hospital Charge Code	81944456
Hospital Revenue Code	272
Min. Negotiated Rate	$13.29
Max. Negotiated Rate	$95.95
Rate for Payer: Aetna Commercial	$81.19
Rate for Payer: Amerigroup CHIP/Medicaid	$13.29
Rate for Payer: BCBS of TX Blue Advantage	$44.29
Rate for Payer: BCBS of TX Blue Essentials	$53.14
Rate for Payer: BCBS of TX PPO	$59.05
Rate for Payer: Cash Price	$129.91
Rate for Payer: Multiplan Auto	$95.95
Rate for Payer: Multiplan Commercial	$95.95
Rate for Payer: Multiplan Workers Comp	$95.95
Rate for Payer: Scott and White EPO/PPO	$73.81
Rate for Payer: Superior Health Plan EPO	$20.08

SUTURE, COATED VICRYL UND BR 2-0 CLOSURE 27'''' CT-2 -- DHF

Facility

$147.62

Hospital Charge Code	81944456
Hospital Revenue Code	272
Min. Negotiated Rate	$13.29
Max. Negotiated Rate	$95.95
Rate for Payer: Aetna Commercial	$81.19
Rate for Payer: Amerigroup CHIP/Medicaid	$13.29
Rate for Payer: BCBS of TX Blue Advantage	$44.29
Rate for Payer: BCBS of TX Blue Essentials	$53.14
Rate for Payer: BCBS of TX PPO	$59.05
Rate for Payer: Cash Price	$129.91
Rate for Payer: Multiplan Auto	$95.95
Rate for Payer: Multiplan Commercial	$95.95
Rate for Payer: Multiplan Workers Comp	$95.95
Rate for Payer: Scott and White EPO/PPO	$73.81
Rate for Payer: Superior Health Plan EPO	$20.08

SUTURE, COATED VICRYL UND BR 2-0 CUT. 27'''' X-1 -- DHF

Facility

$202.44

Hospital Charge Code	81944704
Hospital Revenue Code	272
Min. Negotiated Rate	$18.22
Max. Negotiated Rate	$131.59
Rate for Payer: Aetna Commercial	$111.34
Rate for Payer: Amerigroup CHIP/Medicaid	$18.22
Rate for Payer: BCBS of TX Blue Advantage	$60.73
Rate for Payer: BCBS of TX Blue Essentials	$72.88
Rate for Payer: BCBS of TX PPO	$80.98
Rate for Payer: Cash Price	$178.15
Rate for Payer: Multiplan Auto	$131.59
Rate for Payer: Multiplan Commercial	$131.59
Rate for Payer: Multiplan Workers Comp	$131.59
Rate for Payer: Scott and White EPO/PPO	$101.22
Rate for Payer: Superior Health Plan EPO	$27.53

SUTURE, COATED VICRYL UND BR 2-0 G.I. 27'''' SH -- DHF

Facility

$142.72

Hospital Charge Code	81943706
Hospital Revenue Code	272
Min. Negotiated Rate	$12.84
Max. Negotiated Rate	$92.77
Rate for Payer: Aetna Commercial	$78.50
Rate for Payer: Amerigroup CHIP/Medicaid	$12.84
Rate for Payer: BCBS of TX Blue Advantage	$42.82
Rate for Payer: BCBS of TX Blue Essentials	$51.38
Rate for Payer: BCBS of TX PPO	$57.09
Rate for Payer: Cash Price	$125.59
Rate for Payer: Multiplan Auto	$92.77
Rate for Payer: Multiplan Commercial	$92.77
Rate for Payer: Multiplan Workers Comp	$92.77
Rate for Payer: Scott and White EPO/PPO	$71.36
Rate for Payer: Superior Health Plan EPO	$19.41

SUTURE, COATED VICRYL UND BR 2-0 LIGAPAK 54'''' -- DHF

Facility

$142.72

Hospital Charge Code	81943706
Hospital Revenue Code	272
Min. Negotiated Rate	$12.84
Max. Negotiated Rate	$92.77
Rate for Payer: Aetna Commercial	$78.50
Rate for Payer: Amerigroup CHIP/Medicaid	$12.84
Rate for Payer: BCBS of TX Blue Advantage	$42.82
Rate for Payer: BCBS of TX Blue Essentials	$51.38
Rate for Payer: BCBS of TX PPO	$57.09
Rate for Payer: Cash Price	$125.59
Rate for Payer: Multiplan Auto	$92.77
Rate for Payer: Multiplan Commercial	$92.77
Rate for Payer: Multiplan Workers Comp	$92.77
Rate for Payer: Scott and White EPO/PPO	$71.36
Rate for Payer: Superior Health Plan EPO	$19.41

Know your out-of-pocket cost for care.

All Charges