White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)

Facility

$1,687.00

Service Code	HCPCS C1713
Hospital Charge Code	146479
Hospital Revenue Code	278
Min. Negotiated Rate	$151.83
Max. Negotiated Rate	$1,214.64
Rate for Payer: Amerigroup CHIP/Medicaid	$151.83
Rate for Payer: BCBS of TX Blue Advantage	$506.10
Rate for Payer: BCBS of TX Blue Essentials	$607.32
Rate for Payer: BCBS of TX PPO	$674.80
Rate for Payer: Cash Price	$1,147.16
Rate for Payer: Cigna Medicaid	$1,214.64
Rate for Payer: Molina CHIP/Medicaid	$1,214.64
Rate for Payer: Multiplan Auto	$843.50
Rate for Payer: Multiplan Commercial	$843.50
Rate for Payer: Multiplan Workers Comp	$843.50
Rate for Payer: Parkland Medicaid	$1,214.64
Rate for Payer: Scott and White EPO/PPO	$843.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,214.64
Rate for Payer: Superior Health Plan EPO	$229.43

ANCHOR SUTURE 3.5 POPLOK W/ HIFI

Facility

$2,909.00

Service Code	HCPCS C1713
Hospital Charge Code	145480
Hospital Revenue Code	278
Min. Negotiated Rate	$727.25
Max. Negotiated Rate	$1,454.50
Rate for Payer: Cash Price	$1,978.12
Rate for Payer: Cigna Commercial	$727.25
Rate for Payer: Multiplan Auto	$1,454.50
Rate for Payer: Multiplan Commercial	$1,454.50
Rate for Payer: Multiplan Workers Comp	$1,454.50
Rate for Payer: Scott and White EPO/PPO	$1,454.50

ANCHOR SUTURE 3.5 POPLOK W/ HIFI

Facility

$2,909.00

Service Code	HCPCS C1713
Hospital Charge Code	145480
Hospital Revenue Code	278
Min. Negotiated Rate	$261.81
Max. Negotiated Rate	$2,094.48
Rate for Payer: Amerigroup CHIP/Medicaid	$261.81
Rate for Payer: BCBS of TX Blue Advantage	$872.70
Rate for Payer: BCBS of TX Blue Essentials	$1,047.24
Rate for Payer: BCBS of TX PPO	$1,163.60
Rate for Payer: Cash Price	$1,978.12
Rate for Payer: Cigna Medicaid	$2,094.48
Rate for Payer: Molina CHIP/Medicaid	$2,094.48
Rate for Payer: Multiplan Auto	$1,454.50
Rate for Payer: Multiplan Commercial	$1,454.50
Rate for Payer: Multiplan Workers Comp	$1,454.50
Rate for Payer: Parkland Medicaid	$2,094.48
Rate for Payer: Scott and White EPO/PPO	$1,454.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,094.48
Rate for Payer: Superior Health Plan EPO	$395.62

ANCHOR, SUTURE-BLUE W/DRIVER & 3 HIFI SUTURES

Facility

$2,182.00

Service Code	HCPCS C1713
Hospital Charge Code	141588
Hospital Revenue Code	278
Min. Negotiated Rate	$545.50
Max. Negotiated Rate	$1,091.00
Rate for Payer: Cash Price	$1,483.76
Rate for Payer: Cigna Commercial	$545.50
Rate for Payer: Multiplan Auto	$1,091.00
Rate for Payer: Multiplan Commercial	$1,091.00
Rate for Payer: Multiplan Workers Comp	$1,091.00
Rate for Payer: Scott and White EPO/PPO	$1,091.00

ANCHOR, SUTURE-BLUE W/DRIVER & 3 HIFI SUTURES

Facility

$2,182.00

Service Code	HCPCS C1713
Hospital Charge Code	141588
Hospital Revenue Code	278
Min. Negotiated Rate	$196.38
Max. Negotiated Rate	$1,571.04
Rate for Payer: Amerigroup CHIP/Medicaid	$196.38
Rate for Payer: BCBS of TX Blue Advantage	$654.60
Rate for Payer: BCBS of TX Blue Essentials	$785.52
Rate for Payer: BCBS of TX PPO	$872.80
Rate for Payer: Cash Price	$1,483.76
Rate for Payer: Cigna Medicaid	$1,571.04
Rate for Payer: Molina CHIP/Medicaid	$1,571.04
Rate for Payer: Multiplan Auto	$1,091.00
Rate for Payer: Multiplan Commercial	$1,091.00
Rate for Payer: Multiplan Workers Comp	$1,091.00
Rate for Payer: Parkland Medicaid	$1,571.04
Rate for Payer: Scott and White EPO/PPO	$1,091.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,571.04
Rate for Payer: Superior Health Plan EPO	$296.75

ANCHOR SUTURE HEALIX TRANSTEND

Facility

$7,765.00

Service Code	HCPCS C1713
Hospital Charge Code	8398515
Hospital Revenue Code	278
Min. Negotiated Rate	$698.85
Max. Negotiated Rate	$5,590.80
Rate for Payer: Amerigroup CHIP/Medicaid	$698.85
Rate for Payer: BCBS of TX Blue Advantage	$2,329.50
Rate for Payer: BCBS of TX Blue Essentials	$2,795.40
Rate for Payer: BCBS of TX PPO	$3,106.00
Rate for Payer: Cash Price	$5,280.20
Rate for Payer: Cigna Medicaid	$5,590.80
Rate for Payer: Molina CHIP/Medicaid	$5,590.80
Rate for Payer: Multiplan Auto	$3,882.50
Rate for Payer: Multiplan Commercial	$3,882.50
Rate for Payer: Multiplan Workers Comp	$3,882.50
Rate for Payer: Parkland Medicaid	$5,590.80
Rate for Payer: Scott and White EPO/PPO	$3,882.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,590.80
Rate for Payer: Superior Health Plan EPO	$1,056.04

ANCHOR SUTURE HEALIX TRANSTEND

Facility

$7,765.00

Service Code	HCPCS C1713
Hospital Charge Code	8398515
Hospital Revenue Code	278
Min. Negotiated Rate	$1,941.25
Max. Negotiated Rate	$3,882.50
Rate for Payer: Cash Price	$5,280.20
Rate for Payer: Cigna Commercial	$1,941.25
Rate for Payer: Multiplan Auto	$3,882.50
Rate for Payer: Multiplan Commercial	$3,882.50
Rate for Payer: Multiplan Workers Comp	$3,882.50
Rate for Payer: Scott and White EPO/PPO	$3,882.50

ANCHOR, SUTURE PEEK KNOTLESS W/2 #2 SUTURES 4.5MM

Facility

$2,848.00

Service Code	HCPCS C1713
Hospital Charge Code	140698
Hospital Revenue Code	278
Min. Negotiated Rate	$256.32
Max. Negotiated Rate	$2,050.56
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	$1,936.64
Rate for Payer: Cigna Medicaid	$2,050.56
Rate for Payer: Molina CHIP/Medicaid	$2,050.56
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: Parkland Medicaid	$2,050.56
Rate for Payer: Scott and White EPO/PPO	$1,424.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,050.56
Rate for Payer: Superior Health Plan EPO	$387.33

ANCHOR, SUTURE PEEK KNOTLESS W/2 #2 SUTURES 4.5MM

Facility

$2,848.00

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: Cash Price	$1,936.64
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

ANCHOR SUTURE PRESFIT GENHIP FLEX

Facility

$5,048.00

Service Code	HCPCS C1713
Hospital Charge Code	8406460
Hospital Revenue Code	278
Min. Negotiated Rate	$454.32
Max. Negotiated Rate	$3,634.56
Rate for Payer: Amerigroup CHIP/Medicaid	$454.32
Rate for Payer: BCBS of TX Blue Advantage	$1,514.40
Rate for Payer: BCBS of TX Blue Essentials	$1,817.28
Rate for Payer: BCBS of TX PPO	$2,019.20
Rate for Payer: Cash Price	$3,432.64
Rate for Payer: Cigna Medicaid	$3,634.56
Rate for Payer: Molina CHIP/Medicaid	$3,634.56
Rate for Payer: Multiplan Auto	$2,524.00
Rate for Payer: Multiplan Commercial	$2,524.00
Rate for Payer: Multiplan Workers Comp	$2,524.00
Rate for Payer: Parkland Medicaid	$3,634.56
Rate for Payer: Scott and White EPO/PPO	$2,524.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,634.56
Rate for Payer: Superior Health Plan EPO	$686.53

ANCHOR SUTURE PRESFIT GENHIP FLEX

Facility

$5,048.00

Service Code	HCPCS C1713
Hospital Charge Code	8406460
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.00
Max. Negotiated Rate	$2,524.00
Rate for Payer: Cash Price	$3,432.64
Rate for Payer: Cigna Commercial	$1,262.00
Rate for Payer: Multiplan Auto	$2,524.00
Rate for Payer: Multiplan Commercial	$2,524.00
Rate for Payer: Multiplan Workers Comp	$2,524.00
Rate for Payer: Scott and White EPO/PPO	$2,524.00

ANCHOR SUTURE QUICK ANCHOR PLUS

Facility

$5,471.00

Service Code	HCPCS C1713
Hospital Charge Code	8394457
Hospital Revenue Code	278
Min. Negotiated Rate	$492.39
Max. Negotiated Rate	$3,939.12
Rate for Payer: Amerigroup CHIP/Medicaid	$492.39
Rate for Payer: BCBS of TX Blue Advantage	$1,641.30
Rate for Payer: BCBS of TX Blue Essentials	$1,969.56
Rate for Payer: BCBS of TX PPO	$2,188.40
Rate for Payer: Cash Price	$3,720.28
Rate for Payer: Cigna Medicaid	$3,939.12
Rate for Payer: Molina CHIP/Medicaid	$3,939.12
Rate for Payer: Multiplan Auto	$2,735.50
Rate for Payer: Multiplan Commercial	$2,735.50
Rate for Payer: Multiplan Workers Comp	$2,735.50
Rate for Payer: Parkland Medicaid	$3,939.12
Rate for Payer: Scott and White EPO/PPO	$2,735.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,939.12
Rate for Payer: Superior Health Plan EPO	$744.06

ANCHOR SUTURE QUICK ANCHOR PLUS

Facility

$5,471.00

Service Code	HCPCS C1713
Hospital Charge Code	8394457
Hospital Revenue Code	278
Min. Negotiated Rate	$1,367.75
Max. Negotiated Rate	$2,735.50
Rate for Payer: Cash Price	$3,720.28
Rate for Payer: Cigna Commercial	$1,367.75
Rate for Payer: Multiplan Auto	$2,735.50
Rate for Payer: Multiplan Commercial	$2,735.50
Rate for Payer: Multiplan Workers Comp	$2,735.50
Rate for Payer: Scott and White EPO/PPO	$2,735.50

anchor suture sys y-knot w/ribbon

Facility

$5,889.00

Service Code	HCPCS C1713
Hospital Charge Code	8708541
Hospital Revenue Code	278
Min. Negotiated Rate	$530.01
Max. Negotiated Rate	$4,240.08
Rate for Payer: Amerigroup CHIP/Medicaid	$530.01
Rate for Payer: BCBS of TX Blue Advantage	$1,766.70
Rate for Payer: BCBS of TX Blue Essentials	$2,120.04
Rate for Payer: BCBS of TX PPO	$2,355.60
Rate for Payer: Cash Price	$4,004.52
Rate for Payer: Cigna Medicaid	$4,240.08
Rate for Payer: Molina CHIP/Medicaid	$4,240.08
Rate for Payer: Multiplan Auto	$2,944.50
Rate for Payer: Multiplan Commercial	$2,944.50
Rate for Payer: Multiplan Workers Comp	$2,944.50
Rate for Payer: Parkland Medicaid	$4,240.08
Rate for Payer: Scott and White EPO/PPO	$2,944.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,240.08
Rate for Payer: Superior Health Plan EPO	$800.90

anchor suture sys y-knot w/ribbon

Facility

$5,889.00

Service Code	HCPCS C1713
Hospital Charge Code	8708541
Hospital Revenue Code	278
Min. Negotiated Rate	$1,472.25
Max. Negotiated Rate	$2,944.50
Rate for Payer: Cash Price	$4,004.52
Rate for Payer: Cigna Commercial	$1,472.25
Rate for Payer: Multiplan Auto	$2,944.50
Rate for Payer: Multiplan Commercial	$2,944.50
Rate for Payer: Multiplan Workers Comp	$2,944.50
Rate for Payer: Scott and White EPO/PPO	$2,944.50

anchor suture toggleloc

Facility

$3,855.00

Service Code	HCPCS C1713
Hospital Charge Code	8720600
Hospital Revenue Code	278
Min. Negotiated Rate	$346.95
Max. Negotiated Rate	$2,775.60
Rate for Payer: Amerigroup CHIP/Medicaid	$346.95
Rate for Payer: BCBS of TX Blue Advantage	$1,156.50
Rate for Payer: BCBS of TX Blue Essentials	$1,387.80
Rate for Payer: BCBS of TX PPO	$1,542.00
Rate for Payer: Cash Price	$2,621.40
Rate for Payer: Cigna Medicaid	$2,775.60
Rate for Payer: Molina CHIP/Medicaid	$2,775.60
Rate for Payer: Multiplan Auto	$1,927.50
Rate for Payer: Multiplan Commercial	$1,927.50
Rate for Payer: Multiplan Workers Comp	$1,927.50
Rate for Payer: Parkland Medicaid	$2,775.60
Rate for Payer: Scott and White EPO/PPO	$1,927.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,775.60
Rate for Payer: Superior Health Plan EPO	$524.28

anchor suture toggleloc

Facility

$3,855.00

Service Code	HCPCS C1713
Hospital Charge Code	8720600
Hospital Revenue Code	278
Min. Negotiated Rate	$963.75
Max. Negotiated Rate	$1,927.50
Rate for Payer: Cash Price	$2,621.40
Rate for Payer: Cigna Commercial	$963.75
Rate for Payer: Multiplan Auto	$1,927.50
Rate for Payer: Multiplan Commercial	$1,927.50
Rate for Payer: Multiplan Workers Comp	$1,927.50
Rate for Payer: Scott and White EPO/PPO	$1,927.50

anchor suture y knot

Facility

$3,024.00

Service Code	HCPCS C1713
Hospital Charge Code	8688555
Hospital Revenue Code	278
Min. Negotiated Rate	$272.16
Max. Negotiated Rate	$2,177.28
Rate for Payer: Amerigroup CHIP/Medicaid	$272.16
Rate for Payer: BCBS of TX Blue Advantage	$907.20
Rate for Payer: BCBS of TX Blue Essentials	$1,088.64
Rate for Payer: BCBS of TX PPO	$1,209.60
Rate for Payer: Cash Price	$2,056.32
Rate for Payer: Cigna Medicaid	$2,177.28
Rate for Payer: Molina CHIP/Medicaid	$2,177.28
Rate for Payer: Multiplan Auto	$1,512.00
Rate for Payer: Multiplan Commercial	$1,512.00
Rate for Payer: Multiplan Workers Comp	$1,512.00
Rate for Payer: Parkland Medicaid	$2,177.28
Rate for Payer: Scott and White EPO/PPO	$1,512.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,177.28
Rate for Payer: Superior Health Plan EPO	$411.26

anchor suture y knot

Facility

$3,024.00

Service Code	HCPCS C1713
Hospital Charge Code	8688555
Hospital Revenue Code	278
Min. Negotiated Rate	$756.00
Max. Negotiated Rate	$1,512.00
Rate for Payer: Cash Price	$2,056.32
Rate for Payer: Cigna Commercial	$756.00
Rate for Payer: Multiplan Auto	$1,512.00
Rate for Payer: Multiplan Commercial	$1,512.00
Rate for Payer: Multiplan Workers Comp	$1,512.00
Rate for Payer: Scott and White EPO/PPO	$1,512.00

ANCHOR SUTURE Y-KNOT 1.3 BLUE RIBBON

Facility

$5,385.00

Service Code	HCPCS C1713
Hospital Charge Code	144882
Hospital Revenue Code	278
Min. Negotiated Rate	$484.65
Max. Negotiated Rate	$3,877.20
Rate for Payer: Amerigroup CHIP/Medicaid	$484.65
Rate for Payer: BCBS of TX Blue Advantage	$1,615.50
Rate for Payer: BCBS of TX Blue Essentials	$1,938.60
Rate for Payer: BCBS of TX PPO	$2,154.00
Rate for Payer: Cash Price	$3,661.80
Rate for Payer: Cigna Medicaid	$3,877.20
Rate for Payer: Molina CHIP/Medicaid	$3,877.20
Rate for Payer: Multiplan Auto	$2,692.50
Rate for Payer: Multiplan Commercial	$2,692.50
Rate for Payer: Multiplan Workers Comp	$2,692.50
Rate for Payer: Parkland Medicaid	$3,877.20
Rate for Payer: Scott and White EPO/PPO	$2,692.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,877.20
Rate for Payer: Superior Health Plan EPO	$732.36

ANCHOR SUTURE Y-KNOT 1.3 BLUE RIBBON

Facility

$5,385.00

Service Code	HCPCS C1713
Hospital Charge Code	144882
Hospital Revenue Code	278
Min. Negotiated Rate	$1,346.25
Max. Negotiated Rate	$2,692.50
Rate for Payer: Cash Price	$3,661.80
Rate for Payer: Cigna Commercial	$1,346.25
Rate for Payer: Multiplan Auto	$2,692.50
Rate for Payer: Multiplan Commercial	$2,692.50
Rate for Payer: Multiplan Workers Comp	$2,692.50
Rate for Payer: Scott and White EPO/PPO	$2,692.50

ANCHOR SUTURE Y-KNOT 1.3MM WHT/BLK

Facility

$2,807.00

Service Code	HCPCS C1713
Hospital Charge Code	144881
Hospital Revenue Code	278
Min. Negotiated Rate	$252.63
Max. Negotiated Rate	$2,021.04
Rate for Payer: Amerigroup CHIP/Medicaid	$252.63
Rate for Payer: BCBS of TX Blue Advantage	$842.10
Rate for Payer: BCBS of TX Blue Essentials	$1,010.52
Rate for Payer: BCBS of TX PPO	$1,122.80
Rate for Payer: Cash Price	$1,908.76
Rate for Payer: Cigna Medicaid	$2,021.04
Rate for Payer: Molina CHIP/Medicaid	$2,021.04
Rate for Payer: Multiplan Auto	$1,403.50
Rate for Payer: Multiplan Commercial	$1,403.50
Rate for Payer: Multiplan Workers Comp	$1,403.50
Rate for Payer: Parkland Medicaid	$2,021.04
Rate for Payer: Scott and White EPO/PPO	$1,403.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,021.04
Rate for Payer: Superior Health Plan EPO	$381.75

ANCHOR SUTURE Y-KNOT 1.3MM WHT/BLK

Facility

$2,807.00

Service Code	HCPCS C1713
Hospital Charge Code	144881
Hospital Revenue Code	278
Min. Negotiated Rate	$701.75
Max. Negotiated Rate	$1,403.50
Rate for Payer: Cash Price	$1,908.76
Rate for Payer: Cigna Commercial	$701.75
Rate for Payer: Multiplan Auto	$1,403.50
Rate for Payer: Multiplan Commercial	$1,403.50
Rate for Payer: Multiplan Workers Comp	$1,403.50
Rate for Payer: Scott and White EPO/PPO	$1,403.50

anchor suture y-knot rc

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Charge Code	8708546
Hospital Revenue Code	278
Min. Negotiated Rate	$723.00
Max. Negotiated Rate	$1,446.00
Rate for Payer: Cash Price	$1,966.56
Rate for Payer: Cigna Commercial	$723.00
Rate for Payer: Multiplan Auto	$1,446.00
Rate for Payer: Multiplan Commercial	$1,446.00
Rate for Payer: Multiplan Workers Comp	$1,446.00
Rate for Payer: Scott and White EPO/PPO	$1,446.00

anchor suture y-knot rc

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Charge Code	8708546
Hospital Revenue Code	278
Min. Negotiated Rate	$260.28
Max. Negotiated Rate	$2,082.24
Rate for Payer: Amerigroup CHIP/Medicaid	$260.28
Rate for Payer: BCBS of TX Blue Advantage	$867.60
Rate for Payer: BCBS of TX Blue Essentials	$1,041.12
Rate for Payer: BCBS of TX PPO	$1,156.80
Rate for Payer: Cash Price	$1,966.56
Rate for Payer: Cigna Medicaid	$2,082.24
Rate for Payer: Molina CHIP/Medicaid	$2,082.24
Rate for Payer: Multiplan Auto	$1,446.00
Rate for Payer: Multiplan Commercial	$1,446.00
Rate for Payer: Multiplan Workers Comp	$1,446.00
Rate for Payer: Parkland Medicaid	$2,082.24
Rate for Payer: Scott and White EPO/PPO	$1,446.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,082.24
Rate for Payer: Superior Health Plan EPO	$393.31

Know your out-of-pocket cost for care.

All Charges