White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ANCHOR SUTURE Y-KNOT RC W/NEEDLE ALL

Facility

$2,805.00

Service Code	HCPCS C1713
Hospital Charge Code	145479
Hospital Revenue Code	278
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$1,402.50
Rate for Payer: Cash Price	$1,907.40
Rate for Payer: Cigna Commercial	$701.25
Rate for Payer: Multiplan Auto	$1,402.50
Rate for Payer: Multiplan Commercial	$1,402.50
Rate for Payer: Multiplan Workers Comp	$1,402.50
Rate for Payer: Scott and White EPO/PPO	$1,402.50

ANCHOR SUTURE Y-KNOT RC W/NEEDLE ALL

Facility

$2,805.00

Service Code	HCPCS C1713
Hospital Charge Code	145479
Hospital Revenue Code	278
Min. Negotiated Rate	$252.45
Max. Negotiated Rate	$2,019.60
Rate for Payer: Amerigroup CHIP/Medicaid	$252.45
Rate for Payer: BCBS of TX Blue Advantage	$841.50
Rate for Payer: BCBS of TX Blue Essentials	$1,009.80
Rate for Payer: BCBS of TX PPO	$1,122.00
Rate for Payer: Cash Price	$1,907.40
Rate for Payer: Cigna Medicaid	$2,019.60
Rate for Payer: Molina CHIP/Medicaid	$2,019.60
Rate for Payer: Multiplan Auto	$1,402.50
Rate for Payer: Multiplan Commercial	$1,402.50
Rate for Payer: Multiplan Workers Comp	$1,402.50
Rate for Payer: Parkland Medicaid	$2,019.60
Rate for Payer: Scott and White EPO/PPO	$1,402.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,019.60
Rate for Payer: Superior Health Plan EPO	$381.48

ANCHOR SUTURE Y-KNOT YP1301B

Facility

$4,578.00

Service Code	HCPCS C1713
Hospital Charge Code	145072
Hospital Revenue Code	278
Min. Negotiated Rate	$412.02
Max. Negotiated Rate	$3,296.16
Rate for Payer: Amerigroup CHIP/Medicaid	$412.02
Rate for Payer: BCBS of TX Blue Advantage	$1,373.40
Rate for Payer: BCBS of TX Blue Essentials	$1,648.08
Rate for Payer: BCBS of TX PPO	$1,831.20
Rate for Payer: Cash Price	$3,113.04
Rate for Payer: Cigna Medicaid	$3,296.16
Rate for Payer: Molina CHIP/Medicaid	$3,296.16
Rate for Payer: Multiplan Auto	$2,289.00
Rate for Payer: Multiplan Commercial	$2,289.00
Rate for Payer: Multiplan Workers Comp	$2,289.00
Rate for Payer: Parkland Medicaid	$3,296.16
Rate for Payer: Scott and White EPO/PPO	$2,289.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,296.16
Rate for Payer: Superior Health Plan EPO	$622.61

ANCHOR SUTURE Y-KNOT YP1301B

Facility

$4,578.00

Service Code	HCPCS C1713
Hospital Charge Code	145072
Hospital Revenue Code	278
Min. Negotiated Rate	$1,144.50
Max. Negotiated Rate	$2,289.00
Rate for Payer: Cash Price	$3,113.04
Rate for Payer: Cigna Commercial	$1,144.50
Rate for Payer: Multiplan Auto	$2,289.00
Rate for Payer: Multiplan Commercial	$2,289.00
Rate for Payer: Multiplan Workers Comp	$2,289.00
Rate for Payer: Scott and White EPO/PPO	$2,289.00

ANCHOR SUTURE Y-KNOT YP1802

Facility

$4,744.00

Service Code	HCPCS C1713
Hospital Charge Code	145073
Hospital Revenue Code	278
Min. Negotiated Rate	$426.96
Max. Negotiated Rate	$3,415.68
Rate for Payer: Amerigroup CHIP/Medicaid	$426.96
Rate for Payer: BCBS of TX Blue Advantage	$1,423.20
Rate for Payer: BCBS of TX Blue Essentials	$1,707.84
Rate for Payer: BCBS of TX PPO	$1,897.60
Rate for Payer: Cash Price	$3,225.92
Rate for Payer: Cigna Medicaid	$3,415.68
Rate for Payer: Molina CHIP/Medicaid	$3,415.68
Rate for Payer: Multiplan Auto	$2,372.00
Rate for Payer: Multiplan Commercial	$2,372.00
Rate for Payer: Multiplan Workers Comp	$2,372.00
Rate for Payer: Parkland Medicaid	$3,415.68
Rate for Payer: Scott and White EPO/PPO	$2,372.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,415.68
Rate for Payer: Superior Health Plan EPO	$645.18

ANCHOR SUTURE Y-KNOT YP1802

Facility

$4,744.00

Service Code	HCPCS C1713
Hospital Charge Code	145073
Hospital Revenue Code	278
Min. Negotiated Rate	$1,186.00
Max. Negotiated Rate	$2,372.00
Rate for Payer: Cash Price	$3,225.92
Rate for Payer: Cigna Commercial	$1,186.00
Rate for Payer: Multiplan Auto	$2,372.00
Rate for Payer: Multiplan Commercial	$2,372.00
Rate for Payer: Multiplan Workers Comp	$2,372.00
Rate for Payer: Scott and White EPO/PPO	$2,372.00

ANCHOR SUT VERSALOCK

Facility

$3,975.90

Service Code	HCPCS C1713
Hospital Charge Code	992124
Hospital Revenue Code	278
Min. Negotiated Rate	$993.98
Max. Negotiated Rate	$1,987.95
Rate for Payer: Cash Price	$2,703.61
Rate for Payer: Cigna Commercial	$993.98
Rate for Payer: Multiplan Auto	$1,987.95
Rate for Payer: Multiplan Commercial	$1,987.95
Rate for Payer: Multiplan Workers Comp	$1,987.95
Rate for Payer: Scott and White EPO/PPO	$1,987.95

ANCHOR SUT VERSALOCK

Facility

$3,975.90

Service Code	HCPCS C1713
Hospital Charge Code	992124
Hospital Revenue Code	278
Min. Negotiated Rate	$357.83
Max. Negotiated Rate	$2,862.65
Rate for Payer: Amerigroup CHIP/Medicaid	$357.83
Rate for Payer: BCBS of TX Blue Advantage	$1,192.77
Rate for Payer: BCBS of TX Blue Essentials	$1,431.32
Rate for Payer: BCBS of TX PPO	$1,590.36
Rate for Payer: Cash Price	$2,703.61
Rate for Payer: Cigna Medicaid	$2,862.65
Rate for Payer: Molina CHIP/Medicaid	$2,862.65
Rate for Payer: Multiplan Auto	$1,987.95
Rate for Payer: Multiplan Commercial	$1,987.95
Rate for Payer: Multiplan Workers Comp	$1,987.95
Rate for Payer: Parkland Medicaid	$2,862.65
Rate for Payer: Scott and White EPO/PPO	$1,987.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,862.65
Rate for Payer: Superior Health Plan EPO	$540.72

ANCHOR Y KNOT

Facility

$5,888.86

Service Code	HCPCS C1713
Hospital Charge Code	992115
Hospital Revenue Code	278
Min. Negotiated Rate	$1,472.21
Max. Negotiated Rate	$2,944.43
Rate for Payer: Cash Price	$4,004.42
Rate for Payer: Cigna Commercial	$1,472.21
Rate for Payer: Multiplan Auto	$2,944.43
Rate for Payer: Multiplan Commercial	$2,944.43
Rate for Payer: Multiplan Workers Comp	$2,944.43
Rate for Payer: Scott and White EPO/PPO	$2,944.43

ANCHOR Y KNOT

Facility

$5,888.86

Service Code	HCPCS C1713
Hospital Charge Code	992115
Hospital Revenue Code	278
Min. Negotiated Rate	$530.00
Max. Negotiated Rate	$4,239.98
Rate for Payer: Amerigroup CHIP/Medicaid	$530.00
Rate for Payer: BCBS of TX Blue Advantage	$1,766.66
Rate for Payer: BCBS of TX Blue Essentials	$2,119.99
Rate for Payer: BCBS of TX PPO	$2,355.54
Rate for Payer: Cash Price	$4,004.42
Rate for Payer: Cigna Medicaid	$4,239.98
Rate for Payer: Molina CHIP/Medicaid	$4,239.98
Rate for Payer: Multiplan Auto	$2,944.43
Rate for Payer: Multiplan Commercial	$2,944.43
Rate for Payer: Multiplan Workers Comp	$2,944.43
Rate for Payer: Parkland Medicaid	$4,239.98
Rate for Payer: Scott and White EPO/PPO	$2,944.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,239.98
Rate for Payer: Superior Health Plan EPO	$800.88

ANCHOR Y KNOT ALL SUTURE W/ 3 HI FI RIBBON

Facility

$5,406.00

Service Code	HCPCS C1713
Hospital Charge Code	146176
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$2,703.00
Rate for Payer: Cash Price	$3,676.08
Rate for Payer: Cigna Commercial	$1,351.50
Rate for Payer: Multiplan Auto	$2,703.00
Rate for Payer: Multiplan Commercial	$2,703.00
Rate for Payer: Multiplan Workers Comp	$2,703.00
Rate for Payer: Scott and White EPO/PPO	$2,703.00

ANCHOR Y KNOT ALL SUTURE W/ 3 HI FI RIBBON

Facility

$5,406.00

Service Code	HCPCS C1713
Hospital Charge Code	146176
Hospital Revenue Code	278
Min. Negotiated Rate	$486.54
Max. Negotiated Rate	$3,892.32
Rate for Payer: Amerigroup CHIP/Medicaid	$486.54
Rate for Payer: BCBS of TX Blue Advantage	$1,621.80
Rate for Payer: BCBS of TX Blue Essentials	$1,946.16
Rate for Payer: BCBS of TX PPO	$2,162.40
Rate for Payer: Cash Price	$3,676.08
Rate for Payer: Cigna Medicaid	$3,892.32
Rate for Payer: Molina CHIP/Medicaid	$3,892.32
Rate for Payer: Multiplan Auto	$2,703.00
Rate for Payer: Multiplan Commercial	$2,703.00
Rate for Payer: Multiplan Workers Comp	$2,703.00
Rate for Payer: Parkland Medicaid	$3,892.32
Rate for Payer: Scott and White EPO/PPO	$2,703.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,892.32
Rate for Payer: Superior Health Plan EPO	$735.22

ANCHOR Y KNOT FLEX ALL SUTURE 1.8MM W 2 HI FI RIBBON

Facility

$5,117.00

Service Code	HCPCS C1713
Hospital Charge Code	146144
Hospital Revenue Code	278
Min. Negotiated Rate	$460.53
Max. Negotiated Rate	$3,684.24
Rate for Payer: Amerigroup CHIP/Medicaid	$460.53
Rate for Payer: BCBS of TX Blue Advantage	$1,535.10
Rate for Payer: BCBS of TX Blue Essentials	$1,842.12
Rate for Payer: BCBS of TX PPO	$2,046.80
Rate for Payer: Cash Price	$3,479.56
Rate for Payer: Cigna Medicaid	$3,684.24
Rate for Payer: Molina CHIP/Medicaid	$3,684.24
Rate for Payer: Multiplan Auto	$2,558.50
Rate for Payer: Multiplan Commercial	$2,558.50
Rate for Payer: Multiplan Workers Comp	$2,558.50
Rate for Payer: Parkland Medicaid	$3,684.24
Rate for Payer: Scott and White EPO/PPO	$2,558.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,684.24
Rate for Payer: Superior Health Plan EPO	$695.91

ANCHOR Y KNOT FLEX ALL SUTURE 1.8MM W 2 HI FI RIBBON

Facility

$5,117.00

Service Code	HCPCS C1713
Hospital Charge Code	146144
Hospital Revenue Code	278
Min. Negotiated Rate	$1,279.25
Max. Negotiated Rate	$2,558.50
Rate for Payer: Cash Price	$3,479.56
Rate for Payer: Cigna Commercial	$1,279.25
Rate for Payer: Multiplan Auto	$2,558.50
Rate for Payer: Multiplan Commercial	$2,558.50
Rate for Payer: Multiplan Workers Comp	$2,558.50
Rate for Payer: Scott and White EPO/PPO	$2,558.50

ANCHOR Y KNOT PROFLEX W/ HI-FI 1.3MM

Facility

$4,578.00

Service Code	HCPCS C1713
Hospital Charge Code	145180
Hospital Revenue Code	278
Min. Negotiated Rate	$1,144.50
Max. Negotiated Rate	$2,289.00
Rate for Payer: Cash Price	$3,113.04
Rate for Payer: Cigna Commercial	$1,144.50
Rate for Payer: Multiplan Auto	$2,289.00
Rate for Payer: Multiplan Commercial	$2,289.00
Rate for Payer: Multiplan Workers Comp	$2,289.00
Rate for Payer: Scott and White EPO/PPO	$2,289.00

ANCHOR Y KNOT PROFLEX W/ HI-FI 1.3MM

Facility

$4,578.00

Service Code	HCPCS C1713
Hospital Charge Code	145180
Hospital Revenue Code	278
Min. Negotiated Rate	$412.02
Max. Negotiated Rate	$3,296.16
Rate for Payer: Amerigroup CHIP/Medicaid	$412.02
Rate for Payer: BCBS of TX Blue Advantage	$1,373.40
Rate for Payer: BCBS of TX Blue Essentials	$1,648.08
Rate for Payer: BCBS of TX PPO	$1,831.20
Rate for Payer: Cash Price	$3,113.04
Rate for Payer: Cigna Medicaid	$3,296.16
Rate for Payer: Molina CHIP/Medicaid	$3,296.16
Rate for Payer: Multiplan Auto	$2,289.00
Rate for Payer: Multiplan Commercial	$2,289.00
Rate for Payer: Multiplan Workers Comp	$2,289.00
Rate for Payer: Parkland Medicaid	$3,296.16
Rate for Payer: Scott and White EPO/PPO	$2,289.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,296.16
Rate for Payer: Superior Health Plan EPO	$622.61

ANCHOR Y KNOT PROFLEX W/ RIBBON 1.8MM

Facility

$5,574.00

Service Code	HCPCS C1713
Hospital Charge Code	145179
Hospital Revenue Code	278
Min. Negotiated Rate	$1,393.50
Max. Negotiated Rate	$2,787.00
Rate for Payer: Cash Price	$3,790.32
Rate for Payer: Cigna Commercial	$1,393.50
Rate for Payer: Multiplan Auto	$2,787.00
Rate for Payer: Multiplan Commercial	$2,787.00
Rate for Payer: Multiplan Workers Comp	$2,787.00
Rate for Payer: Scott and White EPO/PPO	$2,787.00

ANCHOR Y KNOT PROFLEX W/ RIBBON 1.8MM

Facility

$5,574.00

Service Code	HCPCS C1713
Hospital Charge Code	145179
Hospital Revenue Code	278
Min. Negotiated Rate	$501.66
Max. Negotiated Rate	$4,013.28
Rate for Payer: Amerigroup CHIP/Medicaid	$501.66
Rate for Payer: BCBS of TX Blue Advantage	$1,672.20
Rate for Payer: BCBS of TX Blue Essentials	$2,006.64
Rate for Payer: BCBS of TX PPO	$2,229.60
Rate for Payer: Cash Price	$3,790.32
Rate for Payer: Cigna Medicaid	$4,013.28
Rate for Payer: Molina CHIP/Medicaid	$4,013.28
Rate for Payer: Multiplan Auto	$2,787.00
Rate for Payer: Multiplan Commercial	$2,787.00
Rate for Payer: Multiplan Workers Comp	$2,787.00
Rate for Payer: Parkland Medicaid	$4,013.28
Rate for Payer: Scott and White EPO/PPO	$2,787.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,013.28
Rate for Payer: Superior Health Plan EPO	$758.06

ANCH SUT ALLTHREAD -- DHF

Facility

$821.00

Service Code	HCPCS C1713
Hospital Charge Code	40106999
Hospital Revenue Code	278
Min. Negotiated Rate	$73.89
Max. Negotiated Rate	$591.12
Rate for Payer: Amerigroup CHIP/Medicaid	$73.89
Rate for Payer: BCBS of TX Blue Advantage	$246.30
Rate for Payer: BCBS of TX Blue Essentials	$295.56
Rate for Payer: BCBS of TX PPO	$328.40
Rate for Payer: Cash Price	$558.28
Rate for Payer: Cigna Medicaid	$591.12
Rate for Payer: Molina CHIP/Medicaid	$591.12
Rate for Payer: Multiplan Auto	$410.50
Rate for Payer: Multiplan Commercial	$410.50
Rate for Payer: Multiplan Workers Comp	$410.50
Rate for Payer: Parkland Medicaid	$591.12
Rate for Payer: Scott and White EPO/PPO	$410.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$591.12
Rate for Payer: Superior Health Plan EPO	$111.66

ANCH SUT ALLTHREAD -- DHF

Facility

$821.00

Service Code	HCPCS C1713
Hospital Charge Code	40106999
Hospital Revenue Code	278
Min. Negotiated Rate	$205.25
Max. Negotiated Rate	$410.50
Rate for Payer: Cash Price	$558.28
Rate for Payer: Cigna Commercial	$205.25
Rate for Payer: Multiplan Auto	$410.50
Rate for Payer: Multiplan Commercial	$410.50
Rate for Payer: Multiplan Workers Comp	$410.50
Rate for Payer: Scott and White EPO/PPO	$410.50

ANCH SUT MORPHIX -- DHF

Facility

$4,926.00

Service Code	HCPCS C1713
Hospital Charge Code	40107187
Hospital Revenue Code	278
Min. Negotiated Rate	$443.34
Max. Negotiated Rate	$3,546.72
Rate for Payer: Amerigroup CHIP/Medicaid	$443.34
Rate for Payer: BCBS of TX Blue Advantage	$1,477.80
Rate for Payer: BCBS of TX Blue Essentials	$1,773.36
Rate for Payer: BCBS of TX PPO	$1,970.40
Rate for Payer: Cash Price	$3,349.68
Rate for Payer: Cigna Medicaid	$3,546.72
Rate for Payer: Molina CHIP/Medicaid	$3,546.72
Rate for Payer: Multiplan Auto	$2,463.00
Rate for Payer: Multiplan Commercial	$2,463.00
Rate for Payer: Multiplan Workers Comp	$2,463.00
Rate for Payer: Parkland Medicaid	$3,546.72
Rate for Payer: Scott and White EPO/PPO	$2,463.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,546.72
Rate for Payer: Superior Health Plan EPO	$669.94

ANCH SUT MORPHIX -- DHF

Facility

$4,926.00

Service Code	HCPCS C1713
Hospital Charge Code	40107187
Hospital Revenue Code	278
Min. Negotiated Rate	$1,231.50
Max. Negotiated Rate	$2,463.00
Rate for Payer: Cash Price	$3,349.68
Rate for Payer: Cigna Commercial	$1,231.50
Rate for Payer: Multiplan Auto	$2,463.00
Rate for Payer: Multiplan Commercial	$2,463.00
Rate for Payer: Multiplan Workers Comp	$2,463.00
Rate for Payer: Scott and White EPO/PPO	$2,463.00

ANCH SUTURE KNOTLESS PUNCH TAC

Facility

$4,132.00

Service Code	HCPCS C1713
Hospital Charge Code	8428502
Hospital Revenue Code	278
Min. Negotiated Rate	$371.88
Max. Negotiated Rate	$2,975.04
Rate for Payer: Amerigroup CHIP/Medicaid	$371.88
Rate for Payer: BCBS of TX Blue Advantage	$1,239.60
Rate for Payer: BCBS of TX Blue Essentials	$1,487.52
Rate for Payer: BCBS of TX PPO	$1,652.80
Rate for Payer: Cash Price	$2,809.76
Rate for Payer: Cigna Medicaid	$2,975.04
Rate for Payer: Molina CHIP/Medicaid	$2,975.04
Rate for Payer: Multiplan Auto	$2,066.00
Rate for Payer: Multiplan Commercial	$2,066.00
Rate for Payer: Multiplan Workers Comp	$2,066.00
Rate for Payer: Parkland Medicaid	$2,975.04
Rate for Payer: Scott and White EPO/PPO	$2,066.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,975.04
Rate for Payer: Superior Health Plan EPO	$561.95

ANCH SUTURE KNOTLESS PUNCH TAC

Facility

$4,132.00

Service Code	HCPCS C1713
Hospital Charge Code	8428502
Hospital Revenue Code	278
Min. Negotiated Rate	$1,033.00
Max. Negotiated Rate	$2,066.00
Rate for Payer: Cash Price	$2,809.76
Rate for Payer: Cigna Commercial	$1,033.00
Rate for Payer: Multiplan Auto	$2,066.00
Rate for Payer: Multiplan Commercial	$2,066.00
Rate for Payer: Multiplan Workers Comp	$2,066.00
Rate for Payer: Scott and White EPO/PPO	$2,066.00

ANCH SUT Y-KNOT -- DHF

Facility

$3,901.00

Service Code	HCPCS C1713
Hospital Charge Code	40199044
Hospital Revenue Code	278
Min. Negotiated Rate	$351.09
Max. Negotiated Rate	$2,808.72
Rate for Payer: Amerigroup CHIP/Medicaid	$351.09
Rate for Payer: BCBS of TX Blue Advantage	$1,170.30
Rate for Payer: BCBS of TX Blue Essentials	$1,404.36
Rate for Payer: BCBS of TX PPO	$1,560.40
Rate for Payer: Cash Price	$2,652.68
Rate for Payer: Cigna Medicaid	$2,808.72
Rate for Payer: Molina CHIP/Medicaid	$2,808.72
Rate for Payer: Multiplan Auto	$1,950.50
Rate for Payer: Multiplan Commercial	$1,950.50
Rate for Payer: Multiplan Workers Comp	$1,950.50
Rate for Payer: Parkland Medicaid	$2,808.72
Rate for Payer: Scott and White EPO/PPO	$1,950.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,808.72
Rate for Payer: Superior Health Plan EPO	$530.54

Know your out-of-pocket cost for care.

All Charges