White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SUT FIBERTAPE -- DHF

Facility

$490.32

Hospital Charge Code	81943334
Hospital Revenue Code	272
Min. Negotiated Rate	$44.13
Max. Negotiated Rate	$353.03
Rate for Payer: Amerigroup CHIP/Medicaid	$44.13
Rate for Payer: BCBS of TX Blue Advantage	$147.10
Rate for Payer: BCBS of TX Blue Essentials	$176.52
Rate for Payer: BCBS of TX PPO	$196.13
Rate for Payer: Cash Price	$333.42
Rate for Payer: Cigna Medicaid	$353.03
Rate for Payer: Molina CHIP/Medicaid	$353.03
Rate for Payer: Multiplan Auto	$318.71
Rate for Payer: Multiplan Commercial	$318.71
Rate for Payer: Multiplan Workers Comp	$318.71
Rate for Payer: Parkland Medicaid	$353.03
Rate for Payer: Scott and White EPO/PPO	$245.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$353.03
Rate for Payer: Superior Health Plan EPO	$66.68

SUT OBGYN MERLN -- DHF

Facility

$138.61

Hospital Charge Code	81944407
Hospital Revenue Code	272
Rate for Payer: Cash Price	$94.25

SUT OBGYN MERLN -- DHF

Facility

$138.61

Hospital Charge Code	81944407
Hospital Revenue Code	272
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$99.80
Rate for Payer: Amerigroup CHIP/Medicaid	$12.47
Rate for Payer: BCBS of TX Blue Advantage	$41.58
Rate for Payer: BCBS of TX Blue Essentials	$49.90
Rate for Payer: BCBS of TX PPO	$55.44
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cigna Medicaid	$99.80
Rate for Payer: Molina CHIP/Medicaid	$99.80
Rate for Payer: Multiplan Auto	$90.10
Rate for Payer: Multiplan Commercial	$90.10
Rate for Payer: Multiplan Workers Comp	$90.10
Rate for Payer: Parkland Medicaid	$99.80
Rate for Payer: Scott and White EPO/PPO	$69.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.80
Rate for Payer: Superior Health Plan EPO	$18.85

SUT ORTHOBG GUT -- DHF

Facility

$336.09

Hospital Charge Code	81944753
Hospital Revenue Code	272
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$241.98
Rate for Payer: Amerigroup CHIP/Medicaid	$30.25
Rate for Payer: BCBS of TX Blue Advantage	$100.83
Rate for Payer: BCBS of TX Blue Essentials	$120.99
Rate for Payer: BCBS of TX PPO	$134.44
Rate for Payer: Cash Price	$228.54
Rate for Payer: Cigna Medicaid	$241.98
Rate for Payer: Molina CHIP/Medicaid	$241.98
Rate for Payer: Multiplan Auto	$218.46
Rate for Payer: Multiplan Commercial	$218.46
Rate for Payer: Multiplan Workers Comp	$218.46
Rate for Payer: Parkland Medicaid	$241.98
Rate for Payer: Scott and White EPO/PPO	$168.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$241.98
Rate for Payer: Superior Health Plan EPO	$45.71

SUT ORTHOBG GUT -- DHF

Facility

$336.09

Hospital Charge Code	81944753
Hospital Revenue Code	272
Rate for Payer: Cash Price	$228.54

SUT PAK GUT -- DHF

Facility

$138.28

Hospital Charge Code	81944803
Hospital Revenue Code	272
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$99.56
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	$94.03
Rate for Payer: Cigna Medicaid	$99.56
Rate for Payer: Molina CHIP/Medicaid	$99.56
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: Parkland Medicaid	$99.56
Rate for Payer: Scott and White EPO/PPO	$69.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.56
Rate for Payer: Superior Health Plan EPO	$18.81

SUT PAK GUT -- DHF

Facility

$138.28

Hospital Charge Code	81944803
Hospital Revenue Code	272
Rate for Payer: Cash Price	$94.03

SUT PASSER -- DHF

Facility

$166.75

Hospital Charge Code	81774010
Hospital Revenue Code	272
Min. Negotiated Rate	$15.01
Max. Negotiated Rate	$120.06
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	$113.39
Rate for Payer: Cigna Medicaid	$120.06
Rate for Payer: Molina CHIP/Medicaid	$120.06
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: Parkland Medicaid	$120.06
Rate for Payer: Scott and White EPO/PPO	$83.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.06
Rate for Payer: Superior Health Plan EPO	$22.68

SUT PASSER -- DHF

Facility

$166.75

Hospital Charge Code	81774010
Hospital Revenue Code	272
Rate for Payer: Cash Price	$113.39

SUT RETREIVER -- DHF

Facility

$92.16

Hospital Charge Code	81774051
Hospital Revenue Code	272
Rate for Payer: Cash Price	$62.67

SUT RETREIVER -- DHF

Facility

$92.16

Hospital Charge Code	81774051
Hospital Revenue Code	272
Min. Negotiated Rate	$8.29
Max. Negotiated Rate	$66.36
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	$62.67
Rate for Payer: Cigna Medicaid	$66.36
Rate for Payer: Molina CHIP/Medicaid	$66.36
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: Parkland Medicaid	$66.36
Rate for Payer: Scott and White EPO/PPO	$46.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.36
Rate for Payer: Superior Health Plan EPO	$12.53

SUT SPEC AS -- DHF

Facility

$735.24

Hospital Charge Code	81945578
Hospital Revenue Code	272
Min. Negotiated Rate	$66.17
Max. Negotiated Rate	$529.37
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	$499.96
Rate for Payer: Cigna Medicaid	$529.37
Rate for Payer: Molina CHIP/Medicaid	$529.37
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: Parkland Medicaid	$529.37
Rate for Payer: Scott and White EPO/PPO	$367.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$529.37
Rate for Payer: Superior Health Plan EPO	$99.99

SUT SPEC AS -- DHF

Facility

$735.24

Hospital Charge Code	81945578
Hospital Revenue Code	272
Rate for Payer: Cash Price	$499.96

SUT STAPLE REM -- DHF

Facility

$138.28

Hospital Charge Code	81945651
Hospital Revenue Code	272
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$99.56
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	$94.03
Rate for Payer: Cigna Medicaid	$99.56
Rate for Payer: Molina CHIP/Medicaid	$99.56
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: Parkland Medicaid	$99.56
Rate for Payer: Scott and White EPO/PPO	$69.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.56
Rate for Payer: Superior Health Plan EPO	$18.81

SUT STAPLE REM -- DHF

Facility

$138.28

Hospital Charge Code	81945651
Hospital Revenue Code	272
Rate for Payer: Cash Price	$94.03

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	$903.44
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	$853.25
Rate for Payer: Cigna Medicaid	$903.44
Rate for Payer: Molina CHIP/Medicaid	$903.44
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: Parkland Medicaid	$903.44
Rate for Payer: Scott and White EPO/PPO	$627.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$903.44
Rate for Payer: Superior Health Plan EPO	$170.65

SUT STP END HERN -- DHF

Facility

$1,254.78

Hospital Charge Code	81945800
Hospital Revenue Code	272
Rate for Payer: Cash Price	$853.25

SUTURE 0 VLOC GS-22 NON-ABSORB

Facility

$176.51

Hospital Charge Code	146435
Hospital Revenue Code	272
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$127.09
Rate for Payer: Amerigroup CHIP/Medicaid	$15.89
Rate for Payer: BCBS of TX Blue Advantage	$52.95
Rate for Payer: BCBS of TX Blue Essentials	$63.54
Rate for Payer: BCBS of TX PPO	$70.60
Rate for Payer: Cash Price	$120.03
Rate for Payer: Cigna Medicaid	$127.09
Rate for Payer: Molina CHIP/Medicaid	$127.09
Rate for Payer: Multiplan Auto	$114.73
Rate for Payer: Multiplan Commercial	$114.73
Rate for Payer: Multiplan Workers Comp	$114.73
Rate for Payer: Parkland Medicaid	$127.09
Rate for Payer: Scott and White EPO/PPO	$88.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$127.09
Rate for Payer: Superior Health Plan EPO	$24.01

SUTURE 0 VLOC GS-22 NON-ABSORB

Facility

$176.51

Hospital Charge Code	146435
Hospital Revenue Code	272
Rate for Payer: Cash Price	$120.03

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	$99.57
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	$94.04
Rate for Payer: Cigna Medicaid	$99.57
Rate for Payer: Molina CHIP/Medicaid	$99.57
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: Parkland Medicaid	$99.57
Rate for Payer: Scott and White EPO/PPO	$69.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$99.57
Rate for Payer: Superior Health Plan EPO	$18.81

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

Facility

$138.29

Hospital Charge Code	135489
Hospital Revenue Code	272
Rate for Payer: Cash Price	$94.04

SUTURE,CATED VCRYL,3-0,CT-1,27,UNDYD

Facility

$6.88

Hospital Charge Code	993117
Hospital Revenue Code	270
Rate for Payer: Cash Price	$4.68

SUTURE,CATED VCRYL,3-0,CT-1,27,UNDYD

Facility

$6.88

Hospital Charge Code	993117
Hospital Revenue Code	270
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$4.95
Rate for Payer: Amerigroup CHIP/Medicaid	$0.62
Rate for Payer: BCBS of TX Blue Advantage	$2.06
Rate for Payer: BCBS of TX Blue Essentials	$2.48
Rate for Payer: BCBS of TX PPO	$2.75
Rate for Payer: Cash Price	$4.68
Rate for Payer: Cigna Medicaid	$4.95
Rate for Payer: Molina CHIP/Medicaid	$4.95
Rate for Payer: Multiplan Auto	$4.47
Rate for Payer: Multiplan Commercial	$4.47
Rate for Payer: Multiplan Workers Comp	$4.47
Rate for Payer: Parkland Medicaid	$4.95
Rate for Payer: Scott and White EPO/PPO	$3.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.95
Rate for Payer: Superior Health Plan EPO	$0.94

SUTURE, CHROMIC GUT, 5-0, P-3, 18, UNDYED

Facility

$10.34

Service Code	HCPCS C1763
Hospital Charge Code	8602524
Hospital Revenue Code	278
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$5.17
Rate for Payer: Cash Price	$7.03
Rate for Payer: Cigna Commercial	$2.58
Rate for Payer: Multiplan Auto	$5.17
Rate for Payer: Multiplan Commercial	$5.17
Rate for Payer: Multiplan Workers Comp	$5.17
Rate for Payer: Scott and White EPO/PPO	$5.17

SUTURE, CHROMIC GUT, 5-0, P-3, 18, UNDYED

Facility

$10.34

Service Code	HCPCS C1763
Hospital Charge Code	993735
Hospital Revenue Code	278
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$7.44
Rate for Payer: Amerigroup CHIP/Medicaid	$0.93
Rate for Payer: BCBS of TX Blue Advantage	$3.10
Rate for Payer: BCBS of TX Blue Essentials	$3.72
Rate for Payer: BCBS of TX PPO	$4.14
Rate for Payer: Cash Price	$7.03
Rate for Payer: Cigna Medicaid	$7.44
Rate for Payer: Molina CHIP/Medicaid	$7.44
Rate for Payer: Multiplan Auto	$5.17
Rate for Payer: Multiplan Commercial	$5.17
Rate for Payer: Multiplan Workers Comp	$5.17
Rate for Payer: Parkland Medicaid	$7.44
Rate for Payer: Scott and White EPO/PPO	$5.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.44
Rate for Payer: Superior Health Plan EPO	$1.41

Know your out-of-pocket cost for care.

All Charges