White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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	8602524
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

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	$308.90
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	$291.74
Rate for Payer: Cigna Medicaid	$308.90
Rate for Payer: Molina CHIP/Medicaid	$308.90
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: Parkland Medicaid	$308.90
Rate for Payer: Scott and White EPO/PPO	$214.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$308.90
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	$291.74

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
Rate for Payer: Cash Price	$137.66

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	$145.76
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	$137.66
Rate for Payer: Cigna Medicaid	$145.76
Rate for Payer: Molina CHIP/Medicaid	$145.76
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: Parkland Medicaid	$145.76
Rate for Payer: Scott and White EPO/PPO	$101.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.76
Rate for Payer: Superior Health Plan EPO	$27.53

SUTURE, COATED VICRYL, 2-0, MH, 27, VIOLI

Facility

$10.52

Hospital Charge Code	993797
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7.15

SUTURE, COATED VICRYL, 2-0, MH, 27, VIOLI

Facility

$10.52

Hospital Charge Code	993797
Hospital Revenue Code	272
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$7.57
Rate for Payer: Amerigroup CHIP/Medicaid	$0.95
Rate for Payer: BCBS of TX Blue Advantage	$3.16
Rate for Payer: BCBS of TX Blue Essentials	$3.79
Rate for Payer: BCBS of TX PPO	$4.21
Rate for Payer: Cash Price	$7.15
Rate for Payer: Cigna Medicaid	$7.57
Rate for Payer: Molina CHIP/Medicaid	$7.57
Rate for Payer: Multiplan Auto	$6.84
Rate for Payer: Multiplan Commercial	$6.84
Rate for Payer: Multiplan Workers Comp	$6.84
Rate for Payer: Parkland Medicaid	$7.57
Rate for Payer: Scott and White EPO/PPO	$5.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.57
Rate for Payer: Superior Health Plan EPO	$1.43

SUTURE, COATED VICRYL,3-0,SH-1,27, UNDYED

Facility

$5.72

Hospital Charge Code	992889
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.89

SUTURE, COATED VICRYL,3-0,SH-1,27, UNDYED

Facility

$5.72

Hospital Charge Code	992889
Hospital Revenue Code	272
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$4.12
Rate for Payer: Amerigroup CHIP/Medicaid	$0.51
Rate for Payer: BCBS of TX Blue Advantage	$1.72
Rate for Payer: BCBS of TX Blue Essentials	$2.06
Rate for Payer: BCBS of TX PPO	$2.29
Rate for Payer: Cash Price	$3.89
Rate for Payer: Cigna Medicaid	$4.12
Rate for Payer: Molina CHIP/Medicaid	$4.12
Rate for Payer: Multiplan Auto	$3.72
Rate for Payer: Multiplan Commercial	$3.72
Rate for Payer: Multiplan Workers Comp	$3.72
Rate for Payer: Parkland Medicaid	$4.12
Rate for Payer: Scott and White EPO/PPO	$2.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.12
Rate for Payer: Superior Health Plan EPO	$0.78

SUTURE, COATED VICRYL, 3-0, SH, 27, VIOLET

Facility

$4.99

Hospital Charge Code	992895
Hospital Revenue Code	272
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$3.59
Rate for Payer: Amerigroup CHIP/Medicaid	$0.45
Rate for Payer: BCBS of TX Blue Advantage	$1.50
Rate for Payer: BCBS of TX Blue Essentials	$1.80
Rate for Payer: BCBS of TX PPO	$2.00
Rate for Payer: Cash Price	$3.39
Rate for Payer: Cigna Medicaid	$3.59
Rate for Payer: Molina CHIP/Medicaid	$3.59
Rate for Payer: Multiplan Auto	$3.24
Rate for Payer: Multiplan Commercial	$3.24
Rate for Payer: Multiplan Workers Comp	$3.24
Rate for Payer: Parkland Medicaid	$3.59
Rate for Payer: Scott and White EPO/PPO	$2.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3.59
Rate for Payer: Superior Health Plan EPO	$0.68

SUTURE, COATED VICRYL, 3-0, SH, 27, VIOLET

Facility

$4.99

Hospital Charge Code	992895
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.39

SUTURE, COATED VICRYL, 4-0, P-3, 18, UNDYED

Facility

$14.46

Hospital Charge Code	992893
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.83

SUTURE, COATED VICRYL, 4-0, P-3, 18, UNDYED

Facility

$14.46

Hospital Charge Code	992893
Hospital Revenue Code	272
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$10.41
Rate for Payer: Amerigroup CHIP/Medicaid	$1.30
Rate for Payer: BCBS of TX Blue Advantage	$4.34
Rate for Payer: BCBS of TX Blue Essentials	$5.21
Rate for Payer: BCBS of TX PPO	$5.78
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cigna Medicaid	$10.41
Rate for Payer: Molina CHIP/Medicaid	$10.41
Rate for Payer: Multiplan Auto	$9.40
Rate for Payer: Multiplan Commercial	$9.40
Rate for Payer: Multiplan Workers Comp	$9.40
Rate for Payer: Parkland Medicaid	$10.41
Rate for Payer: Scott and White EPO/PPO	$7.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.41
Rate for Payer: Superior Health Plan EPO	$1.97

SUTURE, COATED VICRYL, 4-0, PC-3, 18, UNDYED

Facility

$14.46

Hospital Charge Code	992894
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.83

SUTURE, COATED VICRYL, 4-0, PC-3, 18, UNDYED

Facility

$14.46

Hospital Charge Code	992894
Hospital Revenue Code	272
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$10.41
Rate for Payer: Amerigroup CHIP/Medicaid	$1.30
Rate for Payer: BCBS of TX Blue Advantage	$4.34
Rate for Payer: BCBS of TX Blue Essentials	$5.21
Rate for Payer: BCBS of TX PPO	$5.78
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cigna Medicaid	$10.41
Rate for Payer: Molina CHIP/Medicaid	$10.41
Rate for Payer: Multiplan Auto	$9.40
Rate for Payer: Multiplan Commercial	$9.40
Rate for Payer: Multiplan Workers Comp	$9.40
Rate for Payer: Parkland Medicaid	$10.41
Rate for Payer: Scott and White EPO/PPO	$7.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.41
Rate for Payer: Superior Health Plan EPO	$1.97

SUTURE, COATED VICRYL, 4-0, PS-2, 18, UNDYED

Facility

$13.17

Hospital Charge Code	992896
Hospital Revenue Code	272
Rate for Payer: Cash Price	$8.96

SUTURE, COATED VICRYL, 4-0, PS-2, 18, UNDYED

Facility

$13.17

Hospital Charge Code	992896
Hospital Revenue Code	272
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$9.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1.19
Rate for Payer: BCBS of TX Blue Advantage	$3.95
Rate for Payer: BCBS of TX Blue Essentials	$4.74
Rate for Payer: BCBS of TX PPO	$5.27
Rate for Payer: Cash Price	$8.96
Rate for Payer: Cigna Medicaid	$9.48
Rate for Payer: Molina CHIP/Medicaid	$9.48
Rate for Payer: Multiplan Auto	$8.56
Rate for Payer: Multiplan Commercial	$8.56
Rate for Payer: Multiplan Workers Comp	$8.56
Rate for Payer: Parkland Medicaid	$9.48
Rate for Payer: Scott and White EPO/PPO	$6.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.48
Rate for Payer: Superior Health Plan EPO	$1.79

SUTURE, COATED VICRYL PLUS, 1, CTX, 36'

Facility

$5.73

Hospital Charge Code	992997
Hospital Revenue Code	272
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$4.13
Rate for Payer: Amerigroup CHIP/Medicaid	$0.52
Rate for Payer: BCBS of TX Blue Advantage	$1.72
Rate for Payer: BCBS of TX Blue Essentials	$2.06
Rate for Payer: BCBS of TX PPO	$2.29
Rate for Payer: Cash Price	$3.90
Rate for Payer: Cigna Medicaid	$4.13
Rate for Payer: Molina CHIP/Medicaid	$4.13
Rate for Payer: Multiplan Auto	$3.72
Rate for Payer: Multiplan Commercial	$3.72
Rate for Payer: Multiplan Workers Comp	$3.72
Rate for Payer: Parkland Medicaid	$4.13
Rate for Payer: Scott and White EPO/PPO	$2.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.13
Rate for Payer: Superior Health Plan EPO	$0.78

SUTURE, COATED VICRYL PLUS, 1, CTX, 36'

Facility

$5.73

Hospital Charge Code	992997
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3.90

SUTURE COATED VICRYL UND BR 1 ORTHO 27 OS-6

Facility

$7.95

Hospital Charge Code	993742
Hospital Revenue Code	272
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.72
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.38
Rate for Payer: BCBS of TX Blue Essentials	$2.86
Rate for Payer: BCBS of TX PPO	$3.18
Rate for Payer: Cash Price	$5.41
Rate for Payer: Cigna Medicaid	$5.72
Rate for Payer: Molina CHIP/Medicaid	$5.72
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	$5.72
Rate for Payer: Scott and White EPO/PPO	$3.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.72
Rate for Payer: Superior Health Plan EPO	$1.08

SUTURE COATED VICRYL UND BR 1 ORTHO 27 OS-6

Facility

$7.95

Hospital Charge Code	993742
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5.41

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
Rate for Payer: Cash Price	$72.10

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	$76.34
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	$72.10
Rate for Payer: Cigna Medicaid	$76.34
Rate for Payer: Molina CHIP/Medicaid	$76.34
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: Parkland Medicaid	$76.34
Rate for Payer: Scott and White EPO/PPO	$53.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76.34
Rate for Payer: Superior Health Plan EPO	$14.42

SUTURE, COATED VICRYL UND BR 3-0 CLOSURE 27' CT-1 -- DHF

Facility

$257.57

Hospital Charge Code	81945107
Hospital Revenue Code	272
Rate for Payer: Cash Price	$175.15

Know your out-of-pocket cost for care.

All Charges