White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SUTURE, PROLENE BL MONO 5-0 PLASTIC 18' PS-2 12/BX -- DHF

Facility

$276.09

Hospital Charge Code	81941601
Hospital Revenue Code	272
Min. Negotiated Rate	$24.85
Max. Negotiated Rate	$198.78
Rate for Payer: Amerigroup CHIP/Medicaid	$24.85
Rate for Payer: BCBS of TX Blue Advantage	$82.83
Rate for Payer: BCBS of TX Blue Essentials	$99.39
Rate for Payer: BCBS of TX PPO	$110.44
Rate for Payer: Cash Price	$187.74
Rate for Payer: Cigna Medicaid	$198.78
Rate for Payer: Molina CHIP/Medicaid	$198.78
Rate for Payer: Multiplan Auto	$179.46
Rate for Payer: Multiplan Commercial	$179.46
Rate for Payer: Multiplan Workers Comp	$179.46
Rate for Payer: Parkland Medicaid	$198.78
Rate for Payer: Scott and White EPO/PPO	$138.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.78
Rate for Payer: Superior Health Plan EPO	$37.55

SUTURE, PROLENE BL MONO 6-0 CARDIO 24' BV-1,BV-1 -- DHF

Facility

$308.30

Hospital Charge Code	81940454
Hospital Revenue Code	272
Rate for Payer: Cash Price	$209.64

SUTURE, PROLENE BL MONO 6-0 CARDIO 24' BV-1,BV-1 -- DHF

Facility

$308.30

Hospital Charge Code	81940454
Hospital Revenue Code	272
Min. Negotiated Rate	$27.75
Max. Negotiated Rate	$221.98
Rate for Payer: Amerigroup CHIP/Medicaid	$27.75
Rate for Payer: BCBS of TX Blue Advantage	$92.49
Rate for Payer: BCBS of TX Blue Essentials	$110.99
Rate for Payer: BCBS of TX PPO	$123.32
Rate for Payer: Cash Price	$209.64
Rate for Payer: Cigna Medicaid	$221.98
Rate for Payer: Molina CHIP/Medicaid	$221.98
Rate for Payer: Multiplan Auto	$200.40
Rate for Payer: Multiplan Commercial	$200.40
Rate for Payer: Multiplan Workers Comp	$200.40
Rate for Payer: Parkland Medicaid	$221.98
Rate for Payer: Scott and White EPO/PPO	$154.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$221.98
Rate for Payer: Superior Health Plan EPO	$41.93

SUTURE, PROLENE BL MONO 7-0 CARDIO 2-30' BV175-6 -- DHF

Facility

$642.60

Hospital Charge Code	81941551
Hospital Revenue Code	272
Min. Negotiated Rate	$57.83
Max. Negotiated Rate	$462.67
Rate for Payer: Amerigroup CHIP/Medicaid	$57.83
Rate for Payer: BCBS of TX Blue Advantage	$192.78
Rate for Payer: BCBS of TX Blue Essentials	$231.34
Rate for Payer: BCBS of TX PPO	$257.04
Rate for Payer: Cash Price	$436.97
Rate for Payer: Cigna Medicaid	$462.67
Rate for Payer: Molina CHIP/Medicaid	$462.67
Rate for Payer: Multiplan Auto	$417.69
Rate for Payer: Multiplan Commercial	$417.69
Rate for Payer: Multiplan Workers Comp	$417.69
Rate for Payer: Parkland Medicaid	$462.67
Rate for Payer: Scott and White EPO/PPO	$321.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$462.67
Rate for Payer: Superior Health Plan EPO	$87.39

SUTURE, PROLENE BL MONO 7-0 CARDIO 2-30' BV175-6 -- DHF

Facility

$642.60

Hospital Charge Code	81941551
Hospital Revenue Code	272
Rate for Payer: Cash Price	$436.97

suture quill 3-0monoderm 3.5x3.5 ya1019q

Facility

$42.40

Hospital Charge Code	8626512
Hospital Revenue Code	272
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$30.53
Rate for Payer: Amerigroup CHIP/Medicaid	$3.82
Rate for Payer: BCBS of TX Blue Advantage	$12.72
Rate for Payer: BCBS of TX Blue Essentials	$15.26
Rate for Payer: BCBS of TX PPO	$16.96
Rate for Payer: Cash Price	$28.83
Rate for Payer: Cigna Medicaid	$30.53
Rate for Payer: Molina CHIP/Medicaid	$30.53
Rate for Payer: Multiplan Auto	$27.56
Rate for Payer: Multiplan Commercial	$27.56
Rate for Payer: Multiplan Workers Comp	$27.56
Rate for Payer: Parkland Medicaid	$30.53
Rate for Payer: Scott and White EPO/PPO	$21.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$30.53
Rate for Payer: Superior Health Plan EPO	$5.77

suture quill 3-0monoderm 3.5x3.5 ya1019q

Facility

$42.40

Hospital Charge Code	8626512
Hospital Revenue Code	272
Rate for Payer: Cash Price	$28.83

SUTURE QUILL MONDERM 14X14 YA-1016Q-0

Facility

$73.87

Hospital Charge Code	145345
Hospital Revenue Code	272
Rate for Payer: Cash Price	$50.23

SUTURE QUILL MONDERM 14X14 YA-1016Q-0

Facility

$73.87

Hospital Charge Code	145345
Hospital Revenue Code	272
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$53.19
Rate for Payer: Amerigroup CHIP/Medicaid	$6.65
Rate for Payer: BCBS of TX Blue Advantage	$22.16
Rate for Payer: BCBS of TX Blue Essentials	$26.59
Rate for Payer: BCBS of TX PPO	$29.55
Rate for Payer: Cash Price	$50.23
Rate for Payer: Cigna Medicaid	$53.19
Rate for Payer: Molina CHIP/Medicaid	$53.19
Rate for Payer: Multiplan Auto	$48.02
Rate for Payer: Multiplan Commercial	$48.02
Rate for Payer: Multiplan Workers Comp	$48.02
Rate for Payer: Parkland Medicaid	$53.19
Rate for Payer: Scott and White EPO/PPO	$36.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.19
Rate for Payer: Superior Health Plan EPO	$10.05

SUTURE QUILL MONODERM 3-0 7X7 YA-1001Q-0

Facility

$56.61

Hospital Charge Code	145344
Hospital Revenue Code	272
Rate for Payer: Cash Price	$38.49

SUTURE QUILL MONODERM 3-0 7X7 YA-1001Q-0

Facility

$56.61

Hospital Charge Code	145344
Hospital Revenue Code	272
Min. Negotiated Rate	$5.09
Max. Negotiated Rate	$40.76
Rate for Payer: Amerigroup CHIP/Medicaid	$5.09
Rate for Payer: BCBS of TX Blue Advantage	$16.98
Rate for Payer: BCBS of TX Blue Essentials	$20.38
Rate for Payer: BCBS of TX PPO	$22.64
Rate for Payer: Cash Price	$38.49
Rate for Payer: Cigna Medicaid	$40.76
Rate for Payer: Molina CHIP/Medicaid	$40.76
Rate for Payer: Multiplan Auto	$36.80
Rate for Payer: Multiplan Commercial	$36.80
Rate for Payer: Multiplan Workers Comp	$36.80
Rate for Payer: Parkland Medicaid	$40.76
Rate for Payer: Scott and White EPO/PPO	$28.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$40.76
Rate for Payer: Superior Health Plan EPO	$7.70

SUTURES, ETHICON NONABSORBABLE NYLON

Facility

$6.91

Hospital Charge Code	993780
Hospital Revenue Code	272
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$4.98
Rate for Payer: Amerigroup CHIP/Medicaid	$0.62
Rate for Payer: BCBS of TX Blue Advantage	$2.07
Rate for Payer: BCBS of TX Blue Essentials	$2.49
Rate for Payer: BCBS of TX PPO	$2.76
Rate for Payer: Cash Price	$4.70
Rate for Payer: Cigna Medicaid	$4.98
Rate for Payer: Molina CHIP/Medicaid	$4.98
Rate for Payer: Multiplan Auto	$4.49
Rate for Payer: Multiplan Commercial	$4.49
Rate for Payer: Multiplan Workers Comp	$4.49
Rate for Payer: Parkland Medicaid	$4.98
Rate for Payer: Scott and White EPO/PPO	$3.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.98
Rate for Payer: Superior Health Plan EPO	$0.94

SUTURES, ETHICON NONABSORBABLE NYLON

Facility

$6.91

Hospital Charge Code	993780
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4.70

SUTURE, SILK BLK BR 2-0 G.I.,CARDIO 30' SH -- DHF

Facility

$106.03

Hospital Charge Code	81941700
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, SILK BLK BR 2-0 G.I.,CARDIO 30' SH -- DHF

Facility

$106.03

Hospital Charge Code	81941700
Hospital Revenue Code	272
Rate for Payer: Cash Price	$72.10

SUTURE SRGDC 0 48IN SGL LU E STCH 10MM

Facility

$96.43

Hospital Charge Code	122479
Hospital Revenue Code	272
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$69.43
Rate for Payer: Amerigroup CHIP/Medicaid	$8.68
Rate for Payer: BCBS of TX Blue Advantage	$28.93
Rate for Payer: BCBS of TX Blue Essentials	$34.71
Rate for Payer: BCBS of TX PPO	$38.57
Rate for Payer: Cash Price	$65.57
Rate for Payer: Cigna Medicaid	$69.43
Rate for Payer: Molina CHIP/Medicaid	$69.43
Rate for Payer: Multiplan Auto	$62.68
Rate for Payer: Multiplan Commercial	$62.68
Rate for Payer: Multiplan Workers Comp	$62.68
Rate for Payer: Parkland Medicaid	$69.43
Rate for Payer: Scott and White EPO/PPO	$48.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.43
Rate for Payer: Superior Health Plan EPO	$13.11

SUTURE SRGDC 0 48IN SGL LU E STCH 10MM

Facility

$96.43

Hospital Charge Code	122479
Hospital Revenue Code	272
Rate for Payer: Cash Price	$65.57

SUTURE SRGDC 2-0 48IN SGL LU E STCH 10MM

Facility

$98.43

Hospital Charge Code	122478
Hospital Revenue Code	272
Rate for Payer: Cash Price	$66.93

SUTURE SRGDC 2-0 48IN SGL LU E STCH 10MM

Facility

$98.43

Hospital Charge Code	122478
Hospital Revenue Code	272
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$70.87
Rate for Payer: Amerigroup CHIP/Medicaid	$8.86
Rate for Payer: BCBS of TX Blue Advantage	$29.53
Rate for Payer: BCBS of TX Blue Essentials	$35.43
Rate for Payer: BCBS of TX PPO	$39.37
Rate for Payer: Cash Price	$66.93
Rate for Payer: Cigna Medicaid	$70.87
Rate for Payer: Molina CHIP/Medicaid	$70.87
Rate for Payer: Multiplan Auto	$63.98
Rate for Payer: Multiplan Commercial	$63.98
Rate for Payer: Multiplan Workers Comp	$63.98
Rate for Payer: Parkland Medicaid	$70.87
Rate for Payer: Scott and White EPO/PPO	$49.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70.87
Rate for Payer: Superior Health Plan EPO	$13.39

SUTURE STERLING GREAT WHITE

Facility

$989.72

Hospital Charge Code	8414481
Hospital Revenue Code	272
Rate for Payer: Cash Price	$673.01

SUTURE STERLING GREAT WHITE

Facility

$989.72

Hospital Charge Code	8414481
Hospital Revenue Code	272
Min. Negotiated Rate	$89.07
Max. Negotiated Rate	$712.60
Rate for Payer: Amerigroup CHIP/Medicaid	$89.07
Rate for Payer: BCBS of TX Blue Advantage	$296.92
Rate for Payer: BCBS of TX Blue Essentials	$356.30
Rate for Payer: BCBS of TX PPO	$395.89
Rate for Payer: Cash Price	$673.01
Rate for Payer: Cigna Medicaid	$712.60
Rate for Payer: Molina CHIP/Medicaid	$712.60
Rate for Payer: Multiplan Auto	$643.32
Rate for Payer: Multiplan Commercial	$643.32
Rate for Payer: Multiplan Workers Comp	$643.32
Rate for Payer: Parkland Medicaid	$712.60
Rate for Payer: Scott and White EPO/PPO	$494.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$712.60
Rate for Payer: Superior Health Plan EPO	$134.60

SUTURE, STRATAFIX SYMMETRIC PDS, VOITEL

Facility

$114.23

Hospital Charge Code	993781
Hospital Revenue Code	272
Rate for Payer: Cash Price	$77.68

SUTURE, STRATAFIX SYMMETRIC PDS, VOITEL

Facility

$114.23

Hospital Charge Code	993781
Hospital Revenue Code	272
Min. Negotiated Rate	$10.28
Max. Negotiated Rate	$82.25
Rate for Payer: Amerigroup CHIP/Medicaid	$10.28
Rate for Payer: BCBS of TX Blue Advantage	$34.27
Rate for Payer: BCBS of TX Blue Essentials	$41.12
Rate for Payer: BCBS of TX PPO	$45.69
Rate for Payer: Cash Price	$77.68
Rate for Payer: Cigna Medicaid	$82.25
Rate for Payer: Molina CHIP/Medicaid	$82.25
Rate for Payer: Multiplan Auto	$74.25
Rate for Payer: Multiplan Commercial	$74.25
Rate for Payer: Multiplan Workers Comp	$74.25
Rate for Payer: Parkland Medicaid	$82.25
Rate for Payer: Scott and White EPO/PPO	$57.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$82.25
Rate for Payer: Superior Health Plan EPO	$15.54

Suturetape

Facility

$2,742.65

Hospital Charge Code	992167
Hospital Revenue Code	272
Min. Negotiated Rate	$246.84
Max. Negotiated Rate	$1,974.71
Rate for Payer: Amerigroup CHIP/Medicaid	$246.84
Rate for Payer: BCBS of TX Blue Advantage	$822.79
Rate for Payer: BCBS of TX Blue Essentials	$987.35
Rate for Payer: BCBS of TX PPO	$1,097.06
Rate for Payer: Cash Price	$1,865.00
Rate for Payer: Cigna Medicaid	$1,974.71
Rate for Payer: Molina CHIP/Medicaid	$1,974.71
Rate for Payer: Multiplan Auto	$1,782.72
Rate for Payer: Multiplan Commercial	$1,782.72
Rate for Payer: Multiplan Workers Comp	$1,782.72
Rate for Payer: Parkland Medicaid	$1,974.71
Rate for Payer: Scott and White EPO/PPO	$1,371.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,974.71
Rate for Payer: Superior Health Plan EPO	$373.00

Suturetape

Facility

$2,742.65

Hospital Charge Code	992167
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,865.00

Know your out-of-pocket cost for care.

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