White Rock Medical Center

All Charges

Charge

Type

Setting

Price

BONE DISEASES & ARTHROPATHIES W/O MCC

Facility

$15,771.90

Service Code	MSDRG 554
Min. Negotiated Rate	$6,509.34
Max. Negotiated Rate	$15,771.90
Rate for Payer: BCBS of TX Blue Advantage	$6,509.34
Rate for Payer: BCBS of TX Blue Essentials	$7,810.45
Rate for Payer: BCBS of TX PPO	$8,678.62

Bone Drill 10mm BGH 2 Kit

Facility

$7,286.70

Hospital Charge Code	992587
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,954.96

Bone Drill 10mm BGH 2 Kit

Facility

$7,286.70

Hospital Charge Code	992587
Hospital Revenue Code	272
Min. Negotiated Rate	$655.80
Max. Negotiated Rate	$5,246.42
Rate for Payer: Amerigroup CHIP/Medicaid	$655.80
Rate for Payer: BCBS of TX Blue Advantage	$2,186.01
Rate for Payer: BCBS of TX Blue Essentials	$2,623.21
Rate for Payer: BCBS of TX PPO	$2,914.68
Rate for Payer: Cash Price	$4,954.96
Rate for Payer: Cigna Medicaid	$5,246.42
Rate for Payer: Molina CHIP/Medicaid	$5,246.42
Rate for Payer: Multiplan Auto	$4,736.35
Rate for Payer: Multiplan Commercial	$4,736.35
Rate for Payer: Multiplan Workers Comp	$4,736.35
Rate for Payer: Parkland Medicaid	$5,246.42
Rate for Payer: Scott and White EPO/PPO	$3,643.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,246.42
Rate for Payer: Superior Health Plan EPO	$990.99

BONE FILLER OSTEOCRETE 5CC BASIC

Facility

$12,048.00

Service Code	HCPCS C1602
Hospital Charge Code	145715
Hospital Revenue Code	278
Min. Negotiated Rate	$3,012.00
Max. Negotiated Rate	$6,024.00
Rate for Payer: Cash Price	$8,192.64
Rate for Payer: Cigna Commercial	$3,012.00
Rate for Payer: Multiplan Auto	$6,024.00
Rate for Payer: Multiplan Commercial	$6,024.00
Rate for Payer: Multiplan Workers Comp	$6,024.00
Rate for Payer: Scott and White EPO/PPO	$6,024.00

BONE FILLER OSTEOCRETE 5CC BASIC

Facility

$12,048.00

Service Code	HCPCS C1602
Hospital Charge Code	145715
Hospital Revenue Code	278
Min. Negotiated Rate	$1,084.32
Max. Negotiated Rate	$8,674.56
Rate for Payer: Amerigroup CHIP/Medicaid	$1,084.32
Rate for Payer: Cash Price	$8,192.64
Rate for Payer: Cigna Medicaid	$8,674.56
Rate for Payer: Molina CHIP/Medicaid	$8,674.56
Rate for Payer: Multiplan Auto	$6,024.00
Rate for Payer: Multiplan Commercial	$6,024.00
Rate for Payer: Multiplan Workers Comp	$6,024.00
Rate for Payer: Parkland Medicaid	$8,674.56
Rate for Payer: Scott and White EPO/PPO	$6,024.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,674.56
Rate for Payer: Superior Health Plan EPO	$1,638.53

bone filler resorbable 3.5 & 4.5

Facility

$7,018.00

Service Code	HCPCS C1602
Hospital Charge Code	8394471
Hospital Revenue Code	278
Min. Negotiated Rate	$1,754.50
Max. Negotiated Rate	$3,509.00
Rate for Payer: Cash Price	$4,772.24
Rate for Payer: Cigna Commercial	$1,754.50
Rate for Payer: Multiplan Auto	$3,509.00
Rate for Payer: Multiplan Commercial	$3,509.00
Rate for Payer: Multiplan Workers Comp	$3,509.00
Rate for Payer: Scott and White EPO/PPO	$3,509.00

bone filler resorbable 3.5 & 4.5

Facility

$7,018.00

Service Code	HCPCS C1602
Hospital Charge Code	8394471
Hospital Revenue Code	278
Min. Negotiated Rate	$631.62
Max. Negotiated Rate	$5,052.96
Rate for Payer: Amerigroup CHIP/Medicaid	$631.62
Rate for Payer: Cash Price	$4,772.24
Rate for Payer: Cigna Medicaid	$5,052.96
Rate for Payer: Molina CHIP/Medicaid	$5,052.96
Rate for Payer: Multiplan Auto	$3,509.00
Rate for Payer: Multiplan Commercial	$3,509.00
Rate for Payer: Multiplan Workers Comp	$3,509.00
Rate for Payer: Parkland Medicaid	$5,052.96
Rate for Payer: Scott and White EPO/PPO	$3,509.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,052.96
Rate for Payer: Superior Health Plan EPO	$954.45

Bone graft, any donor area; major or large

Facility

$19,191.15

Service Code	HCPCS 20902
Hospital Charge Code	9900186
Hospital Revenue Code	360
Rate for Payer: Cash Price	$13,049.98

Bone graft, any donor area; major or large

Facility

$15,408.22

Service Code	CPT 20902
Hospital Charge Code	36020902
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Bone graft, any donor area; major or large

Facility

$19,191.15

Service Code	HCPCS 20902
Hospital Charge Code	9900186
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$13,049.98
Rate for Payer: Cash Price	$13,049.98
Rate for Payer: Cash Price	$13,049.98
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$13,817.63
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$13,817.63
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$13,817.63
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,817.63
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Bone graft, any donor area minor or small (eg, dowel or button)

Facility

$15,408.22

Service Code	CPT 20900
Hospital Charge Code	36020900
Hospital Revenue Code	360
Min. Negotiated Rate	$3,122.54
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,122.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Bone graft, any donor area minor or small (eg, dowel or button)

Facility

$25,059.80

Service Code	HCPCS 20900
Hospital Charge Code	9900185
Hospital Revenue Code	360
Min. Negotiated Rate	$3,122.54
Max. Negotiated Rate	$18,043.06
Rate for Payer: Amerigroup CHIP/Medicaid	$3,122.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$17,040.66
Rate for Payer: Cash Price	$17,040.66
Rate for Payer: Cash Price	$17,040.66
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$18,043.06
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$18,043.06
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$18,043.06
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,043.06
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Bone graft, any donor area minor or small (eg, dowel or button)

Facility

$25,059.80

Service Code	HCPCS 20900
Hospital Charge Code	9900185
Hospital Revenue Code	360
Rate for Payer: Cash Price	$17,040.66

bone graft strip unifuze 10cc

Facility

$18,825.00

Service Code	HCPCS C9362
Hospital Charge Code	8720593
Hospital Revenue Code	278
Min. Negotiated Rate	$1,694.25
Max. Negotiated Rate	$13,554.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,694.25
Rate for Payer: BCBS of TX Blue Advantage	$5,647.50
Rate for Payer: BCBS of TX Blue Essentials	$6,777.00
Rate for Payer: BCBS of TX PPO	$7,530.00
Rate for Payer: Cash Price	$12,801.00
Rate for Payer: Cigna Medicaid	$13,554.00
Rate for Payer: Molina CHIP/Medicaid	$13,554.00
Rate for Payer: Multiplan Auto	$9,412.50
Rate for Payer: Multiplan Commercial	$9,412.50
Rate for Payer: Multiplan Workers Comp	$9,412.50
Rate for Payer: Parkland Medicaid	$13,554.00
Rate for Payer: Scott and White EPO/PPO	$9,412.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,554.00
Rate for Payer: Superior Health Plan EPO	$2,560.20

bone graft strip unifuze 10cc

Facility

$18,825.00

Service Code	HCPCS C9362
Hospital Charge Code	8720593
Hospital Revenue Code	278
Min. Negotiated Rate	$4,706.25
Max. Negotiated Rate	$9,412.50
Rate for Payer: Cash Price	$12,801.00
Rate for Payer: Cigna Commercial	$4,706.25
Rate for Payer: Multiplan Auto	$9,412.50
Rate for Payer: Multiplan Commercial	$9,412.50
Rate for Payer: Multiplan Workers Comp	$9,412.50
Rate for Payer: Scott and White EPO/PPO	$9,412.50

bone graft strip unifuze 20cc

Facility

$33,133.00

Service Code	HCPCS C9362
Hospital Charge Code	8720592
Hospital Revenue Code	278
Min. Negotiated Rate	$8,283.25
Max. Negotiated Rate	$16,566.50
Rate for Payer: Cash Price	$22,530.44
Rate for Payer: Cigna Commercial	$8,283.25
Rate for Payer: Multiplan Auto	$16,566.50
Rate for Payer: Multiplan Commercial	$16,566.50
Rate for Payer: Multiplan Workers Comp	$16,566.50
Rate for Payer: Scott and White EPO/PPO	$16,566.50

bone graft strip unifuze 20cc

Facility

$33,133.00

Service Code	HCPCS C9362
Hospital Charge Code	8720592
Hospital Revenue Code	278
Min. Negotiated Rate	$2,981.97
Max. Negotiated Rate	$23,855.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,981.97
Rate for Payer: BCBS of TX Blue Advantage	$9,939.90
Rate for Payer: BCBS of TX Blue Essentials	$11,927.88
Rate for Payer: BCBS of TX PPO	$13,253.20
Rate for Payer: Cash Price	$22,530.44
Rate for Payer: Cigna Medicaid	$23,855.76
Rate for Payer: Molina CHIP/Medicaid	$23,855.76
Rate for Payer: Multiplan Auto	$16,566.50
Rate for Payer: Multiplan Commercial	$16,566.50
Rate for Payer: Multiplan Workers Comp	$16,566.50
Rate for Payer: Parkland Medicaid	$23,855.76
Rate for Payer: Scott and White EPO/PPO	$16,566.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23,855.76
Rate for Payer: Superior Health Plan EPO	$4,506.09

bone graft strip unifuze ba 5cc

Facility

$10,542.00

Service Code	HCPCS C9362
Hospital Charge Code	8720606
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.50
Max. Negotiated Rate	$5,271.00
Rate for Payer: Cash Price	$7,168.56
Rate for Payer: Cigna Commercial	$2,635.50
Rate for Payer: Multiplan Auto	$5,271.00
Rate for Payer: Multiplan Commercial	$5,271.00
Rate for Payer: Multiplan Workers Comp	$5,271.00
Rate for Payer: Scott and White EPO/PPO	$5,271.00

bone graft strip unifuze ba 5cc

Facility

$10,542.00

Service Code	HCPCS C9362
Hospital Charge Code	8720606
Hospital Revenue Code	278
Min. Negotiated Rate	$948.78
Max. Negotiated Rate	$7,590.24
Rate for Payer: Amerigroup CHIP/Medicaid	$948.78
Rate for Payer: BCBS of TX Blue Advantage	$3,162.60
Rate for Payer: BCBS of TX Blue Essentials	$3,795.12
Rate for Payer: BCBS of TX PPO	$4,216.80
Rate for Payer: Cash Price	$7,168.56
Rate for Payer: Cigna Medicaid	$7,590.24
Rate for Payer: Molina CHIP/Medicaid	$7,590.24
Rate for Payer: Multiplan Auto	$5,271.00
Rate for Payer: Multiplan Commercial	$5,271.00
Rate for Payer: Multiplan Workers Comp	$5,271.00
Rate for Payer: Parkland Medicaid	$7,590.24
Rate for Payer: Scott and White EPO/PPO	$5,271.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,590.24
Rate for Payer: Superior Health Plan EPO	$1,433.71

bone graft unfuze 2 med/long block 10cc

Facility

$16,566.00

Service Code	HCPCS C9362
Hospital Charge Code	8720601
Hospital Revenue Code	278
Min. Negotiated Rate	$4,141.50
Max. Negotiated Rate	$8,283.00
Rate for Payer: Cash Price	$11,264.88
Rate for Payer: Cigna Commercial	$4,141.50
Rate for Payer: Multiplan Auto	$8,283.00
Rate for Payer: Multiplan Commercial	$8,283.00
Rate for Payer: Multiplan Workers Comp	$8,283.00
Rate for Payer: Scott and White EPO/PPO	$8,283.00

bone graft unfuze 2 med/long block 10cc

Facility

$16,566.00

Service Code	HCPCS C9362
Hospital Charge Code	8720601
Hospital Revenue Code	278
Min. Negotiated Rate	$1,490.94
Max. Negotiated Rate	$11,927.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1,490.94
Rate for Payer: BCBS of TX Blue Advantage	$4,969.80
Rate for Payer: BCBS of TX Blue Essentials	$5,963.76
Rate for Payer: BCBS of TX PPO	$6,626.40
Rate for Payer: Cash Price	$11,264.88
Rate for Payer: Cigna Medicaid	$11,927.52
Rate for Payer: Molina CHIP/Medicaid	$11,927.52
Rate for Payer: Multiplan Auto	$8,283.00
Rate for Payer: Multiplan Commercial	$8,283.00
Rate for Payer: Multiplan Workers Comp	$8,283.00
Rate for Payer: Parkland Medicaid	$11,927.52
Rate for Payer: Scott and White EPO/PPO	$8,283.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,927.52
Rate for Payer: Superior Health Plan EPO	$2,252.98

bone graft unifuze 1 block large 20cc

Facility

$25,602.00

Service Code	HCPCS C9362
Hospital Charge Code	8720602
Hospital Revenue Code	278
Min. Negotiated Rate	$6,400.50
Max. Negotiated Rate	$12,801.00
Rate for Payer: Cash Price	$17,409.36
Rate for Payer: Cigna Commercial	$6,400.50
Rate for Payer: Multiplan Auto	$12,801.00
Rate for Payer: Multiplan Commercial	$12,801.00
Rate for Payer: Multiplan Workers Comp	$12,801.00
Rate for Payer: Scott and White EPO/PPO	$12,801.00

bone graft unifuze 1 block large 20cc

Facility

$25,602.00

Service Code	HCPCS C9362
Hospital Charge Code	8720602
Hospital Revenue Code	278
Min. Negotiated Rate	$2,304.18
Max. Negotiated Rate	$18,433.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2,304.18
Rate for Payer: BCBS of TX Blue Advantage	$7,680.60
Rate for Payer: BCBS of TX Blue Essentials	$9,216.72
Rate for Payer: BCBS of TX PPO	$10,240.80
Rate for Payer: Cash Price	$17,409.36
Rate for Payer: Cigna Medicaid	$18,433.44
Rate for Payer: Molina CHIP/Medicaid	$18,433.44
Rate for Payer: Multiplan Auto	$12,801.00
Rate for Payer: Multiplan Commercial	$12,801.00
Rate for Payer: Multiplan Workers Comp	$12,801.00
Rate for Payer: Parkland Medicaid	$18,433.44
Rate for Payer: Scott and White EPO/PPO	$12,801.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,433.44
Rate for Payer: Superior Health Plan EPO	$3,481.87

bonegraft unifuze 1 block med 10cc

Facility

$15,060.00

Service Code	HCPCS C1734
Hospital Charge Code	8720612
Hospital Revenue Code	278
Min. Negotiated Rate	$1,355.40
Max. Negotiated Rate	$10,843.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,355.40
Rate for Payer: BCBS of TX Blue Advantage	$4,518.00
Rate for Payer: BCBS of TX Blue Essentials	$5,421.60
Rate for Payer: BCBS of TX PPO	$6,024.00
Rate for Payer: Cash Price	$10,240.80
Rate for Payer: Cigna Medicaid	$10,843.20
Rate for Payer: Molina CHIP/Medicaid	$10,843.20
Rate for Payer: Multiplan Auto	$7,530.00
Rate for Payer: Multiplan Commercial	$7,530.00
Rate for Payer: Multiplan Workers Comp	$7,530.00
Rate for Payer: Parkland Medicaid	$10,843.20
Rate for Payer: Scott and White EPO/PPO	$7,530.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,843.20
Rate for Payer: Superior Health Plan EPO	$2,048.16

bonegraft unifuze 1 block med 10cc

Facility

$15,060.00

Service Code	HCPCS C1734
Hospital Charge Code	8720612
Hospital Revenue Code	278
Min. Negotiated Rate	$3,765.00
Max. Negotiated Rate	$7,530.00
Rate for Payer: Cash Price	$10,240.80
Rate for Payer: Cigna Commercial	$3,765.00
Rate for Payer: Multiplan Auto	$7,530.00
Rate for Payer: Multiplan Commercial	$7,530.00
Rate for Payer: Multiplan Workers Comp	$7,530.00
Rate for Payer: Scott and White EPO/PPO	$7,530.00

Know your out-of-pocket cost for care.

All Charges