White Rock Medical Center

All Charges

Charge

Type

Setting

Price

.Body Fluid Differential

Facility

$242.00

Service Code	HCPCS 89051
Hospital Charge Code	1600295
Hospital Revenue Code	300
Rate for Payer: Cash Price	$164.56

.Body Fluid Differential

Facility

$242.00

Service Code	HCPCS 89051
Hospital Charge Code	1600295
Hospital Revenue Code	300
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$174.24
Rate for Payer: Amerigroup CHIP/Medicaid	$2.18
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.60
Rate for Payer: Amerigroup Medicare	$5.60
Rate for Payer: BCBS of TX Blue Advantage	$72.60
Rate for Payer: BCBS of TX Blue Essentials	$87.12
Rate for Payer: BCBS of TX Medicare	$5.60
Rate for Payer: BCBS of TX PPO	$96.80
Rate for Payer: Cash Price	$164.56
Rate for Payer: Cash Price	$164.56
Rate for Payer: Cigna Medicaid	$174.24
Rate for Payer: Cigna Medicare	$5.60
Rate for Payer: Employer Direct Commercial	$5.60
Rate for Payer: Humana Medicare/TRICARE	$5.60
Rate for Payer: Molina CHIP/Medicaid	$174.24
Rate for Payer: Molina Dual Medicare/Medicaid	$5.60
Rate for Payer: Molina Medicare	$5.60
Rate for Payer: Multiplan Auto	$157.30
Rate for Payer: Multiplan Commercial	$157.30
Rate for Payer: Multiplan Workers Comp	$157.30
Rate for Payer: Parkland Medicaid	$174.24
Rate for Payer: Scott and White EPO/PPO	$7.00
Rate for Payer: Scott and White Medicare	$5.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$174.24
Rate for Payer: Superior Health Plan EPO	$5.60
Rate for Payer: Superior Health Plan Medicare	$5.60
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.60
Rate for Payer: Universal American Medicare	$5.60
Rate for Payer: Wellcare Medicare	$5.60
Rate for Payer: Wellmed Medicare	$5.60

Bold 16 mm

Facility

$409.64

Service Code	HCPCS C1713
Hospital Charge Code	992205
Hospital Revenue Code	278
Min. Negotiated Rate	$102.41
Max. Negotiated Rate	$204.82
Rate for Payer: Cash Price	$278.56
Rate for Payer: Cigna Commercial	$102.41
Rate for Payer: Multiplan Auto	$204.82
Rate for Payer: Multiplan Commercial	$204.82
Rate for Payer: Multiplan Workers Comp	$204.82
Rate for Payer: Scott and White EPO/PPO	$204.82

Bold 16 mm

Facility

$409.64

Service Code	HCPCS C1713
Hospital Charge Code	992205
Hospital Revenue Code	278
Min. Negotiated Rate	$36.87
Max. Negotiated Rate	$294.94
Rate for Payer: Amerigroup CHIP/Medicaid	$36.87
Rate for Payer: BCBS of TX Blue Advantage	$122.89
Rate for Payer: BCBS of TX Blue Essentials	$147.47
Rate for Payer: BCBS of TX PPO	$163.86
Rate for Payer: Cash Price	$278.56
Rate for Payer: Cigna Medicaid	$294.94
Rate for Payer: Molina CHIP/Medicaid	$294.94
Rate for Payer: Multiplan Auto	$204.82
Rate for Payer: Multiplan Commercial	$204.82
Rate for Payer: Multiplan Workers Comp	$204.82
Rate for Payer: Parkland Medicaid	$294.94
Rate for Payer: Scott and White EPO/PPO	$204.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$294.94
Rate for Payer: Superior Health Plan EPO	$55.71

Bolt 20 mm

Facility

$308.72

Hospital Charge Code	993388
Hospital Revenue Code	272
Min. Negotiated Rate	$27.78
Max. Negotiated Rate	$222.28
Rate for Payer: Amerigroup CHIP/Medicaid	$27.78
Rate for Payer: BCBS of TX Blue Advantage	$92.62
Rate for Payer: BCBS of TX Blue Essentials	$111.14
Rate for Payer: BCBS of TX PPO	$123.49
Rate for Payer: Cash Price	$209.93
Rate for Payer: Cigna Medicaid	$222.28
Rate for Payer: Molina CHIP/Medicaid	$222.28
Rate for Payer: Multiplan Auto	$200.67
Rate for Payer: Multiplan Commercial	$200.67
Rate for Payer: Multiplan Workers Comp	$200.67
Rate for Payer: Parkland Medicaid	$222.28
Rate for Payer: Scott and White EPO/PPO	$154.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.28
Rate for Payer: Superior Health Plan EPO	$41.99

Bolt 20 mm

Facility

$308.72

Hospital Charge Code	993388
Hospital Revenue Code	272
Rate for Payer: Cash Price	$209.93

BOLT FOR RING

Facility

$154.36

Hospital Charge Code	993426
Hospital Revenue Code	272
Rate for Payer: Cash Price	$104.96

BOLT FOR RING

Facility

$154.36

Hospital Charge Code	993426
Hospital Revenue Code	272
Min. Negotiated Rate	$13.89
Max. Negotiated Rate	$111.14
Rate for Payer: Amerigroup CHIP/Medicaid	$13.89
Rate for Payer: BCBS of TX Blue Advantage	$46.31
Rate for Payer: BCBS of TX Blue Essentials	$55.57
Rate for Payer: BCBS of TX PPO	$61.74
Rate for Payer: Cash Price	$104.96
Rate for Payer: Cigna Medicaid	$111.14
Rate for Payer: Molina CHIP/Medicaid	$111.14
Rate for Payer: Multiplan Auto	$100.33
Rate for Payer: Multiplan Commercial	$100.33
Rate for Payer: Multiplan Workers Comp	$100.33
Rate for Payer: Parkland Medicaid	$111.14
Rate for Payer: Scott and White EPO/PPO	$77.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.14
Rate for Payer: Superior Health Plan EPO	$20.99

Bone Biopsy Needle/Trocar, Deep

Facility

$2,948.00

Service Code	HCPCS 20225
Hospital Charge Code	8178355
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,004.64
Rate for Payer: Cash Price	$2,004.64
Rate for Payer: Cash Price	$2,004.64
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$2,122.56
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$2,122.56
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$2,122.56
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,122.56
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

Bone Biopsy Needle/Trocar, Deep

Facility

$2,948.00

Service Code	HCPCS 20225
Hospital Charge Code	8178355
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,004.64

Bone Biopsy Needle/Trocar, Superficial

Facility

$2,714.00

Service Code	HCPCS 20220
Hospital Charge Code	7150910
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,845.52

Bone Biopsy Needle/Trocar, Superficial

Facility

$2,714.00

Service Code	HCPCS 20220
Hospital Charge Code	7150910
Hospital Revenue Code	361
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Amerigroup Medicare	$1,659.12
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,659.12
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cash Price	$1,845.52
Rate for Payer: Cigna Commercial	$3,507.10
Rate for Payer: Cigna Medicaid	$1,954.08
Rate for Payer: Cigna Medicare	$1,659.12
Rate for Payer: Employer Direct Commercial	$1,659.12
Rate for Payer: Humana Medicare/TRICARE	$1,659.12
Rate for Payer: Molina CHIP/Medicaid	$1,954.08
Rate for Payer: Molina Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Molina Medicare	$1,659.12
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	$1,954.08
Rate for Payer: Scott and White EPO/PPO	$2,743.07
Rate for Payer: Scott and White Medicare	$1,659.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,954.08
Rate for Payer: Superior Health Plan EPO	$1,659.12
Rate for Payer: Superior Health Plan Medicare	$1,659.12
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,659.12
Rate for Payer: Universal American Medicare	$1,659.12
Rate for Payer: Wellcare Medicare	$1,659.12
Rate for Payer: Wellmed Medicare	$1,659.12

bone callous crush 30cc seaspine

Facility

$2,342.00

Service Code	HCPCS C1713
Hospital Charge Code	130361
Hospital Revenue Code	278
Min. Negotiated Rate	$210.78
Max. Negotiated Rate	$1,686.24
Rate for Payer: Amerigroup CHIP/Medicaid	$210.78
Rate for Payer: BCBS of TX Blue Advantage	$702.60
Rate for Payer: BCBS of TX Blue Essentials	$843.12
Rate for Payer: BCBS of TX PPO	$936.80
Rate for Payer: Cash Price	$1,592.56
Rate for Payer: Cigna Medicaid	$1,686.24
Rate for Payer: Molina CHIP/Medicaid	$1,686.24
Rate for Payer: Multiplan Auto	$1,171.00
Rate for Payer: Multiplan Commercial	$1,171.00
Rate for Payer: Multiplan Workers Comp	$1,171.00
Rate for Payer: Parkland Medicaid	$1,686.24
Rate for Payer: Scott and White EPO/PPO	$1,171.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,686.24
Rate for Payer: Superior Health Plan EPO	$318.51

bone callous crush 30cc seaspine

Facility

$2,342.00

Service Code	HCPCS C1713
Hospital Charge Code	130361
Hospital Revenue Code	278
Min. Negotiated Rate	$585.50
Max. Negotiated Rate	$1,171.00
Rate for Payer: Cash Price	$1,592.56
Rate for Payer: Cigna Commercial	$585.50
Rate for Payer: Multiplan Auto	$1,171.00
Rate for Payer: Multiplan Commercial	$1,171.00
Rate for Payer: Multiplan Workers Comp	$1,171.00
Rate for Payer: Scott and White EPO/PPO	$1,171.00

BONE CEMENT, REFOBACIN, R 1X40 US

Facility

$1,764.10

Service Code	HCPCS C1734
Hospital Charge Code	992294
Hospital Revenue Code	278
Min. Negotiated Rate	$441.02
Max. Negotiated Rate	$882.05
Rate for Payer: Cash Price	$1,199.59
Rate for Payer: Cigna Commercial	$441.02
Rate for Payer: Multiplan Auto	$882.05
Rate for Payer: Multiplan Commercial	$882.05
Rate for Payer: Multiplan Workers Comp	$882.05
Rate for Payer: Scott and White EPO/PPO	$882.05

BONE CEMENT, REFOBACIN, R 1X40 US

Facility

$1,764.10

Service Code	HCPCS C1734
Hospital Charge Code	992294
Hospital Revenue Code	278
Min. Negotiated Rate	$158.77
Max. Negotiated Rate	$1,270.15
Rate for Payer: Amerigroup CHIP/Medicaid	$158.77
Rate for Payer: BCBS of TX Blue Advantage	$529.23
Rate for Payer: BCBS of TX Blue Essentials	$635.08
Rate for Payer: BCBS of TX PPO	$705.64
Rate for Payer: Cash Price	$1,199.59
Rate for Payer: Cigna Medicaid	$1,270.15
Rate for Payer: Molina CHIP/Medicaid	$1,270.15
Rate for Payer: Multiplan Auto	$882.05
Rate for Payer: Multiplan Commercial	$882.05
Rate for Payer: Multiplan Workers Comp	$882.05
Rate for Payer: Parkland Medicaid	$1,270.15
Rate for Payer: Scott and White EPO/PPO	$882.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.15
Rate for Payer: Superior Health Plan EPO	$239.92

BONE DISEASES AND ARTHROPATHIES WITH MCC

Facility

$25,192.10

Service Code	MSDRG 553
Min. Negotiated Rate	$10,643.36
Max. Negotiated Rate	$25,192.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,260.69
Rate for Payer: Amerigroup Medicare	$14,260.69
Rate for Payer: BCBS of TX Medicare	$14,260.69
Rate for Payer: Cigna Commercial	$16,696.34
Rate for Payer: Cigna Medicare	$14,260.69
Rate for Payer: Employer Direct Commercial	$14,260.69
Rate for Payer: Humana Medicare/TRICARE	$14,260.69
Rate for Payer: Molina Dual Medicare/Medicaid	$14,260.69
Rate for Payer: Molina Medicare	$14,260.69
Rate for Payer: Multiplan Auto	$25,192.10
Rate for Payer: Multiplan Commercial	$25,192.10
Rate for Payer: Multiplan Workers Comp	$25,192.10
Rate for Payer: Scott and White EPO/PPO	$11,601.62
Rate for Payer: Scott and White Medicare	$14,260.69
Rate for Payer: Superior Health Plan EPO	$14,260.69
Rate for Payer: Superior Health Plan Medicare	$14,260.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,260.69
Rate for Payer: Universal American Medicare	$14,260.69
Rate for Payer: Wellcare Medicare	$14,260.69
Rate for Payer: Wellmed Medicare	$14,260.69

BONE DISEASES AND ARTHROPATHIES WITHOUT MCC

Facility

$15,583.80

Service Code	MSDRG 554
Min. Negotiated Rate	$6,509.34
Max. Negotiated Rate	$15,583.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,843.92
Rate for Payer: Amerigroup Medicare	$10,843.92
Rate for Payer: BCBS of TX Medicare	$10,843.92
Rate for Payer: Cigna Commercial	$10,691.69
Rate for Payer: Cigna Medicare	$10,843.92
Rate for Payer: Employer Direct Commercial	$10,843.92
Rate for Payer: Humana Medicare/TRICARE	$10,843.92
Rate for Payer: Molina Dual Medicare/Medicaid	$10,843.92
Rate for Payer: Molina Medicare	$10,843.92
Rate for Payer: Multiplan Auto	$15,583.80
Rate for Payer: Multiplan Commercial	$15,583.80
Rate for Payer: Multiplan Workers Comp	$15,583.80
Rate for Payer: Scott and White EPO/PPO	$7,176.75
Rate for Payer: Scott and White Medicare	$10,843.92
Rate for Payer: Superior Health Plan EPO	$10,843.92
Rate for Payer: Superior Health Plan Medicare	$10,843.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,843.92
Rate for Payer: Universal American Medicare	$10,843.92
Rate for Payer: Wellcare Medicare	$10,843.92
Rate for Payer: Wellmed Medicare	$10,843.92

BONE DISEASES & ARTHROPATHIES W MCC

Facility

$25,192.10

Service Code	MSDRG 553
Min. Negotiated Rate	$10,643.36
Max. Negotiated Rate	$25,192.10
Rate for Payer: BCBS of TX Blue Advantage	$10,643.36
Rate for Payer: BCBS of TX Blue Essentials	$12,770.79
Rate for Payer: BCBS of TX PPO	$14,190.32

BONE DISEASES & ARTHROPATHIES W/O MCC

Facility

$15,583.80

Service Code	MSDRG 554
Min. Negotiated Rate	$6,509.34
Max. Negotiated Rate	$15,583.80
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	$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 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 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

Know your out-of-pocket cost for care.

All Charges