White Rock Medical Center

All Charges

Charge

Type

Setting

Price

bone graft unifuze-p small 2.5cc

Facility

$8,193.00

Service Code	HCPCS C9362
Hospital Charge Code	8720607
Hospital Revenue Code	278
Min. Negotiated Rate	$737.37
Max. Negotiated Rate	$5,898.96
Rate for Payer: Amerigroup CHIP/Medicaid	$737.37
Rate for Payer: BCBS of TX Blue Advantage	$2,457.90
Rate for Payer: BCBS of TX Blue Essentials	$2,949.48
Rate for Payer: BCBS of TX PPO	$3,277.20
Rate for Payer: Cash Price	$5,571.24
Rate for Payer: Cigna Medicaid	$5,898.96
Rate for Payer: Molina CHIP/Medicaid	$5,898.96
Rate for Payer: Multiplan Auto	$4,096.50
Rate for Payer: Multiplan Commercial	$4,096.50
Rate for Payer: Multiplan Workers Comp	$4,096.50
Rate for Payer: Parkland Medicaid	$5,898.96
Rate for Payer: Scott and White EPO/PPO	$4,096.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,898.96
Rate for Payer: Superior Health Plan EPO	$1,114.25

bone graft unifuze-p small 2.5cc

Facility

$8,193.00

Service Code	HCPCS C9362
Hospital Charge Code	8720607
Hospital Revenue Code	278
Min. Negotiated Rate	$2,048.25
Max. Negotiated Rate	$4,096.50
Rate for Payer: Cash Price	$5,571.24
Rate for Payer: Cigna Commercial	$2,048.25
Rate for Payer: Multiplan Auto	$4,096.50
Rate for Payer: Multiplan Commercial	$4,096.50
Rate for Payer: Multiplan Workers Comp	$4,096.50
Rate for Payer: Scott and White EPO/PPO	$4,096.50

BONE HARVESTER

Facility

$5,448.00

Hospital Charge Code	8474500
Hospital Revenue Code	272
Min. Negotiated Rate	$490.32
Max. Negotiated Rate	$3,922.56
Rate for Payer: Amerigroup CHIP/Medicaid	$490.32
Rate for Payer: BCBS of TX Blue Advantage	$1,634.40
Rate for Payer: BCBS of TX Blue Essentials	$1,961.28
Rate for Payer: BCBS of TX PPO	$2,179.20
Rate for Payer: Cash Price	$3,704.64
Rate for Payer: Cigna Medicaid	$3,922.56
Rate for Payer: Molina CHIP/Medicaid	$3,922.56
Rate for Payer: Multiplan Auto	$3,541.20
Rate for Payer: Multiplan Commercial	$3,541.20
Rate for Payer: Multiplan Workers Comp	$3,541.20
Rate for Payer: Parkland Medicaid	$3,922.56
Rate for Payer: Scott and White EPO/PPO	$2,724.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,922.56
Rate for Payer: Superior Health Plan EPO	$740.93

BONE HARVESTER

Facility

$5,448.00

Hospital Charge Code	8474500
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,704.64

Bone Marrow Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107064
Hospital Revenue Code	306
Rate for Payer: Cash Price	$210.12

Bone Marrow Culture

Facility

$309.00

Service Code	HCPCS 87070
Hospital Charge Code	4107064
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$222.48
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$92.70
Rate for Payer: BCBS of TX Blue Essentials	$111.24
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$123.60
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cash Price	$210.12
Rate for Payer: Cigna Medicaid	$222.48
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$222.48
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$222.48
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$222.48
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Bone marrow harvesting for transplantation; allogeneic

Facility

$10,000.00

Service Code	CPT 38230
Hospital Charge Code	36038230
Hospital Revenue Code	360
Min. Negotiated Rate	$564.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$564.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Amerigroup Medicare	$1,564.52
Rate for Payer: BCBS of TX Blue Advantage	$2,210.45
Rate for Payer: BCBS of TX Blue Essentials	$2,647.24
Rate for Payer: BCBS of TX Medicare	$1,564.52
Rate for Payer: BCBS of TX PPO	$3,335.52
Rate for Payer: Cigna Commercial	$3,307.12
Rate for Payer: Cigna Medicare	$1,564.52
Rate for Payer: Employer Direct Commercial	$1,564.52
Rate for Payer: Humana Medicare/TRICARE	$1,564.52
Rate for Payer: Molina Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Molina Medicare	$1,564.52
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	$2,595.94
Rate for Payer: Scott and White Medicare	$1,564.52
Rate for Payer: Superior Health Plan EPO	$1,564.52
Rate for Payer: Superior Health Plan Medicare	$1,564.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Universal American Medicare	$1,564.52
Rate for Payer: Wellcare Medicare	$1,564.52
Rate for Payer: Wellmed Medicare	$1,564.52

Bone marrow harvesting for transplantation; allogeneic

Facility

$5,439.36

Service Code	HCPCS 38230
Hospital Charge Code	9900636
Hospital Revenue Code	360
Min. Negotiated Rate	$564.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$564.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Amerigroup Medicare	$1,564.52
Rate for Payer: BCBS of TX Blue Advantage	$2,210.45
Rate for Payer: BCBS of TX Blue Essentials	$2,647.24
Rate for Payer: BCBS of TX Medicare	$1,564.52
Rate for Payer: BCBS of TX PPO	$3,335.52
Rate for Payer: Cash Price	$3,698.76
Rate for Payer: Cash Price	$3,698.76
Rate for Payer: Cash Price	$3,698.76
Rate for Payer: Cigna Commercial	$3,307.12
Rate for Payer: Cigna Medicaid	$3,916.34
Rate for Payer: Cigna Medicare	$1,564.52
Rate for Payer: Employer Direct Commercial	$1,564.52
Rate for Payer: Humana Medicare/TRICARE	$1,564.52
Rate for Payer: Molina CHIP/Medicaid	$3,916.34
Rate for Payer: Molina Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Molina Medicare	$1,564.52
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	$3,916.34
Rate for Payer: Scott and White EPO/PPO	$2,595.94
Rate for Payer: Scott and White Medicare	$1,564.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,916.34
Rate for Payer: Superior Health Plan EPO	$1,564.52
Rate for Payer: Superior Health Plan Medicare	$1,564.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,564.52
Rate for Payer: Universal American Medicare	$1,564.52
Rate for Payer: Wellcare Medicare	$1,564.52
Rate for Payer: Wellmed Medicare	$1,564.52

Bone marrow harvesting for transplantation; allogeneic

Facility

$5,439.36

Service Code	HCPCS 38230
Hospital Charge Code	9900636
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,698.76

BONE PUTTY APEX DBM APX-FP-0

Facility

$4,217.00

Service Code	HCPCS C9359
Hospital Charge Code	145215
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.25
Max. Negotiated Rate	$2,108.50
Rate for Payer: Cash Price	$2,867.56
Rate for Payer: Cigna Commercial	$1,054.25
Rate for Payer: Multiplan Auto	$2,108.50
Rate for Payer: Multiplan Commercial	$2,108.50
Rate for Payer: Multiplan Workers Comp	$2,108.50
Rate for Payer: Scott and White EPO/PPO	$2,108.50

BONE PUTTY APEX DBM APX-FP-0

Facility

$4,217.00

Service Code	HCPCS C9359
Hospital Charge Code	145215
Hospital Revenue Code	278
Min. Negotiated Rate	$379.53
Max. Negotiated Rate	$3,036.24
Rate for Payer: Amerigroup CHIP/Medicaid	$379.53
Rate for Payer: BCBS of TX Blue Advantage	$1,265.10
Rate for Payer: BCBS of TX Blue Essentials	$1,518.12
Rate for Payer: BCBS of TX PPO	$1,686.80
Rate for Payer: Cash Price	$2,867.56
Rate for Payer: Cigna Medicaid	$3,036.24
Rate for Payer: Molina CHIP/Medicaid	$3,036.24
Rate for Payer: Multiplan Auto	$2,108.50
Rate for Payer: Multiplan Commercial	$2,108.50
Rate for Payer: Multiplan Workers Comp	$2,108.50
Rate for Payer: Parkland Medicaid	$3,036.24
Rate for Payer: Scott and White EPO/PPO	$2,108.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,036.24
Rate for Payer: Superior Health Plan EPO	$573.51

BONE PUTTY CRUSH MIX 5CC HG-05C

Facility

$4,819.00

Service Code	HCPCS C9359
Hospital Charge Code	145670
Hospital Revenue Code	278
Min. Negotiated Rate	$1,204.75
Max. Negotiated Rate	$2,409.50
Rate for Payer: Cash Price	$3,276.92
Rate for Payer: Cigna Commercial	$1,204.75
Rate for Payer: Multiplan Auto	$2,409.50
Rate for Payer: Multiplan Commercial	$2,409.50
Rate for Payer: Multiplan Workers Comp	$2,409.50
Rate for Payer: Scott and White EPO/PPO	$2,409.50

BONE PUTTY CRUSH MIX 5CC HG-05C

Facility

$4,819.00

Service Code	HCPCS C9359
Hospital Charge Code	145670
Hospital Revenue Code	278
Min. Negotiated Rate	$433.71
Max. Negotiated Rate	$3,469.68
Rate for Payer: Amerigroup CHIP/Medicaid	$433.71
Rate for Payer: BCBS of TX Blue Advantage	$1,445.70
Rate for Payer: BCBS of TX Blue Essentials	$1,734.84
Rate for Payer: BCBS of TX PPO	$1,927.60
Rate for Payer: Cash Price	$3,276.92
Rate for Payer: Cigna Medicaid	$3,469.68
Rate for Payer: Molina CHIP/Medicaid	$3,469.68
Rate for Payer: Multiplan Auto	$2,409.50
Rate for Payer: Multiplan Commercial	$2,409.50
Rate for Payer: Multiplan Workers Comp	$2,409.50
Rate for Payer: Parkland Medicaid	$3,469.68
Rate for Payer: Scott and White EPO/PPO	$2,409.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,469.68
Rate for Payer: Superior Health Plan EPO	$655.38

bone putty i-factor 1.0 cc

Facility

$4,518.00

Service Code	HCPCS C9359
Hospital Charge Code	8492480
Hospital Revenue Code	278
Min. Negotiated Rate	$406.62
Max. Negotiated Rate	$3,252.96
Rate for Payer: Amerigroup CHIP/Medicaid	$406.62
Rate for Payer: BCBS of TX Blue Advantage	$1,355.40
Rate for Payer: BCBS of TX Blue Essentials	$1,626.48
Rate for Payer: BCBS of TX PPO	$1,807.20
Rate for Payer: Cash Price	$3,072.24
Rate for Payer: Cigna Medicaid	$3,252.96
Rate for Payer: Molina CHIP/Medicaid	$3,252.96
Rate for Payer: Multiplan Auto	$2,259.00
Rate for Payer: Multiplan Commercial	$2,259.00
Rate for Payer: Multiplan Workers Comp	$2,259.00
Rate for Payer: Parkland Medicaid	$3,252.96
Rate for Payer: Scott and White EPO/PPO	$2,259.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,252.96
Rate for Payer: Superior Health Plan EPO	$614.45

bone putty i-factor 1.0 cc

Facility

$4,518.00

Service Code	HCPCS C9359
Hospital Charge Code	8492480
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.50
Max. Negotiated Rate	$2,259.00
Rate for Payer: Cash Price	$3,072.24
Rate for Payer: Cigna Commercial	$1,129.50
Rate for Payer: Multiplan Auto	$2,259.00
Rate for Payer: Multiplan Commercial	$2,259.00
Rate for Payer: Multiplan Workers Comp	$2,259.00
Rate for Payer: Scott and White EPO/PPO	$2,259.00

bone putty ifactor 5.0cc

Facility

$16,867.00

Service Code	HCPCS C9359
Hospital Charge Code	8702511
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.03
Max. Negotiated Rate	$12,144.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,518.03
Rate for Payer: BCBS of TX Blue Advantage	$5,060.10
Rate for Payer: BCBS of TX Blue Essentials	$6,072.12
Rate for Payer: BCBS of TX PPO	$6,746.80
Rate for Payer: Cash Price	$11,469.56
Rate for Payer: Cigna Medicaid	$12,144.24
Rate for Payer: Molina CHIP/Medicaid	$12,144.24
Rate for Payer: Multiplan Auto	$8,433.50
Rate for Payer: Multiplan Commercial	$8,433.50
Rate for Payer: Multiplan Workers Comp	$8,433.50
Rate for Payer: Parkland Medicaid	$12,144.24
Rate for Payer: Scott and White EPO/PPO	$8,433.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,144.24
Rate for Payer: Superior Health Plan EPO	$2,293.91

bone putty ifactor 5.0cc

Facility

$16,867.00

Service Code	HCPCS C9359
Hospital Charge Code	8702511
Hospital Revenue Code	278
Min. Negotiated Rate	$4,216.75
Max. Negotiated Rate	$8,433.50
Rate for Payer: Cash Price	$11,469.56
Rate for Payer: Cigna Commercial	$4,216.75
Rate for Payer: Multiplan Auto	$8,433.50
Rate for Payer: Multiplan Commercial	$8,433.50
Rate for Payer: Multiplan Workers Comp	$8,433.50
Rate for Payer: Scott and White EPO/PPO	$8,433.50

BONE PUTTY IMP 2.5CC

Facility

$2,169.00

Service Code	HCPCS C9359
Hospital Charge Code	144825
Hospital Revenue Code	278
Min. Negotiated Rate	$542.25
Max. Negotiated Rate	$1,084.50
Rate for Payer: Cash Price	$1,474.92
Rate for Payer: Cigna Commercial	$542.25
Rate for Payer: Multiplan Auto	$1,084.50
Rate for Payer: Multiplan Commercial	$1,084.50
Rate for Payer: Multiplan Workers Comp	$1,084.50
Rate for Payer: Scott and White EPO/PPO	$1,084.50

BONE PUTTY IMP 2.5CC

Facility

$2,169.00

Service Code	HCPCS C9359
Hospital Charge Code	144825
Hospital Revenue Code	278
Min. Negotiated Rate	$195.21
Max. Negotiated Rate	$1,561.68
Rate for Payer: Amerigroup CHIP/Medicaid	$195.21
Rate for Payer: BCBS of TX Blue Advantage	$650.70
Rate for Payer: BCBS of TX Blue Essentials	$780.84
Rate for Payer: BCBS of TX PPO	$867.60
Rate for Payer: Cash Price	$1,474.92
Rate for Payer: Cigna Medicaid	$1,561.68
Rate for Payer: Molina CHIP/Medicaid	$1,561.68
Rate for Payer: Multiplan Auto	$1,084.50
Rate for Payer: Multiplan Commercial	$1,084.50
Rate for Payer: Multiplan Workers Comp	$1,084.50
Rate for Payer: Parkland Medicaid	$1,561.68
Rate for Payer: Scott and White EPO/PPO	$1,084.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,561.68
Rate for Payer: Superior Health Plan EPO	$294.98

Bone Removal Screw

Facility

$3,012.05

Service Code	HCPCS C1713
Hospital Charge Code	993125
Hospital Revenue Code	278
Min. Negotiated Rate	$271.08
Max. Negotiated Rate	$2,168.68
Rate for Payer: Amerigroup CHIP/Medicaid	$271.08
Rate for Payer: BCBS of TX Blue Advantage	$903.62
Rate for Payer: BCBS of TX Blue Essentials	$1,084.34
Rate for Payer: BCBS of TX PPO	$1,204.82
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Medicaid	$2,168.68
Rate for Payer: Molina CHIP/Medicaid	$2,168.68
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Parkland Medicaid	$2,168.68
Rate for Payer: Scott and White EPO/PPO	$1,506.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,168.68
Rate for Payer: Superior Health Plan EPO	$409.64

Bone Removal Screw

Facility

$3,012.05

Service Code	HCPCS C1713
Hospital Charge Code	993125
Hospital Revenue Code	278
Min. Negotiated Rate	$753.01
Max. Negotiated Rate	$1,506.03
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Commercial	$753.01
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Scott and White EPO/PPO	$1,506.03

Bone Screw T10 FULL THREAD 3.5mm X L18mm

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992197
Hospital Revenue Code	278
Min. Negotiated Rate	$159.64
Max. Negotiated Rate	$319.27
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Commercial	$159.64
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Scott and White EPO/PPO	$319.27

Bone Screw T10 FULL THREAD 3.5mm X L18mm

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992197
Hospital Revenue Code	278
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$459.76
Rate for Payer: Amerigroup CHIP/Medicaid	$57.47
Rate for Payer: BCBS of TX Blue Advantage	$191.56
Rate for Payer: BCBS of TX Blue Essentials	$229.88
Rate for Payer: BCBS of TX PPO	$255.42
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Medicaid	$459.76
Rate for Payer: Molina CHIP/Medicaid	$459.76
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Parkland Medicaid	$459.76
Rate for Payer: Scott and White EPO/PPO	$319.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.76
Rate for Payer: Superior Health Plan EPO	$86.84

Bone Screw T10 FULL THREAD 3.5mm X L28mm

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992198
Hospital Revenue Code	278
Min. Negotiated Rate	$159.64
Max. Negotiated Rate	$319.27
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Commercial	$159.64
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Scott and White EPO/PPO	$319.27

Bone Screw T10 FULL THREAD 3.5mm X L28mm

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992198
Hospital Revenue Code	278
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$459.76
Rate for Payer: Amerigroup CHIP/Medicaid	$57.47
Rate for Payer: BCBS of TX Blue Advantage	$191.56
Rate for Payer: BCBS of TX Blue Essentials	$229.88
Rate for Payer: BCBS of TX PPO	$255.42
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Medicaid	$459.76
Rate for Payer: Molina CHIP/Medicaid	$459.76
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Parkland Medicaid	$459.76
Rate for Payer: Scott and White EPO/PPO	$319.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.76
Rate for Payer: Superior Health Plan EPO	$86.84

Know your out-of-pocket cost for care.

All Charges