White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CELLULITIS WITHOUT MCC

Facility

$16,754.20

Service Code	MSDRG 603
Min. Negotiated Rate	$7,290.22
Max. Negotiated Rate	$16,754.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,142.92
Rate for Payer: Amerigroup Medicare	$11,142.92
Rate for Payer: BCBS of TX Medicare	$11,142.92
Rate for Payer: Cigna Commercial	$11,217.19
Rate for Payer: Cigna Medicare	$11,142.92
Rate for Payer: Employer Direct Commercial	$11,142.92
Rate for Payer: Humana Medicare/TRICARE	$11,142.92
Rate for Payer: Molina Dual Medicare/Medicaid	$11,142.92
Rate for Payer: Molina Medicare	$11,142.92
Rate for Payer: Multiplan Auto	$16,754.20
Rate for Payer: Multiplan Commercial	$16,754.20
Rate for Payer: Multiplan Workers Comp	$16,754.20
Rate for Payer: Scott and White EPO/PPO	$7,715.75
Rate for Payer: Scott and White Medicare	$11,142.92
Rate for Payer: Superior Health Plan EPO	$11,142.92
Rate for Payer: Superior Health Plan Medicare	$11,142.92
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,142.92
Rate for Payer: Universal American Medicare	$11,142.92
Rate for Payer: Wellcare Medicare	$11,142.92
Rate for Payer: Wellmed Medicare	$11,142.92

CELLULITIS W MCC

Facility

$27,382.80

Service Code	MSDRG 602
Min. Negotiated Rate	$12,418.40
Max. Negotiated Rate	$27,382.80
Rate for Payer: BCBS of TX Blue Advantage	$12,418.40
Rate for Payer: BCBS of TX Blue Essentials	$14,900.64
Rate for Payer: BCBS of TX PPO	$16,556.90

CELLULITIS W/O MCC

Facility

$16,754.20

Service Code	MSDRG 603
Min. Negotiated Rate	$7,290.22
Max. Negotiated Rate	$16,754.20
Rate for Payer: BCBS of TX Blue Advantage	$7,290.22
Rate for Payer: BCBS of TX Blue Essentials	$8,747.42
Rate for Payer: BCBS of TX PPO	$9,719.73

CEMENT BN R 1X40GR

Facility

$722.89

Service Code	HCPCS C1734
Hospital Charge Code	992113
Hospital Revenue Code	278
Min. Negotiated Rate	$65.06
Max. Negotiated Rate	$520.48
Rate for Payer: Amerigroup CHIP/Medicaid	$65.06
Rate for Payer: BCBS of TX Blue Advantage	$216.87
Rate for Payer: BCBS of TX Blue Essentials	$260.24
Rate for Payer: BCBS of TX PPO	$289.16
Rate for Payer: Cash Price	$491.57
Rate for Payer: Cigna Medicaid	$520.48
Rate for Payer: Molina CHIP/Medicaid	$520.48
Rate for Payer: Multiplan Auto	$361.44
Rate for Payer: Multiplan Commercial	$361.44
Rate for Payer: Multiplan Workers Comp	$361.44
Rate for Payer: Parkland Medicaid	$520.48
Rate for Payer: Scott and White EPO/PPO	$361.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$520.48
Rate for Payer: Superior Health Plan EPO	$98.31

CEMENT BN R 1X40GR

Facility

$722.89

Service Code	HCPCS C1734
Hospital Charge Code	992113
Hospital Revenue Code	278
Min. Negotiated Rate	$180.72
Max. Negotiated Rate	$361.44
Rate for Payer: Cash Price	$491.57
Rate for Payer: Cigna Commercial	$180.72
Rate for Payer: Multiplan Auto	$361.44
Rate for Payer: Multiplan Commercial	$361.44
Rate for Payer: Multiplan Workers Comp	$361.44
Rate for Payer: Scott and White EPO/PPO	$361.44

CEMENT BN W/GENTAMICIN REFOBACIN 1X40GR

Facility

$1,716.87

Service Code	HCPCS C1734
Hospital Charge Code	992119
Hospital Revenue Code	278
Min. Negotiated Rate	$429.22
Max. Negotiated Rate	$858.43
Rate for Payer: Cash Price	$1,167.47
Rate for Payer: Cigna Commercial	$429.22
Rate for Payer: Multiplan Auto	$858.43
Rate for Payer: Multiplan Commercial	$858.43
Rate for Payer: Multiplan Workers Comp	$858.43
Rate for Payer: Scott and White EPO/PPO	$858.43

CEMENT BN W/GENTAMICIN REFOBACIN 1X40GR

Facility

$1,716.87

Service Code	HCPCS C1734
Hospital Charge Code	992119
Hospital Revenue Code	278
Min. Negotiated Rate	$154.52
Max. Negotiated Rate	$1,236.15
Rate for Payer: Amerigroup CHIP/Medicaid	$154.52
Rate for Payer: BCBS of TX Blue Advantage	$515.06
Rate for Payer: BCBS of TX Blue Essentials	$618.07
Rate for Payer: BCBS of TX PPO	$686.75
Rate for Payer: Cash Price	$1,167.47
Rate for Payer: Cigna Medicaid	$1,236.15
Rate for Payer: Molina CHIP/Medicaid	$1,236.15
Rate for Payer: Multiplan Auto	$858.43
Rate for Payer: Multiplan Commercial	$858.43
Rate for Payer: Multiplan Workers Comp	$858.43
Rate for Payer: Parkland Medicaid	$1,236.15
Rate for Payer: Scott and White EPO/PPO	$858.43
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,236.15
Rate for Payer: Superior Health Plan EPO	$233.49

CEMENT BONE BIOMET

Facility

$723.00

Service Code	HCPCS C1763
Hospital Charge Code	8692539
Hospital Revenue Code	278
Min. Negotiated Rate	$180.75
Max. Negotiated Rate	$361.50
Rate for Payer: Cash Price	$491.64
Rate for Payer: Cigna Commercial	$180.75
Rate for Payer: Multiplan Auto	$361.50
Rate for Payer: Multiplan Commercial	$361.50
Rate for Payer: Multiplan Workers Comp	$361.50
Rate for Payer: Scott and White EPO/PPO	$361.50

CEMENT BONE BIOMET

Facility

$723.00

Service Code	HCPCS C1763
Hospital Charge Code	8692539
Hospital Revenue Code	278
Min. Negotiated Rate	$65.07
Max. Negotiated Rate	$520.56
Rate for Payer: Amerigroup CHIP/Medicaid	$65.07
Rate for Payer: BCBS of TX Blue Advantage	$216.90
Rate for Payer: BCBS of TX Blue Essentials	$260.28
Rate for Payer: BCBS of TX PPO	$289.20
Rate for Payer: Cash Price	$491.64
Rate for Payer: Cigna Medicaid	$520.56
Rate for Payer: Molina CHIP/Medicaid	$520.56
Rate for Payer: Multiplan Auto	$361.50
Rate for Payer: Multiplan Commercial	$361.50
Rate for Payer: Multiplan Workers Comp	$361.50
Rate for Payer: Parkland Medicaid	$520.56
Rate for Payer: Scott and White EPO/PPO	$361.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$520.56
Rate for Payer: Superior Health Plan EPO	$98.33

CEMENT BONE RADIPAQUE VCF-1009

Facility

$2,590.00

Service Code	HCPCS C1763
Hospital Charge Code	144865
Hospital Revenue Code	278
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$1,864.80
Rate for Payer: Amerigroup CHIP/Medicaid	$233.10
Rate for Payer: BCBS of TX Blue Advantage	$777.00
Rate for Payer: BCBS of TX Blue Essentials	$932.40
Rate for Payer: BCBS of TX PPO	$1,036.00
Rate for Payer: Cash Price	$1,761.20
Rate for Payer: Cigna Medicaid	$1,864.80
Rate for Payer: Molina CHIP/Medicaid	$1,864.80
Rate for Payer: Multiplan Auto	$1,295.00
Rate for Payer: Multiplan Commercial	$1,295.00
Rate for Payer: Multiplan Workers Comp	$1,295.00
Rate for Payer: Parkland Medicaid	$1,864.80
Rate for Payer: Scott and White EPO/PPO	$1,295.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,864.80
Rate for Payer: Superior Health Plan EPO	$352.24

CEMENT BONE RADIPAQUE VCF-1009

Facility

$2,590.00

Service Code	HCPCS C1763
Hospital Charge Code	144865
Hospital Revenue Code	278
Min. Negotiated Rate	$647.50
Max. Negotiated Rate	$1,295.00
Rate for Payer: Cash Price	$1,761.20
Rate for Payer: Cigna Commercial	$647.50
Rate for Payer: Multiplan Auto	$1,295.00
Rate for Payer: Multiplan Commercial	$1,295.00
Rate for Payer: Multiplan Workers Comp	$1,295.00
Rate for Payer: Scott and White EPO/PPO	$1,295.00

CEMENT BONE SPEEDSET

Facility

$656.00

Service Code	HCPCS C1763
Hospital Charge Code	134363
Hospital Revenue Code	278
Min. Negotiated Rate	$59.04
Max. Negotiated Rate	$472.32
Rate for Payer: Amerigroup CHIP/Medicaid	$59.04
Rate for Payer: BCBS of TX Blue Advantage	$196.80
Rate for Payer: BCBS of TX Blue Essentials	$236.16
Rate for Payer: BCBS of TX PPO	$262.40
Rate for Payer: Cash Price	$446.08
Rate for Payer: Cigna Medicaid	$472.32
Rate for Payer: Molina CHIP/Medicaid	$472.32
Rate for Payer: Multiplan Auto	$328.00
Rate for Payer: Multiplan Commercial	$328.00
Rate for Payer: Multiplan Workers Comp	$328.00
Rate for Payer: Parkland Medicaid	$472.32
Rate for Payer: Scott and White EPO/PPO	$328.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$472.32
Rate for Payer: Superior Health Plan EPO	$89.22

CEMENT BONE SPEEDSET

Facility

$656.00

Service Code	HCPCS C1763
Hospital Charge Code	134363
Hospital Revenue Code	278
Min. Negotiated Rate	$164.00
Max. Negotiated Rate	$328.00
Rate for Payer: Cash Price	$446.08
Rate for Payer: Cigna Commercial	$164.00
Rate for Payer: Multiplan Auto	$328.00
Rate for Payer: Multiplan Commercial	$328.00
Rate for Payer: Multiplan Workers Comp	$328.00
Rate for Payer: Scott and White EPO/PPO	$328.00

CEMENT BONE VERTAPLEX HV

Facility

$2,667.00

Service Code	HCPCS C1763
Hospital Charge Code	146142
Hospital Revenue Code	278
Min. Negotiated Rate	$666.75
Max. Negotiated Rate	$1,333.50
Rate for Payer: Cash Price	$1,813.56
Rate for Payer: Cigna Commercial	$666.75
Rate for Payer: Multiplan Auto	$1,333.50
Rate for Payer: Multiplan Commercial	$1,333.50
Rate for Payer: Multiplan Workers Comp	$1,333.50
Rate for Payer: Scott and White EPO/PPO	$1,333.50

CEMENT BONE VERTAPLEX HV

Facility

$2,667.00

Service Code	HCPCS C1763
Hospital Charge Code	146142
Hospital Revenue Code	278
Min. Negotiated Rate	$240.03
Max. Negotiated Rate	$1,920.24
Rate for Payer: Amerigroup CHIP/Medicaid	$240.03
Rate for Payer: BCBS of TX Blue Advantage	$800.10
Rate for Payer: BCBS of TX Blue Essentials	$960.12
Rate for Payer: BCBS of TX PPO	$1,066.80
Rate for Payer: Cash Price	$1,813.56
Rate for Payer: Cigna Medicaid	$1,920.24
Rate for Payer: Molina CHIP/Medicaid	$1,920.24
Rate for Payer: Multiplan Auto	$1,333.50
Rate for Payer: Multiplan Commercial	$1,333.50
Rate for Payer: Multiplan Workers Comp	$1,333.50
Rate for Payer: Parkland Medicaid	$1,920.24
Rate for Payer: Scott and White EPO/PPO	$1,333.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,920.24
Rate for Payer: Superior Health Plan EPO	$362.71

CEMENT CARTRIDGE KYPHON CC02A

Facility

$499.40

Hospital Charge Code	8574473
Hospital Revenue Code	272
Min. Negotiated Rate	$44.95
Max. Negotiated Rate	$359.57
Rate for Payer: Amerigroup CHIP/Medicaid	$44.95
Rate for Payer: BCBS of TX Blue Advantage	$149.82
Rate for Payer: BCBS of TX Blue Essentials	$179.78
Rate for Payer: BCBS of TX PPO	$199.76
Rate for Payer: Cash Price	$339.59
Rate for Payer: Cigna Medicaid	$359.57
Rate for Payer: Molina CHIP/Medicaid	$359.57
Rate for Payer: Multiplan Auto	$324.61
Rate for Payer: Multiplan Commercial	$324.61
Rate for Payer: Multiplan Workers Comp	$324.61
Rate for Payer: Parkland Medicaid	$359.57
Rate for Payer: Scott and White EPO/PPO	$249.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$359.57
Rate for Payer: Superior Health Plan EPO	$67.92

CEMENT CARTRIDGE KYPHON CC02A

Facility

$499.40

Hospital Charge Code	8574473
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

CEMENT KYPHON CX01A

Facility

$1,283.00

Service Code	HCPCS C1763
Hospital Charge Code	8478523
Hospital Revenue Code	278
Min. Negotiated Rate	$320.75
Max. Negotiated Rate	$641.50
Rate for Payer: Cash Price	$872.44
Rate for Payer: Cigna Commercial	$320.75
Rate for Payer: Multiplan Auto	$641.50
Rate for Payer: Multiplan Commercial	$641.50
Rate for Payer: Multiplan Workers Comp	$641.50
Rate for Payer: Scott and White EPO/PPO	$641.50

CEMENT KYPHON CX01A

Facility

$1,283.00

Service Code	HCPCS C1763
Hospital Charge Code	8478523
Hospital Revenue Code	278
Min. Negotiated Rate	$115.47
Max. Negotiated Rate	$923.76
Rate for Payer: Amerigroup CHIP/Medicaid	$115.47
Rate for Payer: BCBS of TX Blue Advantage	$384.90
Rate for Payer: BCBS of TX Blue Essentials	$461.88
Rate for Payer: BCBS of TX PPO	$513.20
Rate for Payer: Cash Price	$872.44
Rate for Payer: Cigna Medicaid	$923.76
Rate for Payer: Molina CHIP/Medicaid	$923.76
Rate for Payer: Multiplan Auto	$641.50
Rate for Payer: Multiplan Commercial	$641.50
Rate for Payer: Multiplan Workers Comp	$641.50
Rate for Payer: Parkland Medicaid	$923.76
Rate for Payer: Scott and White EPO/PPO	$641.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$923.76
Rate for Payer: Superior Health Plan EPO	$174.49

CEMENT KYPHON DELIVERY SYSTEM CDS2A

Facility

$2,474.30

Hospital Charge Code	8478526
Hospital Revenue Code	272
Min. Negotiated Rate	$222.69
Max. Negotiated Rate	$1,781.50
Rate for Payer: Amerigroup CHIP/Medicaid	$222.69
Rate for Payer: BCBS of TX Blue Advantage	$742.29
Rate for Payer: BCBS of TX Blue Essentials	$890.75
Rate for Payer: BCBS of TX PPO	$989.72
Rate for Payer: Cash Price	$1,682.52
Rate for Payer: Cigna Medicaid	$1,781.50
Rate for Payer: Molina CHIP/Medicaid	$1,781.50
Rate for Payer: Multiplan Auto	$1,608.30
Rate for Payer: Multiplan Commercial	$1,608.30
Rate for Payer: Multiplan Workers Comp	$1,608.30
Rate for Payer: Parkland Medicaid	$1,781.50
Rate for Payer: Scott and White EPO/PPO	$1,237.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,781.50
Rate for Payer: Superior Health Plan EPO	$336.50

CEMENT KYPHON DELIVERY SYSTEM CDS2A

Facility

$2,474.30

Hospital Charge Code	8478526
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,682.52

cement mixing compact vac-zimmer

Facility

$635.60

Hospital Charge Code	8614537
Hospital Revenue Code	272
Rate for Payer: Cash Price	$432.21

cement mixing compact vac-zimmer

Facility

$635.60

Hospital Charge Code	8614537
Hospital Revenue Code	272
Min. Negotiated Rate	$57.20
Max. Negotiated Rate	$457.63
Rate for Payer: Amerigroup CHIP/Medicaid	$57.20
Rate for Payer: BCBS of TX Blue Advantage	$190.68
Rate for Payer: BCBS of TX Blue Essentials	$228.82
Rate for Payer: BCBS of TX PPO	$254.24
Rate for Payer: Cash Price	$432.21
Rate for Payer: Cigna Medicaid	$457.63
Rate for Payer: Molina CHIP/Medicaid	$457.63
Rate for Payer: Multiplan Auto	$413.14
Rate for Payer: Multiplan Commercial	$413.14
Rate for Payer: Multiplan Workers Comp	$413.14
Rate for Payer: Parkland Medicaid	$457.63
Rate for Payer: Scott and White EPO/PPO	$317.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$457.63
Rate for Payer: Superior Health Plan EPO	$86.44

CEMT BN ANTIFUL STRY CAP -- DHF

Facility

$1,491.00

Service Code	HCPCS C1713
Hospital Charge Code	40118655
Hospital Revenue Code	278
Min. Negotiated Rate	$372.75
Max. Negotiated Rate	$745.50
Rate for Payer: Cash Price	$1,013.88
Rate for Payer: Cigna Commercial	$372.75
Rate for Payer: Multiplan Auto	$745.50
Rate for Payer: Multiplan Commercial	$745.50
Rate for Payer: Multiplan Workers Comp	$745.50
Rate for Payer: Scott and White EPO/PPO	$745.50

CEMT BN ANTIFUL STRY CAP -- DHF

Facility

$1,491.00

Service Code	HCPCS C1713
Hospital Charge Code	40118655
Hospital Revenue Code	278
Min. Negotiated Rate	$134.19
Max. Negotiated Rate	$1,073.52
Rate for Payer: Amerigroup CHIP/Medicaid	$134.19
Rate for Payer: BCBS of TX Blue Advantage	$447.30
Rate for Payer: BCBS of TX Blue Essentials	$536.76
Rate for Payer: BCBS of TX PPO	$596.40
Rate for Payer: Cash Price	$1,013.88
Rate for Payer: Cigna Medicaid	$1,073.52
Rate for Payer: Molina CHIP/Medicaid	$1,073.52
Rate for Payer: Multiplan Auto	$745.50
Rate for Payer: Multiplan Commercial	$745.50
Rate for Payer: Multiplan Workers Comp	$745.50
Rate for Payer: Parkland Medicaid	$1,073.52
Rate for Payer: Scott and White EPO/PPO	$745.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,073.52
Rate for Payer: Superior Health Plan EPO	$202.78

Know your out-of-pocket cost for care.

All Charges