White Rock Medical Center

All Charges

Charge

Type

Setting

Price

IMP JOINT TOE -- DHF

Facility

$5,187.41

Service Code	HCPCS C1776
Hospital Charge Code	82401498
Hospital Revenue Code	278
Min. Negotiated Rate	$466.87
Max. Negotiated Rate	$2,593.70
Rate for Payer: Aetna Commercial	$1,556.22
Rate for Payer: Amerigroup CHIP/Medicaid	$466.87
Rate for Payer: BCBS of TX Blue Advantage	$1,556.22
Rate for Payer: BCBS of TX Blue Essentials	$1,867.47
Rate for Payer: BCBS of TX PPO	$2,074.96
Rate for Payer: Cash Price	$4,564.92
Rate for Payer: Multiplan Auto	$2,593.70
Rate for Payer: Multiplan Commercial	$2,593.70
Rate for Payer: Multiplan Workers Comp	$2,593.70
Rate for Payer: Scott and White EPO/PPO	$2,593.70
Rate for Payer: Superior Health Plan EPO	$705.49

IMPL ANCHOR SUTURE WITH ORTHOCORD

Facility

$5,214.87

Service Code	HCPCS C1713
Hospital Charge Code	8446469
Hospital Revenue Code	278
Min. Negotiated Rate	$469.34
Max. Negotiated Rate	$2,607.44
Rate for Payer: Aetna Commercial	$1,564.46
Rate for Payer: Amerigroup CHIP/Medicaid	$469.34
Rate for Payer: BCBS of TX Blue Advantage	$1,564.46
Rate for Payer: BCBS of TX Blue Essentials	$1,877.35
Rate for Payer: BCBS of TX PPO	$2,085.95
Rate for Payer: Cash Price	$4,589.09
Rate for Payer: Multiplan Auto	$2,607.44
Rate for Payer: Multiplan Commercial	$2,607.44
Rate for Payer: Multiplan Workers Comp	$2,607.44
Rate for Payer: Scott and White EPO/PPO	$2,607.44
Rate for Payer: Superior Health Plan EPO	$709.22

IMPL ANCHOR SUTURE WITH ORTHOCORD

Facility

$5,214.87

Service Code	HCPCS C1713
Hospital Charge Code	8446469
Hospital Revenue Code	278
Min. Negotiated Rate	$1,303.72
Max. Negotiated Rate	$2,607.44
Rate for Payer: Aetna Commercial	$1,564.46
Rate for Payer: Cash Price	$4,589.09
Rate for Payer: Cigna Commercial	$1,303.72
Rate for Payer: Multiplan Auto	$2,607.44
Rate for Payer: Multiplan Commercial	$2,607.44
Rate for Payer: Multiplan Workers Comp	$2,607.44
Rate for Payer: Scott and White EPO/PPO	$2,607.44

Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, br

Facility

$10,000.00

Service Code	CPT 15777
Hospital Charge Code	36015777
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for cl

Facility

$10,000.00

Service Code	CPT 49568
Hospital Charge Code	36049568
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

Implantation or replacement of device for intrathecal or epidural drug infusion programmable pump,

Facility

$41,621.43

Service Code	CPT 62362
Hospital Charge Code	36062362
Hospital Revenue Code	360
Min. Negotiated Rate	$359.75
Max. Negotiated Rate	$41,621.43
Rate for Payer: Aetna Commercial	$13,390.00
Rate for Payer: Aetna Medicare	$24,465.46
Rate for Payer: Amerigroup CHIP/Medicaid	$11,575.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,310.31
Rate for Payer: Amerigroup Medicare	$16,310.31
Rate for Payer: BCBS of TX Blue Advantage	$27,582.45
Rate for Payer: BCBS of TX Blue Essentials	$33,032.88
Rate for Payer: BCBS of TX Medicare	$16,310.31
Rate for Payer: BCBS of TX PPO	$41,621.43
Rate for Payer: Cigna Commercial	$36,947.57
Rate for Payer: Cigna Medicaid	$11,575.10
Rate for Payer: Cigna Medicare	$16,310.31
Rate for Payer: Employer Direct Commercial	$16,310.31
Rate for Payer: Humana Medicare/TRICARE	$16,310.31
Rate for Payer: Molina CHIP/Medicaid	$11,575.10
Rate for Payer: Molina Dual Medicare/Medicaid	$16,310.31
Rate for Payer: Molina Medicare	$16,310.31
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	$11,575.10
Rate for Payer: Scott and White EPO/PPO	$359.75
Rate for Payer: Scott and White Medicare	$16,310.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,575.10
Rate for Payer: Superior Health Plan EPO	$16,310.31
Rate for Payer: Superior Health Plan Medicare	$16,310.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,310.31
Rate for Payer: Universal American Medicare	$16,310.31
Rate for Payer: Wellcare Medicare	$16,310.31
Rate for Payer: Wellmed Medicare	$16,310.31

Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reserv

Facility

$41,621.43

Service Code	CPT 62360
Hospital Charge Code	36062360
Hospital Revenue Code	360
Min. Negotiated Rate	$359.75
Max. Negotiated Rate	$41,621.43
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$24,465.46
Rate for Payer: Amerigroup CHIP/Medicaid	$11,274.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,310.31
Rate for Payer: Amerigroup Medicare	$16,310.31
Rate for Payer: BCBS of TX Blue Advantage	$27,582.45
Rate for Payer: BCBS of TX Blue Essentials	$33,032.88
Rate for Payer: BCBS of TX Medicare	$16,310.31
Rate for Payer: BCBS of TX PPO	$41,621.43
Rate for Payer: Cigna Commercial	$36,947.57
Rate for Payer: Cigna Medicaid	$11,274.86
Rate for Payer: Cigna Medicare	$16,310.31
Rate for Payer: Employer Direct Commercial	$16,310.31
Rate for Payer: Humana Medicare/TRICARE	$16,310.31
Rate for Payer: Molina CHIP/Medicaid	$11,274.86
Rate for Payer: Molina Dual Medicare/Medicaid	$16,310.31
Rate for Payer: Molina Medicare	$16,310.31
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	$11,274.86
Rate for Payer: Scott and White EPO/PPO	$359.75
Rate for Payer: Scott and White Medicare	$16,310.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,274.86
Rate for Payer: Superior Health Plan EPO	$16,310.31
Rate for Payer: Superior Health Plan Medicare	$16,310.31
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,310.31
Rate for Payer: Universal American Medicare	$16,310.31
Rate for Payer: Wellcare Medicare	$16,310.31
Rate for Payer: Wellmed Medicare	$16,310.31

implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speec

Facility

$29,989.79

Service Code	CPT 69714
Hospital Charge Code	36069714
Hospital Revenue Code	360
Min. Negotiated Rate	$265.49
Max. Negotiated Rate	$29,989.79
Rate for Payer: Aetna Commercial	$8,755.00
Rate for Payer: Aetna Medicare	$18,054.70
Rate for Payer: Amerigroup CHIP/Medicaid	$7,885.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,036.47
Rate for Payer: Amerigroup Medicare	$12,036.47
Rate for Payer: BCBS of TX Blue Advantage	$19,874.19
Rate for Payer: BCBS of TX Blue Essentials	$23,801.42
Rate for Payer: BCBS of TX Medicare	$12,036.47
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cigna Commercial	$27,266.10
Rate for Payer: Cigna Medicaid	$7,885.62
Rate for Payer: Cigna Medicare	$12,036.47
Rate for Payer: Employer Direct Commercial	$12,036.47
Rate for Payer: Humana Medicare/TRICARE	$12,036.47
Rate for Payer: Molina CHIP/Medicaid	$7,885.62
Rate for Payer: Molina Dual Medicare/Medicaid	$12,036.47
Rate for Payer: Molina Medicare	$12,036.47
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	$7,885.62
Rate for Payer: Scott and White EPO/PPO	$265.49
Rate for Payer: Scott and White Medicare	$12,036.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,885.62
Rate for Payer: Superior Health Plan EPO	$12,036.47
Rate for Payer: Superior Health Plan Medicare	$12,036.47
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,036.47
Rate for Payer: Universal American Medicare	$12,036.47
Rate for Payer: Wellcare Medicare	$12,036.47
Rate for Payer: Wellmed Medicare	$12,036.47

Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speec

Facility

$10,000.00

Service Code	CPT 69715
Hospital Charge Code	36069715
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
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

Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term

Facility

$13,882.71

Service Code	CPT 62350
Hospital Charge Code	36062350
Hospital Revenue Code	360
Min. Negotiated Rate	$134.37
Max. Negotiated Rate	$13,882.71
Rate for Payer: Aetna Commercial	$6,077.00
Rate for Payer: Aetna Medicare	$9,138.30
Rate for Payer: Amerigroup CHIP/Medicaid	$2,890.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,092.20
Rate for Payer: Amerigroup Medicare	$6,092.20
Rate for Payer: BCBS of TX Blue Advantage	$9,200.05
Rate for Payer: BCBS of TX Blue Essentials	$11,018.02
Rate for Payer: BCBS of TX Medicare	$6,092.20
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cigna Commercial	$13,800.59
Rate for Payer: Cigna Medicaid	$2,890.51
Rate for Payer: Cigna Medicare	$6,092.20
Rate for Payer: Employer Direct Commercial	$6,092.20
Rate for Payer: Humana Medicare/TRICARE	$6,092.20
Rate for Payer: Molina CHIP/Medicaid	$2,890.51
Rate for Payer: Molina Dual Medicare/Medicaid	$6,092.20
Rate for Payer: Molina Medicare	$6,092.20
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	$2,890.51
Rate for Payer: Scott and White EPO/PPO	$134.37
Rate for Payer: Scott and White Medicare	$6,092.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,890.51
Rate for Payer: Superior Health Plan EPO	$6,092.20
Rate for Payer: Superior Health Plan Medicare	$6,092.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,092.20
Rate for Payer: Universal American Medicare	$6,092.20
Rate for Payer: Wellcare Medicare	$6,092.20
Rate for Payer: Wellmed Medicare	$6,092.20

Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term

Facility

$15,074.51

Service Code	CPT 62351
Hospital Charge Code	36062351
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
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	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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	$144.31
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

implant desara uretheral sling

Facility

$6,793.13

Service Code	HCPCS C1771
Hospital Charge Code	8420460
Hospital Revenue Code	278
Min. Negotiated Rate	$1,698.28
Max. Negotiated Rate	$3,396.56
Rate for Payer: Aetna Commercial	$2,037.94
Rate for Payer: Cash Price	$5,977.95
Rate for Payer: Cigna Commercial	$1,698.28
Rate for Payer: Multiplan Auto	$3,396.56
Rate for Payer: Multiplan Commercial	$3,396.56
Rate for Payer: Multiplan Workers Comp	$3,396.56
Rate for Payer: Scott and White EPO/PPO	$3,396.56

implant desara uretheral sling

Facility

$6,793.13

Service Code	HCPCS C1771
Hospital Charge Code	8420460
Hospital Revenue Code	278
Min. Negotiated Rate	$611.38
Max. Negotiated Rate	$3,396.56
Rate for Payer: Aetna Commercial	$2,037.94
Rate for Payer: Amerigroup CHIP/Medicaid	$611.38
Rate for Payer: BCBS of TX Blue Advantage	$2,037.94
Rate for Payer: BCBS of TX Blue Essentials	$2,445.53
Rate for Payer: BCBS of TX PPO	$2,717.25
Rate for Payer: Cash Price	$5,977.95
Rate for Payer: Multiplan Auto	$3,396.56
Rate for Payer: Multiplan Commercial	$3,396.56
Rate for Payer: Multiplan Workers Comp	$3,396.56
Rate for Payer: Scott and White EPO/PPO	$3,396.56
Rate for Payer: Superior Health Plan EPO	$923.87

IMPLANT MATRIX AMNIOTIC MEMBRANE 3X2CM

Facility

$1,355.42

Service Code	HCPCS Q4148
Hospital Charge Code	139288
Hospital Revenue Code	278
Min. Negotiated Rate	$121.99
Max. Negotiated Rate	$677.71
Rate for Payer: Aetna Commercial	$406.63
Rate for Payer: Amerigroup CHIP/Medicaid	$121.99
Rate for Payer: BCBS of TX Blue Advantage	$406.63
Rate for Payer: BCBS of TX Blue Essentials	$487.95
Rate for Payer: BCBS of TX PPO	$542.17
Rate for Payer: Cash Price	$1,192.77
Rate for Payer: Multiplan Auto	$677.71
Rate for Payer: Multiplan Commercial	$677.71
Rate for Payer: Multiplan Workers Comp	$677.71
Rate for Payer: Scott and White EPO/PPO	$677.71
Rate for Payer: Superior Health Plan EPO	$184.34

IMPLANT MATRIX AMNIOTIC MEMBRANE 3X2CM

Facility

$1,355.42

Service Code	HCPCS Q4148
Hospital Charge Code	139288
Hospital Revenue Code	278
Min. Negotiated Rate	$338.86
Max. Negotiated Rate	$677.71
Rate for Payer: Aetna Commercial	$406.63
Rate for Payer: Cash Price	$1,192.77
Rate for Payer: Cigna Commercial	$338.86
Rate for Payer: Multiplan Auto	$677.71
Rate for Payer: Multiplan Commercial	$677.71
Rate for Payer: Multiplan Workers Comp	$677.71
Rate for Payer: Scott and White EPO/PPO	$677.71

IMPLANT MATRIX WOUND AMNIOTIC MEMBRANE 4X3CM

Facility

$1,016.57

Service Code	HCPCS Q4148
Hospital Charge Code	138898
Hospital Revenue Code	278
Min. Negotiated Rate	$91.49
Max. Negotiated Rate	$508.28
Rate for Payer: Aetna Commercial	$304.97
Rate for Payer: Amerigroup CHIP/Medicaid	$91.49
Rate for Payer: BCBS of TX Blue Advantage	$304.97
Rate for Payer: BCBS of TX Blue Essentials	$365.97
Rate for Payer: BCBS of TX PPO	$406.63
Rate for Payer: Cash Price	$894.58
Rate for Payer: Multiplan Auto	$508.28
Rate for Payer: Multiplan Commercial	$508.28
Rate for Payer: Multiplan Workers Comp	$508.28
Rate for Payer: Scott and White EPO/PPO	$508.28
Rate for Payer: Superior Health Plan EPO	$138.25

IMPLANT MATRIX WOUND AMNIOTIC MEMBRANE 4X3CM

Facility

$1,016.57

Service Code	HCPCS Q4148
Hospital Charge Code	138898
Hospital Revenue Code	278
Min. Negotiated Rate	$254.14
Max. Negotiated Rate	$508.28
Rate for Payer: Aetna Commercial	$304.97
Rate for Payer: Cash Price	$894.58
Rate for Payer: Cigna Commercial	$254.14
Rate for Payer: Multiplan Auto	$508.28
Rate for Payer: Multiplan Commercial	$508.28
Rate for Payer: Multiplan Workers Comp	$508.28
Rate for Payer: Scott and White EPO/PPO	$508.28

IMPLANT MATRIX WOUND AMNIOTIC MEMBRANE 6X3CM

Facility

$1,016.75

Service Code	HCPCS Q4148
Hospital Charge Code	138876
Hospital Revenue Code	278
Min. Negotiated Rate	$91.51
Max. Negotiated Rate	$508.38
Rate for Payer: Aetna Commercial	$305.02
Rate for Payer: Amerigroup CHIP/Medicaid	$91.51
Rate for Payer: BCBS of TX Blue Advantage	$305.02
Rate for Payer: BCBS of TX Blue Essentials	$366.03
Rate for Payer: BCBS of TX PPO	$406.70
Rate for Payer: Cash Price	$894.74
Rate for Payer: Multiplan Auto	$508.38
Rate for Payer: Multiplan Commercial	$508.38
Rate for Payer: Multiplan Workers Comp	$508.38
Rate for Payer: Scott and White EPO/PPO	$508.38
Rate for Payer: Superior Health Plan EPO	$138.28

IMPLANT MATRIX WOUND AMNIOTIC MEMBRANE 6X3CM

Facility

$1,016.75

Service Code	HCPCS Q4148
Hospital Charge Code	138876
Hospital Revenue Code	278
Min. Negotiated Rate	$254.19
Max. Negotiated Rate	$508.38
Rate for Payer: Aetna Commercial	$305.02
Rate for Payer: Cash Price	$894.74
Rate for Payer: Cigna Commercial	$254.19
Rate for Payer: Multiplan Auto	$508.38
Rate for Payer: Multiplan Commercial	$508.38
Rate for Payer: Multiplan Workers Comp	$508.38
Rate for Payer: Scott and White EPO/PPO	$508.38

IMPLANT, PERICARDIUM BOVINE VASC PATCH 0.8CMX8CM -- DHF

Facility

$1,303.67

Hospital Charge Code	81759029
Hospital Revenue Code	278
Min. Negotiated Rate	$117.33
Max. Negotiated Rate	$651.84
Rate for Payer: Aetna Commercial	$391.10
Rate for Payer: Amerigroup CHIP/Medicaid	$117.33
Rate for Payer: BCBS of TX Blue Advantage	$391.10
Rate for Payer: BCBS of TX Blue Essentials	$469.32
Rate for Payer: BCBS of TX PPO	$521.47
Rate for Payer: Cash Price	$1,147.23
Rate for Payer: Multiplan Auto	$651.84
Rate for Payer: Multiplan Commercial	$651.84
Rate for Payer: Multiplan Workers Comp	$651.84
Rate for Payer: Scott and White EPO/PPO	$651.84
Rate for Payer: Superior Health Plan EPO	$177.30

IMPLANT, PERICARDIUM BOVINE VASC PATCH 0.8CMX8CM -- DHF

Facility

$1,303.67

Hospital Charge Code	81759029
Hospital Revenue Code	278
Min. Negotiated Rate	$325.92
Max. Negotiated Rate	$651.84
Rate for Payer: Aetna Commercial	$391.10
Rate for Payer: Cash Price	$1,147.23
Rate for Payer: Cigna Commercial	$325.92
Rate for Payer: Multiplan Auto	$651.84
Rate for Payer: Multiplan Commercial	$651.84
Rate for Payer: Multiplan Workers Comp	$651.84
Rate for Payer: Scott and White EPO/PPO	$651.84

IMPLANT, PERICARDIUM BOVINE VASCULAR PATCH 2CMX9CM -- DHF

Facility

$1,970.76

Service Code	HCPCS C1768
Hospital Charge Code	81421158
Hospital Revenue Code	278
Min. Negotiated Rate	$177.37
Max. Negotiated Rate	$985.38
Rate for Payer: Aetna Commercial	$591.23
Rate for Payer: Amerigroup CHIP/Medicaid	$177.37
Rate for Payer: BCBS of TX Blue Advantage	$591.23
Rate for Payer: BCBS of TX Blue Essentials	$709.47
Rate for Payer: BCBS of TX PPO	$788.30
Rate for Payer: Cash Price	$1,734.27
Rate for Payer: Multiplan Auto	$985.38
Rate for Payer: Multiplan Commercial	$985.38
Rate for Payer: Multiplan Workers Comp	$985.38
Rate for Payer: Scott and White EPO/PPO	$985.38
Rate for Payer: Superior Health Plan EPO	$268.02

IMPLANT, PERICARDIUM BOVINE VASCULAR PATCH 2CMX9CM -- DHF

Facility

$1,970.76

Service Code	HCPCS C1768
Hospital Charge Code	81421158
Hospital Revenue Code	278
Min. Negotiated Rate	$492.69
Max. Negotiated Rate	$985.38
Rate for Payer: Aetna Commercial	$591.23
Rate for Payer: Cash Price	$1,734.27
Rate for Payer: Cigna Commercial	$492.69
Rate for Payer: Multiplan Auto	$985.38
Rate for Payer: Multiplan Commercial	$985.38
Rate for Payer: Multiplan Workers Comp	$985.38
Rate for Payer: Scott and White EPO/PPO	$985.38

IMPLANT SCREW LOCKING F THRD T10 3.5X16MM VARIAX

Facility

$1,333.31

Service Code	HCPCS C1713
Hospital Charge Code	132396
Hospital Revenue Code	278
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$666.66
Rate for Payer: Aetna Commercial	$399.99
Rate for Payer: Amerigroup CHIP/Medicaid	$120.00
Rate for Payer: BCBS of TX Blue Advantage	$399.99
Rate for Payer: BCBS of TX Blue Essentials	$479.99
Rate for Payer: BCBS of TX PPO	$533.32
Rate for Payer: Cash Price	$1,173.31
Rate for Payer: Multiplan Auto	$666.66
Rate for Payer: Multiplan Commercial	$666.66
Rate for Payer: Multiplan Workers Comp	$666.66
Rate for Payer: Scott and White EPO/PPO	$666.66
Rate for Payer: Superior Health Plan EPO	$181.33

IMPLANT SCREW LOCKING F THRD T10 3.5X16MM VARIAX

Facility

$1,333.31

Service Code	HCPCS C1713
Hospital Charge Code	132396
Hospital Revenue Code	278
Min. Negotiated Rate	$333.33
Max. Negotiated Rate	$666.66
Rate for Payer: Aetna Commercial	$399.99
Rate for Payer: Cash Price	$1,173.31
Rate for Payer: Cigna Commercial	$333.33
Rate for Payer: Multiplan Auto	$666.66
Rate for Payer: Multiplan Commercial	$666.66
Rate for Payer: Multiplan Workers Comp	$666.66
Rate for Payer: Scott and White EPO/PPO	$666.66

Know your out-of-pocket cost for care.

All Charges