White Rock Medical Center

All Charges

Charge

Type

Setting

Price

IMPL BONE BUTTY OSTEOSPARX 5CC

Facility

$3,266.27

Service Code	HCPCS C1713
Hospital Charge Code	8404461
Hospital Revenue Code	278
Min. Negotiated Rate	$293.96
Max. Negotiated Rate	$1,633.14
Rate for Payer: Aetna Commercial	$979.88
Rate for Payer: Amerigroup CHIP/Medicaid	$293.96
Rate for Payer: BCBS of TX Blue Advantage	$979.88
Rate for Payer: BCBS of TX Blue Essentials	$1,175.86
Rate for Payer: BCBS of TX PPO	$1,306.51
Rate for Payer: Cash Price	$2,874.32
Rate for Payer: Multiplan Auto	$1,633.14
Rate for Payer: Multiplan Commercial	$1,633.14
Rate for Payer: Multiplan Workers Comp	$1,633.14
Rate for Payer: Scott and White EPO/PPO	$1,633.14
Rate for Payer: Superior Health Plan EPO	$444.21

IMPL BONE BUTTY OSTEOSPARX 5CC

Facility

$3,266.27

Service Code	HCPCS C1713
Hospital Charge Code	8404461
Hospital Revenue Code	278
Min. Negotiated Rate	$816.57
Max. Negotiated Rate	$1,633.14
Rate for Payer: Aetna Commercial	$979.88
Rate for Payer: Cash Price	$2,874.32
Rate for Payer: Cigna Commercial	$816.57
Rate for Payer: Multiplan Auto	$1,633.14
Rate for Payer: Multiplan Commercial	$1,633.14
Rate for Payer: Multiplan Workers Comp	$1,633.14
Rate for Payer: Scott and White EPO/PPO	$1,633.14

IMPL BONE CEMENT HYDROSET 15CC

Facility

$25,886.27

Service Code	HCPCS C1713
Hospital Charge Code	8414482
Hospital Revenue Code	278
Min. Negotiated Rate	$2,329.76
Max. Negotiated Rate	$12,943.14
Rate for Payer: Aetna Commercial	$7,765.88
Rate for Payer: Amerigroup CHIP/Medicaid	$2,329.76
Rate for Payer: BCBS of TX Blue Advantage	$7,765.88
Rate for Payer: BCBS of TX Blue Essentials	$9,319.06
Rate for Payer: BCBS of TX PPO	$10,354.51
Rate for Payer: Cash Price	$22,779.92
Rate for Payer: Multiplan Auto	$12,943.14
Rate for Payer: Multiplan Commercial	$12,943.14
Rate for Payer: Multiplan Workers Comp	$12,943.14
Rate for Payer: Scott and White EPO/PPO	$12,943.14
Rate for Payer: Superior Health Plan EPO	$3,520.53

IMPL BONE CEMENT HYDROSET 15CC

Facility

$25,886.27

Service Code	HCPCS C1713
Hospital Charge Code	8414482
Hospital Revenue Code	278
Min. Negotiated Rate	$6,471.57
Max. Negotiated Rate	$12,943.14
Rate for Payer: Aetna Commercial	$7,765.88
Rate for Payer: Cash Price	$22,779.92
Rate for Payer: Cigna Commercial	$6,471.57
Rate for Payer: Multiplan Auto	$12,943.14
Rate for Payer: Multiplan Commercial	$12,943.14
Rate for Payer: Multiplan Workers Comp	$12,943.14
Rate for Payer: Scott and White EPO/PPO	$12,943.14

IMPL BONE FILLER 2

Facility

$17,168.67

Service Code	HCPCS C1713
Hospital Charge Code	8420458
Hospital Revenue Code	278
Min. Negotiated Rate	$1,545.18
Max. Negotiated Rate	$8,584.34
Rate for Payer: Aetna Commercial	$5,150.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1,545.18
Rate for Payer: BCBS of TX Blue Advantage	$5,150.60
Rate for Payer: BCBS of TX Blue Essentials	$6,180.72
Rate for Payer: BCBS of TX PPO	$6,867.47
Rate for Payer: Cash Price	$15,108.43
Rate for Payer: Multiplan Auto	$8,584.34
Rate for Payer: Multiplan Commercial	$8,584.34
Rate for Payer: Multiplan Workers Comp	$8,584.34
Rate for Payer: Scott and White EPO/PPO	$8,584.34
Rate for Payer: Superior Health Plan EPO	$2,334.94

IMPL BONE FILLER 2

Facility

$17,168.67

Service Code	HCPCS C1713
Hospital Charge Code	8420458
Hospital Revenue Code	278
Min. Negotiated Rate	$4,292.17
Max. Negotiated Rate	$8,584.34
Rate for Payer: Aetna Commercial	$5,150.60
Rate for Payer: Cash Price	$15,108.43
Rate for Payer: Cigna Commercial	$4,292.17
Rate for Payer: Multiplan Auto	$8,584.34
Rate for Payer: Multiplan Commercial	$8,584.34
Rate for Payer: Multiplan Workers Comp	$8,584.34
Rate for Payer: Scott and White EPO/PPO	$8,584.34

IMPL BONE FILLER 5CC

Facility

$2,861.44

Service Code	HCPCS C1713
Hospital Charge Code	8420464
Hospital Revenue Code	278
Min. Negotiated Rate	$257.53
Max. Negotiated Rate	$1,430.72
Rate for Payer: Aetna Commercial	$858.43
Rate for Payer: Amerigroup CHIP/Medicaid	$257.53
Rate for Payer: BCBS of TX Blue Advantage	$858.43
Rate for Payer: BCBS of TX Blue Essentials	$1,030.12
Rate for Payer: BCBS of TX PPO	$1,144.58
Rate for Payer: Cash Price	$2,518.07
Rate for Payer: Multiplan Auto	$1,430.72
Rate for Payer: Multiplan Commercial	$1,430.72
Rate for Payer: Multiplan Workers Comp	$1,430.72
Rate for Payer: Scott and White EPO/PPO	$1,430.72
Rate for Payer: Superior Health Plan EPO	$389.16

IMPL BONE FILLER 5CC

Facility

$2,861.44

Service Code	HCPCS C1713
Hospital Charge Code	8420464
Hospital Revenue Code	278
Min. Negotiated Rate	$715.36
Max. Negotiated Rate	$1,430.72
Rate for Payer: Aetna Commercial	$858.43
Rate for Payer: Cash Price	$2,518.07
Rate for Payer: Cigna Commercial	$715.36
Rate for Payer: Multiplan Auto	$1,430.72
Rate for Payer: Multiplan Commercial	$1,430.72
Rate for Payer: Multiplan Workers Comp	$1,430.72
Rate for Payer: Scott and White EPO/PPO	$1,430.72

IMPL BONE GRAFT VIAFORM 5CC

Facility

$9,897.88

Service Code	HCPCS C1713
Hospital Charge Code	8492477
Hospital Revenue Code	278
Min. Negotiated Rate	$2,474.47
Max. Negotiated Rate	$4,948.94
Rate for Payer: Aetna Commercial	$2,969.36
Rate for Payer: Cash Price	$8,710.13
Rate for Payer: Cigna Commercial	$2,474.47
Rate for Payer: Multiplan Auto	$4,948.94
Rate for Payer: Multiplan Commercial	$4,948.94
Rate for Payer: Multiplan Workers Comp	$4,948.94
Rate for Payer: Scott and White EPO/PPO	$4,948.94

IMPL BONE GRAFT VIAFORM 5CC

Facility

$9,897.88

Service Code	HCPCS C1713
Hospital Charge Code	8492477
Hospital Revenue Code	278
Min. Negotiated Rate	$890.81
Max. Negotiated Rate	$4,948.94
Rate for Payer: Aetna Commercial	$2,969.36
Rate for Payer: Amerigroup CHIP/Medicaid	$890.81
Rate for Payer: BCBS of TX Blue Advantage	$2,969.36
Rate for Payer: BCBS of TX Blue Essentials	$3,563.24
Rate for Payer: BCBS of TX PPO	$3,959.15
Rate for Payer: Cash Price	$8,710.13
Rate for Payer: Multiplan Auto	$4,948.94
Rate for Payer: Multiplan Commercial	$4,948.94
Rate for Payer: Multiplan Workers Comp	$4,948.94
Rate for Payer: Scott and White EPO/PPO	$4,948.94
Rate for Payer: Superior Health Plan EPO	$1,346.11

IMPL BONE PUTTY 10CC

Facility

$6,626.51

Service Code	HCPCS C1713
Hospital Charge Code	8394472
Hospital Revenue Code	278
Min. Negotiated Rate	$1,656.63
Max. Negotiated Rate	$3,313.26
Rate for Payer: Aetna Commercial	$1,987.95
Rate for Payer: Cash Price	$5,831.33
Rate for Payer: Cigna Commercial	$1,656.63
Rate for Payer: Multiplan Auto	$3,313.26
Rate for Payer: Multiplan Commercial	$3,313.26
Rate for Payer: Multiplan Workers Comp	$3,313.26
Rate for Payer: Scott and White EPO/PPO	$3,313.26

IMPL BONE PUTTY 10CC

Facility

$6,626.51

Service Code	HCPCS C1713
Hospital Charge Code	8394472
Hospital Revenue Code	278
Min. Negotiated Rate	$596.39
Max. Negotiated Rate	$3,313.26
Rate for Payer: Aetna Commercial	$1,987.95
Rate for Payer: Amerigroup CHIP/Medicaid	$596.39
Rate for Payer: BCBS of TX Blue Advantage	$1,987.95
Rate for Payer: BCBS of TX Blue Essentials	$2,385.54
Rate for Payer: BCBS of TX PPO	$2,650.60
Rate for Payer: Cash Price	$5,831.33
Rate for Payer: Multiplan Auto	$3,313.26
Rate for Payer: Multiplan Commercial	$3,313.26
Rate for Payer: Multiplan Workers Comp	$3,313.26
Rate for Payer: Scott and White EPO/PPO	$3,313.26
Rate for Payer: Superior Health Plan EPO	$901.21

IMPL BONE PUTTY 5CC

Facility

$3,945.78

Service Code	HCPCS C1713
Hospital Charge Code	8490525
Hospital Revenue Code	278
Min. Negotiated Rate	$355.12
Max. Negotiated Rate	$1,972.89
Rate for Payer: Aetna Commercial	$1,183.73
Rate for Payer: Amerigroup CHIP/Medicaid	$355.12
Rate for Payer: BCBS of TX Blue Advantage	$1,183.73
Rate for Payer: BCBS of TX Blue Essentials	$1,420.48
Rate for Payer: BCBS of TX PPO	$1,578.31
Rate for Payer: Cash Price	$3,472.29
Rate for Payer: Multiplan Auto	$1,972.89
Rate for Payer: Multiplan Commercial	$1,972.89
Rate for Payer: Multiplan Workers Comp	$1,972.89
Rate for Payer: Scott and White EPO/PPO	$1,972.89
Rate for Payer: Superior Health Plan EPO	$536.63

IMPL BONE PUTTY 5CC

Facility

$3,945.78

Service Code	HCPCS C1713
Hospital Charge Code	8490525
Hospital Revenue Code	278
Min. Negotiated Rate	$986.44
Max. Negotiated Rate	$1,972.89
Rate for Payer: Aetna Commercial	$1,183.73
Rate for Payer: Cash Price	$3,472.29
Rate for Payer: Cigna Commercial	$986.44
Rate for Payer: Multiplan Auto	$1,972.89
Rate for Payer: Multiplan Commercial	$1,972.89
Rate for Payer: Multiplan Workers Comp	$1,972.89
Rate for Payer: Scott and White EPO/PPO	$1,972.89

IMPL CAGE ACIF 10 DEGREE

Facility

$14,049.58

Service Code	HCPCS C1713
Hospital Charge Code	8404460
Hospital Revenue Code	278
Min. Negotiated Rate	$3,512.40
Max. Negotiated Rate	$7,024.79
Rate for Payer: Aetna Commercial	$4,214.87
Rate for Payer: Cash Price	$12,363.63
Rate for Payer: Cigna Commercial	$3,512.40
Rate for Payer: Multiplan Auto	$7,024.79
Rate for Payer: Multiplan Commercial	$7,024.79
Rate for Payer: Multiplan Workers Comp	$7,024.79
Rate for Payer: Scott and White EPO/PPO	$7,024.79

IMPL CAGE ACIF 10 DEGREE

Facility

$14,049.58

Service Code	HCPCS C1713
Hospital Charge Code	8404460
Hospital Revenue Code	278
Min. Negotiated Rate	$1,264.46
Max. Negotiated Rate	$7,024.79
Rate for Payer: Aetna Commercial	$4,214.87
Rate for Payer: Amerigroup CHIP/Medicaid	$1,264.46
Rate for Payer: BCBS of TX Blue Advantage	$4,214.87
Rate for Payer: BCBS of TX Blue Essentials	$5,057.85
Rate for Payer: BCBS of TX PPO	$5,619.83
Rate for Payer: Cash Price	$12,363.63
Rate for Payer: Multiplan Auto	$7,024.79
Rate for Payer: Multiplan Commercial	$7,024.79
Rate for Payer: Multiplan Workers Comp	$7,024.79
Rate for Payer: Scott and White EPO/PPO	$7,024.79
Rate for Payer: Superior Health Plan EPO	$1,910.74

IMPL CAGE PEEK ALIF

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	8428492
Hospital Revenue Code	278
Min. Negotiated Rate	$9,036.14
Max. Negotiated Rate	$18,072.29
Rate for Payer: Aetna Commercial	$10,843.37
Rate for Payer: Cash Price	$31,807.23
Rate for Payer: Cigna Commercial	$9,036.14
Rate for Payer: Multiplan Auto	$18,072.29
Rate for Payer: Multiplan Commercial	$18,072.29
Rate for Payer: Multiplan Workers Comp	$18,072.29
Rate for Payer: Scott and White EPO/PPO	$18,072.29

IMPL CAGE PEEK ALIF

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	8428492
Hospital Revenue Code	278
Min. Negotiated Rate	$3,253.01
Max. Negotiated Rate	$18,072.29
Rate for Payer: Aetna Commercial	$10,843.37
Rate for Payer: Amerigroup CHIP/Medicaid	$3,253.01
Rate for Payer: BCBS of TX Blue Advantage	$10,843.37
Rate for Payer: BCBS of TX Blue Essentials	$13,012.05
Rate for Payer: BCBS of TX PPO	$14,457.83
Rate for Payer: Cash Price	$31,807.23
Rate for Payer: Multiplan Auto	$18,072.29
Rate for Payer: Multiplan Commercial	$18,072.29
Rate for Payer: Multiplan Workers Comp	$18,072.29
Rate for Payer: Scott and White EPO/PPO	$18,072.29
Rate for Payer: Superior Health Plan EPO	$4,915.66

IMPL CARD DEFIB ELLIPSE DUAL

Facility

$109,163.22

Service Code	HCPCS C1721
Hospital Charge Code	8428504
Hospital Revenue Code	275
Min. Negotiated Rate	$27,290.80
Max. Negotiated Rate	$54,581.61
Rate for Payer: Aetna Commercial	$32,748.97
Rate for Payer: Cash Price	$96,063.63
Rate for Payer: Cigna Commercial	$27,290.80
Rate for Payer: Multiplan Auto	$54,581.61
Rate for Payer: Multiplan Commercial	$54,581.61
Rate for Payer: Multiplan Workers Comp	$54,581.61
Rate for Payer: Scott and White EPO/PPO	$54,581.61

IMPL CARD DEFIB ELLIPSE DUAL

Facility

$109,163.22

Service Code	HCPCS C1721
Hospital Charge Code	8428504
Hospital Revenue Code	275
Min. Negotiated Rate	$9,824.69
Max. Negotiated Rate	$54,581.61
Rate for Payer: Aetna Commercial	$32,748.97
Rate for Payer: Amerigroup CHIP/Medicaid	$9,824.69
Rate for Payer: BCBS of TX Blue Advantage	$32,748.97
Rate for Payer: BCBS of TX Blue Essentials	$39,298.76
Rate for Payer: BCBS of TX PPO	$43,665.29
Rate for Payer: Cash Price	$96,063.63
Rate for Payer: Multiplan Auto	$54,581.61
Rate for Payer: Multiplan Commercial	$54,581.61
Rate for Payer: Multiplan Workers Comp	$54,581.61
Rate for Payer: Scott and White EPO/PPO	$54,581.61
Rate for Payer: Superior Health Plan EPO	$14,846.20

IMPL CEMENT BONE 70G RALLY ALL IN ONE A/B

Facility

$2,469.87

Service Code	HCPCS C1713
Hospital Charge Code	8504485
Hospital Revenue Code	278
Min. Negotiated Rate	$222.29
Max. Negotiated Rate	$1,234.94
Rate for Payer: Aetna Commercial	$740.96
Rate for Payer: Amerigroup CHIP/Medicaid	$222.29
Rate for Payer: BCBS of TX Blue Advantage	$740.96
Rate for Payer: BCBS of TX Blue Essentials	$889.15
Rate for Payer: BCBS of TX PPO	$987.95
Rate for Payer: Cash Price	$2,173.49
Rate for Payer: Multiplan Auto	$1,234.94
Rate for Payer: Multiplan Commercial	$1,234.94
Rate for Payer: Multiplan Workers Comp	$1,234.94
Rate for Payer: Scott and White EPO/PPO	$1,234.94
Rate for Payer: Superior Health Plan EPO	$335.90

IMPL CEMENT BONE 70G RALLY ALL IN ONE A/B

Facility

$2,469.87

Service Code	HCPCS C1713
Hospital Charge Code	8504485
Hospital Revenue Code	278
Min. Negotiated Rate	$617.47
Max. Negotiated Rate	$1,234.94
Rate for Payer: Aetna Commercial	$740.96
Rate for Payer: Cash Price	$2,173.49
Rate for Payer: Cigna Commercial	$617.47
Rate for Payer: Multiplan Auto	$1,234.94
Rate for Payer: Multiplan Commercial	$1,234.94
Rate for Payer: Multiplan Workers Comp	$1,234.94
Rate for Payer: Scott and White EPO/PPO	$1,234.94

IMPL COLLEGEN AREGRAFT 40CM X 70MM

Facility

$10,578.51

Service Code	HCPCS C1768
Hospital Charge Code	8432540
Hospital Revenue Code	278
Min. Negotiated Rate	$2,644.63
Max. Negotiated Rate	$5,289.26
Rate for Payer: Aetna Commercial	$3,173.55
Rate for Payer: Cash Price	$9,309.09
Rate for Payer: Cigna Commercial	$2,644.63
Rate for Payer: Multiplan Auto	$5,289.26
Rate for Payer: Multiplan Commercial	$5,289.26
Rate for Payer: Multiplan Workers Comp	$5,289.26
Rate for Payer: Scott and White EPO/PPO	$5,289.26

IMPL COLLEGEN AREGRAFT 40CM X 70MM

Facility

$10,578.51

Service Code	HCPCS C1768
Hospital Charge Code	8432540
Hospital Revenue Code	278
Min. Negotiated Rate	$952.07
Max. Negotiated Rate	$5,289.26
Rate for Payer: Aetna Commercial	$3,173.55
Rate for Payer: Amerigroup CHIP/Medicaid	$952.07
Rate for Payer: BCBS of TX Blue Advantage	$3,173.55
Rate for Payer: BCBS of TX Blue Essentials	$3,808.26
Rate for Payer: BCBS of TX PPO	$4,231.40
Rate for Payer: Cash Price	$9,309.09
Rate for Payer: Multiplan Auto	$5,289.26
Rate for Payer: Multiplan Commercial	$5,289.26
Rate for Payer: Multiplan Workers Comp	$5,289.26
Rate for Payer: Scott and White EPO/PPO	$5,289.26
Rate for Payer: Superior Health Plan EPO	$1,438.68

IMPL CROSS LINK CONNECTOR

Facility

$6,024.10

Service Code	HCPCS C1713
Hospital Charge Code	8394461
Hospital Revenue Code	278
Min. Negotiated Rate	$542.17
Max. Negotiated Rate	$3,012.05
Rate for Payer: Aetna Commercial	$1,807.23
Rate for Payer: Amerigroup CHIP/Medicaid	$542.17
Rate for Payer: BCBS of TX Blue Advantage	$1,807.23
Rate for Payer: BCBS of TX Blue Essentials	$2,168.68
Rate for Payer: BCBS of TX PPO	$2,409.64
Rate for Payer: Cash Price	$5,301.21
Rate for Payer: Multiplan Auto	$3,012.05
Rate for Payer: Multiplan Commercial	$3,012.05
Rate for Payer: Multiplan Workers Comp	$3,012.05
Rate for Payer: Scott and White EPO/PPO	$3,012.05
Rate for Payer: Superior Health Plan EPO	$819.28

Know your out-of-pocket cost for care.

All Charges