White Rock Medical Center

All Charges

Charge

Type

Setting

Price

IMPL CROSS LINK CONNECTOR

Facility

$6,024.10

Service Code	HCPCS C1713
Hospital Charge Code	8394461
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.02
Max. Negotiated Rate	$3,012.05
Rate for Payer: Aetna Commercial	$1,807.23
Rate for Payer: Cash Price	$5,301.21
Rate for Payer: Cigna Commercial	$1,506.02
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

IMPL DEFIB ICD VIGILANT D233

Facility

$90,433.73

Service Code	HCPCS C1721
Hospital Charge Code	8414455
Hospital Revenue Code	278
Min. Negotiated Rate	$22,608.43
Max. Negotiated Rate	$45,216.86
Rate for Payer: Aetna Commercial	$27,130.12
Rate for Payer: Cash Price	$79,581.68
Rate for Payer: Cigna Commercial	$22,608.43
Rate for Payer: Multiplan Auto	$45,216.86
Rate for Payer: Multiplan Commercial	$45,216.86
Rate for Payer: Multiplan Workers Comp	$45,216.86
Rate for Payer: Scott and White EPO/PPO	$45,216.86

IMPL DEFIB ICD VIGILANT D233

Facility

$90,433.73

Service Code	HCPCS C1721
Hospital Charge Code	8414455
Hospital Revenue Code	278
Min. Negotiated Rate	$8,139.04
Max. Negotiated Rate	$45,216.86
Rate for Payer: Aetna Commercial	$27,130.12
Rate for Payer: Amerigroup CHIP/Medicaid	$8,139.04
Rate for Payer: BCBS of TX Blue Advantage	$27,130.12
Rate for Payer: BCBS of TX Blue Essentials	$32,556.14
Rate for Payer: BCBS of TX PPO	$36,173.49
Rate for Payer: Cash Price	$79,581.68
Rate for Payer: Multiplan Auto	$45,216.86
Rate for Payer: Multiplan Commercial	$45,216.86
Rate for Payer: Multiplan Workers Comp	$45,216.86
Rate for Payer: Scott and White EPO/PPO	$45,216.86
Rate for Payer: Superior Health Plan EPO	$12,298.99

IMPL EXOSHAPE TIBIAL FASTENER

Facility

$4,346.69

Service Code	HCPCS C1713
Hospital Charge Code	8420462
Hospital Revenue Code	278
Min. Negotiated Rate	$391.20
Max. Negotiated Rate	$2,173.34
Rate for Payer: Aetna Commercial	$1,304.01
Rate for Payer: Amerigroup CHIP/Medicaid	$391.20
Rate for Payer: BCBS of TX Blue Advantage	$1,304.01
Rate for Payer: BCBS of TX Blue Essentials	$1,564.81
Rate for Payer: BCBS of TX PPO	$1,738.68
Rate for Payer: Cash Price	$3,825.09
Rate for Payer: Multiplan Auto	$2,173.34
Rate for Payer: Multiplan Commercial	$2,173.34
Rate for Payer: Multiplan Workers Comp	$2,173.34
Rate for Payer: Scott and White EPO/PPO	$2,173.34
Rate for Payer: Superior Health Plan EPO	$591.15

IMPL EXOSHAPE TIBIAL FASTENER

Facility

$4,346.69

Service Code	HCPCS C1713
Hospital Charge Code	8420462
Hospital Revenue Code	278
Min. Negotiated Rate	$1,086.67
Max. Negotiated Rate	$2,173.34
Rate for Payer: Aetna Commercial	$1,304.01
Rate for Payer: Cash Price	$3,825.09
Rate for Payer: Cigna Commercial	$1,086.67
Rate for Payer: Multiplan Auto	$2,173.34
Rate for Payer: Multiplan Commercial	$2,173.34
Rate for Payer: Multiplan Workers Comp	$2,173.34
Rate for Payer: Scott and White EPO/PPO	$2,173.34

IMPL FEM BUTTON LOOP

Facility

$2,272.72

Service Code	HCPCS C1713
Hospital Charge Code	8398514
Hospital Revenue Code	278
Min. Negotiated Rate	$568.18
Max. Negotiated Rate	$1,136.36
Rate for Payer: Aetna Commercial	$681.82
Rate for Payer: Cash Price	$1,999.99
Rate for Payer: Cigna Commercial	$568.18
Rate for Payer: Multiplan Auto	$1,136.36
Rate for Payer: Multiplan Commercial	$1,136.36
Rate for Payer: Multiplan Workers Comp	$1,136.36
Rate for Payer: Scott and White EPO/PPO	$1,136.36

IMPL FEM BUTTON LOOP

Facility

$2,272.72

Service Code	HCPCS C1713
Hospital Charge Code	8398514
Hospital Revenue Code	278
Min. Negotiated Rate	$204.54
Max. Negotiated Rate	$1,136.36
Rate for Payer: Aetna Commercial	$681.82
Rate for Payer: Amerigroup CHIP/Medicaid	$204.54
Rate for Payer: BCBS of TX Blue Advantage	$681.82
Rate for Payer: BCBS of TX Blue Essentials	$818.18
Rate for Payer: BCBS of TX PPO	$909.09
Rate for Payer: Cash Price	$1,999.99
Rate for Payer: Multiplan Auto	$1,136.36
Rate for Payer: Multiplan Commercial	$1,136.36
Rate for Payer: Multiplan Workers Comp	$1,136.36
Rate for Payer: Scott and White EPO/PPO	$1,136.36
Rate for Payer: Superior Health Plan EPO	$309.09

IMPL FEMORAL COMP HI FLX LONG

Facility

$19,454.45

Service Code	HCPCS C1776
Hospital Charge Code	8404478
Hospital Revenue Code	278
Min. Negotiated Rate	$1,750.90
Max. Negotiated Rate	$9,727.22
Rate for Payer: Aetna Commercial	$5,836.34
Rate for Payer: Amerigroup CHIP/Medicaid	$1,750.90
Rate for Payer: BCBS of TX Blue Advantage	$5,836.34
Rate for Payer: BCBS of TX Blue Essentials	$7,003.60
Rate for Payer: BCBS of TX PPO	$7,781.78
Rate for Payer: Cash Price	$17,119.92
Rate for Payer: Multiplan Auto	$9,727.22
Rate for Payer: Multiplan Commercial	$9,727.22
Rate for Payer: Multiplan Workers Comp	$9,727.22
Rate for Payer: Scott and White EPO/PPO	$9,727.22
Rate for Payer: Superior Health Plan EPO	$2,645.81

IMPL FEMORAL COMP HI FLX LONG

Facility

$19,454.45

Service Code	HCPCS C1776
Hospital Charge Code	8404478
Hospital Revenue Code	278
Min. Negotiated Rate	$4,863.61
Max. Negotiated Rate	$9,727.22
Rate for Payer: Aetna Commercial	$5,836.34
Rate for Payer: Cash Price	$17,119.92
Rate for Payer: Cigna Commercial	$4,863.61
Rate for Payer: Multiplan Auto	$9,727.22
Rate for Payer: Multiplan Commercial	$9,727.22
Rate for Payer: Multiplan Workers Comp	$9,727.22
Rate for Payer: Scott and White EPO/PPO	$9,727.22

IMPL FIXATION PIN TYPE 3

Facility

$1,506.02

Service Code	HCPCS C1713
Hospital Charge Code	8420451
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$753.01
Rate for Payer: Aetna Commercial	$451.81
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.81
Rate for Payer: BCBS of TX Blue Essentials	$542.17
Rate for Payer: BCBS of TX PPO	$602.41
Rate for Payer: Cash Price	$1,325.30
Rate for Payer: Multiplan Auto	$753.01
Rate for Payer: Multiplan Commercial	$753.01
Rate for Payer: Multiplan Workers Comp	$753.01
Rate for Payer: Scott and White EPO/PPO	$753.01
Rate for Payer: Superior Health Plan EPO	$204.82

IMPL FIXATION PIN TYPE 3

Facility

$1,506.02

Service Code	HCPCS C1713
Hospital Charge Code	8420451
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.01
Rate for Payer: Aetna Commercial	$451.81
Rate for Payer: Cash Price	$1,325.30
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.01
Rate for Payer: Multiplan Commercial	$753.01
Rate for Payer: Multiplan Workers Comp	$753.01
Rate for Payer: Scott and White EPO/PPO	$753.01

impl graft bone viaform 10cc allograft

Facility

$24,096.39

Service Code	HCPCS C1781
Hospital Charge Code	8666513
Hospital Revenue Code	278
Min. Negotiated Rate	$6,024.10
Max. Negotiated Rate	$12,048.20
Rate for Payer: Aetna Commercial	$7,228.92
Rate for Payer: Cash Price	$21,204.82
Rate for Payer: Cigna Commercial	$6,024.10
Rate for Payer: Multiplan Auto	$12,048.20
Rate for Payer: Multiplan Commercial	$12,048.20
Rate for Payer: Multiplan Workers Comp	$12,048.20
Rate for Payer: Scott and White EPO/PPO	$12,048.20

impl graft bone viaform 10cc allograft

Facility

$24,096.39

Service Code	HCPCS C1781
Hospital Charge Code	8666513
Hospital Revenue Code	278
Min. Negotiated Rate	$2,168.68
Max. Negotiated Rate	$12,048.20
Rate for Payer: Aetna Commercial	$7,228.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2,168.68
Rate for Payer: BCBS of TX Blue Advantage	$7,228.92
Rate for Payer: BCBS of TX Blue Essentials	$8,674.70
Rate for Payer: BCBS of TX PPO	$9,638.56
Rate for Payer: Cash Price	$21,204.82
Rate for Payer: Multiplan Auto	$12,048.20
Rate for Payer: Multiplan Commercial	$12,048.20
Rate for Payer: Multiplan Workers Comp	$12,048.20
Rate for Payer: Scott and White EPO/PPO	$12,048.20
Rate for Payer: Superior Health Plan EPO	$3,277.11

IMPL INTERBODY CAGE

Facility

$33,132.53

Service Code	HCPCS C1713
Hospital Charge Code	8504492
Hospital Revenue Code	278
Min. Negotiated Rate	$2,981.93
Max. Negotiated Rate	$16,566.26
Rate for Payer: Aetna Commercial	$9,939.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,981.93
Rate for Payer: BCBS of TX Blue Advantage	$9,939.76
Rate for Payer: BCBS of TX Blue Essentials	$11,927.71
Rate for Payer: BCBS of TX PPO	$13,253.01
Rate for Payer: Cash Price	$29,156.63
Rate for Payer: Multiplan Auto	$16,566.26
Rate for Payer: Multiplan Commercial	$16,566.26
Rate for Payer: Multiplan Workers Comp	$16,566.26
Rate for Payer: Scott and White EPO/PPO	$16,566.26
Rate for Payer: Superior Health Plan EPO	$4,506.02

IMPL INTERBODY CAGE

Facility

$33,132.53

Service Code	HCPCS C1713
Hospital Charge Code	8504492
Hospital Revenue Code	278
Min. Negotiated Rate	$8,283.13
Max. Negotiated Rate	$16,566.26
Rate for Payer: Aetna Commercial	$9,939.76
Rate for Payer: Cash Price	$29,156.63
Rate for Payer: Cigna Commercial	$8,283.13
Rate for Payer: Multiplan Auto	$16,566.26
Rate for Payer: Multiplan Commercial	$16,566.26
Rate for Payer: Multiplan Workers Comp	$16,566.26
Rate for Payer: Scott and White EPO/PPO	$16,566.26

IMPL LEAD 1456Q/86 QUARTET

Facility

$15,813.25

Service Code	HCPCS C1900
Hospital Charge Code	8502475
Hospital Revenue Code	278
Min. Negotiated Rate	$1,423.19
Max. Negotiated Rate	$7,906.62
Rate for Payer: Aetna Commercial	$4,743.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1,423.19
Rate for Payer: BCBS of TX Blue Advantage	$4,743.98
Rate for Payer: BCBS of TX Blue Essentials	$5,692.77
Rate for Payer: BCBS of TX PPO	$6,325.30
Rate for Payer: Cash Price	$13,915.66
Rate for Payer: Multiplan Auto	$7,906.62
Rate for Payer: Multiplan Commercial	$7,906.62
Rate for Payer: Multiplan Workers Comp	$7,906.62
Rate for Payer: Scott and White EPO/PPO	$7,906.62
Rate for Payer: Superior Health Plan EPO	$2,150.60

IMPL LEAD 1456Q/86 QUARTET

Facility

$15,813.25

Service Code	HCPCS C1900
Hospital Charge Code	8502475
Hospital Revenue Code	278
Min. Negotiated Rate	$3,953.31
Max. Negotiated Rate	$7,906.62
Rate for Payer: Aetna Commercial	$4,743.98
Rate for Payer: Cash Price	$13,915.66
Rate for Payer: Cigna Commercial	$3,953.31
Rate for Payer: Multiplan Auto	$7,906.62
Rate for Payer: Multiplan Commercial	$7,906.62
Rate for Payer: Multiplan Workers Comp	$7,906.62
Rate for Payer: Scott and White EPO/PPO	$7,906.62

IMPL LEAD DEFIB OPTISURE 210Q

Facility

$24,096.39

Service Code	HCPCS C1895
Hospital Charge Code	8404462
Hospital Revenue Code	278
Min. Negotiated Rate	$2,168.68
Max. Negotiated Rate	$12,048.20
Rate for Payer: Aetna Commercial	$7,228.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2,168.68
Rate for Payer: BCBS of TX Blue Advantage	$7,228.92
Rate for Payer: BCBS of TX Blue Essentials	$8,674.70
Rate for Payer: BCBS of TX PPO	$9,638.56
Rate for Payer: Cash Price	$21,204.82
Rate for Payer: Multiplan Auto	$12,048.20
Rate for Payer: Multiplan Commercial	$12,048.20
Rate for Payer: Multiplan Workers Comp	$12,048.20
Rate for Payer: Scott and White EPO/PPO	$12,048.20
Rate for Payer: Superior Health Plan EPO	$3,277.11

IMPL LEAD DEFIB OPTISURE 210Q

Facility

$24,096.39

Service Code	HCPCS C1895
Hospital Charge Code	8404462
Hospital Revenue Code	278
Min. Negotiated Rate	$6,024.10
Max. Negotiated Rate	$12,048.20
Rate for Payer: Aetna Commercial	$7,228.92
Rate for Payer: Cash Price	$21,204.82
Rate for Payer: Cigna Commercial	$6,024.10
Rate for Payer: Multiplan Auto	$12,048.20
Rate for Payer: Multiplan Commercial	$12,048.20
Rate for Payer: Multiplan Workers Comp	$12,048.20
Rate for Payer: Scott and White EPO/PPO	$12,048.20

IMPL LEAD RELIANCE 4 FRONT 0673

Facility

$21,686.75

Service Code	HCPCS C1777
Hospital Charge Code	8414453
Hospital Revenue Code	278
Min. Negotiated Rate	$1,951.81
Max. Negotiated Rate	$10,843.38
Rate for Payer: Aetna Commercial	$6,506.02
Rate for Payer: Amerigroup CHIP/Medicaid	$1,951.81
Rate for Payer: BCBS of TX Blue Advantage	$6,506.02
Rate for Payer: BCBS of TX Blue Essentials	$7,807.23
Rate for Payer: BCBS of TX PPO	$8,674.70
Rate for Payer: Cash Price	$19,084.34
Rate for Payer: Multiplan Auto	$10,843.38
Rate for Payer: Multiplan Commercial	$10,843.38
Rate for Payer: Multiplan Workers Comp	$10,843.38
Rate for Payer: Scott and White EPO/PPO	$10,843.38
Rate for Payer: Superior Health Plan EPO	$2,949.40

IMPL LEAD RELIANCE 4 FRONT 0673

Facility

$21,686.75

Service Code	HCPCS C1777
Hospital Charge Code	8414453
Hospital Revenue Code	278
Min. Negotiated Rate	$5,421.69
Max. Negotiated Rate	$10,843.38
Rate for Payer: Aetna Commercial	$6,506.02
Rate for Payer: Cash Price	$19,084.34
Rate for Payer: Cigna Commercial	$5,421.69
Rate for Payer: Multiplan Auto	$10,843.38
Rate for Payer: Multiplan Commercial	$10,843.38
Rate for Payer: Multiplan Workers Comp	$10,843.38
Rate for Payer: Scott and White EPO/PPO	$10,843.38

IMPL MESH PHASIX SOFT TISSUE RECONSTRUCT

Facility

$11,363.63

Service Code	HCPCS C1781
Hospital Charge Code	8394468
Hospital Revenue Code	278
Min. Negotiated Rate	$1,022.73
Max. Negotiated Rate	$5,681.82
Rate for Payer: Aetna Commercial	$3,409.09
Rate for Payer: Amerigroup CHIP/Medicaid	$1,022.73
Rate for Payer: BCBS of TX Blue Advantage	$3,409.09
Rate for Payer: BCBS of TX Blue Essentials	$4,090.91
Rate for Payer: BCBS of TX PPO	$4,545.45
Rate for Payer: Cash Price	$9,999.99
Rate for Payer: Multiplan Auto	$5,681.82
Rate for Payer: Multiplan Commercial	$5,681.82
Rate for Payer: Multiplan Workers Comp	$5,681.82
Rate for Payer: Scott and White EPO/PPO	$5,681.82
Rate for Payer: Superior Health Plan EPO	$1,545.45

IMPL MESH PHASIX SOFT TISSUE RECONSTRUCT

Facility

$11,363.63

Service Code	HCPCS C1781
Hospital Charge Code	8394468
Hospital Revenue Code	278
Min. Negotiated Rate	$2,840.91
Max. Negotiated Rate	$5,681.82
Rate for Payer: Aetna Commercial	$3,409.09
Rate for Payer: Cash Price	$9,999.99
Rate for Payer: Cigna Commercial	$2,840.91
Rate for Payer: Multiplan Auto	$5,681.82
Rate for Payer: Multiplan Commercial	$5,681.82
Rate for Payer: Multiplan Workers Comp	$5,681.82
Rate for Payer: Scott and White EPO/PPO	$5,681.82

IMPL PACEMAKER QUADRA ALLURE MP RMI

Facility

$51,415.28

Service Code	HCPCS C1882
Hospital Charge Code	8420452
Hospital Revenue Code	275
Min. Negotiated Rate	$12,853.82
Max. Negotiated Rate	$25,707.64
Rate for Payer: Aetna Commercial	$15,424.58
Rate for Payer: Cash Price	$45,245.45
Rate for Payer: Cigna Commercial	$12,853.82
Rate for Payer: Multiplan Auto	$25,707.64
Rate for Payer: Multiplan Commercial	$25,707.64
Rate for Payer: Multiplan Workers Comp	$25,707.64
Rate for Payer: Scott and White EPO/PPO	$25,707.64

IMPL PACEMAKER QUADRA ALLURE MP RMI

Facility

$51,415.28

Service Code	HCPCS C1882
Hospital Charge Code	8420452
Hospital Revenue Code	275
Min. Negotiated Rate	$4,627.38
Max. Negotiated Rate	$25,707.64
Rate for Payer: Aetna Commercial	$15,424.58
Rate for Payer: Amerigroup CHIP/Medicaid	$4,627.38
Rate for Payer: BCBS of TX Blue Advantage	$15,424.58
Rate for Payer: BCBS of TX Blue Essentials	$18,509.50
Rate for Payer: BCBS of TX PPO	$20,566.11
Rate for Payer: Cash Price	$45,245.45
Rate for Payer: Multiplan Auto	$25,707.64
Rate for Payer: Multiplan Commercial	$25,707.64
Rate for Payer: Multiplan Workers Comp	$25,707.64
Rate for Payer: Scott and White EPO/PPO	$25,707.64
Rate for Payer: Superior Health Plan EPO	$6,992.48

Know your out-of-pocket cost for care.

All Charges