White Rock Medical Center

All Charges

Charge

Type

Setting

Price

IMPL PLATE LEVEL 3

Facility

$16,867.47

Service Code	HCPCS C1713
Hospital Charge Code	8420466
Hospital Revenue Code	278
Min. Negotiated Rate	$4,216.87
Max. Negotiated Rate	$8,433.74
Rate for Payer: Aetna Commercial	$5,060.24
Rate for Payer: Cash Price	$14,843.37
Rate for Payer: Cigna Commercial	$4,216.87
Rate for Payer: Multiplan Auto	$8,433.74
Rate for Payer: Multiplan Commercial	$8,433.74
Rate for Payer: Multiplan Workers Comp	$8,433.74
Rate for Payer: Scott and White EPO/PPO	$8,433.74

IMPL PLATE LEVEL 3

Facility

$16,867.47

Service Code	HCPCS C1713
Hospital Charge Code	8420466
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.07
Max. Negotiated Rate	$8,433.74
Rate for Payer: Aetna Commercial	$5,060.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,518.07
Rate for Payer: BCBS of TX Blue Advantage	$5,060.24
Rate for Payer: BCBS of TX Blue Essentials	$6,072.29
Rate for Payer: BCBS of TX PPO	$6,746.99
Rate for Payer: Cash Price	$14,843.37
Rate for Payer: Multiplan Auto	$8,433.74
Rate for Payer: Multiplan Commercial	$8,433.74
Rate for Payer: Multiplan Workers Comp	$8,433.74
Rate for Payer: Scott and White EPO/PPO	$8,433.74
Rate for Payer: Superior Health Plan EPO	$2,293.98

IMPL SCREW CENTER 6.5MM

Facility

$602.40

Service Code	HCPCS C1713
Hospital Charge Code	8504479
Hospital Revenue Code	278
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$301.20
Rate for Payer: Aetna Commercial	$180.72
Rate for Payer: Amerigroup CHIP/Medicaid	$54.22
Rate for Payer: BCBS of TX Blue Advantage	$180.72
Rate for Payer: BCBS of TX Blue Essentials	$216.86
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$530.11
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20
Rate for Payer: Superior Health Plan EPO	$81.93

IMPL SCREW CENTER 6.5MM

Facility

$602.40

Service Code	HCPCS C1713
Hospital Charge Code	8504479
Hospital Revenue Code	278
Min. Negotiated Rate	$150.60
Max. Negotiated Rate	$301.20
Rate for Payer: Aetna Commercial	$180.72
Rate for Payer: Cash Price	$530.11
Rate for Payer: Cigna Commercial	$150.60
Rate for Payer: Multiplan Auto	$301.20
Rate for Payer: Multiplan Commercial	$301.20
Rate for Payer: Multiplan Workers Comp	$301.20
Rate for Payer: Scott and White EPO/PPO	$301.20

IMPL STENT CRTD 8-6MM

Facility

$11,566.26

Service Code	HCPCS C1876
Hospital Charge Code	8504481
Hospital Revenue Code	278
Min. Negotiated Rate	$1,040.96
Max. Negotiated Rate	$5,783.13
Rate for Payer: Aetna Commercial	$3,469.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,040.96
Rate for Payer: BCBS of TX Blue Advantage	$3,469.88
Rate for Payer: BCBS of TX Blue Essentials	$4,163.85
Rate for Payer: BCBS of TX PPO	$4,626.50
Rate for Payer: Cash Price	$10,178.31
Rate for Payer: Multiplan Auto	$5,783.13
Rate for Payer: Multiplan Commercial	$5,783.13
Rate for Payer: Multiplan Workers Comp	$5,783.13
Rate for Payer: Scott and White EPO/PPO	$5,783.13
Rate for Payer: Superior Health Plan EPO	$1,573.01

IMPL STENT CRTD 8-6MM

Facility

$11,566.26

Service Code	HCPCS C1876
Hospital Charge Code	8504481
Hospital Revenue Code	278
Min. Negotiated Rate	$2,891.56
Max. Negotiated Rate	$5,783.13
Rate for Payer: Aetna Commercial	$3,469.88
Rate for Payer: Cash Price	$10,178.31
Rate for Payer: Cigna Commercial	$2,891.56
Rate for Payer: Multiplan Auto	$5,783.13
Rate for Payer: Multiplan Commercial	$5,783.13
Rate for Payer: Multiplan Workers Comp	$5,783.13
Rate for Payer: Scott and White EPO/PPO	$5,783.13

IMPL STRAIGHT ROD

Facility

$2,066.11

Service Code	HCPCS C1713
Hospital Charge Code	8420455
Hospital Revenue Code	278
Min. Negotiated Rate	$185.95
Max. Negotiated Rate	$1,033.06
Rate for Payer: Aetna Commercial	$619.83
Rate for Payer: Amerigroup CHIP/Medicaid	$185.95
Rate for Payer: BCBS of TX Blue Advantage	$619.83
Rate for Payer: BCBS of TX Blue Essentials	$743.80
Rate for Payer: BCBS of TX PPO	$826.44
Rate for Payer: Cash Price	$1,818.18
Rate for Payer: Multiplan Auto	$1,033.06
Rate for Payer: Multiplan Commercial	$1,033.06
Rate for Payer: Multiplan Workers Comp	$1,033.06
Rate for Payer: Scott and White EPO/PPO	$1,033.06
Rate for Payer: Superior Health Plan EPO	$280.99

IMPL STRAIGHT ROD

Facility

$2,066.11

Service Code	HCPCS C1713
Hospital Charge Code	8420455
Hospital Revenue Code	278
Min. Negotiated Rate	$516.53
Max. Negotiated Rate	$1,033.06
Rate for Payer: Aetna Commercial	$619.83
Rate for Payer: Cash Price	$1,818.18
Rate for Payer: Cigna Commercial	$516.53
Rate for Payer: Multiplan Auto	$1,033.06
Rate for Payer: Multiplan Commercial	$1,033.06
Rate for Payer: Multiplan Workers Comp	$1,033.06
Rate for Payer: Scott and White EPO/PPO	$1,033.06

IMPL SYS MINI PTC SPACER

Facility

$7,289.15

Service Code	HCPCS C1713
Hospital Charge Code	8492475
Hospital Revenue Code	278
Min. Negotiated Rate	$1,822.29
Max. Negotiated Rate	$3,644.58
Rate for Payer: Aetna Commercial	$2,186.74
Rate for Payer: Cash Price	$6,414.45
Rate for Payer: Cigna Commercial	$1,822.29
Rate for Payer: Multiplan Auto	$3,644.58
Rate for Payer: Multiplan Commercial	$3,644.58
Rate for Payer: Multiplan Workers Comp	$3,644.58
Rate for Payer: Scott and White EPO/PPO	$3,644.58

IMPL SYS MINI PTC SPACER

Facility

$7,289.15

Service Code	HCPCS C1713
Hospital Charge Code	8492475
Hospital Revenue Code	278
Min. Negotiated Rate	$656.02
Max. Negotiated Rate	$3,644.58
Rate for Payer: Aetna Commercial	$2,186.74
Rate for Payer: Amerigroup CHIP/Medicaid	$656.02
Rate for Payer: BCBS of TX Blue Advantage	$2,186.74
Rate for Payer: BCBS of TX Blue Essentials	$2,624.09
Rate for Payer: BCBS of TX PPO	$2,915.66
Rate for Payer: Cash Price	$6,414.45
Rate for Payer: Multiplan Auto	$3,644.58
Rate for Payer: Multiplan Commercial	$3,644.58
Rate for Payer: Multiplan Workers Comp	$3,644.58
Rate for Payer: Scott and White EPO/PPO	$3,644.58
Rate for Payer: Superior Health Plan EPO	$991.32

IMPL TISSUE MEMBRANE LIQ 2.0ML

Facility

$13,253.01

Service Code	HCPCS C1713
Hospital Charge Code	8394462
Hospital Revenue Code	278
Min. Negotiated Rate	$3,313.25
Max. Negotiated Rate	$6,626.50
Rate for Payer: Aetna Commercial	$3,975.90
Rate for Payer: Cash Price	$11,662.65
Rate for Payer: Cigna Commercial	$3,313.25
Rate for Payer: Multiplan Auto	$6,626.50
Rate for Payer: Multiplan Commercial	$6,626.50
Rate for Payer: Multiplan Workers Comp	$6,626.50
Rate for Payer: Scott and White EPO/PPO	$6,626.50

IMPL TISSUE MEMBRANE LIQ 2.0ML

Facility

$13,253.01

Service Code	HCPCS C1713
Hospital Charge Code	8394462
Hospital Revenue Code	278
Min. Negotiated Rate	$1,192.77
Max. Negotiated Rate	$6,626.50
Rate for Payer: Aetna Commercial	$3,975.90
Rate for Payer: Amerigroup CHIP/Medicaid	$1,192.77
Rate for Payer: BCBS of TX Blue Advantage	$3,975.90
Rate for Payer: BCBS of TX Blue Essentials	$4,771.08
Rate for Payer: BCBS of TX PPO	$5,301.20
Rate for Payer: Cash Price	$11,662.65
Rate for Payer: Multiplan Auto	$6,626.50
Rate for Payer: Multiplan Commercial	$6,626.50
Rate for Payer: Multiplan Workers Comp	$6,626.50
Rate for Payer: Scott and White EPO/PPO	$6,626.50
Rate for Payer: Superior Health Plan EPO	$1,802.41

IMP LUMBAR INTERBODY LATERAL

Facility

$75,301.20

Service Code	HCPCS C1776
Hospital Charge Code	145087
Hospital Revenue Code	278
Min. Negotiated Rate	$18,825.30
Max. Negotiated Rate	$37,650.60
Rate for Payer: Aetna Commercial	$22,590.36
Rate for Payer: Cash Price	$66,265.06
Rate for Payer: Cigna Commercial	$18,825.30
Rate for Payer: Multiplan Auto	$37,650.60
Rate for Payer: Multiplan Commercial	$37,650.60
Rate for Payer: Multiplan Workers Comp	$37,650.60
Rate for Payer: Scott and White EPO/PPO	$37,650.60

IMP LUMBAR INTERBODY LATERAL

Facility

$75,301.20

Service Code	HCPCS C1776
Hospital Charge Code	145087
Hospital Revenue Code	278
Min. Negotiated Rate	$6,777.11
Max. Negotiated Rate	$37,650.60
Rate for Payer: Aetna Commercial	$22,590.36
Rate for Payer: Amerigroup CHIP/Medicaid	$6,777.11
Rate for Payer: BCBS of TX Blue Advantage	$22,590.36
Rate for Payer: BCBS of TX Blue Essentials	$27,108.43
Rate for Payer: BCBS of TX PPO	$30,120.48
Rate for Payer: Cash Price	$66,265.06
Rate for Payer: Multiplan Auto	$37,650.60
Rate for Payer: Multiplan Commercial	$37,650.60
Rate for Payer: Multiplan Workers Comp	$37,650.60
Rate for Payer: Scott and White EPO/PPO	$37,650.60
Rate for Payer: Superior Health Plan EPO	$10,240.96

IMPL VAULT ALIF PEEK PLATE 32MM X 15X 15MM

Facility

$18,072.29

Service Code	HCPCS C1713
Hospital Charge Code	8394465
Hospital Revenue Code	278
Min. Negotiated Rate	$4,518.07
Max. Negotiated Rate	$9,036.14
Rate for Payer: Aetna Commercial	$5,421.69
Rate for Payer: Cash Price	$15,903.62
Rate for Payer: Cigna Commercial	$4,518.07
Rate for Payer: Multiplan Auto	$9,036.14
Rate for Payer: Multiplan Commercial	$9,036.14
Rate for Payer: Multiplan Workers Comp	$9,036.14
Rate for Payer: Scott and White EPO/PPO	$9,036.14

IMPL VAULT ALIF PEEK PLATE 32MM X 15X 15MM

Facility

$18,072.29

Service Code	HCPCS C1713
Hospital Charge Code	8394465
Hospital Revenue Code	278
Min. Negotiated Rate	$1,626.51
Max. Negotiated Rate	$9,036.14
Rate for Payer: Aetna Commercial	$5,421.69
Rate for Payer: Amerigroup CHIP/Medicaid	$1,626.51
Rate for Payer: BCBS of TX Blue Advantage	$5,421.69
Rate for Payer: BCBS of TX Blue Essentials	$6,506.02
Rate for Payer: BCBS of TX PPO	$7,228.92
Rate for Payer: Cash Price	$15,903.62
Rate for Payer: Multiplan Auto	$9,036.14
Rate for Payer: Multiplan Commercial	$9,036.14
Rate for Payer: Multiplan Workers Comp	$9,036.14
Rate for Payer: Scott and White EPO/PPO	$9,036.14
Rate for Payer: Superior Health Plan EPO	$2,457.83

impl vault peek cage 39x15x15

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	8618507
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 vault peek cage 39x15x15

Facility

$36,144.58

Service Code	HCPCS C1713
Hospital Charge Code	8618507
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 WASHER ASNS ORTHO 5MM

Facility

$295.06

Service Code	HCPCS C1713
Hospital Charge Code	8504489
Hospital Revenue Code	278
Min. Negotiated Rate	$26.56
Max. Negotiated Rate	$147.53
Rate for Payer: Aetna Commercial	$88.52
Rate for Payer: Amerigroup CHIP/Medicaid	$26.56
Rate for Payer: BCBS of TX Blue Advantage	$88.52
Rate for Payer: BCBS of TX Blue Essentials	$106.22
Rate for Payer: BCBS of TX PPO	$118.02
Rate for Payer: Cash Price	$259.65
Rate for Payer: Multiplan Auto	$147.53
Rate for Payer: Multiplan Commercial	$147.53
Rate for Payer: Multiplan Workers Comp	$147.53
Rate for Payer: Scott and White EPO/PPO	$147.53
Rate for Payer: Superior Health Plan EPO	$40.13

IMPL WASHER ASNS ORTHO 5MM

Facility

$295.06

Service Code	HCPCS C1713
Hospital Charge Code	8504489
Hospital Revenue Code	278
Min. Negotiated Rate	$73.76
Max. Negotiated Rate	$147.53
Rate for Payer: Aetna Commercial	$88.52
Rate for Payer: Cash Price	$259.65
Rate for Payer: Cigna Commercial	$73.76
Rate for Payer: Multiplan Auto	$147.53
Rate for Payer: Multiplan Commercial	$147.53
Rate for Payer: Multiplan Workers Comp	$147.53
Rate for Payer: Scott and White EPO/PPO	$147.53

IMPL WIRE PILOT NITINOL

Facility

$421.68

Service Code	HCPCS C1713
Hospital Charge Code	8504478
Hospital Revenue Code	278
Min. Negotiated Rate	$37.95
Max. Negotiated Rate	$210.84
Rate for Payer: Aetna Commercial	$126.50
Rate for Payer: Amerigroup CHIP/Medicaid	$37.95
Rate for Payer: BCBS of TX Blue Advantage	$126.50
Rate for Payer: BCBS of TX Blue Essentials	$151.80
Rate for Payer: BCBS of TX PPO	$168.67
Rate for Payer: Cash Price	$371.08
Rate for Payer: Multiplan Auto	$210.84
Rate for Payer: Multiplan Commercial	$210.84
Rate for Payer: Multiplan Workers Comp	$210.84
Rate for Payer: Scott and White EPO/PPO	$210.84
Rate for Payer: Superior Health Plan EPO	$57.35

IMPL WIRE PILOT NITINOL

Facility

$421.68

Service Code	HCPCS C1713
Hospital Charge Code	8504478
Hospital Revenue Code	278
Min. Negotiated Rate	$105.42
Max. Negotiated Rate	$210.84
Rate for Payer: Aetna Commercial	$126.50
Rate for Payer: Cash Price	$371.08
Rate for Payer: Cigna Commercial	$105.42
Rate for Payer: Multiplan Auto	$210.84
Rate for Payer: Multiplan Commercial	$210.84
Rate for Payer: Multiplan Workers Comp	$210.84
Rate for Payer: Scott and White EPO/PPO	$210.84

IMP MONITOR CARD CONFIRM RX -- DHF

Facility

$30,120.48

Service Code	HCPCS C1764
Hospital Charge Code	40003634
Hospital Revenue Code	278
Min. Negotiated Rate	$2,710.84
Max. Negotiated Rate	$15,060.24
Rate for Payer: Aetna Commercial	$9,036.14
Rate for Payer: Amerigroup CHIP/Medicaid	$2,710.84
Rate for Payer: BCBS of TX Blue Advantage	$9,036.14
Rate for Payer: BCBS of TX Blue Essentials	$10,843.37
Rate for Payer: BCBS of TX PPO	$12,048.19
Rate for Payer: Cash Price	$26,506.02
Rate for Payer: Multiplan Auto	$15,060.24
Rate for Payer: Multiplan Commercial	$15,060.24
Rate for Payer: Multiplan Workers Comp	$15,060.24
Rate for Payer: Scott and White EPO/PPO	$15,060.24
Rate for Payer: Superior Health Plan EPO	$4,096.39

IMP MONITOR CARD CONFIRM RX -- DHF

Facility

$30,120.48

Service Code	HCPCS C1764
Hospital Charge Code	40003634
Hospital Revenue Code	278
Min. Negotiated Rate	$7,530.12
Max. Negotiated Rate	$15,060.24
Rate for Payer: Aetna Commercial	$9,036.14
Rate for Payer: Cash Price	$26,506.02
Rate for Payer: Cigna Commercial	$7,530.12
Rate for Payer: Multiplan Auto	$15,060.24
Rate for Payer: Multiplan Commercial	$15,060.24
Rate for Payer: Multiplan Workers Comp	$15,060.24
Rate for Payer: Scott and White EPO/PPO	$15,060.24

IMP PORT INDWELLING -- DHF

Facility

$1,836.33

Service Code	HCPCS C1788
Hospital Charge Code	82402017
Hospital Revenue Code	278
Min. Negotiated Rate	$459.08
Max. Negotiated Rate	$918.16
Rate for Payer: Aetna Commercial	$550.90
Rate for Payer: Cash Price	$1,615.97
Rate for Payer: Cigna Commercial	$459.08
Rate for Payer: Multiplan Auto	$918.16
Rate for Payer: Multiplan Commercial	$918.16
Rate for Payer: Multiplan Workers Comp	$918.16
Rate for Payer: Scott and White EPO/PPO	$918.16

Know your out-of-pocket cost for care.

All Charges