White Rock Medical Center

All Charges

Charge

Type

Setting

Price

IVUS NON CORONARY INITL

Facility

$4,820.00

Service Code	CPT 37252
Hospital Charge Code	4615944
Hospital Revenue Code	360
Min. Negotiated Rate	$433.80
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,651.00
Rate for Payer: Amerigroup CHIP/Medicaid	$433.80
Rate for Payer: Cash Price	$4,241.60
Rate for Payer: Cash Price	$4,241.60
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	$2,410.00
Rate for Payer: Superior Health Plan EPO	$655.52

IVUS NON CORONARY INITL

Facility

$4,820.00

Service Code	CPT 37252
Hospital Charge Code	4615944
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,241.60

juggerloc bone to bone

Facility

$4,301.20

Service Code	HCPCS C1713
Hospital Charge Code	8660509
Hospital Revenue Code	278
Min. Negotiated Rate	$387.11
Max. Negotiated Rate	$2,150.60
Rate for Payer: Aetna Commercial	$1,290.36
Rate for Payer: Amerigroup CHIP/Medicaid	$387.11
Rate for Payer: BCBS of TX Blue Advantage	$1,290.36
Rate for Payer: BCBS of TX Blue Essentials	$1,548.43
Rate for Payer: BCBS of TX PPO	$1,720.48
Rate for Payer: Cash Price	$3,785.06
Rate for Payer: Multiplan Auto	$2,150.60
Rate for Payer: Multiplan Commercial	$2,150.60
Rate for Payer: Multiplan Workers Comp	$2,150.60
Rate for Payer: Scott and White EPO/PPO	$2,150.60
Rate for Payer: Superior Health Plan EPO	$584.96

juggerloc bone to bone

Facility

$4,301.20

Service Code	HCPCS C1713
Hospital Charge Code	8660509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,075.30
Max. Negotiated Rate	$2,150.60
Rate for Payer: Aetna Commercial	$1,290.36
Rate for Payer: Cash Price	$3,785.06
Rate for Payer: Cigna Commercial	$1,075.30
Rate for Payer: Multiplan Auto	$2,150.60
Rate for Payer: Multiplan Commercial	$2,150.60
Rate for Payer: Multiplan Workers Comp	$2,150.60
Rate for Payer: Scott and White EPO/PPO	$2,150.60

juggerloc kit

Facility

$723.22

Hospital Charge Code	8720589
Hospital Revenue Code	272
Min. Negotiated Rate	$65.09
Max. Negotiated Rate	$470.09
Rate for Payer: Aetna Commercial	$397.77
Rate for Payer: Amerigroup CHIP/Medicaid	$65.09
Rate for Payer: BCBS of TX Blue Advantage	$216.97
Rate for Payer: BCBS of TX Blue Essentials	$260.36
Rate for Payer: BCBS of TX PPO	$289.29
Rate for Payer: Cash Price	$636.43
Rate for Payer: Multiplan Auto	$470.09
Rate for Payer: Multiplan Commercial	$470.09
Rate for Payer: Multiplan Workers Comp	$470.09
Rate for Payer: Scott and White EPO/PPO	$361.61
Rate for Payer: Superior Health Plan EPO	$98.36

juggerloc kit

Facility

$723.22

Hospital Charge Code	8720589
Hospital Revenue Code	272
Rate for Payer: Cash Price	$636.43

JUGGERSTITCH CANNULA HALFPIPE

Facility

$385.90

Hospital Charge Code	145085
Hospital Revenue Code	272
Min. Negotiated Rate	$34.73
Max. Negotiated Rate	$250.84
Rate for Payer: Aetna Commercial	$212.24
Rate for Payer: Amerigroup CHIP/Medicaid	$34.73
Rate for Payer: BCBS of TX Blue Advantage	$115.77
Rate for Payer: BCBS of TX Blue Essentials	$138.92
Rate for Payer: BCBS of TX PPO	$154.36
Rate for Payer: Cash Price	$339.59
Rate for Payer: Multiplan Auto	$250.84
Rate for Payer: Multiplan Commercial	$250.84
Rate for Payer: Multiplan Workers Comp	$250.84
Rate for Payer: Scott and White EPO/PPO	$192.95
Rate for Payer: Superior Health Plan EPO	$52.48

JUGGERSTITCH CANNULA HALFPIPE

Facility

$385.90

Hospital Charge Code	145085
Hospital Revenue Code	272
Rate for Payer: Cash Price	$339.59

JUGGERSTITCH CURVED MENISCAL RPR DEVICE

Facility

$1,867.47

Service Code	HCPCS C1776
Hospital Charge Code	145084
Hospital Revenue Code	278
Min. Negotiated Rate	$168.07
Max. Negotiated Rate	$933.74
Rate for Payer: Aetna Commercial	$560.24
Rate for Payer: Amerigroup CHIP/Medicaid	$168.07
Rate for Payer: BCBS of TX Blue Advantage	$560.24
Rate for Payer: BCBS of TX Blue Essentials	$672.29
Rate for Payer: BCBS of TX PPO	$746.99
Rate for Payer: Cash Price	$1,643.37
Rate for Payer: Multiplan Auto	$933.74
Rate for Payer: Multiplan Commercial	$933.74
Rate for Payer: Multiplan Workers Comp	$933.74
Rate for Payer: Scott and White EPO/PPO	$933.74
Rate for Payer: Superior Health Plan EPO	$253.98

JUGGERSTITCH CURVED MENISCAL RPR DEVICE

Facility

$1,867.47

Service Code	HCPCS C1776
Hospital Charge Code	145084
Hospital Revenue Code	278
Min. Negotiated Rate	$466.87
Max. Negotiated Rate	$933.74
Rate for Payer: Aetna Commercial	$560.24
Rate for Payer: Cash Price	$1,643.37
Rate for Payer: Cigna Commercial	$466.87
Rate for Payer: Multiplan Auto	$933.74
Rate for Payer: Multiplan Commercial	$933.74
Rate for Payer: Multiplan Workers Comp	$933.74
Rate for Payer: Scott and White EPO/PPO	$933.74

kerecis micrograft omega3 19cm ea sq/cm

Facility

$332.90

Service Code	HCPCS Q4158
Hospital Charge Code	8672532
Hospital Revenue Code	278
Min. Negotiated Rate	$83.22
Max. Negotiated Rate	$166.45
Rate for Payer: Aetna Commercial	$99.87
Rate for Payer: Cash Price	$292.95
Rate for Payer: Cigna Commercial	$83.22
Rate for Payer: Multiplan Auto	$166.45
Rate for Payer: Multiplan Commercial	$166.45
Rate for Payer: Multiplan Workers Comp	$166.45
Rate for Payer: Scott and White EPO/PPO	$166.45

kerecis micrograft omega3 19cm ea sq/cm

Facility

$332.90

Service Code	HCPCS Q4158
Hospital Charge Code	8672532
Hospital Revenue Code	278
Min. Negotiated Rate	$29.96
Max. Negotiated Rate	$166.45
Rate for Payer: Aetna Commercial	$99.87
Rate for Payer: Amerigroup CHIP/Medicaid	$29.96
Rate for Payer: BCBS of TX Blue Advantage	$99.87
Rate for Payer: BCBS of TX Blue Essentials	$119.84
Rate for Payer: BCBS of TX PPO	$133.16
Rate for Payer: Cash Price	$292.95
Rate for Payer: Multiplan Auto	$166.45
Rate for Payer: Multiplan Commercial	$166.45
Rate for Payer: Multiplan Workers Comp	$166.45
Rate for Payer: Scott and White EPO/PPO	$166.45
Rate for Payer: Superior Health Plan EPO	$45.27

kerecis omega3 1.75x1.75 50200s00b0d per sq cm

Facility

$828.31

Service Code	HCPCS Q4158
Hospital Charge Code	8638509
Hospital Revenue Code	278
Min. Negotiated Rate	$207.08
Max. Negotiated Rate	$414.16
Rate for Payer: Aetna Commercial	$248.49
Rate for Payer: Cash Price	$728.91
Rate for Payer: Cigna Commercial	$207.08
Rate for Payer: Multiplan Auto	$414.16
Rate for Payer: Multiplan Commercial	$414.16
Rate for Payer: Multiplan Workers Comp	$414.16
Rate for Payer: Scott and White EPO/PPO	$414.16

kerecis omega3 1.75x1.75 50200s00b0d per sq cm

Facility

$828.31

Service Code	HCPCS Q4158
Hospital Charge Code	8638509
Hospital Revenue Code	278
Min. Negotiated Rate	$74.55
Max. Negotiated Rate	$414.16
Rate for Payer: Aetna Commercial	$248.49
Rate for Payer: Amerigroup CHIP/Medicaid	$74.55
Rate for Payer: BCBS of TX Blue Advantage	$248.49
Rate for Payer: BCBS of TX Blue Essentials	$298.19
Rate for Payer: BCBS of TX PPO	$331.32
Rate for Payer: Cash Price	$728.91
Rate for Payer: Multiplan Auto	$414.16
Rate for Payer: Multiplan Commercial	$414.16
Rate for Payer: Multiplan Workers Comp	$414.16
Rate for Payer: Scott and White EPO/PPO	$414.16
Rate for Payer: Superior Health Plan EPO	$112.65

kerecis omega3 1.75x1.75 (bx) 50200s00b2d sq cm

Facility

$411.14

Service Code	HCPCS Q4158
Hospital Charge Code	8640532
Hospital Revenue Code	278
Min. Negotiated Rate	$102.78
Max. Negotiated Rate	$205.57
Rate for Payer: Aetna Commercial	$123.34
Rate for Payer: Cash Price	$361.80
Rate for Payer: Cigna Commercial	$102.78
Rate for Payer: Multiplan Auto	$205.57
Rate for Payer: Multiplan Commercial	$205.57
Rate for Payer: Multiplan Workers Comp	$205.57
Rate for Payer: Scott and White EPO/PPO	$205.57

kerecis omega3 1.75x1.75 (bx) 50200s00b2d sq cm

Facility

$411.14

Service Code	HCPCS Q4158
Hospital Charge Code	8640532
Hospital Revenue Code	278
Min. Negotiated Rate	$37.00
Max. Negotiated Rate	$205.57
Rate for Payer: Aetna Commercial	$123.34
Rate for Payer: Amerigroup CHIP/Medicaid	$37.00
Rate for Payer: BCBS of TX Blue Advantage	$123.34
Rate for Payer: BCBS of TX Blue Essentials	$148.01
Rate for Payer: BCBS of TX PPO	$164.46
Rate for Payer: Cash Price	$361.80
Rate for Payer: Multiplan Auto	$205.57
Rate for Payer: Multiplan Commercial	$205.57
Rate for Payer: Multiplan Workers Comp	$205.57
Rate for Payer: Scott and White EPO/PPO	$205.57
Rate for Payer: Superior Health Plan EPO	$55.92

kerecis omega 3 3x3.5 50200s01b0d per sq cm

Facility

$414.58

Service Code	HCPCS Q4158
Hospital Charge Code	8640519
Hospital Revenue Code	278
Min. Negotiated Rate	$103.64
Max. Negotiated Rate	$207.29
Rate for Payer: Aetna Commercial	$124.37
Rate for Payer: Cash Price	$364.83
Rate for Payer: Cigna Commercial	$103.64
Rate for Payer: Multiplan Auto	$207.29
Rate for Payer: Multiplan Commercial	$207.29
Rate for Payer: Multiplan Workers Comp	$207.29
Rate for Payer: Scott and White EPO/PPO	$207.29

kerecis omega 3 3x3.5 50200s01b0d per sq cm

Facility

$414.58

Service Code	HCPCS Q4158
Hospital Charge Code	8640519
Hospital Revenue Code	278
Min. Negotiated Rate	$37.31
Max. Negotiated Rate	$207.29
Rate for Payer: Aetna Commercial	$124.37
Rate for Payer: Amerigroup CHIP/Medicaid	$37.31
Rate for Payer: BCBS of TX Blue Advantage	$124.37
Rate for Payer: BCBS of TX Blue Essentials	$149.25
Rate for Payer: BCBS of TX PPO	$165.83
Rate for Payer: Cash Price	$364.83
Rate for Payer: Multiplan Auto	$207.29
Rate for Payer: Multiplan Commercial	$207.29
Rate for Payer: Multiplan Workers Comp	$207.29
Rate for Payer: Scott and White EPO/PPO	$207.29
Rate for Payer: Superior Health Plan EPO	$56.38

kerecis omega3 3x3.5cm-50200s01b2d

Facility

$256.33

Service Code	HCPCS Q4158
Hospital Charge Code	8630553
Hospital Revenue Code	278
Min. Negotiated Rate	$64.08
Max. Negotiated Rate	$128.16
Rate for Payer: Aetna Commercial	$76.90
Rate for Payer: Cash Price	$225.57
Rate for Payer: Cigna Commercial	$64.08
Rate for Payer: Multiplan Auto	$128.16
Rate for Payer: Multiplan Commercial	$128.16
Rate for Payer: Multiplan Workers Comp	$128.16
Rate for Payer: Scott and White EPO/PPO	$128.16

kerecis omega3 3x3.5cm-50200s01b2d

Facility

$256.33

Service Code	HCPCS Q4158
Hospital Charge Code	8630553
Hospital Revenue Code	278
Min. Negotiated Rate	$23.07
Max. Negotiated Rate	$128.16
Rate for Payer: Aetna Commercial	$76.90
Rate for Payer: Amerigroup CHIP/Medicaid	$23.07
Rate for Payer: BCBS of TX Blue Advantage	$76.90
Rate for Payer: BCBS of TX Blue Essentials	$92.28
Rate for Payer: BCBS of TX PPO	$102.53
Rate for Payer: Cash Price	$225.57
Rate for Payer: Multiplan Auto	$128.16
Rate for Payer: Multiplan Commercial	$128.16
Rate for Payer: Multiplan Workers Comp	$128.16
Rate for Payer: Scott and White EPO/PPO	$128.16
Rate for Payer: Superior Health Plan EPO	$34.86

kerecis omega3 3x7cm(ea) 50200s02b0d sq cm

Facility

$346.51

Service Code	HCPCS Q4158
Hospital Charge Code	8640520
Hospital Revenue Code	278
Min. Negotiated Rate	$31.19
Max. Negotiated Rate	$173.26
Rate for Payer: Aetna Commercial	$103.95
Rate for Payer: Amerigroup CHIP/Medicaid	$31.19
Rate for Payer: BCBS of TX Blue Advantage	$103.95
Rate for Payer: BCBS of TX Blue Essentials	$124.74
Rate for Payer: BCBS of TX PPO	$138.60
Rate for Payer: Cash Price	$304.93
Rate for Payer: Multiplan Auto	$173.26
Rate for Payer: Multiplan Commercial	$173.26
Rate for Payer: Multiplan Workers Comp	$173.26
Rate for Payer: Scott and White EPO/PPO	$173.26
Rate for Payer: Superior Health Plan EPO	$47.13

kerecis omega3 3x7cm(ea) 50200s02b0d sq cm

Facility

$346.51

Service Code	HCPCS Q4158
Hospital Charge Code	8640520
Hospital Revenue Code	278
Min. Negotiated Rate	$86.63
Max. Negotiated Rate	$173.26
Rate for Payer: Aetna Commercial	$103.95
Rate for Payer: Cash Price	$304.93
Rate for Payer: Cigna Commercial	$86.63
Rate for Payer: Multiplan Auto	$173.26
Rate for Payer: Multiplan Commercial	$173.26
Rate for Payer: Multiplan Workers Comp	$173.26
Rate for Payer: Scott and White EPO/PPO	$173.26

kerecis omega 3 7x10 50200s03bod per sq cm

Facility

$274.64

Service Code	HCPCS Q4158
Hospital Charge Code	8638508
Hospital Revenue Code	278
Min. Negotiated Rate	$68.66
Max. Negotiated Rate	$137.32
Rate for Payer: Aetna Commercial	$82.39
Rate for Payer: Cash Price	$241.68
Rate for Payer: Cigna Commercial	$68.66
Rate for Payer: Multiplan Auto	$137.32
Rate for Payer: Multiplan Commercial	$137.32
Rate for Payer: Multiplan Workers Comp	$137.32
Rate for Payer: Scott and White EPO/PPO	$137.32

kerecis omega 3 7x10 50200s03bod per sq cm

Facility

$274.64

Service Code	HCPCS Q4158
Hospital Charge Code	8638508
Hospital Revenue Code	278
Min. Negotiated Rate	$24.72
Max. Negotiated Rate	$137.32
Rate for Payer: Aetna Commercial	$82.39
Rate for Payer: Amerigroup CHIP/Medicaid	$24.72
Rate for Payer: BCBS of TX Blue Advantage	$82.39
Rate for Payer: BCBS of TX Blue Essentials	$98.87
Rate for Payer: BCBS of TX PPO	$109.86
Rate for Payer: Cash Price	$241.68
Rate for Payer: Multiplan Auto	$137.32
Rate for Payer: Multiplan Commercial	$137.32
Rate for Payer: Multiplan Workers Comp	$137.32
Rate for Payer: Scott and White EPO/PPO	$137.32
Rate for Payer: Superior Health Plan EPO	$37.35

kerecis omega3 7x20 (ea) per sq cm

Facility

$323.25

Service Code	HCPCS C1781
Hospital Charge Code	8630552
Hospital Revenue Code	278
Min. Negotiated Rate	$29.09
Max. Negotiated Rate	$161.62
Rate for Payer: Aetna Commercial	$96.98
Rate for Payer: Amerigroup CHIP/Medicaid	$29.09
Rate for Payer: BCBS of TX Blue Advantage	$96.98
Rate for Payer: BCBS of TX Blue Essentials	$116.37
Rate for Payer: BCBS of TX PPO	$129.30
Rate for Payer: Cash Price	$284.46
Rate for Payer: Multiplan Auto	$161.62
Rate for Payer: Multiplan Commercial	$161.62
Rate for Payer: Multiplan Workers Comp	$161.62
Rate for Payer: Scott and White EPO/PPO	$161.62
Rate for Payer: Superior Health Plan EPO	$43.96

Know your out-of-pocket cost for care.

All Charges