White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$98,518.08

Service Code	HCPCS 69714
Hospital Charge Code	9900895
Hospital Revenue Code	360
Rate for Payer: Cash Price	$66,992.29

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

Facility

$98,518.08

Service Code	HCPCS 69714
Hospital Charge Code	9900895
Hospital Revenue Code	360
Min. Negotiated Rate	$7,885.62
Max. Negotiated Rate	$70,933.02
Rate for Payer: Amerigroup CHIP/Medicaid	$7,885.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Amerigroup Medicare	$12,897.19
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	$12,897.19
Rate for Payer: BCBS of TX PPO	$29,989.79
Rate for Payer: Cash Price	$66,992.29
Rate for Payer: Cash Price	$66,992.29
Rate for Payer: Cash Price	$66,992.29
Rate for Payer: Cigna Commercial	$27,262.32
Rate for Payer: Cigna Medicaid	$70,933.02
Rate for Payer: Cigna Medicare	$12,897.19
Rate for Payer: Employer Direct Commercial	$12,897.19
Rate for Payer: Humana Medicare/TRICARE	$12,897.19
Rate for Payer: Molina CHIP/Medicaid	$70,933.02
Rate for Payer: Molina Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Molina Medicare	$12,897.19
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	$70,933.02
Rate for Payer: Scott and White EPO/PPO	$23,859.80
Rate for Payer: Scott and White Medicare	$12,897.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$70,933.02
Rate for Payer: Superior Health Plan EPO	$12,897.19
Rate for Payer: Superior Health Plan Medicare	$12,897.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,897.19
Rate for Payer: Universal American Medicare	$12,897.19
Rate for Payer: Wellcare Medicare	$12,897.19
Rate for Payer: Wellmed Medicare	$12,897.19

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

Facility

$40,184.12

Service Code	CPT 69715
Hospital Charge Code	36069715
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$40,184.12
Rate for Payer: BCBS of TX Blue Advantage	$26,629.95
Rate for Payer: BCBS of TX Blue Essentials	$31,892.16
Rate for Payer: BCBS of TX PPO	$40,184.12
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, osseointegrated implant, temporal bone, with percutaneous attachment to external speec

Facility

$79,340.65

Service Code	HCPCS 69715
Hospital Charge Code	9900896
Hospital Revenue Code	360
Min. Negotiated Rate	$7,140.66
Max. Negotiated Rate	$57,125.27
Rate for Payer: Amerigroup CHIP/Medicaid	$7,140.66
Rate for Payer: BCBS of TX Blue Advantage	$26,629.95
Rate for Payer: BCBS of TX Blue Essentials	$31,892.16
Rate for Payer: BCBS of TX PPO	$40,184.12
Rate for Payer: Cash Price	$53,951.64
Rate for Payer: Cash Price	$53,951.64
Rate for Payer: Cash Price	$53,951.64
Rate for Payer: Cigna Medicaid	$57,125.27
Rate for Payer: Molina CHIP/Medicaid	$57,125.27
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	$57,125.27
Rate for Payer: Scott and White EPO/PPO	$39,670.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$57,125.27
Rate for Payer: Superior Health Plan EPO	$10,790.33

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

Facility

$79,340.65

Service Code	HCPCS 69715
Hospital Charge Code	9900896
Hospital Revenue Code	360
Rate for Payer: Cash Price	$53,951.64

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

Facility

$18,635.09

Service Code	CPT 62350
Hospital Charge Code	36062350
Hospital Revenue Code	360
Min. Negotiated Rate	$2,890.51
Max. Negotiated Rate	$18,635.09
Rate for Payer: Amerigroup CHIP/Medicaid	$2,890.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Amerigroup Medicare	$8,815.84
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	$8,815.84
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cigna Commercial	$18,635.09
Rate for Payer: Cigna Medicare	$8,815.84
Rate for Payer: Employer Direct Commercial	$8,815.84
Rate for Payer: Humana Medicare/TRICARE	$8,815.84
Rate for Payer: Molina Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Molina Medicare	$8,815.84
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	$16,309.30
Rate for Payer: Scott and White Medicare	$8,815.84
Rate for Payer: Superior Health Plan EPO	$8,815.84
Rate for Payer: Superior Health Plan Medicare	$8,815.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Universal American Medicare	$8,815.84
Rate for Payer: Wellcare Medicare	$8,815.84
Rate for Payer: Wellmed Medicare	$8,815.84

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

Facility

$41,062.28

Service Code	HCPCS 62350
Hospital Charge Code	9900752
Hospital Revenue Code	360
Rate for Payer: Cash Price	$27,922.35

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

Facility

$28,192.28

Service Code	HCPCS 62351
Hospital Charge Code	9900753
Hospital Revenue Code	360
Rate for Payer: Cash Price	$19,170.75

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

Facility

$15,408.22

Service Code	CPT 62351
Hospital Charge Code	36062351
Hospital Revenue Code	360
Min. Negotiated Rate	$7,289.28
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
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	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

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

Facility

$28,192.28

Service Code	HCPCS 62351
Hospital Charge Code	9900753
Hospital Revenue Code	360
Min. Negotiated Rate	$2,537.31
Max. Negotiated Rate	$20,298.44
Rate for Payer: Amerigroup CHIP/Medicaid	$2,537.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
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	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$19,170.75
Rate for Payer: Cash Price	$19,170.75
Rate for Payer: Cash Price	$19,170.75
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$20,298.44
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$20,298.44
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$20,298.44
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,298.44
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

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

Facility

$41,062.28

Service Code	HCPCS 62350
Hospital Charge Code	9900752
Hospital Revenue Code	360
Min. Negotiated Rate	$2,890.51
Max. Negotiated Rate	$29,564.84
Rate for Payer: Amerigroup CHIP/Medicaid	$2,890.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Amerigroup Medicare	$8,815.84
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	$8,815.84
Rate for Payer: BCBS of TX PPO	$13,882.71
Rate for Payer: Cash Price	$27,922.35
Rate for Payer: Cash Price	$27,922.35
Rate for Payer: Cash Price	$27,922.35
Rate for Payer: Cigna Commercial	$18,635.09
Rate for Payer: Cigna Medicaid	$29,564.84
Rate for Payer: Cigna Medicare	$8,815.84
Rate for Payer: Employer Direct Commercial	$8,815.84
Rate for Payer: Humana Medicare/TRICARE	$8,815.84
Rate for Payer: Molina CHIP/Medicaid	$29,564.84
Rate for Payer: Molina Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Molina Medicare	$8,815.84
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	$29,564.84
Rate for Payer: Scott and White EPO/PPO	$16,309.30
Rate for Payer: Scott and White Medicare	$8,815.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,564.84
Rate for Payer: Superior Health Plan EPO	$8,815.84
Rate for Payer: Superior Health Plan Medicare	$8,815.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,815.84
Rate for Payer: Universal American Medicare	$8,815.84
Rate for Payer: Wellcare Medicare	$8,815.84
Rate for Payer: Wellmed Medicare	$8,815.84

IMPLANT, CAP LOCKING ALIF

Facility

$4,518.00

Service Code	HCPCS C1776
Hospital Charge Code	144134
Hospital Revenue Code	278
Min. Negotiated Rate	$406.62
Max. Negotiated Rate	$3,252.96
Rate for Payer: Amerigroup CHIP/Medicaid	$406.62
Rate for Payer: BCBS of TX Blue Advantage	$1,355.40
Rate for Payer: BCBS of TX Blue Essentials	$1,626.48
Rate for Payer: BCBS of TX PPO	$1,807.20
Rate for Payer: Cash Price	$3,072.24
Rate for Payer: Cigna Medicaid	$3,252.96
Rate for Payer: Molina CHIP/Medicaid	$3,252.96
Rate for Payer: Multiplan Auto	$2,259.00
Rate for Payer: Multiplan Commercial	$2,259.00
Rate for Payer: Multiplan Workers Comp	$2,259.00
Rate for Payer: Parkland Medicaid	$3,252.96
Rate for Payer: Scott and White EPO/PPO	$2,259.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,252.96
Rate for Payer: Superior Health Plan EPO	$614.45

IMPLANT, CAP LOCKING ALIF

Facility

$4,518.00

Service Code	HCPCS C1776
Hospital Charge Code	144134
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.50
Max. Negotiated Rate	$2,259.00
Rate for Payer: Cash Price	$3,072.24
Rate for Payer: Cigna Commercial	$1,129.50
Rate for Payer: Multiplan Auto	$2,259.00
Rate for Payer: Multiplan Commercial	$2,259.00
Rate for Payer: Multiplan Workers Comp	$2,259.00
Rate for Payer: Scott and White EPO/PPO	$2,259.00

IMPLANT COLLAGEN VERITAS 2CM X 8CM

Facility

$3,737.95

Service Code	HCPCS C9250
Hospital Charge Code	992340
Hospital Revenue Code	278
Min. Negotiated Rate	$934.49
Max. Negotiated Rate	$1,868.97
Rate for Payer: Cash Price	$2,541.81
Rate for Payer: Cigna Commercial	$934.49
Rate for Payer: Multiplan Auto	$1,868.97
Rate for Payer: Multiplan Commercial	$1,868.97
Rate for Payer: Multiplan Workers Comp	$1,868.97
Rate for Payer: Scott and White EPO/PPO	$1,868.97

IMPLANT COLLAGEN VERITAS 2CM X 8CM

Facility

$3,737.95

Service Code	HCPCS C9250
Hospital Charge Code	992340
Hospital Revenue Code	278
Min. Negotiated Rate	$145.67
Max. Negotiated Rate	$2,691.32
Rate for Payer: Amerigroup CHIP/Medicaid	$336.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$145.67
Rate for Payer: Amerigroup Medicare	$145.67
Rate for Payer: BCBS of TX Blue Advantage	$1,121.38
Rate for Payer: BCBS of TX Blue Essentials	$1,345.66
Rate for Payer: BCBS of TX Medicare	$145.67
Rate for Payer: BCBS of TX PPO	$1,495.18
Rate for Payer: Cash Price	$2,541.81
Rate for Payer: Cash Price	$2,541.81
Rate for Payer: Cigna Medicaid	$2,691.32
Rate for Payer: Cigna Medicare	$145.67
Rate for Payer: Employer Direct Commercial	$145.67
Rate for Payer: Humana Medicare/TRICARE	$145.67
Rate for Payer: Molina CHIP/Medicaid	$2,691.32
Rate for Payer: Molina Dual Medicare/Medicaid	$145.67
Rate for Payer: Molina Medicare	$145.67
Rate for Payer: Multiplan Auto	$1,868.97
Rate for Payer: Multiplan Commercial	$1,868.97
Rate for Payer: Multiplan Workers Comp	$1,868.97
Rate for Payer: Parkland Medicaid	$2,691.32
Rate for Payer: Scott and White EPO/PPO	$1,868.97
Rate for Payer: Scott and White Medicare	$145.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,691.32
Rate for Payer: Superior Health Plan EPO	$145.67
Rate for Payer: Superior Health Plan Medicare	$145.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$145.67
Rate for Payer: Universal American Medicare	$145.67
Rate for Payer: Wellcare Medicare	$145.67
Rate for Payer: Wellmed Medicare	$145.67

IMPLANT, COUPLING PIN TO ROD HOFFMAN III

Facility

$3,766.02

Hospital Charge Code	141033
Hospital Revenue Code	272
Min. Negotiated Rate	$338.94
Max. Negotiated Rate	$2,711.53
Rate for Payer: Amerigroup CHIP/Medicaid	$338.94
Rate for Payer: BCBS of TX Blue Advantage	$1,129.81
Rate for Payer: BCBS of TX Blue Essentials	$1,355.77
Rate for Payer: BCBS of TX PPO	$1,506.41
Rate for Payer: Cash Price	$2,560.89
Rate for Payer: Cigna Medicaid	$2,711.53
Rate for Payer: Molina CHIP/Medicaid	$2,711.53
Rate for Payer: Multiplan Auto	$2,447.91
Rate for Payer: Multiplan Commercial	$2,447.91
Rate for Payer: Multiplan Workers Comp	$2,447.91
Rate for Payer: Parkland Medicaid	$2,711.53
Rate for Payer: Scott and White EPO/PPO	$1,883.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,711.53
Rate for Payer: Superior Health Plan EPO	$512.18

IMPLANT, COUPLING PIN TO ROD HOFFMAN III

Facility

$3,766.02

Hospital Charge Code	141033
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,560.89

IMPLANT EXTRACTION FEE - FOOT AND ANKLE

Facility

$3,028.18

Hospital Charge Code	993506
Hospital Revenue Code	270
Min. Negotiated Rate	$272.54
Max. Negotiated Rate	$2,180.29
Rate for Payer: Amerigroup CHIP/Medicaid	$272.54
Rate for Payer: BCBS of TX Blue Advantage	$908.45
Rate for Payer: BCBS of TX Blue Essentials	$1,090.14
Rate for Payer: BCBS of TX PPO	$1,211.27
Rate for Payer: Cash Price	$2,059.16
Rate for Payer: Cigna Medicaid	$2,180.29
Rate for Payer: Molina CHIP/Medicaid	$2,180.29
Rate for Payer: Multiplan Auto	$1,968.32
Rate for Payer: Multiplan Commercial	$1,968.32
Rate for Payer: Multiplan Workers Comp	$1,968.32
Rate for Payer: Parkland Medicaid	$2,180.29
Rate for Payer: Scott and White EPO/PPO	$1,514.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,180.29
Rate for Payer: Superior Health Plan EPO	$411.83

IMPLANT EXTRACTION FEE - FOOT AND ANKLE

Facility

$3,028.18

Hospital Charge Code	993506
Hospital Revenue Code	270
Rate for Payer: Cash Price	$2,059.16

IMPLANT GRAFT BONE TRAUMA FOAM VITOSS PAK 1CC

Facility

$2,644.58

Service Code	HCPCS C1734
Hospital Charge Code	992104
Hospital Revenue Code	278
Min. Negotiated Rate	$238.01
Max. Negotiated Rate	$1,904.10
Rate for Payer: Amerigroup CHIP/Medicaid	$238.01
Rate for Payer: BCBS of TX Blue Advantage	$793.37
Rate for Payer: BCBS of TX Blue Essentials	$952.05
Rate for Payer: BCBS of TX PPO	$1,057.83
Rate for Payer: Cash Price	$1,798.31
Rate for Payer: Cigna Medicaid	$1,904.10
Rate for Payer: Molina CHIP/Medicaid	$1,904.10
Rate for Payer: Multiplan Auto	$1,322.29
Rate for Payer: Multiplan Commercial	$1,322.29
Rate for Payer: Multiplan Workers Comp	$1,322.29
Rate for Payer: Parkland Medicaid	$1,904.10
Rate for Payer: Scott and White EPO/PPO	$1,322.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,904.10
Rate for Payer: Superior Health Plan EPO	$359.66

IMPLANT GRAFT BONE TRAUMA FOAM VITOSS PAK 1CC

Facility

$2,644.58

Service Code	HCPCS C1734
Hospital Charge Code	992104
Hospital Revenue Code	278
Min. Negotiated Rate	$661.14
Max. Negotiated Rate	$1,322.29
Rate for Payer: Cash Price	$1,798.31
Rate for Payer: Cigna Commercial	$661.14
Rate for Payer: Multiplan Auto	$1,322.29
Rate for Payer: Multiplan Commercial	$1,322.29
Rate for Payer: Multiplan Workers Comp	$1,322.29
Rate for Payer: Scott and White EPO/PPO	$1,322.29

IMPLANT GRAFT BONE TRAUMA FOAM VITOSS PAK 2.5CC

Facility

$6,956.00

Service Code	HCPCS C1734
Hospital Charge Code	132252
Hospital Revenue Code	278
Min. Negotiated Rate	$626.04
Max. Negotiated Rate	$5,008.32
Rate for Payer: Amerigroup CHIP/Medicaid	$626.04
Rate for Payer: BCBS of TX Blue Advantage	$2,086.80
Rate for Payer: BCBS of TX Blue Essentials	$2,504.16
Rate for Payer: BCBS of TX PPO	$2,782.40
Rate for Payer: Cash Price	$4,730.08
Rate for Payer: Cigna Medicaid	$5,008.32
Rate for Payer: Molina CHIP/Medicaid	$5,008.32
Rate for Payer: Multiplan Auto	$3,478.00
Rate for Payer: Multiplan Commercial	$3,478.00
Rate for Payer: Multiplan Workers Comp	$3,478.00
Rate for Payer: Parkland Medicaid	$5,008.32
Rate for Payer: Scott and White EPO/PPO	$3,478.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,008.32
Rate for Payer: Superior Health Plan EPO	$946.02

IMPLANT GRAFT BONE TRAUMA FOAM VITOSS PAK 2.5CC

Facility

$6,956.00

Service Code	HCPCS C1734
Hospital Charge Code	132252
Hospital Revenue Code	278
Min. Negotiated Rate	$1,739.00
Max. Negotiated Rate	$3,478.00
Rate for Payer: Cash Price	$4,730.08
Rate for Payer: Cigna Commercial	$1,739.00
Rate for Payer: Multiplan Auto	$3,478.00
Rate for Payer: Multiplan Commercial	$3,478.00
Rate for Payer: Multiplan Workers Comp	$3,478.00
Rate for Payer: Scott and White EPO/PPO	$3,478.00

IMPLANT KNEE BEARING 83/79X14MM VNGRD PST STB

Facility

$11,260.00

Service Code	HCPCS C1776
Hospital Charge Code	128483
Hospital Revenue Code	278
Min. Negotiated Rate	$1,013.40
Max. Negotiated Rate	$8,107.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,013.40
Rate for Payer: BCBS of TX Blue Advantage	$3,378.00
Rate for Payer: BCBS of TX Blue Essentials	$4,053.60
Rate for Payer: BCBS of TX PPO	$4,504.00
Rate for Payer: Cash Price	$7,656.80
Rate for Payer: Cigna Medicaid	$8,107.20
Rate for Payer: Molina CHIP/Medicaid	$8,107.20
Rate for Payer: Multiplan Auto	$5,630.00
Rate for Payer: Multiplan Commercial	$5,630.00
Rate for Payer: Multiplan Workers Comp	$5,630.00
Rate for Payer: Parkland Medicaid	$8,107.20
Rate for Payer: Scott and White EPO/PPO	$5,630.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,107.20
Rate for Payer: Superior Health Plan EPO	$1,531.36

IMPLANT KNEE BEARING 83/79X14MM VNGRD PST STB

Facility

$11,260.00

Service Code	HCPCS C1776
Hospital Charge Code	128483
Hospital Revenue Code	278
Min. Negotiated Rate	$2,815.00
Max. Negotiated Rate	$5,630.00
Rate for Payer: Cash Price	$7,656.80
Rate for Payer: Cigna Commercial	$2,815.00
Rate for Payer: Multiplan Auto	$5,630.00
Rate for Payer: Multiplan Commercial	$5,630.00
Rate for Payer: Multiplan Workers Comp	$5,630.00
Rate for Payer: Scott and White EPO/PPO	$5,630.00

Know your out-of-pocket cost for care.

All Charges