White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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 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 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

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 COMPONENT TIB KN LCK BAR

Facility

$662.00

Service Code	HCPCS C1776
Hospital Charge Code	128528
Hospital Revenue Code	278
Min. Negotiated Rate	$59.58
Max. Negotiated Rate	$476.64
Rate for Payer: Amerigroup CHIP/Medicaid	$59.58
Rate for Payer: BCBS of TX Blue Advantage	$198.60
Rate for Payer: BCBS of TX Blue Essentials	$238.32
Rate for Payer: BCBS of TX PPO	$264.80
Rate for Payer: Cash Price	$450.16
Rate for Payer: Cigna Medicaid	$476.64
Rate for Payer: Molina CHIP/Medicaid	$476.64
Rate for Payer: Multiplan Auto	$331.00
Rate for Payer: Multiplan Commercial	$331.00
Rate for Payer: Multiplan Workers Comp	$331.00
Rate for Payer: Parkland Medicaid	$476.64
Rate for Payer: Scott and White EPO/PPO	$331.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$476.64
Rate for Payer: Superior Health Plan EPO	$90.03

IMPLANT KNEE COMPONENT TIB KN LCK BAR

Facility

$662.00

Service Code	HCPCS C1776
Hospital Charge Code	128528
Hospital Revenue Code	278
Min. Negotiated Rate	$165.50
Max. Negotiated Rate	$331.00
Rate for Payer: Cash Price	$450.16
Rate for Payer: Cigna Commercial	$165.50
Rate for Payer: Multiplan Auto	$331.00
Rate for Payer: Multiplan Commercial	$331.00
Rate for Payer: Multiplan Workers Comp	$331.00
Rate for Payer: Scott and White EPO/PPO	$331.00

IMPLANT KNEE GRIT BLAST STEM W/ SCREW 18MM

Facility

$7,628.00

Service Code	HCPCS C1713
Hospital Charge Code	146226
Hospital Revenue Code	278
Min. Negotiated Rate	$686.52
Max. Negotiated Rate	$5,492.16
Rate for Payer: Amerigroup CHIP/Medicaid	$686.52
Rate for Payer: BCBS of TX Blue Advantage	$2,288.40
Rate for Payer: BCBS of TX Blue Essentials	$2,746.08
Rate for Payer: BCBS of TX PPO	$3,051.20
Rate for Payer: Cash Price	$5,187.04
Rate for Payer: Cigna Medicaid	$5,492.16
Rate for Payer: Molina CHIP/Medicaid	$5,492.16
Rate for Payer: Multiplan Auto	$3,814.00
Rate for Payer: Multiplan Commercial	$3,814.00
Rate for Payer: Multiplan Workers Comp	$3,814.00
Rate for Payer: Parkland Medicaid	$5,492.16
Rate for Payer: Scott and White EPO/PPO	$3,814.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,492.16
Rate for Payer: Superior Health Plan EPO	$1,037.41

IMPLANT KNEE GRIT BLAST STEM W/ SCREW 18MM

Facility

$7,628.00

Service Code	HCPCS C1713
Hospital Charge Code	146226
Hospital Revenue Code	278
Min. Negotiated Rate	$1,907.00
Max. Negotiated Rate	$3,814.00
Rate for Payer: Cash Price	$5,187.04
Rate for Payer: Cigna Commercial	$1,907.00
Rate for Payer: Multiplan Auto	$3,814.00
Rate for Payer: Multiplan Commercial	$3,814.00
Rate for Payer: Multiplan Workers Comp	$3,814.00
Rate for Payer: Scott and White EPO/PPO	$3,814.00

IMPLANT KNEE GRIT BLAST STEM W/ SCREW 20MM

Facility

$7,628.00

Service Code	HCPCS C1713
Hospital Charge Code	146228
Hospital Revenue Code	278
Min. Negotiated Rate	$1,907.00
Max. Negotiated Rate	$3,814.00
Rate for Payer: Cash Price	$5,187.04
Rate for Payer: Cigna Commercial	$1,907.00
Rate for Payer: Multiplan Auto	$3,814.00
Rate for Payer: Multiplan Commercial	$3,814.00
Rate for Payer: Multiplan Workers Comp	$3,814.00
Rate for Payer: Scott and White EPO/PPO	$3,814.00

IMPLANT KNEE GRIT BLAST STEM W/ SCREW 20MM

Facility

$7,628.00

Service Code	HCPCS C1713
Hospital Charge Code	146228
Hospital Revenue Code	278
Min. Negotiated Rate	$686.52
Max. Negotiated Rate	$5,492.16
Rate for Payer: Amerigroup CHIP/Medicaid	$686.52
Rate for Payer: BCBS of TX Blue Advantage	$2,288.40
Rate for Payer: BCBS of TX Blue Essentials	$2,746.08
Rate for Payer: BCBS of TX PPO	$3,051.20
Rate for Payer: Cash Price	$5,187.04
Rate for Payer: Cigna Medicaid	$5,492.16
Rate for Payer: Molina CHIP/Medicaid	$5,492.16
Rate for Payer: Multiplan Auto	$3,814.00
Rate for Payer: Multiplan Commercial	$3,814.00
Rate for Payer: Multiplan Workers Comp	$3,814.00
Rate for Payer: Parkland Medicaid	$5,492.16
Rate for Payer: Scott and White EPO/PPO	$3,814.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,492.16
Rate for Payer: Superior Health Plan EPO	$1,037.41

IMPLANT KNEE TIBIA TRAY W/ TI LOCK BAR AND SCREW 79MM

Facility

$14,092.00

Service Code	HCPCS C1713
Hospital Charge Code	146227
Hospital Revenue Code	278
Min. Negotiated Rate	$1,268.28
Max. Negotiated Rate	$10,146.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,268.28
Rate for Payer: BCBS of TX Blue Advantage	$4,227.60
Rate for Payer: BCBS of TX Blue Essentials	$5,073.12
Rate for Payer: BCBS of TX PPO	$5,636.80
Rate for Payer: Cash Price	$9,582.56
Rate for Payer: Cigna Medicaid	$10,146.24
Rate for Payer: Molina CHIP/Medicaid	$10,146.24
Rate for Payer: Multiplan Auto	$7,046.00
Rate for Payer: Multiplan Commercial	$7,046.00
Rate for Payer: Multiplan Workers Comp	$7,046.00
Rate for Payer: Parkland Medicaid	$10,146.24
Rate for Payer: Scott and White EPO/PPO	$7,046.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,146.24
Rate for Payer: Superior Health Plan EPO	$1,916.51

IMPLANT KNEE TIBIA TRAY W/ TI LOCK BAR AND SCREW 79MM

Facility

$14,092.00

Service Code	HCPCS C1713
Hospital Charge Code	146227
Hospital Revenue Code	278
Min. Negotiated Rate	$3,523.00
Max. Negotiated Rate	$7,046.00
Rate for Payer: Cash Price	$9,582.56
Rate for Payer: Cigna Commercial	$3,523.00
Rate for Payer: Multiplan Auto	$7,046.00
Rate for Payer: Multiplan Commercial	$7,046.00
Rate for Payer: Multiplan Workers Comp	$7,046.00
Rate for Payer: Scott and White EPO/PPO	$7,046.00

IMPLANT KNEE VANGUARD FEMORAL W/ SCREW 75MM

Facility

$36,064.00

Service Code	HCPCS C1713
Hospital Charge Code	146229
Hospital Revenue Code	278
Min. Negotiated Rate	$3,245.76
Max. Negotiated Rate	$25,966.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,245.76
Rate for Payer: BCBS of TX Blue Advantage	$10,819.20
Rate for Payer: BCBS of TX Blue Essentials	$12,983.04
Rate for Payer: BCBS of TX PPO	$14,425.60
Rate for Payer: Cash Price	$24,523.52
Rate for Payer: Cigna Medicaid	$25,966.08
Rate for Payer: Molina CHIP/Medicaid	$25,966.08
Rate for Payer: Multiplan Auto	$18,032.00
Rate for Payer: Multiplan Commercial	$18,032.00
Rate for Payer: Multiplan Workers Comp	$18,032.00
Rate for Payer: Parkland Medicaid	$25,966.08
Rate for Payer: Scott and White EPO/PPO	$18,032.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,966.08
Rate for Payer: Superior Health Plan EPO	$4,904.70

IMPLANT KNEE VANGUARD FEMORAL W/ SCREW 75MM

Facility

$36,064.00

Service Code	HCPCS C1713
Hospital Charge Code	146229
Hospital Revenue Code	278
Min. Negotiated Rate	$9,016.00
Max. Negotiated Rate	$18,032.00
Rate for Payer: Cash Price	$24,523.52
Rate for Payer: Cigna Commercial	$9,016.00
Rate for Payer: Multiplan Auto	$18,032.00
Rate for Payer: Multiplan Commercial	$18,032.00
Rate for Payer: Multiplan Workers Comp	$18,032.00
Rate for Payer: Scott and White EPO/PPO	$18,032.00

IMPLANT LUMBAR INTERBODY LATERAL

Facility

$75,301.00

Service Code	HCPCS C1776
Hospital Charge Code	145087
Hospital Revenue Code	278
Min. Negotiated Rate	$18,825.25
Max. Negotiated Rate	$37,650.50
Rate for Payer: Cash Price	$51,204.68
Rate for Payer: Cigna Commercial	$18,825.25
Rate for Payer: Multiplan Auto	$37,650.50
Rate for Payer: Multiplan Commercial	$37,650.50
Rate for Payer: Multiplan Workers Comp	$37,650.50
Rate for Payer: Scott and White EPO/PPO	$37,650.50

IMPLANT LUMBAR INTERBODY LATERAL

Facility

$75,301.00

Service Code	HCPCS C1776
Hospital Charge Code	145087
Hospital Revenue Code	278
Min. Negotiated Rate	$6,777.09
Max. Negotiated Rate	$54,216.72
Rate for Payer: Amerigroup CHIP/Medicaid	$6,777.09
Rate for Payer: BCBS of TX Blue Advantage	$22,590.30
Rate for Payer: BCBS of TX Blue Essentials	$27,108.36
Rate for Payer: BCBS of TX PPO	$30,120.40
Rate for Payer: Cash Price	$51,204.68
Rate for Payer: Cigna Medicaid	$54,216.72
Rate for Payer: Molina CHIP/Medicaid	$54,216.72
Rate for Payer: Multiplan Auto	$37,650.50
Rate for Payer: Multiplan Commercial	$37,650.50
Rate for Payer: Multiplan Workers Comp	$37,650.50
Rate for Payer: Parkland Medicaid	$54,216.72
Rate for Payer: Scott and White EPO/PPO	$37,650.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$54,216.72
Rate for Payer: Superior Health Plan EPO	$10,240.94

IMPLANT MATRIX AMNIOTIC MEMBRANE 3X2CM

Facility

$1,355.00

Service Code	HCPCS Q4205
Hospital Charge Code	139288
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$975.60
Rate for Payer: Amerigroup CHIP/Medicaid	$121.95
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$14.83
Rate for Payer: BCBS of TX Blue Essentials	$17.80
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$19.74
Rate for Payer: Cash Price	$921.40
Rate for Payer: Cash Price	$921.40
Rate for Payer: Cash Price	$921.40
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$975.60
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$975.60
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$677.50
Rate for Payer: Multiplan Commercial	$677.50
Rate for Payer: Multiplan Workers Comp	$677.50
Rate for Payer: Parkland Medicaid	$975.60
Rate for Payer: Scott and White EPO/PPO	$677.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$975.60
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

IMPLANT MATRIX AMNIOTIC MEMBRANE 3X2CM

Facility

$1,355.00

Service Code	HCPCS Q4205
Hospital Charge Code	139288
Hospital Revenue Code	278
Min. Negotiated Rate	$338.75
Max. Negotiated Rate	$677.50
Rate for Payer: Cash Price	$921.40
Rate for Payer: Cigna Commercial	$338.75
Rate for Payer: Multiplan Auto	$677.50
Rate for Payer: Multiplan Commercial	$677.50
Rate for Payer: Multiplan Workers Comp	$677.50
Rate for Payer: Scott and White EPO/PPO	$677.50

IMPLANT MATRIX WOUND AMNIOTIC MEMBRANE 4X3CM

Facility

$1,017.00

Service Code	HCPCS Q4205
Hospital Charge Code	138898
Hospital Revenue Code	278
Min. Negotiated Rate	$254.25
Max. Negotiated Rate	$508.50
Rate for Payer: Cash Price	$691.56
Rate for Payer: Cigna Commercial	$254.25
Rate for Payer: Multiplan Auto	$508.50
Rate for Payer: Multiplan Commercial	$508.50
Rate for Payer: Multiplan Workers Comp	$508.50
Rate for Payer: Scott and White EPO/PPO	$508.50

Know your out-of-pocket cost for care.

All Charges