White Rock Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT, PIN GUIDE XACTPIN

Facility

$1,453.86

Service Code	HCPCS C1776
Hospital Charge Code	992125
Hospital Revenue Code	278
Min. Negotiated Rate	$363.46
Max. Negotiated Rate	$726.93
Rate for Payer: Cash Price	$988.62
Rate for Payer: Cigna Commercial	$363.46
Rate for Payer: Multiplan Auto	$726.93
Rate for Payer: Multiplan Commercial	$726.93
Rate for Payer: Multiplan Workers Comp	$726.93
Rate for Payer: Scott and White EPO/PPO	$726.93

IMPLANT, PLATE COMPRESS LOCKING NARROW 7H 90MMv

Facility

$3,278.00

Service Code	HCPCS C1776
Hospital Charge Code	141277
Hospital Revenue Code	278
Min. Negotiated Rate	$295.02
Max. Negotiated Rate	$2,360.16
Rate for Payer: Amerigroup CHIP/Medicaid	$295.02
Rate for Payer: BCBS of TX Blue Advantage	$983.40
Rate for Payer: BCBS of TX Blue Essentials	$1,180.08
Rate for Payer: BCBS of TX PPO	$1,311.20
Rate for Payer: Cash Price	$2,229.04
Rate for Payer: Cigna Medicaid	$2,360.16
Rate for Payer: Molina CHIP/Medicaid	$2,360.16
Rate for Payer: Multiplan Auto	$1,639.00
Rate for Payer: Multiplan Commercial	$1,639.00
Rate for Payer: Multiplan Workers Comp	$1,639.00
Rate for Payer: Parkland Medicaid	$2,360.16
Rate for Payer: Scott and White EPO/PPO	$1,639.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,360.16
Rate for Payer: Superior Health Plan EPO	$445.81

IMPLANT, PLATE COMPRESS LOCKING NARROW 7H 90MMv

Facility

$3,278.00

Service Code	HCPCS C1776
Hospital Charge Code	141277
Hospital Revenue Code	278
Min. Negotiated Rate	$819.50
Max. Negotiated Rate	$1,639.00
Rate for Payer: Cash Price	$2,229.04
Rate for Payer: Cigna Commercial	$819.50
Rate for Payer: Multiplan Auto	$1,639.00
Rate for Payer: Multiplan Commercial	$1,639.00
Rate for Payer: Multiplan Workers Comp	$1,639.00
Rate for Payer: Scott and White EPO/PPO	$1,639.00

IMPLANT, PLATE DISTAL RT. 6 HOLE

Facility

$14,870.00

Service Code	HCPCS C1776
Hospital Charge Code	141515
Hospital Revenue Code	278
Min. Negotiated Rate	$1,338.30
Max. Negotiated Rate	$10,706.40
Rate for Payer: Amerigroup CHIP/Medicaid	$1,338.30
Rate for Payer: BCBS of TX Blue Advantage	$4,461.00
Rate for Payer: BCBS of TX Blue Essentials	$5,353.20
Rate for Payer: BCBS of TX PPO	$5,948.00
Rate for Payer: Cash Price	$10,111.60
Rate for Payer: Cigna Medicaid	$10,706.40
Rate for Payer: Molina CHIP/Medicaid	$10,706.40
Rate for Payer: Multiplan Auto	$7,435.00
Rate for Payer: Multiplan Commercial	$7,435.00
Rate for Payer: Multiplan Workers Comp	$7,435.00
Rate for Payer: Parkland Medicaid	$10,706.40
Rate for Payer: Scott and White EPO/PPO	$7,435.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,706.40
Rate for Payer: Superior Health Plan EPO	$2,022.32

IMPLANT, PLATE DISTAL RT. 6 HOLE

Facility

$14,870.00

Service Code	HCPCS C1776
Hospital Charge Code	141515
Hospital Revenue Code	278
Min. Negotiated Rate	$3,717.50
Max. Negotiated Rate	$7,435.00
Rate for Payer: Cash Price	$10,111.60
Rate for Payer: Cigna Commercial	$3,717.50
Rate for Payer: Multiplan Auto	$7,435.00
Rate for Payer: Multiplan Commercial	$7,435.00
Rate for Payer: Multiplan Workers Comp	$7,435.00
Rate for Payer: Scott and White EPO/PPO	$7,435.00

IMPLANT PLATE VOLAR DISTAL RADIUS RT NAR/SHRT

Facility

$9,048.19

Service Code	HCPCS C1734
Hospital Charge Code	992103
Hospital Revenue Code	278
Min. Negotiated Rate	$814.34
Max. Negotiated Rate	$6,514.70
Rate for Payer: Amerigroup CHIP/Medicaid	$814.34
Rate for Payer: BCBS of TX Blue Advantage	$2,714.46
Rate for Payer: BCBS of TX Blue Essentials	$3,257.35
Rate for Payer: BCBS of TX PPO	$3,619.28
Rate for Payer: Cash Price	$6,152.77
Rate for Payer: Cigna Medicaid	$6,514.70
Rate for Payer: Molina CHIP/Medicaid	$6,514.70
Rate for Payer: Multiplan Auto	$4,524.10
Rate for Payer: Multiplan Commercial	$4,524.10
Rate for Payer: Multiplan Workers Comp	$4,524.10
Rate for Payer: Parkland Medicaid	$6,514.70
Rate for Payer: Scott and White EPO/PPO	$4,524.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,514.70
Rate for Payer: Superior Health Plan EPO	$1,230.55

IMPLANT PLATE VOLAR DISTAL RADIUS RT NAR/SHRT

Facility

$9,048.19

Service Code	HCPCS C1734
Hospital Charge Code	992103
Hospital Revenue Code	278
Min. Negotiated Rate	$2,262.05
Max. Negotiated Rate	$4,524.10
Rate for Payer: Cash Price	$6,152.77
Rate for Payer: Cigna Commercial	$2,262.05
Rate for Payer: Multiplan Auto	$4,524.10
Rate for Payer: Multiplan Commercial	$4,524.10
Rate for Payer: Multiplan Workers Comp	$4,524.10
Rate for Payer: Scott and White EPO/PPO	$4,524.10

IMPLANT, PORT SGL LMN SLI

Facility

$2,202.35

Service Code	HCPCS C1788
Hospital Charge Code	992465
Hospital Revenue Code	278
Min. Negotiated Rate	$198.21
Max. Negotiated Rate	$1,585.69
Rate for Payer: Amerigroup CHIP/Medicaid	$198.21
Rate for Payer: BCBS of TX Blue Advantage	$660.71
Rate for Payer: BCBS of TX Blue Essentials	$792.85
Rate for Payer: BCBS of TX PPO	$880.94
Rate for Payer: Cash Price	$1,497.60
Rate for Payer: Cigna Medicaid	$1,585.69
Rate for Payer: Molina CHIP/Medicaid	$1,585.69
Rate for Payer: Multiplan Auto	$1,101.17
Rate for Payer: Multiplan Commercial	$1,101.17
Rate for Payer: Multiplan Workers Comp	$1,101.17
Rate for Payer: Parkland Medicaid	$1,585.69
Rate for Payer: Scott and White EPO/PPO	$1,101.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,585.69
Rate for Payer: Superior Health Plan EPO	$299.52

IMPLANT, PORT SGL LMN SLI

Facility

$2,202.35

Service Code	HCPCS C1788
Hospital Charge Code	992465
Hospital Revenue Code	278
Min. Negotiated Rate	$550.59
Max. Negotiated Rate	$1,101.17
Rate for Payer: Cash Price	$1,497.60
Rate for Payer: Cigna Commercial	$550.59
Rate for Payer: Multiplan Auto	$1,101.17
Rate for Payer: Multiplan Commercial	$1,101.17
Rate for Payer: Multiplan Workers Comp	$1,101.17
Rate for Payer: Scott and White EPO/PPO	$1,101.17

IMPLANT SCREW BONE FULL THREAD 2.7 X 14MM T8

Facility

$614.46

Service Code	HCPCS C1713
Hospital Charge Code	992101
Hospital Revenue Code	278
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$442.41
Rate for Payer: Amerigroup CHIP/Medicaid	$55.30
Rate for Payer: BCBS of TX Blue Advantage	$184.34
Rate for Payer: BCBS of TX Blue Essentials	$221.21
Rate for Payer: BCBS of TX PPO	$245.78
Rate for Payer: Cash Price	$417.83
Rate for Payer: Cigna Medicaid	$442.41
Rate for Payer: Molina CHIP/Medicaid	$442.41
Rate for Payer: Multiplan Auto	$307.23
Rate for Payer: Multiplan Commercial	$307.23
Rate for Payer: Multiplan Workers Comp	$307.23
Rate for Payer: Parkland Medicaid	$442.41
Rate for Payer: Scott and White EPO/PPO	$307.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$442.41
Rate for Payer: Superior Health Plan EPO	$83.57

IMPLANT SCREW BONE FULL THREAD 2.7 X 14MM T8

Facility

$614.46

Service Code	HCPCS C1713
Hospital Charge Code	992101
Hospital Revenue Code	278
Min. Negotiated Rate	$153.62
Max. Negotiated Rate	$307.23
Rate for Payer: Cash Price	$417.83
Rate for Payer: Cigna Commercial	$153.62
Rate for Payer: Multiplan Auto	$307.23
Rate for Payer: Multiplan Commercial	$307.23
Rate for Payer: Multiplan Workers Comp	$307.23
Rate for Payer: Scott and White EPO/PPO	$307.23

IMPLANT, SCREW FULLY THREADED T10 3.5X14MM VARIAX

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992353
Hospital Revenue Code	278
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$459.76
Rate for Payer: Amerigroup CHIP/Medicaid	$57.47
Rate for Payer: BCBS of TX Blue Advantage	$191.56
Rate for Payer: BCBS of TX Blue Essentials	$229.88
Rate for Payer: BCBS of TX PPO	$255.42
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Medicaid	$459.76
Rate for Payer: Molina CHIP/Medicaid	$459.76
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Parkland Medicaid	$459.76
Rate for Payer: Scott and White EPO/PPO	$319.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.76
Rate for Payer: Superior Health Plan EPO	$86.84

IMPLANT, SCREW FULLY THREADED T10 3.5X14MM VARIAX

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992353
Hospital Revenue Code	278
Min. Negotiated Rate	$159.64
Max. Negotiated Rate	$319.27
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Commercial	$159.64
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Scott and White EPO/PPO	$319.27

IMPLANT SCREW FULLY THREADED T10 3.5X20MM VARIAX

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992145
Hospital Revenue Code	278
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$459.76
Rate for Payer: Amerigroup CHIP/Medicaid	$57.47
Rate for Payer: BCBS of TX Blue Advantage	$191.56
Rate for Payer: BCBS of TX Blue Essentials	$229.88
Rate for Payer: BCBS of TX PPO	$255.42
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Medicaid	$459.76
Rate for Payer: Molina CHIP/Medicaid	$459.76
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Parkland Medicaid	$459.76
Rate for Payer: Scott and White EPO/PPO	$319.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.76
Rate for Payer: Superior Health Plan EPO	$86.84

IMPLANT SCREW FULLY THREADED T10 3.5X20MM VARIAX

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992145
Hospital Revenue Code	278
Min. Negotiated Rate	$159.64
Max. Negotiated Rate	$319.27
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Commercial	$159.64
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Scott and White EPO/PPO	$319.27

IMPLANT SCREW INTR 96L/4D 30MMX9MM

Facility

$1,816.00

Service Code	HCPCS C1713
Hospital Charge Code	144152
Hospital Revenue Code	278
Min. Negotiated Rate	$163.44
Max. Negotiated Rate	$1,307.52
Rate for Payer: Amerigroup CHIP/Medicaid	$163.44
Rate for Payer: BCBS of TX Blue Advantage	$544.80
Rate for Payer: BCBS of TX Blue Essentials	$653.76
Rate for Payer: BCBS of TX PPO	$726.40
Rate for Payer: Cash Price	$1,234.88
Rate for Payer: Cigna Medicaid	$1,307.52
Rate for Payer: Molina CHIP/Medicaid	$1,307.52
Rate for Payer: Multiplan Auto	$908.00
Rate for Payer: Multiplan Commercial	$908.00
Rate for Payer: Multiplan Workers Comp	$908.00
Rate for Payer: Parkland Medicaid	$1,307.52
Rate for Payer: Scott and White EPO/PPO	$908.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,307.52
Rate for Payer: Superior Health Plan EPO	$246.98

IMPLANT SCREW INTR 96L/4D 30MMX9MM

Facility

$1,816.00

Service Code	HCPCS C1713
Hospital Charge Code	144152
Hospital Revenue Code	278
Min. Negotiated Rate	$454.00
Max. Negotiated Rate	$908.00
Rate for Payer: Cash Price	$1,234.88
Rate for Payer: Cigna Commercial	$454.00
Rate for Payer: Multiplan Auto	$908.00
Rate for Payer: Multiplan Commercial	$908.00
Rate for Payer: Multiplan Workers Comp	$908.00
Rate for Payer: Scott and White EPO/PPO	$908.00

IMPLANT, SCREW INTRAFX ADV BR 9X30 W/LRG 30MM SHTH

Facility

$6,833.00

Service Code	HCPCS C1713
Hospital Charge Code	139367
Hospital Revenue Code	278
Min. Negotiated Rate	$1,708.25
Max. Negotiated Rate	$3,416.50
Rate for Payer: Cash Price	$4,646.44
Rate for Payer: Cigna Commercial	$1,708.25
Rate for Payer: Multiplan Auto	$3,416.50
Rate for Payer: Multiplan Commercial	$3,416.50
Rate for Payer: Multiplan Workers Comp	$3,416.50
Rate for Payer: Scott and White EPO/PPO	$3,416.50

IMPLANT, SCREW INTRAFX ADV BR 9X30 W/LRG 30MM SHTH

Facility

$6,833.00

Service Code	HCPCS C1713
Hospital Charge Code	139367
Hospital Revenue Code	278
Min. Negotiated Rate	$614.97
Max. Negotiated Rate	$4,919.76
Rate for Payer: Amerigroup CHIP/Medicaid	$614.97
Rate for Payer: BCBS of TX Blue Advantage	$2,049.90
Rate for Payer: BCBS of TX Blue Essentials	$2,459.88
Rate for Payer: BCBS of TX PPO	$2,733.20
Rate for Payer: Cash Price	$4,646.44
Rate for Payer: Cigna Medicaid	$4,919.76
Rate for Payer: Molina CHIP/Medicaid	$4,919.76
Rate for Payer: Multiplan Auto	$3,416.50
Rate for Payer: Multiplan Commercial	$3,416.50
Rate for Payer: Multiplan Workers Comp	$3,416.50
Rate for Payer: Parkland Medicaid	$4,919.76
Rate for Payer: Scott and White EPO/PPO	$3,416.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,919.76
Rate for Payer: Superior Health Plan EPO	$929.29

IMPLANT SCREW LOCK FULL THREAD 2.7 X 14MM

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132389
Hospital Revenue Code	278
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$598.50
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Commercial	$299.25
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Scott and White EPO/PPO	$598.50

IMPLANT SCREW LOCK FULL THREAD 2.7 X 14MM

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132389
Hospital Revenue Code	278
Min. Negotiated Rate	$107.73
Max. Negotiated Rate	$861.84
Rate for Payer: Amerigroup CHIP/Medicaid	$107.73
Rate for Payer: BCBS of TX Blue Advantage	$359.10
Rate for Payer: BCBS of TX Blue Essentials	$430.92
Rate for Payer: BCBS of TX PPO	$478.80
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Medicaid	$861.84
Rate for Payer: Molina CHIP/Medicaid	$861.84
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Parkland Medicaid	$861.84
Rate for Payer: Scott and White EPO/PPO	$598.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$861.84
Rate for Payer: Superior Health Plan EPO	$162.79

IMPLANT SCREW LOCK FULL THREAD 2.7 X 16MM T8

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132390
Hospital Revenue Code	278
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$598.50
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Commercial	$299.25
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Scott and White EPO/PPO	$598.50

IMPLANT SCREW LOCK FULL THREAD 2.7 X 16MM T8

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132390
Hospital Revenue Code	278
Min. Negotiated Rate	$107.73
Max. Negotiated Rate	$861.84
Rate for Payer: Amerigroup CHIP/Medicaid	$107.73
Rate for Payer: BCBS of TX Blue Advantage	$359.10
Rate for Payer: BCBS of TX Blue Essentials	$430.92
Rate for Payer: BCBS of TX PPO	$478.80
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Medicaid	$861.84
Rate for Payer: Molina CHIP/Medicaid	$861.84
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Parkland Medicaid	$861.84
Rate for Payer: Scott and White EPO/PPO	$598.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$861.84
Rate for Payer: Superior Health Plan EPO	$162.79

IMPLANT SCREW LOCK FULL THREAD 2.7 X 18MM T8

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132391
Hospital Revenue Code	278
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$598.50
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Commercial	$299.25
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Scott and White EPO/PPO	$598.50

IMPLANT SCREW LOCK FULL THREAD 2.7 X 18MM T8

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132391
Hospital Revenue Code	278
Min. Negotiated Rate	$107.73
Max. Negotiated Rate	$861.84
Rate for Payer: Amerigroup CHIP/Medicaid	$107.73
Rate for Payer: BCBS of TX Blue Advantage	$359.10
Rate for Payer: BCBS of TX Blue Essentials	$430.92
Rate for Payer: BCBS of TX PPO	$478.80
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Medicaid	$861.84
Rate for Payer: Molina CHIP/Medicaid	$861.84
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Parkland Medicaid	$861.84
Rate for Payer: Scott and White EPO/PPO	$598.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$861.84
Rate for Payer: Superior Health Plan EPO	$162.79

Know your out-of-pocket cost for care.

All Charges