White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$14.83
Max. Negotiated Rate	$732.24
Rate for Payer: Amerigroup CHIP/Medicaid	$91.53
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	$691.56
Rate for Payer: Cash Price	$691.56
Rate for Payer: Cash Price	$691.56
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$732.24
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	$732.24
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
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: Parkland Medicaid	$732.24
Rate for Payer: Scott and White EPO/PPO	$508.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$732.24
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 WOUND AMNIOTIC MEMBRANE 6X3CM

Facility

$1,017.00

Service Code	HCPCS Q4205
Hospital Charge Code	138876
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

IMPLANT MATRIX WOUND AMNIOTIC MEMBRANE 6X3CM

Facility

$1,017.00

Service Code	HCPCS Q4205
Hospital Charge Code	138876
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$732.24
Rate for Payer: Amerigroup CHIP/Medicaid	$91.53
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	$691.56
Rate for Payer: Cash Price	$691.56
Rate for Payer: Cash Price	$691.56
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$732.24
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	$732.24
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
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: Parkland Medicaid	$732.24
Rate for Payer: Scott and White EPO/PPO	$508.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$732.24
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, NAIL IM LONG 125 DEG LEFT 11X340MM TI

Facility

$21,240.96

Service Code	HCPCS C1776
Hospital Charge Code	992150
Hospital Revenue Code	278
Min. Negotiated Rate	$1,911.69
Max. Negotiated Rate	$15,293.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1,911.69
Rate for Payer: BCBS of TX Blue Advantage	$6,372.29
Rate for Payer: BCBS of TX Blue Essentials	$7,646.75
Rate for Payer: BCBS of TX PPO	$8,496.38
Rate for Payer: Cash Price	$14,443.85
Rate for Payer: Cigna Medicaid	$15,293.49
Rate for Payer: Molina CHIP/Medicaid	$15,293.49
Rate for Payer: Multiplan Auto	$10,620.48
Rate for Payer: Multiplan Commercial	$10,620.48
Rate for Payer: Multiplan Workers Comp	$10,620.48
Rate for Payer: Parkland Medicaid	$15,293.49
Rate for Payer: Scott and White EPO/PPO	$10,620.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,293.49
Rate for Payer: Superior Health Plan EPO	$2,888.77

IMPLANT, NAIL IM LONG 125 DEG LEFT 11X340MM TI

Facility

$21,240.96

Service Code	HCPCS C1776
Hospital Charge Code	992150
Hospital Revenue Code	278
Min. Negotiated Rate	$5,310.24
Max. Negotiated Rate	$10,620.48
Rate for Payer: Cash Price	$14,443.85
Rate for Payer: Cigna Commercial	$5,310.24
Rate for Payer: Multiplan Auto	$10,620.48
Rate for Payer: Multiplan Commercial	$10,620.48
Rate for Payer: Multiplan Workers Comp	$10,620.48
Rate for Payer: Scott and White EPO/PPO	$10,620.48

IMPLANT, PERICARDIUM BOVINE VASC PATCH 0.8CMX8CM -- DHF

Facility

$1,304.00

Service Code	HCPCS C1781
Hospital Charge Code	81759029
Hospital Revenue Code	272
Rate for Payer: Cash Price	$886.72

IMPLANT, PERICARDIUM BOVINE VASC PATCH 0.8CMX8CM -- DHF

Facility

$1,304.00

Service Code	HCPCS C1781
Hospital Charge Code	81759029
Hospital Revenue Code	272
Min. Negotiated Rate	$117.36
Max. Negotiated Rate	$938.88
Rate for Payer: Amerigroup CHIP/Medicaid	$117.36
Rate for Payer: BCBS of TX Blue Advantage	$391.20
Rate for Payer: BCBS of TX Blue Essentials	$469.44
Rate for Payer: BCBS of TX PPO	$521.60
Rate for Payer: Cash Price	$886.72
Rate for Payer: Cigna Medicaid	$938.88
Rate for Payer: Molina CHIP/Medicaid	$938.88
Rate for Payer: Multiplan Auto	$847.60
Rate for Payer: Multiplan Commercial	$847.60
Rate for Payer: Multiplan Workers Comp	$847.60
Rate for Payer: Parkland Medicaid	$938.88
Rate for Payer: Scott and White EPO/PPO	$652.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$938.88
Rate for Payer: Superior Health Plan EPO	$177.34

IMPLANT, PERICARDIUM BOVINE VASCULAR PATCH 2CMX9CM -- DHF

Facility

$1,971.00

Service Code	HCPCS C1781
Hospital Charge Code	81421158
Hospital Revenue Code	272
Min. Negotiated Rate	$177.39
Max. Negotiated Rate	$1,419.12
Rate for Payer: Amerigroup CHIP/Medicaid	$177.39
Rate for Payer: BCBS of TX Blue Advantage	$591.30
Rate for Payer: BCBS of TX Blue Essentials	$709.56
Rate for Payer: BCBS of TX PPO	$788.40
Rate for Payer: Cash Price	$1,340.28
Rate for Payer: Cigna Medicaid	$1,419.12
Rate for Payer: Molina CHIP/Medicaid	$1,419.12
Rate for Payer: Multiplan Auto	$1,281.15
Rate for Payer: Multiplan Commercial	$1,281.15
Rate for Payer: Multiplan Workers Comp	$1,281.15
Rate for Payer: Parkland Medicaid	$1,419.12
Rate for Payer: Scott and White EPO/PPO	$985.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,419.12
Rate for Payer: Superior Health Plan EPO	$268.06

IMPLANT, PERICARDIUM BOVINE VASCULAR PATCH 2CMX9CM -- DHF

Facility

$1,971.00

Service Code	HCPCS C1781
Hospital Charge Code	81421158
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,340.28

IMPLANT, PIN GUIDE XACTPIN

Facility

$1,453.86

Service Code	HCPCS C1776
Hospital Charge Code	992125
Hospital Revenue Code	278
Min. Negotiated Rate	$130.85
Max. Negotiated Rate	$1,046.78
Rate for Payer: Amerigroup CHIP/Medicaid	$130.85
Rate for Payer: BCBS of TX Blue Advantage	$436.16
Rate for Payer: BCBS of TX Blue Essentials	$523.39
Rate for Payer: BCBS of TX PPO	$581.54
Rate for Payer: Cash Price	$988.62
Rate for Payer: Cigna Medicaid	$1,046.78
Rate for Payer: Molina CHIP/Medicaid	$1,046.78
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: Parkland Medicaid	$1,046.78
Rate for Payer: Scott and White EPO/PPO	$726.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,046.78
Rate for Payer: Superior Health Plan EPO	$197.72

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	$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 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 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	$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 3.5X14MM 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 3.5X20MM 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 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

Know your out-of-pocket cost for care.

All Charges