White Rock Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT SCREW LOCK FULL THREAD 2.7 X 20MM T8

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132392
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 20MM T8

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132392
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 LOCKING F THRD T10 3.5X10MM VARIAX

Facility

$1,174.70

Service Code	HCPCS C1713
Hospital Charge Code	992146
Hospital Revenue Code	278
Min. Negotiated Rate	$105.72
Max. Negotiated Rate	$845.78
Rate for Payer: Amerigroup CHIP/Medicaid	$105.72
Rate for Payer: BCBS of TX Blue Advantage	$352.41
Rate for Payer: BCBS of TX Blue Essentials	$422.89
Rate for Payer: BCBS of TX PPO	$469.88
Rate for Payer: Cash Price	$798.80
Rate for Payer: Cigna Medicaid	$845.78
Rate for Payer: Molina CHIP/Medicaid	$845.78
Rate for Payer: Multiplan Auto	$587.35
Rate for Payer: Multiplan Commercial	$587.35
Rate for Payer: Multiplan Workers Comp	$587.35
Rate for Payer: Parkland Medicaid	$845.78
Rate for Payer: Scott and White EPO/PPO	$587.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$845.78
Rate for Payer: Superior Health Plan EPO	$159.76

IMPLANT, SCREW LOCKING F THRD T10 3.5X10MM VARIAX

Facility

$1,174.70

Service Code	HCPCS C1713
Hospital Charge Code	992146
Hospital Revenue Code	278
Min. Negotiated Rate	$293.68
Max. Negotiated Rate	$587.35
Rate for Payer: Cash Price	$798.80
Rate for Payer: Cigna Commercial	$293.68
Rate for Payer: Multiplan Auto	$587.35
Rate for Payer: Multiplan Commercial	$587.35
Rate for Payer: Multiplan Workers Comp	$587.35
Rate for Payer: Scott and White EPO/PPO	$587.35

IMPLANT SCREW LOCKING F THRD T10 3.5X16MM VARIAX

Facility

$1,333.00

Service Code	HCPCS C1713
Hospital Charge Code	132396
Hospital Revenue Code	278
Min. Negotiated Rate	$119.97
Max. Negotiated Rate	$959.76
Rate for Payer: Amerigroup CHIP/Medicaid	$119.97
Rate for Payer: BCBS of TX Blue Advantage	$399.90
Rate for Payer: BCBS of TX Blue Essentials	$479.88
Rate for Payer: BCBS of TX PPO	$533.20
Rate for Payer: Cash Price	$906.44
Rate for Payer: Cigna Medicaid	$959.76
Rate for Payer: Molina CHIP/Medicaid	$959.76
Rate for Payer: Multiplan Auto	$666.50
Rate for Payer: Multiplan Commercial	$666.50
Rate for Payer: Multiplan Workers Comp	$666.50
Rate for Payer: Parkland Medicaid	$959.76
Rate for Payer: Scott and White EPO/PPO	$666.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$959.76
Rate for Payer: Superior Health Plan EPO	$181.29

IMPLANT SCREW LOCKING F THRD T10 3.5X16MM VARIAX

Facility

$1,333.00

Service Code	HCPCS C1713
Hospital Charge Code	132396
Hospital Revenue Code	278
Min. Negotiated Rate	$333.25
Max. Negotiated Rate	$666.50
Rate for Payer: Cash Price	$906.44
Rate for Payer: Cigna Commercial	$333.25
Rate for Payer: Multiplan Auto	$666.50
Rate for Payer: Multiplan Commercial	$666.50
Rate for Payer: Multiplan Workers Comp	$666.50
Rate for Payer: Scott and White EPO/PPO	$666.50

IMPLANT, SCREW LOCKING F/T T2 4MM X 30MM

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992159
Hospital Revenue Code	278
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$1,270.84
Rate for Payer: Amerigroup CHIP/Medicaid	$158.86
Rate for Payer: BCBS of TX Blue Advantage	$529.52
Rate for Payer: BCBS of TX Blue Essentials	$635.42
Rate for Payer: BCBS of TX PPO	$706.02
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Medicaid	$1,270.84
Rate for Payer: Molina CHIP/Medicaid	$1,270.84
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Parkland Medicaid	$1,270.84
Rate for Payer: Scott and White EPO/PPO	$882.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.84
Rate for Payer: Superior Health Plan EPO	$240.05

IMPLANT, SCREW LOCKING F/T T2 4MM X 30MM

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992159
Hospital Revenue Code	278
Min. Negotiated Rate	$441.26
Max. Negotiated Rate	$882.53
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Commercial	$441.26
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Scott and White EPO/PPO	$882.53

IMPLANT SCREW VAR 4.0MMX25

Facility

$1,205.00

Service Code	HCPCS C1713
Hospital Charge Code	81360075
Hospital Revenue Code	278
Min. Negotiated Rate	$108.45
Max. Negotiated Rate	$867.60
Rate for Payer: Amerigroup CHIP/Medicaid	$108.45
Rate for Payer: BCBS of TX Blue Advantage	$361.50
Rate for Payer: BCBS of TX Blue Essentials	$433.80
Rate for Payer: BCBS of TX PPO	$482.00
Rate for Payer: Cash Price	$819.40
Rate for Payer: Cigna Medicaid	$867.60
Rate for Payer: Molina CHIP/Medicaid	$867.60
Rate for Payer: Multiplan Auto	$602.50
Rate for Payer: Multiplan Commercial	$602.50
Rate for Payer: Multiplan Workers Comp	$602.50
Rate for Payer: Parkland Medicaid	$867.60
Rate for Payer: Scott and White EPO/PPO	$602.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$867.60
Rate for Payer: Superior Health Plan EPO	$163.88

IMPLANT SCREW VAR 4.0MMX25

Facility

$1,205.00

Service Code	HCPCS C1713
Hospital Charge Code	81360075
Hospital Revenue Code	278
Min. Negotiated Rate	$301.25
Max. Negotiated Rate	$602.50
Rate for Payer: Cash Price	$819.40
Rate for Payer: Cigna Commercial	$301.25
Rate for Payer: Multiplan Auto	$602.50
Rate for Payer: Multiplan Commercial	$602.50
Rate for Payer: Multiplan Workers Comp	$602.50
Rate for Payer: Scott and White EPO/PPO	$602.50

Implant System, Secondary Fixation with BioComposite SwiveLock Anchor

Facility

$7,463.00

Service Code	HCPCS C1713
Hospital Charge Code	145675
Hospital Revenue Code	278
Min. Negotiated Rate	$1,865.75
Max. Negotiated Rate	$3,731.50
Rate for Payer: Cash Price	$5,074.84
Rate for Payer: Cigna Commercial	$1,865.75
Rate for Payer: Multiplan Auto	$3,731.50
Rate for Payer: Multiplan Commercial	$3,731.50
Rate for Payer: Multiplan Workers Comp	$3,731.50
Rate for Payer: Scott and White EPO/PPO	$3,731.50

Implant System, Secondary Fixation with BioComposite SwiveLock Anchor

Facility

$7,463.00

Service Code	HCPCS C1713
Hospital Charge Code	145675
Hospital Revenue Code	278
Min. Negotiated Rate	$671.67
Max. Negotiated Rate	$5,373.36
Rate for Payer: Amerigroup CHIP/Medicaid	$671.67
Rate for Payer: BCBS of TX Blue Advantage	$2,238.90
Rate for Payer: BCBS of TX Blue Essentials	$2,686.68
Rate for Payer: BCBS of TX PPO	$2,985.20
Rate for Payer: Cash Price	$5,074.84
Rate for Payer: Cigna Medicaid	$5,373.36
Rate for Payer: Molina CHIP/Medicaid	$5,373.36
Rate for Payer: Multiplan Auto	$3,731.50
Rate for Payer: Multiplan Commercial	$3,731.50
Rate for Payer: Multiplan Workers Comp	$3,731.50
Rate for Payer: Parkland Medicaid	$5,373.36
Rate for Payer: Scott and White EPO/PPO	$3,731.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,373.36
Rate for Payer: Superior Health Plan EPO	$1,014.97

IMPL BONE BUTTY OSTEOSPARX 5CC

Facility

$3,266.00

Service Code	HCPCS C1734
Hospital Charge Code	8404461
Hospital Revenue Code	278
Min. Negotiated Rate	$816.50
Max. Negotiated Rate	$1,633.00
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cigna Commercial	$816.50
Rate for Payer: Multiplan Auto	$1,633.00
Rate for Payer: Multiplan Commercial	$1,633.00
Rate for Payer: Multiplan Workers Comp	$1,633.00
Rate for Payer: Scott and White EPO/PPO	$1,633.00

IMPL BONE BUTTY OSTEOSPARX 5CC

Facility

$3,266.00

Service Code	HCPCS C1734
Hospital Charge Code	8404461
Hospital Revenue Code	278
Min. Negotiated Rate	$293.94
Max. Negotiated Rate	$2,351.52
Rate for Payer: Amerigroup CHIP/Medicaid	$293.94
Rate for Payer: BCBS of TX Blue Advantage	$979.80
Rate for Payer: BCBS of TX Blue Essentials	$1,175.76
Rate for Payer: BCBS of TX PPO	$1,306.40
Rate for Payer: Cash Price	$2,220.88
Rate for Payer: Cigna Medicaid	$2,351.52
Rate for Payer: Molina CHIP/Medicaid	$2,351.52
Rate for Payer: Multiplan Auto	$1,633.00
Rate for Payer: Multiplan Commercial	$1,633.00
Rate for Payer: Multiplan Workers Comp	$1,633.00
Rate for Payer: Parkland Medicaid	$2,351.52
Rate for Payer: Scott and White EPO/PPO	$1,633.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,351.52
Rate for Payer: Superior Health Plan EPO	$444.18

IMPL BONE CEMENT HYDROSET 15CC

Facility

$25,886.00

Service Code	HCPCS C1763
Hospital Charge Code	8414482
Hospital Revenue Code	278
Min. Negotiated Rate	$6,471.50
Max. Negotiated Rate	$12,943.00
Rate for Payer: Cash Price	$17,602.48
Rate for Payer: Cigna Commercial	$6,471.50
Rate for Payer: Multiplan Auto	$12,943.00
Rate for Payer: Multiplan Commercial	$12,943.00
Rate for Payer: Multiplan Workers Comp	$12,943.00
Rate for Payer: Scott and White EPO/PPO	$12,943.00

IMPL BONE CEMENT HYDROSET 15CC

Facility

$25,886.00

Service Code	HCPCS C1763
Hospital Charge Code	8414482
Hospital Revenue Code	278
Min. Negotiated Rate	$2,329.74
Max. Negotiated Rate	$18,637.92
Rate for Payer: Amerigroup CHIP/Medicaid	$2,329.74
Rate for Payer: BCBS of TX Blue Advantage	$7,765.80
Rate for Payer: BCBS of TX Blue Essentials	$9,318.96
Rate for Payer: BCBS of TX PPO	$10,354.40
Rate for Payer: Cash Price	$17,602.48
Rate for Payer: Cigna Medicaid	$18,637.92
Rate for Payer: Molina CHIP/Medicaid	$18,637.92
Rate for Payer: Multiplan Auto	$12,943.00
Rate for Payer: Multiplan Commercial	$12,943.00
Rate for Payer: Multiplan Workers Comp	$12,943.00
Rate for Payer: Parkland Medicaid	$18,637.92
Rate for Payer: Scott and White EPO/PPO	$12,943.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,637.92
Rate for Payer: Superior Health Plan EPO	$3,520.50

IMPL BONE FILLER 2

Facility

$17,169.00

Service Code	HCPCS C1602
Hospital Charge Code	8420458
Hospital Revenue Code	278
Min. Negotiated Rate	$4,292.25
Max. Negotiated Rate	$8,584.50
Rate for Payer: Cash Price	$11,674.92
Rate for Payer: Cigna Commercial	$4,292.25
Rate for Payer: Multiplan Auto	$8,584.50
Rate for Payer: Multiplan Commercial	$8,584.50
Rate for Payer: Multiplan Workers Comp	$8,584.50
Rate for Payer: Scott and White EPO/PPO	$8,584.50

IMPL BONE FILLER 2

Facility

$17,169.00

Service Code	HCPCS C1602
Hospital Charge Code	8420458
Hospital Revenue Code	278
Min. Negotiated Rate	$1,545.21
Max. Negotiated Rate	$12,361.68
Rate for Payer: Amerigroup CHIP/Medicaid	$1,545.21
Rate for Payer: Cash Price	$11,674.92
Rate for Payer: Cigna Medicaid	$12,361.68
Rate for Payer: Molina CHIP/Medicaid	$12,361.68
Rate for Payer: Multiplan Auto	$8,584.50
Rate for Payer: Multiplan Commercial	$8,584.50
Rate for Payer: Multiplan Workers Comp	$8,584.50
Rate for Payer: Parkland Medicaid	$12,361.68
Rate for Payer: Scott and White EPO/PPO	$8,584.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,361.68
Rate for Payer: Superior Health Plan EPO	$2,334.98

IMPL BONE FILLER 5CC

Facility

$2,861.00

Service Code	HCPCS C1602
Hospital Charge Code	8702509
Hospital Revenue Code	278
Min. Negotiated Rate	$715.25
Max. Negotiated Rate	$1,430.50
Rate for Payer: Cash Price	$1,945.48
Rate for Payer: Cigna Commercial	$715.25
Rate for Payer: Multiplan Auto	$1,430.50
Rate for Payer: Multiplan Commercial	$1,430.50
Rate for Payer: Multiplan Workers Comp	$1,430.50
Rate for Payer: Scott and White EPO/PPO	$1,430.50

IMPL BONE FILLER 5CC

Facility

$2,861.00

Service Code	HCPCS C1602
Hospital Charge Code	8702509
Hospital Revenue Code	278
Min. Negotiated Rate	$257.49
Max. Negotiated Rate	$2,059.92
Rate for Payer: Amerigroup CHIP/Medicaid	$257.49
Rate for Payer: Cash Price	$1,945.48
Rate for Payer: Cigna Medicaid	$2,059.92
Rate for Payer: Molina CHIP/Medicaid	$2,059.92
Rate for Payer: Multiplan Auto	$1,430.50
Rate for Payer: Multiplan Commercial	$1,430.50
Rate for Payer: Multiplan Workers Comp	$1,430.50
Rate for Payer: Parkland Medicaid	$2,059.92
Rate for Payer: Scott and White EPO/PPO	$1,430.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,059.92
Rate for Payer: Superior Health Plan EPO	$389.10

IMPL BONE FILLER 5CC

Facility

$2,861.00

Service Code	HCPCS C1602
Hospital Charge Code	8420464
Hospital Revenue Code	278
Min. Negotiated Rate	$257.49
Max. Negotiated Rate	$2,059.92
Rate for Payer: Amerigroup CHIP/Medicaid	$257.49
Rate for Payer: Cash Price	$1,945.48
Rate for Payer: Cigna Medicaid	$2,059.92
Rate for Payer: Molina CHIP/Medicaid	$2,059.92
Rate for Payer: Multiplan Auto	$1,430.50
Rate for Payer: Multiplan Commercial	$1,430.50
Rate for Payer: Multiplan Workers Comp	$1,430.50
Rate for Payer: Parkland Medicaid	$2,059.92
Rate for Payer: Scott and White EPO/PPO	$1,430.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,059.92
Rate for Payer: Superior Health Plan EPO	$389.10

IMPL BONE FILLER 5CC

Facility

$2,861.00

Service Code	HCPCS C1602
Hospital Charge Code	8420464
Hospital Revenue Code	278
Min. Negotiated Rate	$715.25
Max. Negotiated Rate	$1,430.50
Rate for Payer: Cash Price	$1,945.48
Rate for Payer: Cigna Commercial	$715.25
Rate for Payer: Multiplan Auto	$1,430.50
Rate for Payer: Multiplan Commercial	$1,430.50
Rate for Payer: Multiplan Workers Comp	$1,430.50
Rate for Payer: Scott and White EPO/PPO	$1,430.50

IMPL BONE GRAFT VIAFORM 5CC

Facility

$9,898.00

Service Code	HCPCS C9362
Hospital Charge Code	8492477
Hospital Revenue Code	278
Min. Negotiated Rate	$890.82
Max. Negotiated Rate	$7,126.56
Rate for Payer: Amerigroup CHIP/Medicaid	$890.82
Rate for Payer: BCBS of TX Blue Advantage	$2,969.40
Rate for Payer: BCBS of TX Blue Essentials	$3,563.28
Rate for Payer: BCBS of TX PPO	$3,959.20
Rate for Payer: Cash Price	$6,730.64
Rate for Payer: Cigna Medicaid	$7,126.56
Rate for Payer: Molina CHIP/Medicaid	$7,126.56
Rate for Payer: Multiplan Auto	$4,949.00
Rate for Payer: Multiplan Commercial	$4,949.00
Rate for Payer: Multiplan Workers Comp	$4,949.00
Rate for Payer: Parkland Medicaid	$7,126.56
Rate for Payer: Scott and White EPO/PPO	$4,949.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,126.56
Rate for Payer: Superior Health Plan EPO	$1,346.13

IMPL BONE GRAFT VIAFORM 5CC

Facility

$9,898.00

Service Code	HCPCS C9362
Hospital Charge Code	8492477
Hospital Revenue Code	278
Min. Negotiated Rate	$2,474.50
Max. Negotiated Rate	$4,949.00
Rate for Payer: Cash Price	$6,730.64
Rate for Payer: Cigna Commercial	$2,474.50
Rate for Payer: Multiplan Auto	$4,949.00
Rate for Payer: Multiplan Commercial	$4,949.00
Rate for Payer: Multiplan Workers Comp	$4,949.00
Rate for Payer: Scott and White EPO/PPO	$4,949.00

IMPL BONE PUTTY 10CC

Facility

$6,627.00

Service Code	HCPCS C9359
Hospital Charge Code	8394472
Hospital Revenue Code	278
Min. Negotiated Rate	$596.43
Max. Negotiated Rate	$4,771.44
Rate for Payer: Amerigroup CHIP/Medicaid	$596.43
Rate for Payer: BCBS of TX Blue Advantage	$1,988.10
Rate for Payer: BCBS of TX Blue Essentials	$2,385.72
Rate for Payer: BCBS of TX PPO	$2,650.80
Rate for Payer: Cash Price	$4,506.36
Rate for Payer: Cigna Medicaid	$4,771.44
Rate for Payer: Molina CHIP/Medicaid	$4,771.44
Rate for Payer: Multiplan Auto	$3,313.50
Rate for Payer: Multiplan Commercial	$3,313.50
Rate for Payer: Multiplan Workers Comp	$3,313.50
Rate for Payer: Parkland Medicaid	$4,771.44
Rate for Payer: Scott and White EPO/PPO	$3,313.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,771.44
Rate for Payer: Superior Health Plan EPO	$901.27

Know your out-of-pocket cost for care.

All Charges