White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	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 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 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 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 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

IMPL BONE PUTTY 10CC

Facility

$6,627.00

Service Code	HCPCS C9359
Hospital Charge Code	8394472
Hospital Revenue Code	278
Min. Negotiated Rate	$1,656.75
Max. Negotiated Rate	$3,313.50
Rate for Payer: Cash Price	$4,506.36
Rate for Payer: Cigna Commercial	$1,656.75
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: Scott and White EPO/PPO	$3,313.50

IMPL BONE PUTTY 5CC

Facility

$3,946.00

Service Code	HCPCS C9359
Hospital Charge Code	8490525
Hospital Revenue Code	278
Min. Negotiated Rate	$355.14
Max. Negotiated Rate	$2,841.12
Rate for Payer: Amerigroup CHIP/Medicaid	$355.14
Rate for Payer: BCBS of TX Blue Advantage	$1,183.80
Rate for Payer: BCBS of TX Blue Essentials	$1,420.56
Rate for Payer: BCBS of TX PPO	$1,578.40
Rate for Payer: Cash Price	$2,683.28
Rate for Payer: Cigna Medicaid	$2,841.12
Rate for Payer: Molina CHIP/Medicaid	$2,841.12
Rate for Payer: Multiplan Auto	$1,973.00
Rate for Payer: Multiplan Commercial	$1,973.00
Rate for Payer: Multiplan Workers Comp	$1,973.00
Rate for Payer: Parkland Medicaid	$2,841.12
Rate for Payer: Scott and White EPO/PPO	$1,973.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,841.12
Rate for Payer: Superior Health Plan EPO	$536.66

IMPL BONE PUTTY 5CC

Facility

$3,946.00

Service Code	HCPCS C9359
Hospital Charge Code	8490525
Hospital Revenue Code	278
Min. Negotiated Rate	$986.50
Max. Negotiated Rate	$1,973.00
Rate for Payer: Cash Price	$2,683.28
Rate for Payer: Cigna Commercial	$986.50
Rate for Payer: Multiplan Auto	$1,973.00
Rate for Payer: Multiplan Commercial	$1,973.00
Rate for Payer: Multiplan Workers Comp	$1,973.00
Rate for Payer: Scott and White EPO/PPO	$1,973.00

IMPL CAGE ACIF 10 DEGREE

Facility

$14,050.00

Service Code	HCPCS C1831
Hospital Charge Code	8404460
Hospital Revenue Code	278
Min. Negotiated Rate	$1,264.50
Max. Negotiated Rate	$10,116.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,264.50
Rate for Payer: Cash Price	$9,554.00
Rate for Payer: Cigna Medicaid	$10,116.00
Rate for Payer: Molina CHIP/Medicaid	$10,116.00
Rate for Payer: Multiplan Auto	$7,025.00
Rate for Payer: Multiplan Commercial	$7,025.00
Rate for Payer: Multiplan Workers Comp	$7,025.00
Rate for Payer: Parkland Medicaid	$10,116.00
Rate for Payer: Scott and White EPO/PPO	$7,025.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,116.00
Rate for Payer: Superior Health Plan EPO	$1,910.80

IMPL CAGE ACIF 10 DEGREE

Facility

$14,050.00

Service Code	HCPCS C1831
Hospital Charge Code	8404460
Hospital Revenue Code	278
Min. Negotiated Rate	$3,512.50
Max. Negotiated Rate	$7,025.00
Rate for Payer: Cash Price	$9,554.00
Rate for Payer: Cigna Commercial	$3,512.50
Rate for Payer: Multiplan Auto	$7,025.00
Rate for Payer: Multiplan Commercial	$7,025.00
Rate for Payer: Multiplan Workers Comp	$7,025.00
Rate for Payer: Scott and White EPO/PPO	$7,025.00

IMPL CAGE PEEK ALIF

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	8428492
Hospital Revenue Code	278
Min. Negotiated Rate	$3,253.05
Max. Negotiated Rate	$26,024.40
Rate for Payer: Amerigroup CHIP/Medicaid	$3,253.05
Rate for Payer: Cash Price	$24,578.60
Rate for Payer: Cigna Medicaid	$26,024.40
Rate for Payer: Molina CHIP/Medicaid	$26,024.40
Rate for Payer: Multiplan Auto	$18,072.50
Rate for Payer: Multiplan Commercial	$18,072.50
Rate for Payer: Multiplan Workers Comp	$18,072.50
Rate for Payer: Parkland Medicaid	$26,024.40
Rate for Payer: Scott and White EPO/PPO	$18,072.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,024.40
Rate for Payer: Superior Health Plan EPO	$4,915.72

IMPL CAGE PEEK ALIF

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	8428492
Hospital Revenue Code	278
Min. Negotiated Rate	$9,036.25
Max. Negotiated Rate	$18,072.50
Rate for Payer: Cash Price	$24,578.60
Rate for Payer: Cigna Commercial	$9,036.25
Rate for Payer: Multiplan Auto	$18,072.50
Rate for Payer: Multiplan Commercial	$18,072.50
Rate for Payer: Multiplan Workers Comp	$18,072.50
Rate for Payer: Scott and White EPO/PPO	$18,072.50

IMPL CEMENT BONE 70G RALLY ALL IN ONE A/B

Facility

$2,470.00

Service Code	HCPCS C1763
Hospital Charge Code	8504485
Hospital Revenue Code	278
Min. Negotiated Rate	$617.50
Max. Negotiated Rate	$1,235.00
Rate for Payer: Cash Price	$1,679.60
Rate for Payer: Cigna Commercial	$617.50
Rate for Payer: Multiplan Auto	$1,235.00
Rate for Payer: Multiplan Commercial	$1,235.00
Rate for Payer: Multiplan Workers Comp	$1,235.00
Rate for Payer: Scott and White EPO/PPO	$1,235.00

IMPL CEMENT BONE 70G RALLY ALL IN ONE A/B

Facility

$2,470.00

Service Code	HCPCS C1763
Hospital Charge Code	8504485
Hospital Revenue Code	278
Min. Negotiated Rate	$222.30
Max. Negotiated Rate	$1,778.40
Rate for Payer: Amerigroup CHIP/Medicaid	$222.30
Rate for Payer: BCBS of TX Blue Advantage	$741.00
Rate for Payer: BCBS of TX Blue Essentials	$889.20
Rate for Payer: BCBS of TX PPO	$988.00
Rate for Payer: Cash Price	$1,679.60
Rate for Payer: Cigna Medicaid	$1,778.40
Rate for Payer: Molina CHIP/Medicaid	$1,778.40
Rate for Payer: Multiplan Auto	$1,235.00
Rate for Payer: Multiplan Commercial	$1,235.00
Rate for Payer: Multiplan Workers Comp	$1,235.00
Rate for Payer: Parkland Medicaid	$1,778.40
Rate for Payer: Scott and White EPO/PPO	$1,235.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,778.40
Rate for Payer: Superior Health Plan EPO	$335.92

IMPL CROSS LINK CONNECTOR

Facility

$6,024.00

Service Code	HCPCS C1713
Hospital Charge Code	8394461
Hospital Revenue Code	278
Min. Negotiated Rate	$542.16
Max. Negotiated Rate	$4,337.28
Rate for Payer: Amerigroup CHIP/Medicaid	$542.16
Rate for Payer: BCBS of TX Blue Advantage	$1,807.20
Rate for Payer: BCBS of TX Blue Essentials	$2,168.64
Rate for Payer: BCBS of TX PPO	$2,409.60
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Medicaid	$4,337.28
Rate for Payer: Molina CHIP/Medicaid	$4,337.28
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Parkland Medicaid	$4,337.28
Rate for Payer: Scott and White EPO/PPO	$3,012.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,337.28
Rate for Payer: Superior Health Plan EPO	$819.26

IMPL CROSS LINK CONNECTOR

Facility

$6,024.00

Service Code	HCPCS C1713
Hospital Charge Code	8394461
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.00
Max. Negotiated Rate	$3,012.00
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Commercial	$1,506.00
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Scott and White EPO/PPO	$3,012.00

IMPL DEFIB ICD VIGILANT D233

Facility

$90,434.00

Service Code	HCPCS C1721
Hospital Charge Code	8404462
Hospital Revenue Code	278
Min. Negotiated Rate	$8,139.06
Max. Negotiated Rate	$65,112.48
Rate for Payer: Amerigroup CHIP/Medicaid	$8,139.06
Rate for Payer: BCBS of TX Blue Advantage	$27,130.20
Rate for Payer: BCBS of TX Blue Essentials	$32,556.24
Rate for Payer: BCBS of TX PPO	$36,173.60
Rate for Payer: Cash Price	$61,495.12
Rate for Payer: Cigna Medicaid	$65,112.48
Rate for Payer: Molina CHIP/Medicaid	$65,112.48
Rate for Payer: Multiplan Auto	$45,217.00
Rate for Payer: Multiplan Commercial	$45,217.00
Rate for Payer: Multiplan Workers Comp	$45,217.00
Rate for Payer: Parkland Medicaid	$65,112.48
Rate for Payer: Scott and White EPO/PPO	$45,217.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65,112.48
Rate for Payer: Superior Health Plan EPO	$12,299.02

IMPL DEFIB ICD VIGILANT D233

Facility

$90,434.00

Service Code	HCPCS C1721
Hospital Charge Code	8404462
Hospital Revenue Code	278
Min. Negotiated Rate	$22,608.50
Max. Negotiated Rate	$45,217.00
Rate for Payer: Cash Price	$61,495.12
Rate for Payer: Cigna Commercial	$22,608.50
Rate for Payer: Multiplan Auto	$45,217.00
Rate for Payer: Multiplan Commercial	$45,217.00
Rate for Payer: Multiplan Workers Comp	$45,217.00
Rate for Payer: Scott and White EPO/PPO	$45,217.00

IMPL DEFIB ICD VIGILANT D233

Facility

$90,434.00

Service Code	HCPCS C1721
Hospital Charge Code	8414455
Hospital Revenue Code	278
Min. Negotiated Rate	$22,608.50
Max. Negotiated Rate	$45,217.00
Rate for Payer: Cash Price	$61,495.12
Rate for Payer: Cigna Commercial	$22,608.50
Rate for Payer: Multiplan Auto	$45,217.00
Rate for Payer: Multiplan Commercial	$45,217.00
Rate for Payer: Multiplan Workers Comp	$45,217.00
Rate for Payer: Scott and White EPO/PPO	$45,217.00

IMPL DEFIB ICD VIGILANT D233

Facility

$90,434.00

Service Code	HCPCS C1721
Hospital Charge Code	8414455
Hospital Revenue Code	278
Min. Negotiated Rate	$8,139.06
Max. Negotiated Rate	$65,112.48
Rate for Payer: Amerigroup CHIP/Medicaid	$8,139.06
Rate for Payer: BCBS of TX Blue Advantage	$27,130.20
Rate for Payer: BCBS of TX Blue Essentials	$32,556.24
Rate for Payer: BCBS of TX PPO	$36,173.60
Rate for Payer: Cash Price	$61,495.12
Rate for Payer: Cigna Medicaid	$65,112.48
Rate for Payer: Molina CHIP/Medicaid	$65,112.48
Rate for Payer: Multiplan Auto	$45,217.00
Rate for Payer: Multiplan Commercial	$45,217.00
Rate for Payer: Multiplan Workers Comp	$45,217.00
Rate for Payer: Parkland Medicaid	$65,112.48
Rate for Payer: Scott and White EPO/PPO	$45,217.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65,112.48
Rate for Payer: Superior Health Plan EPO	$12,299.02

Know your out-of-pocket cost for care.

All Charges