White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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 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 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	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

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	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 DELIVERY SYS,DISTAL BICEPS, BC

Facility

$11,048.19

Service Code	HCPCS C1776
Hospital Charge Code	992112
Hospital Revenue Code	278
Min. Negotiated Rate	$2,762.05
Max. Negotiated Rate	$5,524.10
Rate for Payer: Cash Price	$7,512.77
Rate for Payer: Cigna Commercial	$2,762.05
Rate for Payer: Multiplan Auto	$5,524.10
Rate for Payer: Multiplan Commercial	$5,524.10
Rate for Payer: Multiplan Workers Comp	$5,524.10
Rate for Payer: Scott and White EPO/PPO	$5,524.10

IMPL DELIVERY SYS,DISTAL BICEPS, BC

Facility

$11,048.19

Service Code	HCPCS C1776
Hospital Charge Code	992112
Hospital Revenue Code	278
Min. Negotiated Rate	$994.34
Max. Negotiated Rate	$7,954.70
Rate for Payer: Amerigroup CHIP/Medicaid	$994.34
Rate for Payer: BCBS of TX Blue Advantage	$3,314.46
Rate for Payer: BCBS of TX Blue Essentials	$3,977.35
Rate for Payer: BCBS of TX PPO	$4,419.28
Rate for Payer: Cash Price	$7,512.77
Rate for Payer: Cigna Medicaid	$7,954.70
Rate for Payer: Molina CHIP/Medicaid	$7,954.70
Rate for Payer: Multiplan Auto	$5,524.10
Rate for Payer: Multiplan Commercial	$5,524.10
Rate for Payer: Multiplan Workers Comp	$5,524.10
Rate for Payer: Parkland Medicaid	$7,954.70
Rate for Payer: Scott and White EPO/PPO	$5,524.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,954.70
Rate for Payer: Superior Health Plan EPO	$1,502.55

IMPL DISTAL REPAIR KIT

Facility

$9,470.00

Service Code	HCPCS C1776
Hospital Charge Code	8420457
Hospital Revenue Code	278
Min. Negotiated Rate	$852.30
Max. Negotiated Rate	$6,818.40
Rate for Payer: Amerigroup CHIP/Medicaid	$852.30
Rate for Payer: BCBS of TX Blue Advantage	$2,841.00
Rate for Payer: BCBS of TX Blue Essentials	$3,409.20
Rate for Payer: BCBS of TX PPO	$3,788.00
Rate for Payer: Cash Price	$6,439.60
Rate for Payer: Cigna Medicaid	$6,818.40
Rate for Payer: Molina CHIP/Medicaid	$6,818.40
Rate for Payer: Multiplan Auto	$4,735.00
Rate for Payer: Multiplan Commercial	$4,735.00
Rate for Payer: Multiplan Workers Comp	$4,735.00
Rate for Payer: Parkland Medicaid	$6,818.40
Rate for Payer: Scott and White EPO/PPO	$4,735.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,818.40
Rate for Payer: Superior Health Plan EPO	$1,287.92

IMPL DISTAL REPAIR KIT

Facility

$9,470.00

Service Code	HCPCS C1776
Hospital Charge Code	8420457
Hospital Revenue Code	278
Min. Negotiated Rate	$2,367.50
Max. Negotiated Rate	$4,735.00
Rate for Payer: Cash Price	$6,439.60
Rate for Payer: Cigna Commercial	$2,367.50
Rate for Payer: Multiplan Auto	$4,735.00
Rate for Payer: Multiplan Commercial	$4,735.00
Rate for Payer: Multiplan Workers Comp	$4,735.00
Rate for Payer: Scott and White EPO/PPO	$4,735.00

IMPL FEM BUTTON LOOP

Facility

$2,273.00

Service Code	HCPCS C1776
Hospital Charge Code	8398514
Hospital Revenue Code	278
Min. Negotiated Rate	$204.57
Max. Negotiated Rate	$1,636.56
Rate for Payer: Amerigroup CHIP/Medicaid	$204.57
Rate for Payer: BCBS of TX Blue Advantage	$681.90
Rate for Payer: BCBS of TX Blue Essentials	$818.28
Rate for Payer: BCBS of TX PPO	$909.20
Rate for Payer: Cash Price	$1,545.64
Rate for Payer: Cigna Medicaid	$1,636.56
Rate for Payer: Molina CHIP/Medicaid	$1,636.56
Rate for Payer: Multiplan Auto	$1,136.50
Rate for Payer: Multiplan Commercial	$1,136.50
Rate for Payer: Multiplan Workers Comp	$1,136.50
Rate for Payer: Parkland Medicaid	$1,636.56
Rate for Payer: Scott and White EPO/PPO	$1,136.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,636.56
Rate for Payer: Superior Health Plan EPO	$309.13

IMPL FEM BUTTON LOOP

Facility

$2,273.00

Service Code	HCPCS C1776
Hospital Charge Code	8398514
Hospital Revenue Code	278
Min. Negotiated Rate	$568.25
Max. Negotiated Rate	$1,136.50
Rate for Payer: Cash Price	$1,545.64
Rate for Payer: Cigna Commercial	$568.25
Rate for Payer: Multiplan Auto	$1,136.50
Rate for Payer: Multiplan Commercial	$1,136.50
Rate for Payer: Multiplan Workers Comp	$1,136.50
Rate for Payer: Scott and White EPO/PPO	$1,136.50

IMPL FEMORAL COMP HI FLX LONG

Facility

$19,454.00

Service Code	HCPCS C1776
Hospital Charge Code	8404478
Hospital Revenue Code	278
Min. Negotiated Rate	$4,863.50
Max. Negotiated Rate	$9,727.00
Rate for Payer: Cash Price	$13,228.72
Rate for Payer: Cigna Commercial	$4,863.50
Rate for Payer: Multiplan Auto	$9,727.00
Rate for Payer: Multiplan Commercial	$9,727.00
Rate for Payer: Multiplan Workers Comp	$9,727.00
Rate for Payer: Scott and White EPO/PPO	$9,727.00

IMPL FEMORAL COMP HI FLX LONG

Facility

$19,454.00

Service Code	HCPCS C1776
Hospital Charge Code	8404478
Hospital Revenue Code	278
Min. Negotiated Rate	$1,750.86
Max. Negotiated Rate	$14,006.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,750.86
Rate for Payer: BCBS of TX Blue Advantage	$5,836.20
Rate for Payer: BCBS of TX Blue Essentials	$7,003.44
Rate for Payer: BCBS of TX PPO	$7,781.60
Rate for Payer: Cash Price	$13,228.72
Rate for Payer: Cigna Medicaid	$14,006.88
Rate for Payer: Molina CHIP/Medicaid	$14,006.88
Rate for Payer: Multiplan Auto	$9,727.00
Rate for Payer: Multiplan Commercial	$9,727.00
Rate for Payer: Multiplan Workers Comp	$9,727.00
Rate for Payer: Parkland Medicaid	$14,006.88
Rate for Payer: Scott and White EPO/PPO	$9,727.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,006.88
Rate for Payer: Superior Health Plan EPO	$2,645.74

IMPL FIXATION PIN TYPE 3

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8420451
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

IMPL FIXATION PIN TYPE 3

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8420451
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

Know your out-of-pocket cost for care.

All Charges