White Rock Medical Center

All Charges

Charge

Type

Setting

Price

impl graft bone viaform 10cc allograft

Facility

$24,096.00

Service Code	HCPCS C1762
Hospital Charge Code	8666513
Hospital Revenue Code	278
Min. Negotiated Rate	$6,024.00
Max. Negotiated Rate	$12,048.00
Rate for Payer: Cash Price	$16,385.28
Rate for Payer: Cigna Commercial	$6,024.00
Rate for Payer: Multiplan Auto	$12,048.00
Rate for Payer: Multiplan Commercial	$12,048.00
Rate for Payer: Multiplan Workers Comp	$12,048.00
Rate for Payer: Scott and White EPO/PPO	$12,048.00

impl graft bone viaform 10cc allograft

Facility

$24,096.00

Service Code	HCPCS C1762
Hospital Charge Code	8666513
Hospital Revenue Code	278
Min. Negotiated Rate	$2,168.64
Max. Negotiated Rate	$17,349.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,168.64
Rate for Payer: BCBS of TX Blue Advantage	$7,228.80
Rate for Payer: BCBS of TX Blue Essentials	$8,674.56
Rate for Payer: BCBS of TX PPO	$9,638.40
Rate for Payer: Cash Price	$16,385.28
Rate for Payer: Cigna Medicaid	$17,349.12
Rate for Payer: Molina CHIP/Medicaid	$17,349.12
Rate for Payer: Multiplan Auto	$12,048.00
Rate for Payer: Multiplan Commercial	$12,048.00
Rate for Payer: Multiplan Workers Comp	$12,048.00
Rate for Payer: Parkland Medicaid	$17,349.12
Rate for Payer: Scott and White EPO/PPO	$12,048.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,349.12
Rate for Payer: Superior Health Plan EPO	$3,277.06

IMPL LEAD RELIANCE 4 FRONT 0673

Facility

$21,687.00

Service Code	HCPCS C1776
Hospital Charge Code	8414453
Hospital Revenue Code	278
Min. Negotiated Rate	$5,421.75
Max. Negotiated Rate	$10,843.50
Rate for Payer: Cash Price	$14,747.16
Rate for Payer: Cigna Commercial	$5,421.75
Rate for Payer: Multiplan Auto	$10,843.50
Rate for Payer: Multiplan Commercial	$10,843.50
Rate for Payer: Multiplan Workers Comp	$10,843.50
Rate for Payer: Scott and White EPO/PPO	$10,843.50

IMPL LEAD RELIANCE 4 FRONT 0673

Facility

$21,687.00

Service Code	HCPCS C1776
Hospital Charge Code	8414453
Hospital Revenue Code	278
Min. Negotiated Rate	$1,951.83
Max. Negotiated Rate	$15,614.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1,951.83
Rate for Payer: BCBS of TX Blue Advantage	$6,506.10
Rate for Payer: BCBS of TX Blue Essentials	$7,807.32
Rate for Payer: BCBS of TX PPO	$8,674.80
Rate for Payer: Cash Price	$14,747.16
Rate for Payer: Cigna Medicaid	$15,614.64
Rate for Payer: Molina CHIP/Medicaid	$15,614.64
Rate for Payer: Multiplan Auto	$10,843.50
Rate for Payer: Multiplan Commercial	$10,843.50
Rate for Payer: Multiplan Workers Comp	$10,843.50
Rate for Payer: Parkland Medicaid	$15,614.64
Rate for Payer: Scott and White EPO/PPO	$10,843.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,614.64
Rate for Payer: Superior Health Plan EPO	$2,949.43

IMPL LOCKING CAP

Facility

$904.00

Service Code	HCPCS C1776
Hospital Charge Code	8394475
Hospital Revenue Code	278
Min. Negotiated Rate	$81.36
Max. Negotiated Rate	$650.88
Rate for Payer: Amerigroup CHIP/Medicaid	$81.36
Rate for Payer: BCBS of TX Blue Advantage	$271.20
Rate for Payer: BCBS of TX Blue Essentials	$325.44
Rate for Payer: BCBS of TX PPO	$361.60
Rate for Payer: Cash Price	$614.72
Rate for Payer: Cigna Medicaid	$650.88
Rate for Payer: Molina CHIP/Medicaid	$650.88
Rate for Payer: Multiplan Auto	$452.00
Rate for Payer: Multiplan Commercial	$452.00
Rate for Payer: Multiplan Workers Comp	$452.00
Rate for Payer: Parkland Medicaid	$650.88
Rate for Payer: Scott and White EPO/PPO	$452.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$650.88
Rate for Payer: Superior Health Plan EPO	$122.94

IMPL LOCKING CAP

Facility

$904.00

Service Code	HCPCS C1776
Hospital Charge Code	8394475
Hospital Revenue Code	278
Min. Negotiated Rate	$226.00
Max. Negotiated Rate	$452.00
Rate for Payer: Cash Price	$614.72
Rate for Payer: Cigna Commercial	$226.00
Rate for Payer: Multiplan Auto	$452.00
Rate for Payer: Multiplan Commercial	$452.00
Rate for Payer: Multiplan Workers Comp	$452.00
Rate for Payer: Scott and White EPO/PPO	$452.00

IMPL MESH HERNIA COMP SYM12

Facility

$3,421.45

Service Code	HCPCS C1781
Hospital Charge Code	992350
Hospital Revenue Code	272
Min. Negotiated Rate	$307.93
Max. Negotiated Rate	$2,463.44
Rate for Payer: Amerigroup CHIP/Medicaid	$307.93
Rate for Payer: BCBS of TX Blue Advantage	$1,026.43
Rate for Payer: BCBS of TX Blue Essentials	$1,231.72
Rate for Payer: BCBS of TX PPO	$1,368.58
Rate for Payer: Cash Price	$2,326.59
Rate for Payer: Cigna Medicaid	$2,463.44
Rate for Payer: Molina CHIP/Medicaid	$2,463.44
Rate for Payer: Multiplan Auto	$2,223.94
Rate for Payer: Multiplan Commercial	$2,223.94
Rate for Payer: Multiplan Workers Comp	$2,223.94
Rate for Payer: Parkland Medicaid	$2,463.44
Rate for Payer: Scott and White EPO/PPO	$1,710.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,463.44
Rate for Payer: Superior Health Plan EPO	$465.32

IMPL MESH HERNIA COMP SYM12

Facility

$3,421.45

Service Code	HCPCS C1781
Hospital Charge Code	992350
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,326.59

IMPL MESH PHASIX SOFT TISSUE RECONSTRUCT

Facility

$11,364.00

Service Code	HCPCS C1781
Hospital Charge Code	8394468
Hospital Revenue Code	272
Min. Negotiated Rate	$1,022.76
Max. Negotiated Rate	$8,182.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1,022.76
Rate for Payer: BCBS of TX Blue Advantage	$3,409.20
Rate for Payer: BCBS of TX Blue Essentials	$4,091.04
Rate for Payer: BCBS of TX PPO	$4,545.60
Rate for Payer: Cash Price	$7,727.52
Rate for Payer: Cigna Medicaid	$8,182.08
Rate for Payer: Molina CHIP/Medicaid	$8,182.08
Rate for Payer: Multiplan Auto	$7,386.60
Rate for Payer: Multiplan Commercial	$7,386.60
Rate for Payer: Multiplan Workers Comp	$7,386.60
Rate for Payer: Parkland Medicaid	$8,182.08
Rate for Payer: Scott and White EPO/PPO	$5,682.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,182.08
Rate for Payer: Superior Health Plan EPO	$1,545.50

IMPL MESH PHASIX SOFT TISSUE RECONSTRUCT

Facility

$11,364.00

Service Code	HCPCS C1781
Hospital Charge Code	8394468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,727.52

IMPL PLATE LEVEL 3

Facility

$16,867.00

Service Code	HCPCS C1776
Hospital Charge Code	8420466
Hospital Revenue Code	278
Min. Negotiated Rate	$4,216.75
Max. Negotiated Rate	$8,433.50
Rate for Payer: Cash Price	$11,469.56
Rate for Payer: Cigna Commercial	$4,216.75
Rate for Payer: Multiplan Auto	$8,433.50
Rate for Payer: Multiplan Commercial	$8,433.50
Rate for Payer: Multiplan Workers Comp	$8,433.50
Rate for Payer: Scott and White EPO/PPO	$8,433.50

IMPL PLATE LEVEL 3

Facility

$16,867.00

Service Code	HCPCS C1776
Hospital Charge Code	8420466
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.03
Max. Negotiated Rate	$12,144.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,518.03
Rate for Payer: BCBS of TX Blue Advantage	$5,060.10
Rate for Payer: BCBS of TX Blue Essentials	$6,072.12
Rate for Payer: BCBS of TX PPO	$6,746.80
Rate for Payer: Cash Price	$11,469.56
Rate for Payer: Cigna Medicaid	$12,144.24
Rate for Payer: Molina CHIP/Medicaid	$12,144.24
Rate for Payer: Multiplan Auto	$8,433.50
Rate for Payer: Multiplan Commercial	$8,433.50
Rate for Payer: Multiplan Workers Comp	$8,433.50
Rate for Payer: Parkland Medicaid	$12,144.24
Rate for Payer: Scott and White EPO/PPO	$8,433.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,144.24
Rate for Payer: Superior Health Plan EPO	$2,293.91

IMPL STRAIGHT ROD

Facility

$2,066.00

Service Code	HCPCS C1776
Hospital Charge Code	8420455
Hospital Revenue Code	278
Min. Negotiated Rate	$516.50
Max. Negotiated Rate	$1,033.00
Rate for Payer: Cash Price	$1,404.88
Rate for Payer: Cigna Commercial	$516.50
Rate for Payer: Multiplan Auto	$1,033.00
Rate for Payer: Multiplan Commercial	$1,033.00
Rate for Payer: Multiplan Workers Comp	$1,033.00
Rate for Payer: Scott and White EPO/PPO	$1,033.00

IMPL STRAIGHT ROD

Facility

$2,066.00

Service Code	HCPCS C1776
Hospital Charge Code	8420455
Hospital Revenue Code	278
Min. Negotiated Rate	$185.94
Max. Negotiated Rate	$1,487.52
Rate for Payer: Amerigroup CHIP/Medicaid	$185.94
Rate for Payer: BCBS of TX Blue Advantage	$619.80
Rate for Payer: BCBS of TX Blue Essentials	$743.76
Rate for Payer: BCBS of TX PPO	$826.40
Rate for Payer: Cash Price	$1,404.88
Rate for Payer: Cigna Medicaid	$1,487.52
Rate for Payer: Molina CHIP/Medicaid	$1,487.52
Rate for Payer: Multiplan Auto	$1,033.00
Rate for Payer: Multiplan Commercial	$1,033.00
Rate for Payer: Multiplan Workers Comp	$1,033.00
Rate for Payer: Parkland Medicaid	$1,487.52
Rate for Payer: Scott and White EPO/PPO	$1,033.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,487.52
Rate for Payer: Superior Health Plan EPO	$280.98

IMPL SYS MINI PTC SPACER

Facility

$7,289.00

Service Code	HCPCS C1821
Hospital Charge Code	8492475
Hospital Revenue Code	278
Min. Negotiated Rate	$1,822.25
Max. Negotiated Rate	$3,644.50
Rate for Payer: Cash Price	$4,956.52
Rate for Payer: Cigna Commercial	$1,822.25
Rate for Payer: Multiplan Auto	$3,644.50
Rate for Payer: Multiplan Commercial	$3,644.50
Rate for Payer: Multiplan Workers Comp	$3,644.50
Rate for Payer: Scott and White EPO/PPO	$3,644.50

IMPL SYS MINI PTC SPACER

Facility

$7,289.00

Service Code	HCPCS C1821
Hospital Charge Code	8492475
Hospital Revenue Code	278
Min. Negotiated Rate	$656.01
Max. Negotiated Rate	$5,248.08
Rate for Payer: Amerigroup CHIP/Medicaid	$656.01
Rate for Payer: BCBS of TX Blue Advantage	$2,186.70
Rate for Payer: BCBS of TX Blue Essentials	$2,624.04
Rate for Payer: BCBS of TX PPO	$2,915.60
Rate for Payer: Cash Price	$4,956.52
Rate for Payer: Cigna Medicaid	$5,248.08
Rate for Payer: Molina CHIP/Medicaid	$5,248.08
Rate for Payer: Multiplan Auto	$3,644.50
Rate for Payer: Multiplan Commercial	$3,644.50
Rate for Payer: Multiplan Workers Comp	$3,644.50
Rate for Payer: Parkland Medicaid	$5,248.08
Rate for Payer: Scott and White EPO/PPO	$3,644.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,248.08
Rate for Payer: Superior Health Plan EPO	$991.30

IMPL TISSUE MEMBRANE LIQ 2.0ML

Facility

$13,253.00

Service Code	HCPCS Q4205
Hospital Charge Code	8394462
Hospital Revenue Code	278
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$9,542.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1,192.77
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	$9,012.04
Rate for Payer: Cash Price	$9,012.04
Rate for Payer: Cash Price	$9,012.04
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$9,542.16
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	$9,542.16
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$6,626.50
Rate for Payer: Multiplan Commercial	$6,626.50
Rate for Payer: Multiplan Workers Comp	$6,626.50
Rate for Payer: Parkland Medicaid	$9,542.16
Rate for Payer: Scott and White EPO/PPO	$6,626.50
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,542.16
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

IMPL TISSUE MEMBRANE LIQ 2.0ML

Facility

$13,253.00

Service Code	HCPCS Q4205
Hospital Charge Code	8394462
Hospital Revenue Code	278
Min. Negotiated Rate	$3,313.25
Max. Negotiated Rate	$6,626.50
Rate for Payer: Cash Price	$9,012.04
Rate for Payer: Cigna Commercial	$3,313.25
Rate for Payer: Multiplan Auto	$6,626.50
Rate for Payer: Multiplan Commercial	$6,626.50
Rate for Payer: Multiplan Workers Comp	$6,626.50
Rate for Payer: Scott and White EPO/PPO	$6,626.50

IMPL VAULT ALIF PEEK PLATE 32MM X 15X 15MM

Facility

$18,072.00

Service Code	HCPCS C1776
Hospital Charge Code	8394465
Hospital Revenue Code	278
Min. Negotiated Rate	$1,626.48
Max. Negotiated Rate	$13,011.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,626.48
Rate for Payer: BCBS of TX Blue Advantage	$5,421.60
Rate for Payer: BCBS of TX Blue Essentials	$6,505.92
Rate for Payer: BCBS of TX PPO	$7,228.80
Rate for Payer: Cash Price	$12,288.96
Rate for Payer: Cigna Medicaid	$13,011.84
Rate for Payer: Molina CHIP/Medicaid	$13,011.84
Rate for Payer: Multiplan Auto	$9,036.00
Rate for Payer: Multiplan Commercial	$9,036.00
Rate for Payer: Multiplan Workers Comp	$9,036.00
Rate for Payer: Parkland Medicaid	$13,011.84
Rate for Payer: Scott and White EPO/PPO	$9,036.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,011.84
Rate for Payer: Superior Health Plan EPO	$2,457.79

IMPL VAULT ALIF PEEK PLATE 32MM X 15X 15MM

Facility

$18,072.00

Service Code	HCPCS C1776
Hospital Charge Code	8394465
Hospital Revenue Code	278
Min. Negotiated Rate	$4,518.00
Max. Negotiated Rate	$9,036.00
Rate for Payer: Cash Price	$12,288.96
Rate for Payer: Cigna Commercial	$4,518.00
Rate for Payer: Multiplan Auto	$9,036.00
Rate for Payer: Multiplan Commercial	$9,036.00
Rate for Payer: Multiplan Workers Comp	$9,036.00
Rate for Payer: Scott and White EPO/PPO	$9,036.00

impl vault peek cage 39x15x15

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	8618507
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 vault peek cage 39x15x15

Facility

$36,145.00

Service Code	HCPCS C1831
Hospital Charge Code	8618507
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

IMP POUCH DEFIB -- DHF

Facility

$9,006.00

Service Code	HCPCS C1721
Hospital Charge Code	40230211
Hospital Revenue Code	278
Min. Negotiated Rate	$810.54
Max. Negotiated Rate	$6,484.32
Rate for Payer: Amerigroup CHIP/Medicaid	$810.54
Rate for Payer: BCBS of TX Blue Advantage	$2,701.80
Rate for Payer: BCBS of TX Blue Essentials	$3,242.16
Rate for Payer: BCBS of TX PPO	$3,602.40
Rate for Payer: Cash Price	$6,124.08
Rate for Payer: Cigna Medicaid	$6,484.32
Rate for Payer: Molina CHIP/Medicaid	$6,484.32
Rate for Payer: Multiplan Auto	$4,503.00
Rate for Payer: Multiplan Commercial	$4,503.00
Rate for Payer: Multiplan Workers Comp	$4,503.00
Rate for Payer: Parkland Medicaid	$6,484.32
Rate for Payer: Scott and White EPO/PPO	$4,503.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,484.32
Rate for Payer: Superior Health Plan EPO	$1,224.82

IMP POUCH DEFIB -- DHF

Facility

$9,006.00

Service Code	HCPCS C1721
Hospital Charge Code	40230211
Hospital Revenue Code	278
Min. Negotiated Rate	$2,251.50
Max. Negotiated Rate	$4,503.00
Rate for Payer: Cash Price	$6,124.08
Rate for Payer: Cigna Commercial	$2,251.50
Rate for Payer: Multiplan Auto	$4,503.00
Rate for Payer: Multiplan Commercial	$4,503.00
Rate for Payer: Multiplan Workers Comp	$4,503.00
Rate for Payer: Scott and White EPO/PPO	$4,503.00

IMP PROSTHESIS BREAST

Facility

$6,596.00

Service Code	HCPCS C1789
Hospital Charge Code	8592512
Hospital Revenue Code	278
Min. Negotiated Rate	$1,649.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$4,485.28
Rate for Payer: Cigna Commercial	$1,649.00
Rate for Payer: Multiplan Auto	$3,298.00
Rate for Payer: Multiplan Commercial	$3,298.00
Rate for Payer: Multiplan Workers Comp	$3,298.00
Rate for Payer: Scott and White EPO/PPO	$3,298.00

Know your out-of-pocket cost for care.

All Charges