White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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	$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 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 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

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

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 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 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

IMP PROSTHESIS BREAST

Facility

$6,596.00

Service Code	HCPCS C1789
Hospital Charge Code	8592512
Hospital Revenue Code	278
Min. Negotiated Rate	$593.64
Max. Negotiated Rate	$4,749.12
Rate for Payer: Amerigroup CHIP/Medicaid	$593.64
Rate for Payer: BCBS of TX Blue Advantage	$1,978.80
Rate for Payer: BCBS of TX Blue Essentials	$2,374.56
Rate for Payer: BCBS of TX PPO	$2,638.40
Rate for Payer: Cash Price	$4,485.28
Rate for Payer: Cigna Medicaid	$4,749.12
Rate for Payer: Molina CHIP/Medicaid	$4,749.12
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: Parkland Medicaid	$4,749.12
Rate for Payer: Scott and White EPO/PPO	$3,298.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,749.12
Rate for Payer: Superior Health Plan EPO	$897.06

IMP RECRDR CARD REVEAL -- DHF

Facility

$22,833.00

Service Code	HCPCS C1764
Hospital Charge Code	82403726
Hospital Revenue Code	278
Min. Negotiated Rate	$5,708.25
Max. Negotiated Rate	$11,416.50
Rate for Payer: Cash Price	$15,526.44
Rate for Payer: Cigna Commercial	$5,708.25
Rate for Payer: Multiplan Auto	$11,416.50
Rate for Payer: Multiplan Commercial	$11,416.50
Rate for Payer: Multiplan Workers Comp	$11,416.50
Rate for Payer: Scott and White EPO/PPO	$11,416.50

IMP RECRDR CARD REVEAL -- DHF

Facility

$22,833.00

Service Code	HCPCS C1764
Hospital Charge Code	82403726
Hospital Revenue Code	278
Min. Negotiated Rate	$2,054.97
Max. Negotiated Rate	$16,439.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,054.97
Rate for Payer: BCBS of TX Blue Advantage	$6,849.90
Rate for Payer: BCBS of TX Blue Essentials	$8,219.88
Rate for Payer: BCBS of TX PPO	$9,133.20
Rate for Payer: Cash Price	$15,526.44
Rate for Payer: Cigna Medicaid	$16,439.76
Rate for Payer: Molina CHIP/Medicaid	$16,439.76
Rate for Payer: Multiplan Auto	$11,416.50
Rate for Payer: Multiplan Commercial	$11,416.50
Rate for Payer: Multiplan Workers Comp	$11,416.50
Rate for Payer: Parkland Medicaid	$16,439.76
Rate for Payer: Scott and White EPO/PPO	$11,416.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,439.76
Rate for Payer: Superior Health Plan EPO	$3,105.29

impress catheter

Facility

$14.76

Hospital Charge Code	993567
Hospital Revenue Code	270
Rate for Payer: Cash Price	$10.04

impress catheter

Facility

$14.76

Hospital Charge Code	993567
Hospital Revenue Code	270
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$10.63
Rate for Payer: Amerigroup CHIP/Medicaid	$1.33
Rate for Payer: BCBS of TX Blue Advantage	$4.43
Rate for Payer: BCBS of TX Blue Essentials	$5.31
Rate for Payer: BCBS of TX PPO	$5.90
Rate for Payer: Cash Price	$10.04
Rate for Payer: Cigna Medicaid	$10.63
Rate for Payer: Molina CHIP/Medicaid	$10.63
Rate for Payer: Multiplan Auto	$9.59
Rate for Payer: Multiplan Commercial	$9.59
Rate for Payer: Multiplan Workers Comp	$9.59
Rate for Payer: Parkland Medicaid	$10.63
Rate for Payer: Scott and White EPO/PPO	$7.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.63
Rate for Payer: Superior Health Plan EPO	$2.01

imp spacer spinal

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	8670509
Hospital Revenue Code	278
Min. Negotiated Rate	$3,375.00
Max. Negotiated Rate	$6,750.00
Rate for Payer: Cash Price	$9,180.00
Rate for Payer: Cigna Commercial	$3,375.00
Rate for Payer: Multiplan Auto	$6,750.00
Rate for Payer: Multiplan Commercial	$6,750.00
Rate for Payer: Multiplan Workers Comp	$6,750.00
Rate for Payer: Scott and White EPO/PPO	$6,750.00

imp spacer spinal

Facility

$13,500.00

Service Code	HCPCS C1713
Hospital Charge Code	8670509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,215.00
Max. Negotiated Rate	$9,720.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,215.00
Rate for Payer: BCBS of TX Blue Advantage	$4,050.00
Rate for Payer: BCBS of TX Blue Essentials	$4,860.00
Rate for Payer: BCBS of TX PPO	$5,400.00
Rate for Payer: Cash Price	$9,180.00
Rate for Payer: Cigna Medicaid	$9,720.00
Rate for Payer: Molina CHIP/Medicaid	$9,720.00
Rate for Payer: Multiplan Auto	$6,750.00
Rate for Payer: Multiplan Commercial	$6,750.00
Rate for Payer: Multiplan Workers Comp	$6,750.00
Rate for Payer: Parkland Medicaid	$9,720.00
Rate for Payer: Scott and White EPO/PPO	$6,750.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,720.00
Rate for Payer: Superior Health Plan EPO	$1,836.00

INACTIVE CODE

Facility

$10,000.00

Service Code	CPT 49901
Hospital Charge Code	36049901
Hospital Revenue Code	360
Min. Negotiated Rate	$10,000.00
Max. Negotiated Rate	$10,000.00
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00

INBONE CALCANEAL DRILL 10 MM X 2.4 MM

Facility

$1,157.70

Hospital Charge Code	993436
Hospital Revenue Code	272
Rate for Payer: Cash Price	$787.24

INBONE CALCANEAL DRILL 10 MM X 2.4 MM

Facility

$1,157.70

Hospital Charge Code	993436
Hospital Revenue Code	272
Min. Negotiated Rate	$104.19
Max. Negotiated Rate	$833.54
Rate for Payer: Amerigroup CHIP/Medicaid	$104.19
Rate for Payer: BCBS of TX Blue Advantage	$347.31
Rate for Payer: BCBS of TX Blue Essentials	$416.77
Rate for Payer: BCBS of TX PPO	$463.08
Rate for Payer: Cash Price	$787.24
Rate for Payer: Cigna Medicaid	$833.54
Rate for Payer: Molina CHIP/Medicaid	$833.54
Rate for Payer: Multiplan Auto	$752.50
Rate for Payer: Multiplan Commercial	$752.50
Rate for Payer: Multiplan Workers Comp	$752.50
Rate for Payer: Parkland Medicaid	$833.54
Rate for Payer: Scott and White EPO/PPO	$578.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$833.54
Rate for Payer: Superior Health Plan EPO	$157.45

Inbone drill 6mm

Facility

$3,282.42

Hospital Charge Code	993318
Hospital Revenue Code	272
Min. Negotiated Rate	$295.42
Max. Negotiated Rate	$2,363.34
Rate for Payer: Amerigroup CHIP/Medicaid	$295.42
Rate for Payer: BCBS of TX Blue Advantage	$984.73
Rate for Payer: BCBS of TX Blue Essentials	$1,181.67
Rate for Payer: BCBS of TX PPO	$1,312.97
Rate for Payer: Cash Price	$2,232.05
Rate for Payer: Cigna Medicaid	$2,363.34
Rate for Payer: Molina CHIP/Medicaid	$2,363.34
Rate for Payer: Multiplan Auto	$2,133.57
Rate for Payer: Multiplan Commercial	$2,133.57
Rate for Payer: Multiplan Workers Comp	$2,133.57
Rate for Payer: Parkland Medicaid	$2,363.34
Rate for Payer: Scott and White EPO/PPO	$1,641.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,363.34
Rate for Payer: Superior Health Plan EPO	$446.41

Inbone drill 6mm

Facility

$3,282.42

Hospital Charge Code	993318
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,232.05

INBONE DRILL SIZE 2 ANTI-ROTATION NOTCH

Facility

$635.60

Hospital Charge Code	993443
Hospital Revenue Code	272
Rate for Payer: Cash Price	$432.21

INBONE DRILL SIZE 2 ANTI-ROTATION NOTCH

Facility

$635.60

Hospital Charge Code	993443
Hospital Revenue Code	272
Min. Negotiated Rate	$57.20
Max. Negotiated Rate	$457.63
Rate for Payer: Amerigroup CHIP/Medicaid	$57.20
Rate for Payer: BCBS of TX Blue Advantage	$190.68
Rate for Payer: BCBS of TX Blue Essentials	$228.82
Rate for Payer: BCBS of TX PPO	$254.24
Rate for Payer: Cash Price	$432.21
Rate for Payer: Cigna Medicaid	$457.63
Rate for Payer: Molina CHIP/Medicaid	$457.63
Rate for Payer: Multiplan Auto	$413.14
Rate for Payer: Multiplan Commercial	$413.14
Rate for Payer: Multiplan Workers Comp	$413.14
Rate for Payer: Parkland Medicaid	$457.63
Rate for Payer: Scott and White EPO/PPO	$317.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$457.63
Rate for Payer: Superior Health Plan EPO	$86.44

Inbone drill size 3 anti-rotation notch

Facility

$2,319.28

Service Code	HCPCS C1734
Hospital Charge Code	992177
Hospital Revenue Code	278
Min. Negotiated Rate	$579.82
Max. Negotiated Rate	$1,159.64
Rate for Payer: Cash Price	$1,577.11
Rate for Payer: Cigna Commercial	$579.82
Rate for Payer: Multiplan Auto	$1,159.64
Rate for Payer: Multiplan Commercial	$1,159.64
Rate for Payer: Multiplan Workers Comp	$1,159.64
Rate for Payer: Scott and White EPO/PPO	$1,159.64

Know your out-of-pocket cost for care.

All Charges