White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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

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

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
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 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 drill 6mm

Facility

$3,282.42

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

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 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 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 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

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	$208.74
Max. Negotiated Rate	$1,669.88
Rate for Payer: Amerigroup CHIP/Medicaid	$208.74
Rate for Payer: BCBS of TX Blue Advantage	$695.78
Rate for Payer: BCBS of TX Blue Essentials	$834.94
Rate for Payer: BCBS of TX PPO	$927.71
Rate for Payer: Cash Price	$1,577.11
Rate for Payer: Cigna Medicaid	$1,669.88
Rate for Payer: Molina CHIP/Medicaid	$1,669.88
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: Parkland Medicaid	$1,669.88
Rate for Payer: Scott and White EPO/PPO	$1,159.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,669.88
Rate for Payer: Superior Health Plan EPO	$315.42

Inbone drill size 4 anti-rotation notch

Facility

$2,319.28

Service Code	HCPCS C1734
Hospital Charge Code	992178
Hospital Revenue Code	278
Min. Negotiated Rate	$208.74
Max. Negotiated Rate	$1,669.88
Rate for Payer: Amerigroup CHIP/Medicaid	$208.74
Rate for Payer: BCBS of TX Blue Advantage	$695.78
Rate for Payer: BCBS of TX Blue Essentials	$834.94
Rate for Payer: BCBS of TX PPO	$927.71
Rate for Payer: Cash Price	$1,577.11
Rate for Payer: Cigna Medicaid	$1,669.88
Rate for Payer: Molina CHIP/Medicaid	$1,669.88
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: Parkland Medicaid	$1,669.88
Rate for Payer: Scott and White EPO/PPO	$1,159.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,669.88
Rate for Payer: Superior Health Plan EPO	$315.42

Inbone drill size 4 anti-rotation notch

Facility

$2,319.28

Service Code	HCPCS C1734
Hospital Charge Code	992178
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

INBONE DRILL TALAR PEG 4MM

Facility

$562.96

Hospital Charge Code	993440
Hospital Revenue Code	272
Rate for Payer: Cash Price	$382.81

INBONE DRILL TALAR PEG 4MM

Facility

$562.96

Hospital Charge Code	993440
Hospital Revenue Code	272
Min. Negotiated Rate	$50.67
Max. Negotiated Rate	$405.33
Rate for Payer: Amerigroup CHIP/Medicaid	$50.67
Rate for Payer: BCBS of TX Blue Advantage	$168.89
Rate for Payer: BCBS of TX Blue Essentials	$202.67
Rate for Payer: BCBS of TX PPO	$225.18
Rate for Payer: Cash Price	$382.81
Rate for Payer: Cigna Medicaid	$405.33
Rate for Payer: Molina CHIP/Medicaid	$405.33
Rate for Payer: Multiplan Auto	$365.92
Rate for Payer: Multiplan Commercial	$365.92
Rate for Payer: Multiplan Workers Comp	$365.92
Rate for Payer: Parkland Medicaid	$405.33
Rate for Payer: Scott and White EPO/PPO	$281.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$405.33
Rate for Payer: Superior Health Plan EPO	$76.56

INBONE EVERLAST SZ 2 8MM TOTAL ANKLE SYSTEM

Facility

$34,245.96

Service Code	HCPCS C1734
Hospital Charge Code	992288
Hospital Revenue Code	278
Min. Negotiated Rate	$3,082.14
Max. Negotiated Rate	$24,657.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3,082.14
Rate for Payer: BCBS of TX Blue Advantage	$10,273.79
Rate for Payer: BCBS of TX Blue Essentials	$12,328.55
Rate for Payer: BCBS of TX PPO	$13,698.38
Rate for Payer: Cash Price	$23,287.25
Rate for Payer: Cigna Medicaid	$24,657.09
Rate for Payer: Molina CHIP/Medicaid	$24,657.09
Rate for Payer: Multiplan Auto	$17,122.98
Rate for Payer: Multiplan Commercial	$17,122.98
Rate for Payer: Multiplan Workers Comp	$17,122.98
Rate for Payer: Parkland Medicaid	$24,657.09
Rate for Payer: Scott and White EPO/PPO	$17,122.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,657.09
Rate for Payer: Superior Health Plan EPO	$4,657.45

INBONE EVERLAST SZ 2 8MM TOTAL ANKLE SYSTEM

Facility

$34,245.96

Service Code	HCPCS C1734
Hospital Charge Code	992288
Hospital Revenue Code	278
Min. Negotiated Rate	$8,561.49
Max. Negotiated Rate	$17,122.98
Rate for Payer: Cash Price	$23,287.25
Rate for Payer: Cigna Commercial	$8,561.49
Rate for Payer: Multiplan Auto	$17,122.98
Rate for Payer: Multiplan Commercial	$17,122.98
Rate for Payer: Multiplan Workers Comp	$17,122.98
Rate for Payer: Scott and White EPO/PPO	$17,122.98

Inbone everlast sz 3+ 10mm total ankle system

Facility

$46,656.63

Service Code	HCPCS C1734
Hospital Charge Code	992179
Hospital Revenue Code	278
Min. Negotiated Rate	$4,199.10
Max. Negotiated Rate	$33,592.77
Rate for Payer: Amerigroup CHIP/Medicaid	$4,199.10
Rate for Payer: BCBS of TX Blue Advantage	$13,996.99
Rate for Payer: BCBS of TX Blue Essentials	$16,796.39
Rate for Payer: BCBS of TX PPO	$18,662.65
Rate for Payer: Cash Price	$31,726.51
Rate for Payer: Cigna Medicaid	$33,592.77
Rate for Payer: Molina CHIP/Medicaid	$33,592.77
Rate for Payer: Multiplan Auto	$23,328.31
Rate for Payer: Multiplan Commercial	$23,328.31
Rate for Payer: Multiplan Workers Comp	$23,328.31
Rate for Payer: Parkland Medicaid	$33,592.77
Rate for Payer: Scott and White EPO/PPO	$23,328.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$33,592.77
Rate for Payer: Superior Health Plan EPO	$6,345.30

Inbone everlast sz 3+ 10mm total ankle system

Facility

$46,656.63

Service Code	HCPCS C1734
Hospital Charge Code	992179
Hospital Revenue Code	278
Min. Negotiated Rate	$11,664.16
Max. Negotiated Rate	$23,328.31
Rate for Payer: Cash Price	$31,726.51
Rate for Payer: Cigna Commercial	$11,664.16
Rate for Payer: Multiplan Auto	$23,328.31
Rate for Payer: Multiplan Commercial	$23,328.31
Rate for Payer: Multiplan Workers Comp	$23,328.31
Rate for Payer: Scott and White EPO/PPO	$23,328.31

INBONE EVERLAST SZ 3 8MM TOTAL ANKLE SYSTEM

Facility

$34,245.96

Service Code	HCPCS C1734
Hospital Charge Code	992259
Hospital Revenue Code	278
Min. Negotiated Rate	$3,082.14
Max. Negotiated Rate	$24,657.09
Rate for Payer: Amerigroup CHIP/Medicaid	$3,082.14
Rate for Payer: BCBS of TX Blue Advantage	$10,273.79
Rate for Payer: BCBS of TX Blue Essentials	$12,328.55
Rate for Payer: BCBS of TX PPO	$13,698.38
Rate for Payer: Cash Price	$23,287.25
Rate for Payer: Cigna Medicaid	$24,657.09
Rate for Payer: Molina CHIP/Medicaid	$24,657.09
Rate for Payer: Multiplan Auto	$17,122.98
Rate for Payer: Multiplan Commercial	$17,122.98
Rate for Payer: Multiplan Workers Comp	$17,122.98
Rate for Payer: Parkland Medicaid	$24,657.09
Rate for Payer: Scott and White EPO/PPO	$17,122.98
Rate for Payer: Superior Health Plan CHIP/Medicaid	$24,657.09
Rate for Payer: Superior Health Plan EPO	$4,657.45

Know your out-of-pocket cost for care.

All Charges