White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 POLY DOME SZ 2 6MM SULCUS

Facility

$23,059.16

Service Code	HCPCS C1734
Hospital Charge Code	992262
Hospital Revenue Code	278
Min. Negotiated Rate	$5,764.79
Max. Negotiated Rate	$11,529.58
Rate for Payer: Cash Price	$15,680.23
Rate for Payer: Cigna Commercial	$5,764.79
Rate for Payer: Multiplan Auto	$11,529.58
Rate for Payer: Multiplan Commercial	$11,529.58
Rate for Payer: Multiplan Workers Comp	$11,529.58
Rate for Payer: Scott and White EPO/PPO	$11,529.58

INBONE POLY DOME SZ 2 6MM SULCUS

Facility

$23,059.16

Service Code	HCPCS C1734
Hospital Charge Code	992262
Hospital Revenue Code	278
Min. Negotiated Rate	$2,075.32
Max. Negotiated Rate	$16,602.60
Rate for Payer: Amerigroup CHIP/Medicaid	$2,075.32
Rate for Payer: BCBS of TX Blue Advantage	$6,917.75
Rate for Payer: BCBS of TX Blue Essentials	$8,301.30
Rate for Payer: BCBS of TX PPO	$9,223.66
Rate for Payer: Cash Price	$15,680.23
Rate for Payer: Cigna Medicaid	$16,602.60
Rate for Payer: Molina CHIP/Medicaid	$16,602.60
Rate for Payer: Multiplan Auto	$11,529.58
Rate for Payer: Multiplan Commercial	$11,529.58
Rate for Payer: Multiplan Workers Comp	$11,529.58
Rate for Payer: Parkland Medicaid	$16,602.60
Rate for Payer: Scott and White EPO/PPO	$11,529.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,602.60
Rate for Payer: Superior Health Plan EPO	$3,136.05

Inbone screw bone remover sterile

Facility

$1,861.40

Service Code	HCPCS C1713
Hospital Charge Code	993349
Hospital Revenue Code	278
Min. Negotiated Rate	$465.35
Max. Negotiated Rate	$930.70
Rate for Payer: Cash Price	$1,265.75
Rate for Payer: Cigna Commercial	$465.35
Rate for Payer: Multiplan Auto	$930.70
Rate for Payer: Multiplan Commercial	$930.70
Rate for Payer: Multiplan Workers Comp	$930.70
Rate for Payer: Scott and White EPO/PPO	$930.70

Inbone screw bone remover sterile

Facility

$1,861.40

Service Code	HCPCS C1713
Hospital Charge Code	993349
Hospital Revenue Code	278
Min. Negotiated Rate	$167.53
Max. Negotiated Rate	$1,340.21
Rate for Payer: Amerigroup CHIP/Medicaid	$167.53
Rate for Payer: BCBS of TX Blue Advantage	$558.42
Rate for Payer: BCBS of TX Blue Essentials	$670.10
Rate for Payer: BCBS of TX PPO	$744.56
Rate for Payer: Cash Price	$1,265.75
Rate for Payer: Cigna Medicaid	$1,340.21
Rate for Payer: Molina CHIP/Medicaid	$1,340.21
Rate for Payer: Multiplan Auto	$930.70
Rate for Payer: Multiplan Commercial	$930.70
Rate for Payer: Multiplan Workers Comp	$930.70
Rate for Payer: Parkland Medicaid	$1,340.21
Rate for Payer: Scott and White EPO/PPO	$930.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,340.21
Rate for Payer: Superior Health Plan EPO	$253.15

Inbone steinmann pin 2.4mm

Facility

$363.20

Service Code	HCPCS C1713
Hospital Charge Code	993317
Hospital Revenue Code	278
Min. Negotiated Rate	$32.69
Max. Negotiated Rate	$261.50
Rate for Payer: Amerigroup CHIP/Medicaid	$32.69
Rate for Payer: BCBS of TX Blue Advantage	$108.96
Rate for Payer: BCBS of TX Blue Essentials	$130.75
Rate for Payer: BCBS of TX PPO	$145.28
Rate for Payer: Cash Price	$246.98
Rate for Payer: Cigna Medicaid	$261.50
Rate for Payer: Molina CHIP/Medicaid	$261.50
Rate for Payer: Multiplan Auto	$181.60
Rate for Payer: Multiplan Commercial	$181.60
Rate for Payer: Multiplan Workers Comp	$181.60
Rate for Payer: Parkland Medicaid	$261.50
Rate for Payer: Scott and White EPO/PPO	$181.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$261.50
Rate for Payer: Superior Health Plan EPO	$49.40

Inbone steinmann pin 2.4mm

Facility

$363.20

Service Code	HCPCS C1713
Hospital Charge Code	993317
Hospital Revenue Code	278
Min. Negotiated Rate	$90.80
Max. Negotiated Rate	$181.60
Rate for Payer: Cash Price	$246.98
Rate for Payer: Cigna Commercial	$90.80
Rate for Payer: Multiplan Auto	$181.60
Rate for Payer: Multiplan Commercial	$181.60
Rate for Payer: Multiplan Workers Comp	$181.60
Rate for Payer: Scott and White EPO/PPO	$181.60

INBONE STEM TIBIAL BASE SIZE 16 MM RIGHT & LEFT

Facility

$5,078.31

Service Code	HCPCS C1734
Hospital Charge Code	992254
Hospital Revenue Code	278
Min. Negotiated Rate	$1,269.58
Max. Negotiated Rate	$2,539.16
Rate for Payer: Cash Price	$3,453.25
Rate for Payer: Cigna Commercial	$1,269.58
Rate for Payer: Multiplan Auto	$2,539.16
Rate for Payer: Multiplan Commercial	$2,539.16
Rate for Payer: Multiplan Workers Comp	$2,539.16
Rate for Payer: Scott and White EPO/PPO	$2,539.16

INBONE STEM TIBIAL BASE SIZE 16 MM RIGHT & LEFT

Facility

$5,078.31

Service Code	HCPCS C1734
Hospital Charge Code	992254
Hospital Revenue Code	278
Min. Negotiated Rate	$457.05
Max. Negotiated Rate	$3,656.38
Rate for Payer: Amerigroup CHIP/Medicaid	$457.05
Rate for Payer: BCBS of TX Blue Advantage	$1,523.49
Rate for Payer: BCBS of TX Blue Essentials	$1,828.19
Rate for Payer: BCBS of TX PPO	$2,031.32
Rate for Payer: Cash Price	$3,453.25
Rate for Payer: Cigna Medicaid	$3,656.38
Rate for Payer: Molina CHIP/Medicaid	$3,656.38
Rate for Payer: Multiplan Auto	$2,539.16
Rate for Payer: Multiplan Commercial	$2,539.16
Rate for Payer: Multiplan Workers Comp	$2,539.16
Rate for Payer: Parkland Medicaid	$3,656.38
Rate for Payer: Scott and White EPO/PPO	$2,539.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,656.38
Rate for Payer: Superior Health Plan EPO	$690.65

INBONE STEM TIBIAL BASE SIZE 18 MM RIGHT & LEFT

Facility

$14,674.70

Service Code	HCPCS C1734
Hospital Charge Code	992174
Hospital Revenue Code	278
Min. Negotiated Rate	$1,320.72
Max. Negotiated Rate	$10,565.78
Rate for Payer: Amerigroup CHIP/Medicaid	$1,320.72
Rate for Payer: BCBS of TX Blue Advantage	$4,402.41
Rate for Payer: BCBS of TX Blue Essentials	$5,282.89
Rate for Payer: BCBS of TX PPO	$5,869.88
Rate for Payer: Cash Price	$9,978.80
Rate for Payer: Cigna Medicaid	$10,565.78
Rate for Payer: Molina CHIP/Medicaid	$10,565.78
Rate for Payer: Multiplan Auto	$7,337.35
Rate for Payer: Multiplan Commercial	$7,337.35
Rate for Payer: Multiplan Workers Comp	$7,337.35
Rate for Payer: Parkland Medicaid	$10,565.78
Rate for Payer: Scott and White EPO/PPO	$7,337.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,565.78
Rate for Payer: Superior Health Plan EPO	$1,995.76

INBONE STEM TIBIAL BASE SIZE 18 MM RIGHT & LEFT

Facility

$14,674.70

Service Code	HCPCS C1734
Hospital Charge Code	992174
Hospital Revenue Code	278
Min. Negotiated Rate	$3,668.68
Max. Negotiated Rate	$7,337.35
Rate for Payer: Cash Price	$9,978.80
Rate for Payer: Cigna Commercial	$3,668.68
Rate for Payer: Multiplan Auto	$7,337.35
Rate for Payer: Multiplan Commercial	$7,337.35
Rate for Payer: Multiplan Workers Comp	$7,337.35
Rate for Payer: Scott and White EPO/PPO	$7,337.35

INBONE STEM TIBIAL MID SIZE 14 MM RIGHT & LEFT

Facility

$4,891.57

Service Code	HCPCS C1734
Hospital Charge Code	992255
Hospital Revenue Code	278
Min. Negotiated Rate	$1,222.89
Max. Negotiated Rate	$2,445.78
Rate for Payer: Cash Price	$3,326.27
Rate for Payer: Cigna Commercial	$1,222.89
Rate for Payer: Multiplan Auto	$2,445.78
Rate for Payer: Multiplan Commercial	$2,445.78
Rate for Payer: Multiplan Workers Comp	$2,445.78
Rate for Payer: Scott and White EPO/PPO	$2,445.78

INBONE STEM TIBIAL MID SIZE 14 MM RIGHT & LEFT

Facility

$4,891.57

Service Code	HCPCS C1734
Hospital Charge Code	992255
Hospital Revenue Code	278
Min. Negotiated Rate	$440.24
Max. Negotiated Rate	$3,521.93
Rate for Payer: Amerigroup CHIP/Medicaid	$440.24
Rate for Payer: BCBS of TX Blue Advantage	$1,467.47
Rate for Payer: BCBS of TX Blue Essentials	$1,760.97
Rate for Payer: BCBS of TX PPO	$1,956.63
Rate for Payer: Cash Price	$3,326.27
Rate for Payer: Cigna Medicaid	$3,521.93
Rate for Payer: Molina CHIP/Medicaid	$3,521.93
Rate for Payer: Multiplan Auto	$2,445.78
Rate for Payer: Multiplan Commercial	$2,445.78
Rate for Payer: Multiplan Workers Comp	$2,445.78
Rate for Payer: Parkland Medicaid	$3,521.93
Rate for Payer: Scott and White EPO/PPO	$2,445.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,521.93
Rate for Payer: Superior Health Plan EPO	$665.25

Inbone stem tibial mid size 16 mm right & left

Facility

$14,379.52

Service Code	HCPCS C1734
Hospital Charge Code	992175
Hospital Revenue Code	278
Min. Negotiated Rate	$1,294.16
Max. Negotiated Rate	$10,353.25
Rate for Payer: Amerigroup CHIP/Medicaid	$1,294.16
Rate for Payer: BCBS of TX Blue Advantage	$4,313.86
Rate for Payer: BCBS of TX Blue Essentials	$5,176.63
Rate for Payer: BCBS of TX PPO	$5,751.81
Rate for Payer: Cash Price	$9,778.07
Rate for Payer: Cigna Medicaid	$10,353.25
Rate for Payer: Molina CHIP/Medicaid	$10,353.25
Rate for Payer: Multiplan Auto	$7,189.76
Rate for Payer: Multiplan Commercial	$7,189.76
Rate for Payer: Multiplan Workers Comp	$7,189.76
Rate for Payer: Parkland Medicaid	$10,353.25
Rate for Payer: Scott and White EPO/PPO	$7,189.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,353.25
Rate for Payer: Superior Health Plan EPO	$1,955.61

Inbone stem tibial mid size 16 mm right & left

Facility

$14,379.52

Service Code	HCPCS C1734
Hospital Charge Code	992175
Hospital Revenue Code	278
Min. Negotiated Rate	$3,594.88
Max. Negotiated Rate	$7,189.76
Rate for Payer: Cash Price	$9,778.07
Rate for Payer: Cigna Commercial	$3,594.88
Rate for Payer: Multiplan Auto	$7,189.76
Rate for Payer: Multiplan Commercial	$7,189.76
Rate for Payer: Multiplan Workers Comp	$7,189.76
Rate for Payer: Scott and White EPO/PPO	$7,189.76

INBONE STEM TIBIAL TOP SIZE 12 MM RIGHT & LEFT

Facility

$6,737.89

Service Code	HCPCS C1734
Hospital Charge Code	992287
Hospital Revenue Code	278
Min. Negotiated Rate	$606.41
Max. Negotiated Rate	$4,851.28
Rate for Payer: Amerigroup CHIP/Medicaid	$606.41
Rate for Payer: BCBS of TX Blue Advantage	$2,021.37
Rate for Payer: BCBS of TX Blue Essentials	$2,425.64
Rate for Payer: BCBS of TX PPO	$2,695.16
Rate for Payer: Cash Price	$4,581.77
Rate for Payer: Cigna Medicaid	$4,851.28
Rate for Payer: Molina CHIP/Medicaid	$4,851.28
Rate for Payer: Multiplan Auto	$3,368.95
Rate for Payer: Multiplan Commercial	$3,368.95
Rate for Payer: Multiplan Workers Comp	$3,368.95
Rate for Payer: Parkland Medicaid	$4,851.28
Rate for Payer: Scott and White EPO/PPO	$3,368.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,851.28
Rate for Payer: Superior Health Plan EPO	$916.35

INBONE STEM TIBIAL TOP SIZE 12 MM RIGHT & LEFT

Facility

$6,737.89

Service Code	HCPCS C1734
Hospital Charge Code	992287
Hospital Revenue Code	278
Min. Negotiated Rate	$1,684.47
Max. Negotiated Rate	$3,368.95
Rate for Payer: Cash Price	$4,581.77
Rate for Payer: Cigna Commercial	$1,684.47
Rate for Payer: Multiplan Auto	$3,368.95
Rate for Payer: Multiplan Commercial	$3,368.95
Rate for Payer: Multiplan Workers Comp	$3,368.95
Rate for Payer: Scott and White EPO/PPO	$3,368.95

INBONE STEM TIBIAL TOP SIZE 14 MM RIGHT & LEFT

Facility

$4,819.28

Service Code	HCPCS C1734
Hospital Charge Code	992256
Hospital Revenue Code	278
Min. Negotiated Rate	$1,204.82
Max. Negotiated Rate	$2,409.64
Rate for Payer: Cash Price	$3,277.11
Rate for Payer: Cigna Commercial	$1,204.82
Rate for Payer: Multiplan Auto	$2,409.64
Rate for Payer: Multiplan Commercial	$2,409.64
Rate for Payer: Multiplan Workers Comp	$2,409.64
Rate for Payer: Scott and White EPO/PPO	$2,409.64

INBONE STEM TIBIAL TOP SIZE 14 MM RIGHT & LEFT

Facility

$4,819.28

Service Code	HCPCS C1734
Hospital Charge Code	992256
Hospital Revenue Code	278
Min. Negotiated Rate	$433.74
Max. Negotiated Rate	$3,469.88
Rate for Payer: Amerigroup CHIP/Medicaid	$433.74
Rate for Payer: BCBS of TX Blue Advantage	$1,445.78
Rate for Payer: BCBS of TX Blue Essentials	$1,734.94
Rate for Payer: BCBS of TX PPO	$1,927.71
Rate for Payer: Cash Price	$3,277.11
Rate for Payer: Cigna Medicaid	$3,469.88
Rate for Payer: Molina CHIP/Medicaid	$3,469.88
Rate for Payer: Multiplan Auto	$2,409.64
Rate for Payer: Multiplan Commercial	$2,409.64
Rate for Payer: Multiplan Workers Comp	$2,409.64
Rate for Payer: Parkland Medicaid	$3,469.88
Rate for Payer: Scott and White EPO/PPO	$2,409.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,469.88
Rate for Payer: Superior Health Plan EPO	$655.42

Inbone stem tibial Top size 16 mm right & left

Facility

$13,463.86

Service Code	HCPCS C1734
Hospital Charge Code	992176
Hospital Revenue Code	278
Min. Negotiated Rate	$1,211.75
Max. Negotiated Rate	$9,693.98
Rate for Payer: Amerigroup CHIP/Medicaid	$1,211.75
Rate for Payer: BCBS of TX Blue Advantage	$4,039.16
Rate for Payer: BCBS of TX Blue Essentials	$4,846.99
Rate for Payer: BCBS of TX PPO	$5,385.54
Rate for Payer: Cash Price	$9,155.42
Rate for Payer: Cigna Medicaid	$9,693.98
Rate for Payer: Molina CHIP/Medicaid	$9,693.98
Rate for Payer: Multiplan Auto	$6,731.93
Rate for Payer: Multiplan Commercial	$6,731.93
Rate for Payer: Multiplan Workers Comp	$6,731.93
Rate for Payer: Parkland Medicaid	$9,693.98
Rate for Payer: Scott and White EPO/PPO	$6,731.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,693.98
Rate for Payer: Superior Health Plan EPO	$1,831.08

Inbone stem tibial Top size 16 mm right & left

Facility

$13,463.86

Service Code	HCPCS C1734
Hospital Charge Code	992176
Hospital Revenue Code	278
Min. Negotiated Rate	$3,365.97
Max. Negotiated Rate	$6,731.93
Rate for Payer: Cash Price	$9,155.42
Rate for Payer: Cigna Commercial	$3,365.97
Rate for Payer: Multiplan Auto	$6,731.93
Rate for Payer: Multiplan Commercial	$6,731.93
Rate for Payer: Multiplan Workers Comp	$6,731.93
Rate for Payer: Scott and White EPO/PPO	$6,731.93

INBONE TALAR DOME SZ 2 SULCUS

Facility

$13,132.53

Service Code	HCPCS C1734
Hospital Charge Code	992261
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.93
Max. Negotiated Rate	$9,455.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,181.93
Rate for Payer: BCBS of TX Blue Advantage	$3,939.76
Rate for Payer: BCBS of TX Blue Essentials	$4,727.71
Rate for Payer: BCBS of TX PPO	$5,253.01
Rate for Payer: Cash Price	$8,930.12
Rate for Payer: Cigna Medicaid	$9,455.42
Rate for Payer: Molina CHIP/Medicaid	$9,455.42
Rate for Payer: Multiplan Auto	$6,566.27
Rate for Payer: Multiplan Commercial	$6,566.27
Rate for Payer: Multiplan Workers Comp	$6,566.27
Rate for Payer: Parkland Medicaid	$9,455.42
Rate for Payer: Scott and White EPO/PPO	$6,566.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,455.42
Rate for Payer: Superior Health Plan EPO	$1,786.02

INBONE TALAR DOME SZ 2 SULCUS

Facility

$13,132.53

Service Code	HCPCS C1734
Hospital Charge Code	992261
Hospital Revenue Code	278
Min. Negotiated Rate	$3,283.13
Max. Negotiated Rate	$6,566.27
Rate for Payer: Cash Price	$8,930.12
Rate for Payer: Cigna Commercial	$3,283.13
Rate for Payer: Multiplan Auto	$6,566.27
Rate for Payer: Multiplan Commercial	$6,566.27
Rate for Payer: Multiplan Workers Comp	$6,566.27
Rate for Payer: Scott and White EPO/PPO	$6,566.27

INBONE TALAR DOME SZ 3 SULCUS

Facility

$13,132.53

Service Code	HCPCS C1734
Hospital Charge Code	992258
Hospital Revenue Code	278
Min. Negotiated Rate	$3,283.13
Max. Negotiated Rate	$6,566.27
Rate for Payer: Cash Price	$8,930.12
Rate for Payer: Cigna Commercial	$3,283.13
Rate for Payer: Multiplan Auto	$6,566.27
Rate for Payer: Multiplan Commercial	$6,566.27
Rate for Payer: Multiplan Workers Comp	$6,566.27
Rate for Payer: Scott and White EPO/PPO	$6,566.27

INBONE TALAR DOME SZ 3 SULCUS

Facility

$13,132.53

Service Code	HCPCS C1734
Hospital Charge Code	992258
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.93
Max. Negotiated Rate	$9,455.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,181.93
Rate for Payer: BCBS of TX Blue Advantage	$3,939.76
Rate for Payer: BCBS of TX Blue Essentials	$4,727.71
Rate for Payer: BCBS of TX PPO	$5,253.01
Rate for Payer: Cash Price	$8,930.12
Rate for Payer: Cigna Medicaid	$9,455.42
Rate for Payer: Molina CHIP/Medicaid	$9,455.42
Rate for Payer: Multiplan Auto	$6,566.27
Rate for Payer: Multiplan Commercial	$6,566.27
Rate for Payer: Multiplan Workers Comp	$6,566.27
Rate for Payer: Parkland Medicaid	$9,455.42
Rate for Payer: Scott and White EPO/PPO	$6,566.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,455.42
Rate for Payer: Superior Health Plan EPO	$1,786.02

Know your out-of-pocket cost for care.

All Charges