White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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	$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 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 REAMER 10MM

Facility

$1,157.70

Hospital Charge Code	993444
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 TALAR REAMER 10MM

Facility

$1,157.70

Hospital Charge Code	993444
Hospital Revenue Code	272
Rate for Payer: Cash Price	$787.24

INBONE TALAR STEM 10MM LG

Facility

$9,632.53

Service Code	HCPCS C1734
Hospital Charge Code	992257
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.13
Max. Negotiated Rate	$4,816.27
Rate for Payer: Cash Price	$6,550.12
Rate for Payer: Cigna Commercial	$2,408.13
Rate for Payer: Multiplan Auto	$4,816.27
Rate for Payer: Multiplan Commercial	$4,816.27
Rate for Payer: Multiplan Workers Comp	$4,816.27
Rate for Payer: Scott and White EPO/PPO	$4,816.27

INBONE TALAR STEM 10MM LG

Facility

$9,632.53

Service Code	HCPCS C1734
Hospital Charge Code	992257
Hospital Revenue Code	278
Min. Negotiated Rate	$866.93
Max. Negotiated Rate	$6,935.42
Rate for Payer: Amerigroup CHIP/Medicaid	$866.93
Rate for Payer: BCBS of TX Blue Advantage	$2,889.76
Rate for Payer: BCBS of TX Blue Essentials	$3,467.71
Rate for Payer: BCBS of TX PPO	$3,853.01
Rate for Payer: Cash Price	$6,550.12
Rate for Payer: Cigna Medicaid	$6,935.42
Rate for Payer: Molina CHIP/Medicaid	$6,935.42
Rate for Payer: Multiplan Auto	$4,816.27
Rate for Payer: Multiplan Commercial	$4,816.27
Rate for Payer: Multiplan Workers Comp	$4,816.27
Rate for Payer: Parkland Medicaid	$6,935.42
Rate for Payer: Scott and White EPO/PPO	$4,816.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,935.42
Rate for Payer: Superior Health Plan EPO	$1,310.02

INBONE TIB TRAY LEFT SZ 2 LNG

Facility

$18,085.78

Service Code	HCPCS C1734
Hospital Charge Code	992260
Hospital Revenue Code	278
Min. Negotiated Rate	$1,627.72
Max. Negotiated Rate	$13,021.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,627.72
Rate for Payer: BCBS of TX Blue Advantage	$5,425.73
Rate for Payer: BCBS of TX Blue Essentials	$6,510.88
Rate for Payer: BCBS of TX PPO	$7,234.31
Rate for Payer: Cash Price	$12,298.33
Rate for Payer: Cigna Medicaid	$13,021.76
Rate for Payer: Molina CHIP/Medicaid	$13,021.76
Rate for Payer: Multiplan Auto	$9,042.89
Rate for Payer: Multiplan Commercial	$9,042.89
Rate for Payer: Multiplan Workers Comp	$9,042.89
Rate for Payer: Parkland Medicaid	$13,021.76
Rate for Payer: Scott and White EPO/PPO	$9,042.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,021.76
Rate for Payer: Superior Health Plan EPO	$2,459.67

INBONE TIB TRAY LEFT SZ 2 LNG

Facility

$18,085.78

Service Code	HCPCS C1734
Hospital Charge Code	992260
Hospital Revenue Code	278
Min. Negotiated Rate	$4,521.44
Max. Negotiated Rate	$9,042.89
Rate for Payer: Cash Price	$12,298.33
Rate for Payer: Cigna Commercial	$4,521.44
Rate for Payer: Multiplan Auto	$9,042.89
Rate for Payer: Multiplan Commercial	$9,042.89
Rate for Payer: Multiplan Workers Comp	$9,042.89
Rate for Payer: Scott and White EPO/PPO	$9,042.89

INBONE TIB TRAY LEFT SZ 4 LNG

Facility

$37,915.66

Service Code	HCPCS C1734
Hospital Charge Code	992142
Hospital Revenue Code	278
Min. Negotiated Rate	$3,412.41
Max. Negotiated Rate	$27,299.28
Rate for Payer: Amerigroup CHIP/Medicaid	$3,412.41
Rate for Payer: BCBS of TX Blue Advantage	$11,374.70
Rate for Payer: BCBS of TX Blue Essentials	$13,649.64
Rate for Payer: BCBS of TX PPO	$15,166.26
Rate for Payer: Cash Price	$25,782.65
Rate for Payer: Cigna Medicaid	$27,299.28
Rate for Payer: Molina CHIP/Medicaid	$27,299.28
Rate for Payer: Multiplan Auto	$18,957.83
Rate for Payer: Multiplan Commercial	$18,957.83
Rate for Payer: Multiplan Workers Comp	$18,957.83
Rate for Payer: Parkland Medicaid	$27,299.28
Rate for Payer: Scott and White EPO/PPO	$18,957.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,299.28
Rate for Payer: Superior Health Plan EPO	$5,156.53

INBONE TIB TRAY LEFT SZ 4 LNG

Facility

$37,915.66

Service Code	HCPCS C1734
Hospital Charge Code	992142
Hospital Revenue Code	278
Min. Negotiated Rate	$9,478.92
Max. Negotiated Rate	$18,957.83
Rate for Payer: Cash Price	$25,782.65
Rate for Payer: Cigna Commercial	$9,478.92
Rate for Payer: Multiplan Auto	$18,957.83
Rate for Payer: Multiplan Commercial	$18,957.83
Rate for Payer: Multiplan Workers Comp	$18,957.83
Rate for Payer: Scott and White EPO/PPO	$18,957.83

INBORN AND OTHER DISORDERS OF METABOLISM

Facility

$26,662.70

Service Code	MSDRG 642
Min. Negotiated Rate	$10,866.10
Max. Negotiated Rate	$26,662.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15,182.69
Rate for Payer: Amerigroup Medicare	$15,182.69
Rate for Payer: BCBS of TX Blue Advantage	$10,866.10
Rate for Payer: BCBS of TX Blue Essentials	$13,038.06
Rate for Payer: BCBS of TX Medicare	$15,182.69
Rate for Payer: BCBS of TX PPO	$14,487.29
Rate for Payer: Cigna Commercial	$18,316.65
Rate for Payer: Cigna Medicare	$15,182.69
Rate for Payer: Employer Direct Commercial	$15,182.69
Rate for Payer: Humana Medicare/TRICARE	$15,182.69
Rate for Payer: Molina Dual Medicare/Medicaid	$15,182.69
Rate for Payer: Molina Medicare	$15,182.69
Rate for Payer: Multiplan Auto	$26,662.70
Rate for Payer: Multiplan Commercial	$26,662.70
Rate for Payer: Multiplan Workers Comp	$26,662.70
Rate for Payer: Scott and White EPO/PPO	$12,278.88
Rate for Payer: Scott and White Medicare	$15,182.69
Rate for Payer: Superior Health Plan EPO	$15,182.69
Rate for Payer: Superior Health Plan Medicare	$15,182.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$15,182.69
Rate for Payer: Universal American Medicare	$15,182.69
Rate for Payer: Wellcare Medicare	$15,182.69
Rate for Payer: Wellmed Medicare	$15,182.69

INBORN ERRORS OF METABOLISM

Facility

$15,941.14

Service Code	APR-DRG 4234
Min. Negotiated Rate	$15,029.86
Max. Negotiated Rate	$15,941.14
Rate for Payer: Amerigroup CHIP/Medicaid	$15,029.86
Rate for Payer: Cigna Medicaid	$15,029.86
Rate for Payer: Molina CHIP/Medicaid	$15,029.86
Rate for Payer: Parkland Medicaid	$15,029.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15,941.14

INBORN ERRORS OF METABOLISM

Facility

$10,270.10

Service Code	APR-DRG 4232
Min. Negotiated Rate	$9,683.01
Max. Negotiated Rate	$10,270.10
Rate for Payer: Amerigroup CHIP/Medicaid	$9,683.01
Rate for Payer: Cigna Medicaid	$9,683.01
Rate for Payer: Molina CHIP/Medicaid	$9,683.01
Rate for Payer: Parkland Medicaid	$9,683.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,270.10

INBORN ERRORS OF METABOLISM

Facility

$7,649.02

Service Code	APR-DRG 4231
Min. Negotiated Rate	$7,211.76
Max. Negotiated Rate	$7,649.02
Rate for Payer: Amerigroup CHIP/Medicaid	$7,211.76
Rate for Payer: Cigna Medicaid	$7,211.76
Rate for Payer: Molina CHIP/Medicaid	$7,211.76
Rate for Payer: Parkland Medicaid	$7,211.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,649.02

INBORN ERRORS OF METABOLISM

Facility

$12,891.19

Service Code	APR-DRG 4233
Min. Negotiated Rate	$12,154.26
Max. Negotiated Rate	$12,891.19
Rate for Payer: Amerigroup CHIP/Medicaid	$12,154.26
Rate for Payer: Cigna Medicaid	$12,154.26
Rate for Payer: Molina CHIP/Medicaid	$12,154.26
Rate for Payer: Parkland Medicaid	$12,154.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,891.19

INCISIONAL BX SKIN SEP/ADDL

Facility

$1,014.00

Service Code	HCPCS 11107
Hospital Charge Code	7150056
Hospital Revenue Code	761
Rate for Payer: Cash Price	$689.52

INCISIONAL BX SKIN SEP/ADDL

Facility

$1,014.00

Service Code	HCPCS 11107
Hospital Charge Code	7150056
Hospital Revenue Code	761
Min. Negotiated Rate	$37.23
Max. Negotiated Rate	$730.08
Rate for Payer: Amerigroup CHIP/Medicaid	$91.26
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$689.52
Rate for Payer: Cash Price	$689.52
Rate for Payer: Cigna Medicaid	$730.08
Rate for Payer: Molina CHIP/Medicaid	$730.08
Rate for Payer: Multiplan Auto	$659.10
Rate for Payer: Multiplan Commercial	$659.10
Rate for Payer: Multiplan Workers Comp	$659.10
Rate for Payer: Parkland Medicaid	$730.08
Rate for Payer: Scott and White EPO/PPO	$37.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$730.08
Rate for Payer: Superior Health Plan EPO	$137.90

Know your out-of-pocket cost for care.

All Charges