White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Body plethysmography (throacic gas volume)

Facility

$527.00

Service Code	CPT 94726
Hospital Charge Code	4049201
Hospital Revenue Code	460
Rate for Payer: Cash Price	$463.76

Body plethysmography (throacic gas volume)

Facility

$527.00

Service Code	CPT 94726
Hospital Charge Code	4049201
Hospital Revenue Code	460
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$650.28
Rate for Payer: Aetna Commercial	$289.85
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$47.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$440.39
Rate for Payer: BCBS of TX Blue Essentials	$526.45
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$587.19
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$342.55
Rate for Payer: Multiplan Commercial	$342.55
Rate for Payer: Multiplan Workers Comp	$342.55
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

Bone Biopsy Needle/Trocar, Deep

Facility

$2,948.00

Service Code	CPT 20225
Hospital Charge Code	8178355
Hospital Revenue Code	361
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,594.24
Rate for Payer: Cash Price	$2,594.24
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$486.45
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$486.45
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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
Rate for Payer: Parkland Medicaid	$486.45
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

Bone Biopsy Needle/Trocar, Superficial

Facility

$2,714.00

Service Code	CPT 20220
Hospital Charge Code	7150910
Hospital Revenue Code	361
Min. Negotiated Rate	$32.70
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,400.00
Rate for Payer: Aetna Medicare	$2,224.11
Rate for Payer: Amerigroup CHIP/Medicaid	$486.45
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Amerigroup Medicare	$1,482.74
Rate for Payer: BCBS of TX Blue Advantage	$2,292.24
Rate for Payer: BCBS of TX Blue Essentials	$2,745.20
Rate for Payer: BCBS of TX Medicare	$1,482.74
Rate for Payer: BCBS of TX PPO	$3,458.95
Rate for Payer: Cash Price	$2,388.32
Rate for Payer: Cash Price	$2,388.32
Rate for Payer: Cigna Commercial	$3,358.84
Rate for Payer: Cigna Medicaid	$486.45
Rate for Payer: Cigna Medicare	$1,482.74
Rate for Payer: Employer Direct Commercial	$1,482.74
Rate for Payer: Humana Medicare/TRICARE	$1,482.74
Rate for Payer: Molina CHIP/Medicaid	$486.45
Rate for Payer: Molina Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Molina Medicare	$1,482.74
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
Rate for Payer: Parkland Medicaid	$486.45
Rate for Payer: Scott and White EPO/PPO	$32.70
Rate for Payer: Scott and White Medicare	$1,482.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$486.45
Rate for Payer: Superior Health Plan EPO	$1,482.74
Rate for Payer: Superior Health Plan Medicare	$1,482.74
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,482.74
Rate for Payer: Universal American Medicare	$1,482.74
Rate for Payer: Wellcare Medicare	$1,482.74
Rate for Payer: Wellmed Medicare	$1,482.74

BONE DISEASES AND ARTHROPATHIES WITH MCC

Facility

$25,678.50

Service Code	MSDRG 553
Min. Negotiated Rate	$10,356.98
Max. Negotiated Rate	$25,678.50
Rate for Payer: Aetna Commercial	$15,204.38
Rate for Payer: Aetna Medicare	$18,748.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,499.17
Rate for Payer: Amerigroup Medicare	$12,499.17
Rate for Payer: BCBS of TX Blue Advantage	$10,356.98
Rate for Payer: BCBS of TX Blue Essentials	$12,770.79
Rate for Payer: BCBS of TX Medicare	$12,499.17
Rate for Payer: BCBS of TX PPO	$14,190.32
Rate for Payer: Cigna Commercial	$17,407.32
Rate for Payer: Cigna Medicare	$12,499.17
Rate for Payer: Employer Direct Commercial	$12,499.17
Rate for Payer: Humana Medicare/TRICARE	$12,499.17
Rate for Payer: Molina Dual Medicare/Medicaid	$12,499.17
Rate for Payer: Molina Medicare	$12,499.17
Rate for Payer: Multiplan Auto	$25,678.50
Rate for Payer: Multiplan Commercial	$25,678.50
Rate for Payer: Multiplan Workers Comp	$25,678.50
Rate for Payer: Scott and White EPO/PPO	$11,825.62
Rate for Payer: Scott and White Medicare	$12,499.17
Rate for Payer: Superior Health Plan EPO	$12,499.17
Rate for Payer: Superior Health Plan Medicare	$12,499.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,499.17
Rate for Payer: Universal American Medicare	$12,499.17
Rate for Payer: Wellcare Medicare	$12,499.17
Rate for Payer: Wellmed Medicare	$12,499.17

BONE DISEASES AND ARTHROPATHIES WITHOUT MCC

Facility

$15,614.20

Service Code	MSDRG 554
Min. Negotiated Rate	$6,270.26
Max. Negotiated Rate	$15,614.20
Rate for Payer: Aetna Commercial	$9,245.25
Rate for Payer: Aetna Medicare	$13,078.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,719.18
Rate for Payer: Amerigroup Medicare	$8,719.18
Rate for Payer: BCBS of TX Blue Advantage	$6,270.26
Rate for Payer: BCBS of TX Blue Essentials	$7,810.45
Rate for Payer: BCBS of TX Medicare	$8,719.18
Rate for Payer: BCBS of TX PPO	$8,678.62
Rate for Payer: Cigna Commercial	$10,584.78
Rate for Payer: Cigna Medicare	$8,719.18
Rate for Payer: Employer Direct Commercial	$8,719.18
Rate for Payer: Humana Medicare/TRICARE	$8,719.18
Rate for Payer: Molina Dual Medicare/Medicaid	$8,719.18
Rate for Payer: Molina Medicare	$8,719.18
Rate for Payer: Multiplan Auto	$15,614.20
Rate for Payer: Multiplan Commercial	$15,614.20
Rate for Payer: Multiplan Workers Comp	$15,614.20
Rate for Payer: Scott and White EPO/PPO	$7,190.75
Rate for Payer: Scott and White Medicare	$8,719.18
Rate for Payer: Superior Health Plan EPO	$8,719.18
Rate for Payer: Superior Health Plan Medicare	$8,719.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,719.18
Rate for Payer: Universal American Medicare	$8,719.18
Rate for Payer: Wellcare Medicare	$8,719.18
Rate for Payer: Wellmed Medicare	$8,719.18

BONE FILLER 10CC

Facility

$5,120.48

Service Code	HCPCS C1713
Hospital Charge Code	8394471
Hospital Revenue Code	278
Min. Negotiated Rate	$1,280.12
Max. Negotiated Rate	$2,560.24
Rate for Payer: Aetna Commercial	$1,536.14
Rate for Payer: Cash Price	$4,506.02
Rate for Payer: Cigna Commercial	$1,280.12
Rate for Payer: Multiplan Auto	$2,560.24
Rate for Payer: Multiplan Commercial	$2,560.24
Rate for Payer: Multiplan Workers Comp	$2,560.24
Rate for Payer: Scott and White EPO/PPO	$2,560.24

BONE FILLER 10CC

Facility

$5,120.48

Service Code	HCPCS C1713
Hospital Charge Code	8394471
Hospital Revenue Code	278
Min. Negotiated Rate	$460.84
Max. Negotiated Rate	$2,560.24
Rate for Payer: Aetna Commercial	$1,536.14
Rate for Payer: Amerigroup CHIP/Medicaid	$460.84
Rate for Payer: BCBS of TX Blue Advantage	$1,536.14
Rate for Payer: BCBS of TX Blue Essentials	$1,843.37
Rate for Payer: BCBS of TX PPO	$2,048.19
Rate for Payer: Cash Price	$4,506.02
Rate for Payer: Multiplan Auto	$2,560.24
Rate for Payer: Multiplan Commercial	$2,560.24
Rate for Payer: Multiplan Workers Comp	$2,560.24
Rate for Payer: Scott and White EPO/PPO	$2,560.24
Rate for Payer: Superior Health Plan EPO	$696.39

bone filler resorbable 3.5 & 4.5

Facility

$7,018.07

Service Code	HCPCS C1713
Hospital Charge Code	8702509
Hospital Revenue Code	278
Min. Negotiated Rate	$631.63
Max. Negotiated Rate	$3,509.04
Rate for Payer: Aetna Commercial	$2,105.42
Rate for Payer: Amerigroup CHIP/Medicaid	$631.63
Rate for Payer: BCBS of TX Blue Advantage	$2,105.42
Rate for Payer: BCBS of TX Blue Essentials	$2,526.51
Rate for Payer: BCBS of TX PPO	$2,807.23
Rate for Payer: Cash Price	$6,175.90
Rate for Payer: Multiplan Auto	$3,509.04
Rate for Payer: Multiplan Commercial	$3,509.04
Rate for Payer: Multiplan Workers Comp	$3,509.04
Rate for Payer: Scott and White EPO/PPO	$3,509.04
Rate for Payer: Superior Health Plan EPO	$954.46

bone filler resorbable 3.5 & 4.5

Facility

$7,018.07

Service Code	HCPCS C1713
Hospital Charge Code	8702509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,754.52
Max. Negotiated Rate	$3,509.04
Rate for Payer: Aetna Commercial	$2,105.42
Rate for Payer: Cash Price	$6,175.90
Rate for Payer: Cigna Commercial	$1,754.52
Rate for Payer: Multiplan Auto	$3,509.04
Rate for Payer: Multiplan Commercial	$3,509.04
Rate for Payer: Multiplan Workers Comp	$3,509.04
Rate for Payer: Scott and White EPO/PPO	$3,509.04

Bone graft, any donor area; major or large

Facility

$15,074.51

Service Code	CPT 20902
Hospital Charge Code	36020902
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$2,398.52
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$2,398.52
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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
Rate for Payer: Parkland Medicaid	$2,398.52
Rate for Payer: Scott and White EPO/PPO	$144.31
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,398.52
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

Bone graft, any donor area minor or small (eg, dowel or button)

Facility

$15,074.51

Service Code	CPT 20900
Hospital Charge Code	36020900
Hospital Revenue Code	360
Min. Negotiated Rate	$144.31
Max. Negotiated Rate	$15,074.51
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$9,814.08
Rate for Payer: Amerigroup CHIP/Medicaid	$3,122.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Amerigroup Medicare	$6,542.72
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$6,542.72
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$14,821.16
Rate for Payer: Cigna Medicaid	$3,122.54
Rate for Payer: Cigna Medicare	$6,542.72
Rate for Payer: Employer Direct Commercial	$6,542.72
Rate for Payer: Humana Medicare/TRICARE	$6,542.72
Rate for Payer: Molina CHIP/Medicaid	$3,122.54
Rate for Payer: Molina Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Molina Medicare	$6,542.72
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
Rate for Payer: Parkland Medicaid	$3,122.54
Rate for Payer: Scott and White EPO/PPO	$144.31
Rate for Payer: Scott and White Medicare	$6,542.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,122.54
Rate for Payer: Superior Health Plan EPO	$6,542.72
Rate for Payer: Superior Health Plan Medicare	$6,542.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,542.72
Rate for Payer: Universal American Medicare	$6,542.72
Rate for Payer: Wellcare Medicare	$6,542.72
Rate for Payer: Wellmed Medicare	$6,542.72

bone graft strip unifuze 10cc

Facility

$18,825.30

Service Code	HCPCS C9359
Hospital Charge Code	8720593
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$9,412.65
Rate for Payer: Aetna Commercial	$5,647.59
Rate for Payer: Amerigroup CHIP/Medicaid	$1,694.28
Rate for Payer: BCBS of TX Blue Advantage	$5,647.59
Rate for Payer: BCBS of TX Blue Essentials	$6,777.11
Rate for Payer: BCBS of TX PPO	$7,530.12
Rate for Payer: Cash Price	$16,566.26
Rate for Payer: Cash Price	$16,566.26
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$9,412.65
Rate for Payer: Multiplan Commercial	$9,412.65
Rate for Payer: Multiplan Workers Comp	$9,412.65
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$9,412.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$2,560.24

bone graft strip unifuze 10cc

Facility

$18,825.30

Service Code	HCPCS C9359
Hospital Charge Code	8720593
Hospital Revenue Code	278
Min. Negotiated Rate	$4,706.32
Max. Negotiated Rate	$9,412.65
Rate for Payer: Aetna Commercial	$5,647.59
Rate for Payer: Cash Price	$16,566.26
Rate for Payer: Cigna Commercial	$4,706.32
Rate for Payer: Multiplan Auto	$9,412.65
Rate for Payer: Multiplan Commercial	$9,412.65
Rate for Payer: Multiplan Workers Comp	$9,412.65
Rate for Payer: Scott and White EPO/PPO	$9,412.65

bone graft strip unifuze 20cc

Facility

$33,132.53

Service Code	HCPCS C9359
Hospital Charge Code	8720592
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$16,566.26
Rate for Payer: Aetna Commercial	$9,939.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,981.93
Rate for Payer: BCBS of TX Blue Advantage	$9,939.76
Rate for Payer: BCBS of TX Blue Essentials	$11,927.71
Rate for Payer: BCBS of TX PPO	$13,253.01
Rate for Payer: Cash Price	$29,156.63
Rate for Payer: Cash Price	$29,156.63
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$16,566.26
Rate for Payer: Multiplan Commercial	$16,566.26
Rate for Payer: Multiplan Workers Comp	$16,566.26
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$16,566.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$4,506.02

bone graft strip unifuze 20cc

Facility

$33,132.53

Service Code	HCPCS C9359
Hospital Charge Code	8720592
Hospital Revenue Code	278
Min. Negotiated Rate	$8,283.13
Max. Negotiated Rate	$16,566.26
Rate for Payer: Aetna Commercial	$9,939.76
Rate for Payer: Cash Price	$29,156.63
Rate for Payer: Cigna Commercial	$8,283.13
Rate for Payer: Multiplan Auto	$16,566.26
Rate for Payer: Multiplan Commercial	$16,566.26
Rate for Payer: Multiplan Workers Comp	$16,566.26
Rate for Payer: Scott and White EPO/PPO	$16,566.26

bone graft strip unifuze ba 5cc

Facility

$10,542.17

Service Code	HCPCS C9359
Hospital Charge Code	8720614
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$5,271.08
Rate for Payer: Aetna Commercial	$3,162.65
Rate for Payer: Amerigroup CHIP/Medicaid	$948.80
Rate for Payer: BCBS of TX Blue Advantage	$3,162.65
Rate for Payer: BCBS of TX Blue Essentials	$3,795.18
Rate for Payer: BCBS of TX PPO	$4,216.87
Rate for Payer: Cash Price	$9,277.11
Rate for Payer: Cash Price	$9,277.11
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$5,271.08
Rate for Payer: Multiplan Commercial	$5,271.08
Rate for Payer: Multiplan Workers Comp	$5,271.08
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$5,271.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$1,433.74

bone graft strip unifuze ba 5cc

Facility

$10,542.17

Service Code	HCPCS C9359
Hospital Charge Code	8720614
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.54
Max. Negotiated Rate	$5,271.08
Rate for Payer: Aetna Commercial	$3,162.65
Rate for Payer: Cash Price	$9,277.11
Rate for Payer: Cigna Commercial	$2,635.54
Rate for Payer: Multiplan Auto	$5,271.08
Rate for Payer: Multiplan Commercial	$5,271.08
Rate for Payer: Multiplan Workers Comp	$5,271.08
Rate for Payer: Scott and White EPO/PPO	$5,271.08

bone graft unfuze 2 med/long block 10cc

Facility

$16,566.27

Service Code	HCPCS C9359
Hospital Charge Code	8720601
Hospital Revenue Code	278
Min. Negotiated Rate	$4,141.57
Max. Negotiated Rate	$8,283.14
Rate for Payer: Aetna Commercial	$4,969.88
Rate for Payer: Cash Price	$14,578.32
Rate for Payer: Cigna Commercial	$4,141.57
Rate for Payer: Multiplan Auto	$8,283.14
Rate for Payer: Multiplan Commercial	$8,283.14
Rate for Payer: Multiplan Workers Comp	$8,283.14
Rate for Payer: Scott and White EPO/PPO	$8,283.14

bone graft unfuze 2 med/long block 10cc

Facility

$16,566.27

Service Code	HCPCS C9359
Hospital Charge Code	8720601
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$8,283.14
Rate for Payer: Aetna Commercial	$4,969.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,490.96
Rate for Payer: BCBS of TX Blue Advantage	$4,969.88
Rate for Payer: BCBS of TX Blue Essentials	$5,963.86
Rate for Payer: BCBS of TX PPO	$6,626.51
Rate for Payer: Cash Price	$14,578.32
Rate for Payer: Cash Price	$14,578.32
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$8,283.14
Rate for Payer: Multiplan Commercial	$8,283.14
Rate for Payer: Multiplan Workers Comp	$8,283.14
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$8,283.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$2,253.01

bone graft unifuze 1 block large 20cc

Facility

$25,602.41

Service Code	HCPCS C9359
Hospital Charge Code	8720602
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$12,801.20
Rate for Payer: Aetna Commercial	$7,680.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2,304.22
Rate for Payer: BCBS of TX Blue Advantage	$7,680.72
Rate for Payer: BCBS of TX Blue Essentials	$9,216.87
Rate for Payer: BCBS of TX PPO	$10,240.96
Rate for Payer: Cash Price	$22,530.12
Rate for Payer: Cash Price	$22,530.12
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$12,801.20
Rate for Payer: Multiplan Commercial	$12,801.20
Rate for Payer: Multiplan Workers Comp	$12,801.20
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$12,801.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$3,481.93

bone graft unifuze 1 block large 20cc

Facility

$25,602.41

Service Code	HCPCS C9359
Hospital Charge Code	8720602
Hospital Revenue Code	278
Min. Negotiated Rate	$6,400.60
Max. Negotiated Rate	$12,801.20
Rate for Payer: Aetna Commercial	$7,680.72
Rate for Payer: Cash Price	$22,530.12
Rate for Payer: Cigna Commercial	$6,400.60
Rate for Payer: Multiplan Auto	$12,801.20
Rate for Payer: Multiplan Commercial	$12,801.20
Rate for Payer: Multiplan Workers Comp	$12,801.20
Rate for Payer: Scott and White EPO/PPO	$12,801.20

bonegraft unifuze 1 block med 10cc

Facility

$15,060.24

Service Code	HCPCS C9359
Hospital Charge Code	8720612
Hospital Revenue Code	278
Min. Negotiated Rate	$3,765.06
Max. Negotiated Rate	$7,530.12
Rate for Payer: Aetna Commercial	$4,518.07
Rate for Payer: Cash Price	$13,253.01
Rate for Payer: Cigna Commercial	$3,765.06
Rate for Payer: Multiplan Auto	$7,530.12
Rate for Payer: Multiplan Commercial	$7,530.12
Rate for Payer: Multiplan Workers Comp	$7,530.12
Rate for Payer: Scott and White EPO/PPO	$7,530.12

bonegraft unifuze 1 block med 10cc

Facility

$15,060.24

Service Code	HCPCS C9359
Hospital Charge Code	8720612
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$7,530.12
Rate for Payer: Aetna Commercial	$4,518.07
Rate for Payer: Amerigroup CHIP/Medicaid	$1,355.42
Rate for Payer: BCBS of TX Blue Advantage	$4,518.07
Rate for Payer: BCBS of TX Blue Essentials	$5,421.69
Rate for Payer: BCBS of TX PPO	$6,024.10
Rate for Payer: Cash Price	$13,253.01
Rate for Payer: Cash Price	$13,253.01
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$7,530.12
Rate for Payer: Multiplan Commercial	$7,530.12
Rate for Payer: Multiplan Workers Comp	$7,530.12
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$7,530.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$2,048.19

bone graft unifuze1 block small 5cc

Facility

$9,789.16

Service Code	HCPCS C9359
Hospital Charge Code	8720613
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$4,894.58
Rate for Payer: Aetna Commercial	$2,936.75
Rate for Payer: Amerigroup CHIP/Medicaid	$881.02
Rate for Payer: BCBS of TX Blue Advantage	$2,936.75
Rate for Payer: BCBS of TX Blue Essentials	$3,524.10
Rate for Payer: BCBS of TX PPO	$3,915.66
Rate for Payer: Cash Price	$8,614.46
Rate for Payer: Cash Price	$8,614.46
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$4,894.58
Rate for Payer: Multiplan Commercial	$4,894.58
Rate for Payer: Multiplan Workers Comp	$4,894.58
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$4,894.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$1,331.33

Know your out-of-pocket cost for care.

All Charges