White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

bone graft unifuze 2 sm/long block 5cc

Facility

$12,048.19

Service Code	HCPCS C9359
Hospital Charge Code	8720611
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$6,024.10
Rate for Payer: Aetna Commercial	$3,614.46
Rate for Payer: Amerigroup CHIP/Medicaid	$1,084.34
Rate for Payer: BCBS of TX Blue Advantage	$3,614.46
Rate for Payer: BCBS of TX Blue Essentials	$4,337.35
Rate for Payer: BCBS of TX PPO	$4,819.28
Rate for Payer: Cash Price	$10,602.41
Rate for Payer: Cash Price	$10,602.41
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$6,024.10
Rate for Payer: Multiplan Commercial	$6,024.10
Rate for Payer: Multiplan Workers Comp	$6,024.10
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$6,024.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$1,638.55

bone graft unifuze 2 sm/long block 5cc

Facility

$12,048.19

Service Code	HCPCS C9359
Hospital Charge Code	8720611
Hospital Revenue Code	278
Min. Negotiated Rate	$3,012.05
Max. Negotiated Rate	$6,024.10
Rate for Payer: Aetna Commercial	$3,614.46
Rate for Payer: Cash Price	$10,602.41
Rate for Payer: Cigna Commercial	$3,012.05
Rate for Payer: Multiplan Auto	$6,024.10
Rate for Payer: Multiplan Commercial	$6,024.10
Rate for Payer: Multiplan Workers Comp	$6,024.10
Rate for Payer: Scott and White EPO/PPO	$6,024.10

bone graft unifuze-p large 10cc

Facility

$19,036.14

Service Code	HCPCS C9359
Hospital Charge Code	8720597
Hospital Revenue Code	278
Min. Negotiated Rate	$4,759.04
Max. Negotiated Rate	$9,518.07
Rate for Payer: Aetna Commercial	$5,710.84
Rate for Payer: Cash Price	$16,751.80
Rate for Payer: Cigna Commercial	$4,759.04
Rate for Payer: Multiplan Auto	$9,518.07
Rate for Payer: Multiplan Commercial	$9,518.07
Rate for Payer: Multiplan Workers Comp	$9,518.07
Rate for Payer: Scott and White EPO/PPO	$9,518.07

bone graft unifuze-p large 10cc

Facility

$19,036.14

Service Code	HCPCS C9359
Hospital Charge Code	8720597
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$9,518.07
Rate for Payer: Aetna Commercial	$5,710.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,713.25
Rate for Payer: BCBS of TX Blue Advantage	$5,710.84
Rate for Payer: BCBS of TX Blue Essentials	$6,853.01
Rate for Payer: BCBS of TX PPO	$7,614.46
Rate for Payer: Cash Price	$16,751.80
Rate for Payer: Cash Price	$16,751.80
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$9,518.07
Rate for Payer: Multiplan Commercial	$9,518.07
Rate for Payer: Multiplan Workers Comp	$9,518.07
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$9,518.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$2,588.92

bone graft unifuze-p med 5.0cc

Facility

$13,253.01

Service Code	HCPCS C9359
Hospital Charge Code	8720606
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$6,626.50
Rate for Payer: Aetna Commercial	$3,975.90
Rate for Payer: Amerigroup CHIP/Medicaid	$1,192.77
Rate for Payer: BCBS of TX Blue Advantage	$3,975.90
Rate for Payer: BCBS of TX Blue Essentials	$4,771.08
Rate for Payer: BCBS of TX PPO	$5,301.20
Rate for Payer: Cash Price	$11,662.65
Rate for Payer: Cash Price	$11,662.65
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
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	$150.09
Rate for Payer: Scott and White EPO/PPO	$6,626.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$1,802.41

bone graft unifuze-p med 5.0cc

Facility

$13,253.01

Service Code	HCPCS C9359
Hospital Charge Code	8720606
Hospital Revenue Code	278
Min. Negotiated Rate	$3,313.25
Max. Negotiated Rate	$6,626.50
Rate for Payer: Aetna Commercial	$3,975.90
Rate for Payer: Cash Price	$11,662.65
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

bone graft unifuze-p small 2.5cc

Facility

$8,192.77

Service Code	HCPCS C9359
Hospital Charge Code	8720607
Hospital Revenue Code	278
Min. Negotiated Rate	$2,048.19
Max. Negotiated Rate	$4,096.38
Rate for Payer: Aetna Commercial	$2,457.83
Rate for Payer: Cash Price	$7,209.64
Rate for Payer: Cigna Commercial	$2,048.19
Rate for Payer: Multiplan Auto	$4,096.38
Rate for Payer: Multiplan Commercial	$4,096.38
Rate for Payer: Multiplan Workers Comp	$4,096.38
Rate for Payer: Scott and White EPO/PPO	$4,096.38

bone graft unifuze-p small 2.5cc

Facility

$8,192.77

Service Code	HCPCS C9359
Hospital Charge Code	8720607
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$4,096.38
Rate for Payer: Aetna Commercial	$2,457.83
Rate for Payer: Amerigroup CHIP/Medicaid	$737.35
Rate for Payer: BCBS of TX Blue Advantage	$2,457.83
Rate for Payer: BCBS of TX Blue Essentials	$2,949.40
Rate for Payer: BCBS of TX PPO	$3,277.11
Rate for Payer: Cash Price	$7,209.64
Rate for Payer: Cash Price	$7,209.64
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$4,096.38
Rate for Payer: Multiplan Commercial	$4,096.38
Rate for Payer: Multiplan Workers Comp	$4,096.38
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$4,096.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$1,114.22

BONE HARVESTER

Facility

$5,448.00

Hospital Charge Code	8474500
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,794.24

BONE HARVESTER

Facility

$5,448.00

Hospital Charge Code	8474500
Hospital Revenue Code	272
Min. Negotiated Rate	$490.32
Max. Negotiated Rate	$3,541.20
Rate for Payer: Aetna Commercial	$2,996.40
Rate for Payer: Amerigroup CHIP/Medicaid	$490.32
Rate for Payer: BCBS of TX Blue Advantage	$1,634.40
Rate for Payer: BCBS of TX Blue Essentials	$1,961.28
Rate for Payer: BCBS of TX PPO	$2,179.20
Rate for Payer: Cash Price	$4,794.24
Rate for Payer: Multiplan Auto	$3,541.20
Rate for Payer: Multiplan Commercial	$3,541.20
Rate for Payer: Multiplan Workers Comp	$3,541.20
Rate for Payer: Scott and White EPO/PPO	$2,724.00
Rate for Payer: Superior Health Plan EPO	$740.93

Bone Marrow Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107064
Hospital Revenue Code	306
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$200.85
Rate for Payer: Aetna Commercial	$9.05
Rate for Payer: Aetna Medicare	$12.93
Rate for Payer: Amerigroup CHIP/Medicaid	$3.36
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.62
Rate for Payer: Amerigroup Medicare	$8.62
Rate for Payer: BCBS of TX Blue Advantage	$14.22
Rate for Payer: BCBS of TX Blue Essentials	$17.07
Rate for Payer: BCBS of TX Medicare	$8.62
Rate for Payer: BCBS of TX PPO	$19.05
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cash Price	$271.92
Rate for Payer: Cigna Medicaid	$8.62
Rate for Payer: Cigna Medicare	$8.62
Rate for Payer: Employer Direct Commercial	$8.62
Rate for Payer: Humana Medicare/TRICARE	$8.62
Rate for Payer: Molina CHIP/Medicaid	$8.62
Rate for Payer: Molina Dual Medicare/Medicaid	$8.62
Rate for Payer: Molina Medicare	$8.62
Rate for Payer: Multiplan Auto	$200.85
Rate for Payer: Multiplan Commercial	$200.85
Rate for Payer: Multiplan Workers Comp	$200.85
Rate for Payer: Parkland Medicaid	$8.62
Rate for Payer: Scott and White EPO/PPO	$10.78
Rate for Payer: Scott and White Medicare	$8.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.62
Rate for Payer: Superior Health Plan EPO	$8.62
Rate for Payer: Superior Health Plan Medicare	$8.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.62
Rate for Payer: Universal American Medicare	$8.62
Rate for Payer: Wellcare Medicare	$8.62
Rate for Payer: Wellmed Medicare	$8.62

Bone Marrow Culture

Facility

$309.00

Service Code	CPT 87070
Hospital Charge Code	4107064
Hospital Revenue Code	306
Rate for Payer: Cash Price	$271.92

Bone marrow harvesting for transplantation; allogeneic

Facility

$10,000.00

Service Code	CPT 38230
Hospital Charge Code	36038230
Hospital Revenue Code	360
Min. Negotiated Rate	$30.95
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,104.82
Rate for Payer: Amerigroup CHIP/Medicaid	$564.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,403.21
Rate for Payer: Amerigroup Medicare	$1,403.21
Rate for Payer: BCBS of TX Blue Advantage	$2,210.45
Rate for Payer: BCBS of TX Blue Essentials	$2,647.24
Rate for Payer: BCBS of TX Medicare	$1,403.21
Rate for Payer: BCBS of TX PPO	$3,335.52
Rate for Payer: Cigna Commercial	$3,178.68
Rate for Payer: Cigna Medicaid	$564.62
Rate for Payer: Cigna Medicare	$1,403.21
Rate for Payer: Employer Direct Commercial	$1,403.21
Rate for Payer: Humana Medicare/TRICARE	$1,403.21
Rate for Payer: Molina CHIP/Medicaid	$564.62
Rate for Payer: Molina Dual Medicare/Medicaid	$1,403.21
Rate for Payer: Molina Medicare	$1,403.21
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	$564.62
Rate for Payer: Scott and White EPO/PPO	$30.95
Rate for Payer: Scott and White Medicare	$1,403.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.62
Rate for Payer: Superior Health Plan EPO	$1,403.21
Rate for Payer: Superior Health Plan Medicare	$1,403.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,403.21
Rate for Payer: Universal American Medicare	$1,403.21
Rate for Payer: Wellcare Medicare	$1,403.21
Rate for Payer: Wellmed Medicare	$1,403.21

BONE PUTTY APEX DBM APX-FP-0

Facility

$4,216.87

Service Code	HCPCS C1713
Hospital Charge Code	145215
Hospital Revenue Code	278
Min. Negotiated Rate	$379.52
Max. Negotiated Rate	$2,108.44
Rate for Payer: Aetna Commercial	$1,265.06
Rate for Payer: Amerigroup CHIP/Medicaid	$379.52
Rate for Payer: BCBS of TX Blue Advantage	$1,265.06
Rate for Payer: BCBS of TX Blue Essentials	$1,518.07
Rate for Payer: BCBS of TX PPO	$1,686.75
Rate for Payer: Cash Price	$3,710.85
Rate for Payer: Multiplan Auto	$2,108.44
Rate for Payer: Multiplan Commercial	$2,108.44
Rate for Payer: Multiplan Workers Comp	$2,108.44
Rate for Payer: Scott and White EPO/PPO	$2,108.44
Rate for Payer: Superior Health Plan EPO	$573.49

BONE PUTTY APEX DBM APX-FP-0

Facility

$4,216.87

Service Code	HCPCS C1713
Hospital Charge Code	145215
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.22
Max. Negotiated Rate	$2,108.44
Rate for Payer: Aetna Commercial	$1,265.06
Rate for Payer: Cash Price	$3,710.85
Rate for Payer: Cigna Commercial	$1,054.22
Rate for Payer: Multiplan Auto	$2,108.44
Rate for Payer: Multiplan Commercial	$2,108.44
Rate for Payer: Multiplan Workers Comp	$2,108.44
Rate for Payer: Scott and White EPO/PPO	$2,108.44

bone putty i-factor 1.0 cc

Facility

$4,518.07

Service Code	HCPCS C1713
Hospital Charge Code	8492480
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.52
Max. Negotiated Rate	$2,259.04
Rate for Payer: Aetna Commercial	$1,355.42
Rate for Payer: Cash Price	$3,975.90
Rate for Payer: Cigna Commercial	$1,129.52
Rate for Payer: Multiplan Auto	$2,259.04
Rate for Payer: Multiplan Commercial	$2,259.04
Rate for Payer: Multiplan Workers Comp	$2,259.04
Rate for Payer: Scott and White EPO/PPO	$2,259.04

bone putty i-factor 1.0 cc

Facility

$4,518.07

Service Code	HCPCS C1713
Hospital Charge Code	8492480
Hospital Revenue Code	278
Min. Negotiated Rate	$406.63
Max. Negotiated Rate	$2,259.04
Rate for Payer: Aetna Commercial	$1,355.42
Rate for Payer: Amerigroup CHIP/Medicaid	$406.63
Rate for Payer: BCBS of TX Blue Advantage	$1,355.42
Rate for Payer: BCBS of TX Blue Essentials	$1,626.51
Rate for Payer: BCBS of TX PPO	$1,807.23
Rate for Payer: Cash Price	$3,975.90
Rate for Payer: Multiplan Auto	$2,259.04
Rate for Payer: Multiplan Commercial	$2,259.04
Rate for Payer: Multiplan Workers Comp	$2,259.04
Rate for Payer: Scott and White EPO/PPO	$2,259.04
Rate for Payer: Superior Health Plan EPO	$614.46

bone putty ifactor 5.0cc

Facility

$16,867.47

Service Code	HCPCS C1713
Hospital Charge Code	8702511
Hospital Revenue Code	278
Min. Negotiated Rate	$4,216.87
Max. Negotiated Rate	$8,433.74
Rate for Payer: Aetna Commercial	$5,060.24
Rate for Payer: Cash Price	$14,843.37
Rate for Payer: Cigna Commercial	$4,216.87
Rate for Payer: Multiplan Auto	$8,433.74
Rate for Payer: Multiplan Commercial	$8,433.74
Rate for Payer: Multiplan Workers Comp	$8,433.74
Rate for Payer: Scott and White EPO/PPO	$8,433.74

bone putty ifactor 5.0cc

Facility

$16,867.47

Service Code	HCPCS C1713
Hospital Charge Code	8702511
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.07
Max. Negotiated Rate	$8,433.74
Rate for Payer: Aetna Commercial	$5,060.24
Rate for Payer: Amerigroup CHIP/Medicaid	$1,518.07
Rate for Payer: BCBS of TX Blue Advantage	$5,060.24
Rate for Payer: BCBS of TX Blue Essentials	$6,072.29
Rate for Payer: BCBS of TX PPO	$6,746.99
Rate for Payer: Cash Price	$14,843.37
Rate for Payer: Multiplan Auto	$8,433.74
Rate for Payer: Multiplan Commercial	$8,433.74
Rate for Payer: Multiplan Workers Comp	$8,433.74
Rate for Payer: Scott and White EPO/PPO	$8,433.74
Rate for Payer: Superior Health Plan EPO	$2,293.98

BONE PUTTY IMP 2.5CC

Facility

$2,168.67

Service Code	HCPCS C1713
Hospital Charge Code	144825
Hospital Revenue Code	278
Min. Negotiated Rate	$542.17
Max. Negotiated Rate	$1,084.34
Rate for Payer: Aetna Commercial	$650.60
Rate for Payer: Cash Price	$1,908.43
Rate for Payer: Cigna Commercial	$542.17
Rate for Payer: Multiplan Auto	$1,084.34
Rate for Payer: Multiplan Commercial	$1,084.34
Rate for Payer: Multiplan Workers Comp	$1,084.34
Rate for Payer: Scott and White EPO/PPO	$1,084.34

BONE PUTTY IMP 2.5CC

Facility

$2,168.67

Service Code	HCPCS C1713
Hospital Charge Code	144825
Hospital Revenue Code	278
Min. Negotiated Rate	$195.18
Max. Negotiated Rate	$1,084.34
Rate for Payer: Aetna Commercial	$650.60
Rate for Payer: Amerigroup CHIP/Medicaid	$195.18
Rate for Payer: BCBS of TX Blue Advantage	$650.60
Rate for Payer: BCBS of TX Blue Essentials	$780.72
Rate for Payer: BCBS of TX PPO	$867.47
Rate for Payer: Cash Price	$1,908.43
Rate for Payer: Multiplan Auto	$1,084.34
Rate for Payer: Multiplan Commercial	$1,084.34
Rate for Payer: Multiplan Workers Comp	$1,084.34
Rate for Payer: Scott and White EPO/PPO	$1,084.34
Rate for Payer: Superior Health Plan EPO	$294.94

BONE VITOSS 10ML

Facility

$19,989.22

Service Code	HCPCS C9359
Hospital Charge Code	138881
Hospital Revenue Code	278
Min. Negotiated Rate	$150.09
Max. Negotiated Rate	$9,994.61
Rate for Payer: Aetna Commercial	$5,996.77
Rate for Payer: Amerigroup CHIP/Medicaid	$1,799.03
Rate for Payer: BCBS of TX Blue Advantage	$5,996.77
Rate for Payer: BCBS of TX Blue Essentials	$7,196.12
Rate for Payer: BCBS of TX PPO	$7,995.69
Rate for Payer: Cash Price	$17,590.51
Rate for Payer: Cash Price	$17,590.51
Rate for Payer: Cigna Medicaid	$150.09
Rate for Payer: Molina CHIP/Medicaid	$150.09
Rate for Payer: Multiplan Auto	$9,994.61
Rate for Payer: Multiplan Commercial	$9,994.61
Rate for Payer: Multiplan Workers Comp	$9,994.61
Rate for Payer: Parkland Medicaid	$150.09
Rate for Payer: Scott and White EPO/PPO	$9,994.61
Rate for Payer: Superior Health Plan CHIP/Medicaid	$150.09
Rate for Payer: Superior Health Plan EPO	$2,718.53

BONE VITOSS 10ML

Facility

$19,989.22

Service Code	HCPCS C9359
Hospital Charge Code	138881
Hospital Revenue Code	278
Min. Negotiated Rate	$4,997.30
Max. Negotiated Rate	$9,994.61
Rate for Payer: Aetna Commercial	$5,996.77
Rate for Payer: Cash Price	$17,590.51
Rate for Payer: Cigna Commercial	$4,997.30
Rate for Payer: Multiplan Auto	$9,994.61
Rate for Payer: Multiplan Commercial	$9,994.61
Rate for Payer: Multiplan Workers Comp	$9,994.61
Rate for Payer: Scott and White EPO/PPO	$9,994.61

BONE VITOSS 5ML

Facility

$13,043.67

Service Code	HCPCS C1713
Hospital Charge Code	8666519
Hospital Revenue Code	278
Min. Negotiated Rate	$1,173.93
Max. Negotiated Rate	$6,521.84
Rate for Payer: Aetna Commercial	$3,913.10
Rate for Payer: Amerigroup CHIP/Medicaid	$1,173.93
Rate for Payer: BCBS of TX Blue Advantage	$3,913.10
Rate for Payer: BCBS of TX Blue Essentials	$4,695.72
Rate for Payer: BCBS of TX PPO	$5,217.47
Rate for Payer: Cash Price	$11,478.43
Rate for Payer: Multiplan Auto	$6,521.84
Rate for Payer: Multiplan Commercial	$6,521.84
Rate for Payer: Multiplan Workers Comp	$6,521.84
Rate for Payer: Scott and White EPO/PPO	$6,521.84
Rate for Payer: Superior Health Plan EPO	$1,773.94

Know your out-of-pocket cost for care.

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