White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ALLOGRAFT AMNIOFIX 2X12 APS-5212

Facility

$5,991.00

Service Code	HCPCS C1762
Hospital Charge Code	145327
Hospital Revenue Code	278
Min. Negotiated Rate	$539.19
Max. Negotiated Rate	$4,313.52
Rate for Payer: Amerigroup CHIP/Medicaid	$539.19
Rate for Payer: BCBS of TX Blue Advantage	$1,797.30
Rate for Payer: BCBS of TX Blue Essentials	$2,156.76
Rate for Payer: BCBS of TX PPO	$2,396.40
Rate for Payer: Cash Price	$4,073.88
Rate for Payer: Cigna Medicaid	$4,313.52
Rate for Payer: Molina CHIP/Medicaid	$4,313.52
Rate for Payer: Multiplan Auto	$2,995.50
Rate for Payer: Multiplan Commercial	$2,995.50
Rate for Payer: Multiplan Workers Comp	$2,995.50
Rate for Payer: Parkland Medicaid	$4,313.52
Rate for Payer: Scott and White EPO/PPO	$2,995.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,313.52
Rate for Payer: Superior Health Plan EPO	$814.78

ALLOGRAFT AMNIOFIX 6X4 AAS-5460

Facility

$10,846.00

Service Code	HCPCS C1762
Hospital Charge Code	120838
Hospital Revenue Code	278
Min. Negotiated Rate	$2,711.50
Max. Negotiated Rate	$5,423.00
Rate for Payer: Cash Price	$7,375.28
Rate for Payer: Cigna Commercial	$2,711.50
Rate for Payer: Multiplan Auto	$5,423.00
Rate for Payer: Multiplan Commercial	$5,423.00
Rate for Payer: Multiplan Workers Comp	$5,423.00
Rate for Payer: Scott and White EPO/PPO	$5,423.00

ALLOGRAFT AMNIOFIX 6X4 AAS-5460

Facility

$10,846.00

Service Code	HCPCS C1762
Hospital Charge Code	120838
Hospital Revenue Code	278
Min. Negotiated Rate	$976.14
Max. Negotiated Rate	$7,809.12
Rate for Payer: Amerigroup CHIP/Medicaid	$976.14
Rate for Payer: BCBS of TX Blue Advantage	$3,253.80
Rate for Payer: BCBS of TX Blue Essentials	$3,904.56
Rate for Payer: BCBS of TX PPO	$4,338.40
Rate for Payer: Cash Price	$7,375.28
Rate for Payer: Cigna Medicaid	$7,809.12
Rate for Payer: Molina CHIP/Medicaid	$7,809.12
Rate for Payer: Multiplan Auto	$5,423.00
Rate for Payer: Multiplan Commercial	$5,423.00
Rate for Payer: Multiplan Workers Comp	$5,423.00
Rate for Payer: Parkland Medicaid	$7,809.12
Rate for Payer: Scott and White EPO/PPO	$5,423.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,809.12
Rate for Payer: Superior Health Plan EPO	$1,475.06

ALLOGRAFT AMNIOTIC AMNIIX DUAL LAYER 4X4

Facility

$8,642.00

Service Code	HCPCS C1762
Hospital Charge Code	146441
Hospital Revenue Code	278
Min. Negotiated Rate	$777.78
Max. Negotiated Rate	$6,222.24
Rate for Payer: Amerigroup CHIP/Medicaid	$777.78
Rate for Payer: BCBS of TX Blue Advantage	$2,592.60
Rate for Payer: BCBS of TX Blue Essentials	$3,111.12
Rate for Payer: BCBS of TX PPO	$3,456.80
Rate for Payer: Cash Price	$5,876.56
Rate for Payer: Cigna Medicaid	$6,222.24
Rate for Payer: Molina CHIP/Medicaid	$6,222.24
Rate for Payer: Multiplan Auto	$4,321.00
Rate for Payer: Multiplan Commercial	$4,321.00
Rate for Payer: Multiplan Workers Comp	$4,321.00
Rate for Payer: Parkland Medicaid	$6,222.24
Rate for Payer: Scott and White EPO/PPO	$4,321.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,222.24
Rate for Payer: Superior Health Plan EPO	$1,175.31

ALLOGRAFT AMNIOTIC AMNIIX DUAL LAYER 4X4

Facility

$8,642.00

Service Code	HCPCS C1762
Hospital Charge Code	146441
Hospital Revenue Code	278
Min. Negotiated Rate	$2,160.50
Max. Negotiated Rate	$4,321.00
Rate for Payer: Cash Price	$5,876.56
Rate for Payer: Cigna Commercial	$2,160.50
Rate for Payer: Multiplan Auto	$4,321.00
Rate for Payer: Multiplan Commercial	$4,321.00
Rate for Payer: Multiplan Workers Comp	$4,321.00
Rate for Payer: Scott and White EPO/PPO	$4,321.00

ALLOGRAFT AMNIOTIC AMNIIX DUAL LAYER 4X6

Facility

$11,111.00

Service Code	HCPCS C1762
Hospital Charge Code	146442
Hospital Revenue Code	278
Min. Negotiated Rate	$999.99
Max. Negotiated Rate	$7,999.92
Rate for Payer: Amerigroup CHIP/Medicaid	$999.99
Rate for Payer: BCBS of TX Blue Advantage	$3,333.30
Rate for Payer: BCBS of TX Blue Essentials	$3,999.96
Rate for Payer: BCBS of TX PPO	$4,444.40
Rate for Payer: Cash Price	$7,555.48
Rate for Payer: Cigna Medicaid	$7,999.92
Rate for Payer: Molina CHIP/Medicaid	$7,999.92
Rate for Payer: Multiplan Auto	$5,555.50
Rate for Payer: Multiplan Commercial	$5,555.50
Rate for Payer: Multiplan Workers Comp	$5,555.50
Rate for Payer: Parkland Medicaid	$7,999.92
Rate for Payer: Scott and White EPO/PPO	$5,555.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,999.92
Rate for Payer: Superior Health Plan EPO	$1,511.10

ALLOGRAFT AMNIOTIC AMNIIX DUAL LAYER 4X6

Facility

$11,111.00

Service Code	HCPCS C1762
Hospital Charge Code	146442
Hospital Revenue Code	278
Min. Negotiated Rate	$2,777.75
Max. Negotiated Rate	$5,555.50
Rate for Payer: Cash Price	$7,555.48
Rate for Payer: Cigna Commercial	$2,777.75
Rate for Payer: Multiplan Auto	$5,555.50
Rate for Payer: Multiplan Commercial	$5,555.50
Rate for Payer: Multiplan Workers Comp	$5,555.50
Rate for Payer: Scott and White EPO/PPO	$5,555.50

allograft amniotic tissue 4x4

Facility

$8,434.00

Service Code	HCPCS C1762
Hospital Charge Code	8394479
Hospital Revenue Code	278
Min. Negotiated Rate	$2,108.50
Max. Negotiated Rate	$4,217.00
Rate for Payer: Cash Price	$5,735.12
Rate for Payer: Cigna Commercial	$2,108.50
Rate for Payer: Multiplan Auto	$4,217.00
Rate for Payer: Multiplan Commercial	$4,217.00
Rate for Payer: Multiplan Workers Comp	$4,217.00
Rate for Payer: Scott and White EPO/PPO	$4,217.00

allograft amniotic tissue 4x4

Facility

$8,434.00

Service Code	HCPCS C1762
Hospital Charge Code	8394479
Hospital Revenue Code	278
Min. Negotiated Rate	$759.06
Max. Negotiated Rate	$6,072.48
Rate for Payer: Amerigroup CHIP/Medicaid	$759.06
Rate for Payer: BCBS of TX Blue Advantage	$2,530.20
Rate for Payer: BCBS of TX Blue Essentials	$3,036.24
Rate for Payer: BCBS of TX PPO	$3,373.60
Rate for Payer: Cash Price	$5,735.12
Rate for Payer: Cigna Medicaid	$6,072.48
Rate for Payer: Molina CHIP/Medicaid	$6,072.48
Rate for Payer: Multiplan Auto	$4,217.00
Rate for Payer: Multiplan Commercial	$4,217.00
Rate for Payer: Multiplan Workers Comp	$4,217.00
Rate for Payer: Parkland Medicaid	$6,072.48
Rate for Payer: Scott and White EPO/PPO	$4,217.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,072.48
Rate for Payer: Superior Health Plan EPO	$1,147.02

ALLOGRAFT AMNIOTIC TISSUE 4X6

Facility

$13,253.00

Service Code	HCPCS C1762
Hospital Charge Code	8394477
Hospital Revenue Code	278
Min. Negotiated Rate	$3,313.25
Max. Negotiated Rate	$6,626.50
Rate for Payer: Cash Price	$9,012.04
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

ALLOGRAFT AMNIOTIC TISSUE 4X6

Facility

$13,253.00

Service Code	HCPCS C1762
Hospital Charge Code	8394477
Hospital Revenue Code	278
Min. Negotiated Rate	$1,192.77
Max. Negotiated Rate	$9,542.16
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	$9,012.04
Rate for Payer: Cigna Medicaid	$9,542.16
Rate for Payer: Molina CHIP/Medicaid	$9,542.16
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	$9,542.16
Rate for Payer: Scott and White EPO/PPO	$6,626.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,542.16
Rate for Payer: Superior Health Plan EPO	$1,802.41

ALLOGRAFT ANT TIBIALS TENDON FROZEN

Facility

$12,183.00

Service Code	HCPCS C1762
Hospital Charge Code	146264
Hospital Revenue Code	278
Min. Negotiated Rate	$1,096.47
Max. Negotiated Rate	$8,771.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,096.47
Rate for Payer: BCBS of TX Blue Advantage	$3,654.90
Rate for Payer: BCBS of TX Blue Essentials	$4,385.88
Rate for Payer: BCBS of TX PPO	$4,873.20
Rate for Payer: Cash Price	$8,284.44
Rate for Payer: Cigna Medicaid	$8,771.76
Rate for Payer: Molina CHIP/Medicaid	$8,771.76
Rate for Payer: Multiplan Auto	$6,091.50
Rate for Payer: Multiplan Commercial	$6,091.50
Rate for Payer: Multiplan Workers Comp	$6,091.50
Rate for Payer: Parkland Medicaid	$8,771.76
Rate for Payer: Scott and White EPO/PPO	$6,091.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,771.76
Rate for Payer: Superior Health Plan EPO	$1,656.89

ALLOGRAFT ANT TIBIALS TENDON FROZEN

Facility

$12,183.00

Service Code	HCPCS C1762
Hospital Charge Code	146264
Hospital Revenue Code	278
Min. Negotiated Rate	$3,045.75
Max. Negotiated Rate	$6,091.50
Rate for Payer: Cash Price	$8,284.44
Rate for Payer: Cigna Commercial	$3,045.75
Rate for Payer: Multiplan Auto	$6,091.50
Rate for Payer: Multiplan Commercial	$6,091.50
Rate for Payer: Multiplan Workers Comp	$6,091.50
Rate for Payer: Scott and White EPO/PPO	$6,091.50

ALLOGRAFT BONE 10-20MM X =19.5CM ACHILLES TENDON CALCANEUS D

Facility

$10,818.55

Hospital Charge Code	993873
Hospital Revenue Code	272
Min. Negotiated Rate	$973.67
Max. Negotiated Rate	$7,789.36
Rate for Payer: Amerigroup CHIP/Medicaid	$973.67
Rate for Payer: BCBS of TX Blue Advantage	$3,245.57
Rate for Payer: BCBS of TX Blue Essentials	$3,894.68
Rate for Payer: BCBS of TX PPO	$4,327.42
Rate for Payer: Cash Price	$7,356.61
Rate for Payer: Cigna Medicaid	$7,789.36
Rate for Payer: Molina CHIP/Medicaid	$7,789.36
Rate for Payer: Multiplan Auto	$7,032.06
Rate for Payer: Multiplan Commercial	$7,032.06
Rate for Payer: Multiplan Workers Comp	$7,032.06
Rate for Payer: Parkland Medicaid	$7,789.36
Rate for Payer: Scott and White EPO/PPO	$5,409.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,789.36
Rate for Payer: Superior Health Plan EPO	$1,471.32

ALLOGRAFT BONE 10-20MM X =19.5CM ACHILLES TENDON CALCANEUS D

Facility

$10,818.55

Hospital Charge Code	993873
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,356.61

ALLOGRAFT HUMAN TISSUE ALLOPATCH HD ULTRA THICK 8CM X 4CM =1

Facility

$12,258.00

Service Code	HCPCS C1762
Hospital Charge Code	993874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,064.50
Max. Negotiated Rate	$6,129.00
Rate for Payer: Cash Price	$8,335.44
Rate for Payer: Cigna Commercial	$3,064.50
Rate for Payer: Multiplan Auto	$6,129.00
Rate for Payer: Multiplan Commercial	$6,129.00
Rate for Payer: Multiplan Workers Comp	$6,129.00
Rate for Payer: Scott and White EPO/PPO	$6,129.00

ALLOGRAFT HUMAN TISSUE ALLOPATCH HD ULTRA THICK 8CM X 4CM =1

Facility

$12,258.00

Service Code	HCPCS C1762
Hospital Charge Code	120839
Hospital Revenue Code	278
Min. Negotiated Rate	$3,064.50
Max. Negotiated Rate	$6,129.00
Rate for Payer: Cash Price	$8,335.44
Rate for Payer: Cigna Commercial	$3,064.50
Rate for Payer: Multiplan Auto	$6,129.00
Rate for Payer: Multiplan Commercial	$6,129.00
Rate for Payer: Multiplan Workers Comp	$6,129.00
Rate for Payer: Scott and White EPO/PPO	$6,129.00

ALLOGRAFT HUMAN TISSUE ALLOPATCH HD ULTRA THICK 8CM X 4CM =1

Facility

$12,258.00

Service Code	HCPCS C1762
Hospital Charge Code	993874
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.22
Max. Negotiated Rate	$8,825.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,103.22
Rate for Payer: BCBS of TX Blue Advantage	$3,677.40
Rate for Payer: BCBS of TX Blue Essentials	$4,412.88
Rate for Payer: BCBS of TX PPO	$4,903.20
Rate for Payer: Cash Price	$8,335.44
Rate for Payer: Cigna Medicaid	$8,825.76
Rate for Payer: Molina CHIP/Medicaid	$8,825.76
Rate for Payer: Multiplan Auto	$6,129.00
Rate for Payer: Multiplan Commercial	$6,129.00
Rate for Payer: Multiplan Workers Comp	$6,129.00
Rate for Payer: Parkland Medicaid	$8,825.76
Rate for Payer: Scott and White EPO/PPO	$6,129.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,825.76
Rate for Payer: Superior Health Plan EPO	$1,667.09

ALLOGRAFT HUMAN TISSUE ALLOPATCH HD ULTRA THICK 8CM X 4CM =1

Facility

$12,258.00

Service Code	HCPCS C1762
Hospital Charge Code	120839
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.22
Max. Negotiated Rate	$8,825.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,103.22
Rate for Payer: BCBS of TX Blue Advantage	$3,677.40
Rate for Payer: BCBS of TX Blue Essentials	$4,412.88
Rate for Payer: BCBS of TX PPO	$4,903.20
Rate for Payer: Cash Price	$8,335.44
Rate for Payer: Cigna Medicaid	$8,825.76
Rate for Payer: Molina CHIP/Medicaid	$8,825.76
Rate for Payer: Multiplan Auto	$6,129.00
Rate for Payer: Multiplan Commercial	$6,129.00
Rate for Payer: Multiplan Workers Comp	$6,129.00
Rate for Payer: Parkland Medicaid	$8,825.76
Rate for Payer: Scott and White EPO/PPO	$6,129.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,825.76
Rate for Payer: Superior Health Plan EPO	$1,667.09

ALLOGRAFT HUMAN TISSUE MATRION 25SQCM 5CM X 5CM MESHED

Facility

$938.00

Service Code	HCPCS C1762
Hospital Charge Code	146034
Hospital Revenue Code	278
Min. Negotiated Rate	$84.42
Max. Negotiated Rate	$675.36
Rate for Payer: Amerigroup CHIP/Medicaid	$84.42
Rate for Payer: BCBS of TX Blue Advantage	$281.40
Rate for Payer: BCBS of TX Blue Essentials	$337.68
Rate for Payer: BCBS of TX PPO	$375.20
Rate for Payer: Cash Price	$637.84
Rate for Payer: Cigna Medicaid	$675.36
Rate for Payer: Molina CHIP/Medicaid	$675.36
Rate for Payer: Multiplan Auto	$469.00
Rate for Payer: Multiplan Commercial	$469.00
Rate for Payer: Multiplan Workers Comp	$469.00
Rate for Payer: Parkland Medicaid	$675.36
Rate for Payer: Scott and White EPO/PPO	$469.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$675.36
Rate for Payer: Superior Health Plan EPO	$127.57

ALLOGRAFT HUMAN TISSUE MATRION 25SQCM 5CM X 5CM MESHED

Facility

$938.00

Service Code	HCPCS C1762
Hospital Charge Code	146034
Hospital Revenue Code	278
Min. Negotiated Rate	$234.50
Max. Negotiated Rate	$469.00
Rate for Payer: Cash Price	$637.84
Rate for Payer: Cigna Commercial	$234.50
Rate for Payer: Multiplan Auto	$469.00
Rate for Payer: Multiplan Commercial	$469.00
Rate for Payer: Multiplan Workers Comp	$469.00
Rate for Payer: Scott and White EPO/PPO	$469.00

ALLOGRAFT ZAVATRIX VIABLE 10CC

Facility

$24,096.00

Service Code	HCPCS C1762
Hospital Charge Code	8720609
Hospital Revenue Code	278
Min. Negotiated Rate	$6,024.00
Max. Negotiated Rate	$12,048.00
Rate for Payer: Cash Price	$16,385.28
Rate for Payer: Cigna Commercial	$6,024.00
Rate for Payer: Multiplan Auto	$12,048.00
Rate for Payer: Multiplan Commercial	$12,048.00
Rate for Payer: Multiplan Workers Comp	$12,048.00
Rate for Payer: Scott and White EPO/PPO	$12,048.00

ALLOGRAFT ZAVATRIX VIABLE 10CC

Facility

$24,096.00

Service Code	HCPCS C1762
Hospital Charge Code	8720609
Hospital Revenue Code	278
Min. Negotiated Rate	$2,168.64
Max. Negotiated Rate	$17,349.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,168.64
Rate for Payer: BCBS of TX Blue Advantage	$7,228.80
Rate for Payer: BCBS of TX Blue Essentials	$8,674.56
Rate for Payer: BCBS of TX PPO	$9,638.40
Rate for Payer: Cash Price	$16,385.28
Rate for Payer: Cigna Medicaid	$17,349.12
Rate for Payer: Molina CHIP/Medicaid	$17,349.12
Rate for Payer: Multiplan Auto	$12,048.00
Rate for Payer: Multiplan Commercial	$12,048.00
Rate for Payer: Multiplan Workers Comp	$12,048.00
Rate for Payer: Parkland Medicaid	$17,349.12
Rate for Payer: Scott and White EPO/PPO	$12,048.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,349.12
Rate for Payer: Superior Health Plan EPO	$3,277.06

ALLOGRAFT ZAVATRIX VIABLE 15CC

Facility

$34,837.00

Service Code	HCPCS C1762
Hospital Charge Code	8720608
Hospital Revenue Code	278
Min. Negotiated Rate	$3,135.33
Max. Negotiated Rate	$25,082.64
Rate for Payer: Amerigroup CHIP/Medicaid	$3,135.33
Rate for Payer: BCBS of TX Blue Advantage	$10,451.10
Rate for Payer: BCBS of TX Blue Essentials	$12,541.32
Rate for Payer: BCBS of TX PPO	$13,934.80
Rate for Payer: Cash Price	$23,689.16
Rate for Payer: Cigna Medicaid	$25,082.64
Rate for Payer: Molina CHIP/Medicaid	$25,082.64
Rate for Payer: Multiplan Auto	$17,418.50
Rate for Payer: Multiplan Commercial	$17,418.50
Rate for Payer: Multiplan Workers Comp	$17,418.50
Rate for Payer: Parkland Medicaid	$25,082.64
Rate for Payer: Scott and White EPO/PPO	$17,418.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,082.64
Rate for Payer: Superior Health Plan EPO	$4,737.83

ALLOGRAFT ZAVATRIX VIABLE 15CC

Facility

$34,837.00

Service Code	HCPCS C1762
Hospital Charge Code	8720608
Hospital Revenue Code	278
Min. Negotiated Rate	$8,709.25
Max. Negotiated Rate	$17,418.50
Rate for Payer: Cash Price	$23,689.16
Rate for Payer: Cigna Commercial	$8,709.25
Rate for Payer: Multiplan Auto	$17,418.50
Rate for Payer: Multiplan Commercial	$17,418.50
Rate for Payer: Multiplan Workers Comp	$17,418.50
Rate for Payer: Scott and White EPO/PPO	$17,418.50

Know your out-of-pocket cost for care.

All Charges