White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Platelet Antibody Profile SO

Facility

$527.00

Service Code	CPT 86022
Hospital Charge Code	1701010
Hospital Revenue Code	302
Rate for Payer: Cash Price	$463.76

Platelet Antibody Profile SO

Facility

$527.00

Service Code	CPT 86022
Hospital Charge Code	1701010
Hospital Revenue Code	302
Min. Negotiated Rate	$7.16
Max. Negotiated Rate	$342.55
Rate for Payer: Aetna Commercial	$19.28
Rate for Payer: Aetna Medicare	$27.56
Rate for Payer: Amerigroup CHIP/Medicaid	$7.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.37
Rate for Payer: Amerigroup Medicare	$18.37
Rate for Payer: BCBS of TX Blue Advantage	$30.31
Rate for Payer: BCBS of TX Blue Essentials	$36.37
Rate for Payer: BCBS of TX Medicare	$18.37
Rate for Payer: BCBS of TX PPO	$40.60
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Medicaid	$18.37
Rate for Payer: Cigna Medicare	$18.37
Rate for Payer: Employer Direct Commercial	$18.37
Rate for Payer: Humana Medicare/TRICARE	$18.37
Rate for Payer: Molina CHIP/Medicaid	$18.37
Rate for Payer: Molina Dual Medicare/Medicaid	$18.37
Rate for Payer: Molina Medicare	$18.37
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: Parkland Medicaid	$18.37
Rate for Payer: Scott and White EPO/PPO	$22.96
Rate for Payer: Scott and White Medicare	$18.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.37
Rate for Payer: Superior Health Plan EPO	$18.37
Rate for Payer: Superior Health Plan Medicare	$18.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.37
Rate for Payer: Universal American Medicare	$18.37
Rate for Payer: Wellcare Medicare	$18.37
Rate for Payer: Wellmed Medicare	$18.37

Platelet Count

Facility

$177.00

Service Code	CPT 85049
Hospital Charge Code	1611870
Hospital Revenue Code	305
Rate for Payer: Cash Price	$155.76

Platelet Count

Facility

$177.00

Service Code	CPT 85049
Hospital Charge Code	1611870
Hospital Revenue Code	305
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$115.05
Rate for Payer: Aetna Commercial	$4.71
Rate for Payer: Aetna Medicare	$6.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.48
Rate for Payer: Amerigroup Medicare	$4.48
Rate for Payer: BCBS of TX Blue Advantage	$7.39
Rate for Payer: BCBS of TX Blue Essentials	$8.87
Rate for Payer: BCBS of TX Medicare	$4.48
Rate for Payer: BCBS of TX PPO	$9.90
Rate for Payer: Cash Price	$155.76
Rate for Payer: Cash Price	$155.76
Rate for Payer: Cigna Medicaid	$4.48
Rate for Payer: Cigna Medicare	$4.48
Rate for Payer: Employer Direct Commercial	$4.48
Rate for Payer: Humana Medicare/TRICARE	$4.48
Rate for Payer: Molina CHIP/Medicaid	$4.48
Rate for Payer: Molina Dual Medicare/Medicaid	$4.48
Rate for Payer: Molina Medicare	$4.48
Rate for Payer: Multiplan Auto	$115.05
Rate for Payer: Multiplan Commercial	$115.05
Rate for Payer: Multiplan Workers Comp	$115.05
Rate for Payer: Parkland Medicaid	$4.48
Rate for Payer: Scott and White EPO/PPO	$5.60
Rate for Payer: Scott and White Medicare	$4.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.48
Rate for Payer: Superior Health Plan EPO	$4.48
Rate for Payer: Superior Health Plan Medicare	$4.48
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.48
Rate for Payer: Universal American Medicare	$4.48
Rate for Payer: Wellcare Medicare	$4.48
Rate for Payer: Wellmed Medicare	$4.48

PLATE LEVEL 1

Facility

$12,048.19

Service Code	HCPCS C1713
Hospital Charge Code	8428494
Hospital Revenue Code	278
Min. Negotiated Rate	$1,084.34
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: 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
Rate for Payer: Superior Health Plan EPO	$1,638.55

PLATE LEVEL 1

Facility

$12,048.19

Service Code	HCPCS C1713
Hospital Charge Code	8428494
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

PLATE LEVEL 2

Facility

$14,457.83

Service Code	HCPCS C1713
Hospital Charge Code	8430486
Hospital Revenue Code	278
Min. Negotiated Rate	$3,614.46
Max. Negotiated Rate	$7,228.92
Rate for Payer: Aetna Commercial	$4,337.35
Rate for Payer: Cash Price	$12,722.89
Rate for Payer: Cigna Commercial	$3,614.46
Rate for Payer: Multiplan Auto	$7,228.92
Rate for Payer: Multiplan Commercial	$7,228.92
Rate for Payer: Multiplan Workers Comp	$7,228.92
Rate for Payer: Scott and White EPO/PPO	$7,228.92

PLATE LEVEL 2

Facility

$14,457.83

Service Code	HCPCS C1713
Hospital Charge Code	8430486
Hospital Revenue Code	278
Min. Negotiated Rate	$1,301.20
Max. Negotiated Rate	$7,228.92
Rate for Payer: Aetna Commercial	$4,337.35
Rate for Payer: Amerigroup CHIP/Medicaid	$1,301.20
Rate for Payer: BCBS of TX Blue Advantage	$4,337.35
Rate for Payer: BCBS of TX Blue Essentials	$5,204.82
Rate for Payer: BCBS of TX PPO	$5,783.13
Rate for Payer: Cash Price	$12,722.89
Rate for Payer: Multiplan Auto	$7,228.92
Rate for Payer: Multiplan Commercial	$7,228.92
Rate for Payer: Multiplan Workers Comp	$7,228.92
Rate for Payer: Scott and White EPO/PPO	$7,228.92
Rate for Payer: Superior Health Plan EPO	$1,966.26

PLATE LEVEL 3 #2

Facility

$7,289.15

Service Code	HCPCS C1713
Hospital Charge Code	8492479
Hospital Revenue Code	278
Min. Negotiated Rate	$1,822.29
Max. Negotiated Rate	$3,644.58
Rate for Payer: Aetna Commercial	$2,186.74
Rate for Payer: Cash Price	$6,414.45
Rate for Payer: Cigna Commercial	$1,822.29
Rate for Payer: Multiplan Auto	$3,644.58
Rate for Payer: Multiplan Commercial	$3,644.58
Rate for Payer: Multiplan Workers Comp	$3,644.58
Rate for Payer: Scott and White EPO/PPO	$3,644.58

PLATE LEVEL 3 #2

Facility

$7,289.15

Service Code	HCPCS C1713
Hospital Charge Code	8492479
Hospital Revenue Code	278
Min. Negotiated Rate	$656.02
Max. Negotiated Rate	$3,644.58
Rate for Payer: Aetna Commercial	$2,186.74
Rate for Payer: Amerigroup CHIP/Medicaid	$656.02
Rate for Payer: BCBS of TX Blue Advantage	$2,186.74
Rate for Payer: BCBS of TX Blue Essentials	$2,624.09
Rate for Payer: BCBS of TX PPO	$2,915.66
Rate for Payer: Cash Price	$6,414.45
Rate for Payer: Multiplan Auto	$3,644.58
Rate for Payer: Multiplan Commercial	$3,644.58
Rate for Payer: Multiplan Workers Comp	$3,644.58
Rate for Payer: Scott and White EPO/PPO	$3,644.58
Rate for Payer: Superior Health Plan EPO	$991.32

PLATE LEVEL 4 ACP

Facility

$19,277.11

Service Code	HCPCS C1713
Hospital Charge Code	8492478
Hospital Revenue Code	278
Min. Negotiated Rate	$1,734.94
Max. Negotiated Rate	$9,638.56
Rate for Payer: Aetna Commercial	$5,783.13
Rate for Payer: Amerigroup CHIP/Medicaid	$1,734.94
Rate for Payer: BCBS of TX Blue Advantage	$5,783.13
Rate for Payer: BCBS of TX Blue Essentials	$6,939.76
Rate for Payer: BCBS of TX PPO	$7,710.84
Rate for Payer: Cash Price	$16,963.86
Rate for Payer: Multiplan Auto	$9,638.56
Rate for Payer: Multiplan Commercial	$9,638.56
Rate for Payer: Multiplan Workers Comp	$9,638.56
Rate for Payer: Scott and White EPO/PPO	$9,638.56
Rate for Payer: Superior Health Plan EPO	$2,621.69

PLATE LEVEL 4 ACP

Facility

$19,277.11

Service Code	HCPCS C1713
Hospital Charge Code	8492478
Hospital Revenue Code	278
Min. Negotiated Rate	$4,819.28
Max. Negotiated Rate	$9,638.56
Rate for Payer: Aetna Commercial	$5,783.13
Rate for Payer: Cash Price	$16,963.86
Rate for Payer: Cigna Commercial	$4,819.28
Rate for Payer: Multiplan Auto	$9,638.56
Rate for Payer: Multiplan Commercial	$9,638.56
Rate for Payer: Multiplan Workers Comp	$9,638.56
Rate for Payer: Scott and White EPO/PPO	$9,638.56

PLATE LOCK COMP NARROW 12 HOLE

Facility

$15,100.82

Service Code	HCPCS C1713
Hospital Charge Code	8406479
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.20
Max. Negotiated Rate	$7,550.41
Rate for Payer: Aetna Commercial	$4,530.25
Rate for Payer: Cash Price	$13,288.72
Rate for Payer: Cigna Commercial	$3,775.20
Rate for Payer: Multiplan Auto	$7,550.41
Rate for Payer: Multiplan Commercial	$7,550.41
Rate for Payer: Multiplan Workers Comp	$7,550.41
Rate for Payer: Scott and White EPO/PPO	$7,550.41

PLATE LOCK COMP NARROW 12 HOLE

Facility

$15,100.82

Service Code	HCPCS C1713
Hospital Charge Code	8406479
Hospital Revenue Code	278
Min. Negotiated Rate	$1,359.07
Max. Negotiated Rate	$7,550.41
Rate for Payer: Aetna Commercial	$4,530.25
Rate for Payer: Amerigroup CHIP/Medicaid	$1,359.07
Rate for Payer: BCBS of TX Blue Advantage	$4,530.25
Rate for Payer: BCBS of TX Blue Essentials	$5,436.30
Rate for Payer: BCBS of TX PPO	$6,040.33
Rate for Payer: Cash Price	$13,288.72
Rate for Payer: Multiplan Auto	$7,550.41
Rate for Payer: Multiplan Commercial	$7,550.41
Rate for Payer: Multiplan Workers Comp	$7,550.41
Rate for Payer: Scott and White EPO/PPO	$7,550.41
Rate for Payer: Superior Health Plan EPO	$2,053.71

PLATE LOCKING 9 HOLE

Facility

$6,018.07

Service Code	HCPCS C1713
Hospital Charge Code	145259
Hospital Revenue Code	278
Min. Negotiated Rate	$541.63
Max. Negotiated Rate	$3,009.04
Rate for Payer: Aetna Commercial	$1,805.42
Rate for Payer: Amerigroup CHIP/Medicaid	$541.63
Rate for Payer: BCBS of TX Blue Advantage	$1,805.42
Rate for Payer: BCBS of TX Blue Essentials	$2,166.51
Rate for Payer: BCBS of TX PPO	$2,407.23
Rate for Payer: Cash Price	$5,295.90
Rate for Payer: Multiplan Auto	$3,009.04
Rate for Payer: Multiplan Commercial	$3,009.04
Rate for Payer: Multiplan Workers Comp	$3,009.04
Rate for Payer: Scott and White EPO/PPO	$3,009.04
Rate for Payer: Superior Health Plan EPO	$818.46

PLATE LOCKING 9 HOLE

Facility

$6,018.07

Service Code	HCPCS C1713
Hospital Charge Code	145259
Hospital Revenue Code	278
Min. Negotiated Rate	$1,504.52
Max. Negotiated Rate	$3,009.04
Rate for Payer: Aetna Commercial	$1,805.42
Rate for Payer: Cash Price	$5,295.90
Rate for Payer: Cigna Commercial	$1,504.52
Rate for Payer: Multiplan Auto	$3,009.04
Rate for Payer: Multiplan Commercial	$3,009.04
Rate for Payer: Multiplan Workers Comp	$3,009.04
Rate for Payer: Scott and White EPO/PPO	$3,009.04

PLATE LUMBAR 15MM

Facility

$9,036.14

Service Code	HCPCS C1713
Hospital Charge Code	8428498
Hospital Revenue Code	278
Min. Negotiated Rate	$2,259.04
Max. Negotiated Rate	$4,518.07
Rate for Payer: Aetna Commercial	$2,710.84
Rate for Payer: Cash Price	$7,951.80
Rate for Payer: Cigna Commercial	$2,259.04
Rate for Payer: Multiplan Auto	$4,518.07
Rate for Payer: Multiplan Commercial	$4,518.07
Rate for Payer: Multiplan Workers Comp	$4,518.07
Rate for Payer: Scott and White EPO/PPO	$4,518.07

PLATE LUMBAR 15MM

Facility

$9,036.14

Service Code	HCPCS C1713
Hospital Charge Code	8428498
Hospital Revenue Code	278
Min. Negotiated Rate	$813.25
Max. Negotiated Rate	$4,518.07
Rate for Payer: Aetna Commercial	$2,710.84
Rate for Payer: Amerigroup CHIP/Medicaid	$813.25
Rate for Payer: BCBS of TX Blue Advantage	$2,710.84
Rate for Payer: BCBS of TX Blue Essentials	$3,253.01
Rate for Payer: BCBS of TX PPO	$3,614.46
Rate for Payer: Cash Price	$7,951.80
Rate for Payer: Multiplan Auto	$4,518.07
Rate for Payer: Multiplan Commercial	$4,518.07
Rate for Payer: Multiplan Workers Comp	$4,518.07
Rate for Payer: Scott and White EPO/PPO	$4,518.07
Rate for Payer: Superior Health Plan EPO	$1,228.92

PLATE OCLECRANON

Facility

$5,404.34

Service Code	HCPCS C1713
Hospital Charge Code	140788
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.08
Max. Negotiated Rate	$2,702.17
Rate for Payer: Aetna Commercial	$1,621.30
Rate for Payer: Cash Price	$4,755.82
Rate for Payer: Cigna Commercial	$1,351.08
Rate for Payer: Multiplan Auto	$2,702.17
Rate for Payer: Multiplan Commercial	$2,702.17
Rate for Payer: Multiplan Workers Comp	$2,702.17
Rate for Payer: Scott and White EPO/PPO	$2,702.17

PLATE OCLECRANON

Facility

$5,404.34

Service Code	HCPCS C1713
Hospital Charge Code	140788
Hospital Revenue Code	278
Min. Negotiated Rate	$486.39
Max. Negotiated Rate	$2,702.17
Rate for Payer: Aetna Commercial	$1,621.30
Rate for Payer: Amerigroup CHIP/Medicaid	$486.39
Rate for Payer: BCBS of TX Blue Advantage	$1,621.30
Rate for Payer: BCBS of TX Blue Essentials	$1,945.56
Rate for Payer: BCBS of TX PPO	$2,161.74
Rate for Payer: Cash Price	$4,755.82
Rate for Payer: Multiplan Auto	$2,702.17
Rate for Payer: Multiplan Commercial	$2,702.17
Rate for Payer: Multiplan Workers Comp	$2,702.17
Rate for Payer: Scott and White EPO/PPO	$2,702.17
Rate for Payer: Superior Health Plan EPO	$734.99

PLATE OTHER -- DHF

Facility

$1,127.77

Service Code	HCPCS C1713
Hospital Charge Code	81338436
Hospital Revenue Code	278
Min. Negotiated Rate	$281.94
Max. Negotiated Rate	$563.88
Rate for Payer: Aetna Commercial	$338.33
Rate for Payer: Cash Price	$992.44
Rate for Payer: Cigna Commercial	$281.94
Rate for Payer: Multiplan Auto	$563.88
Rate for Payer: Multiplan Commercial	$563.88
Rate for Payer: Multiplan Workers Comp	$563.88
Rate for Payer: Scott and White EPO/PPO	$563.88

PLATE OTHER -- DHF

Facility

$1,127.77

Service Code	HCPCS C1713
Hospital Charge Code	81338436
Hospital Revenue Code	278
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$563.88
Rate for Payer: Aetna Commercial	$338.33
Rate for Payer: Amerigroup CHIP/Medicaid	$101.50
Rate for Payer: BCBS of TX Blue Advantage	$338.33
Rate for Payer: BCBS of TX Blue Essentials	$406.00
Rate for Payer: BCBS of TX PPO	$451.11
Rate for Payer: Cash Price	$992.44
Rate for Payer: Multiplan Auto	$563.88
Rate for Payer: Multiplan Commercial	$563.88
Rate for Payer: Multiplan Workers Comp	$563.88
Rate for Payer: Scott and White EPO/PPO	$563.88
Rate for Payer: Superior Health Plan EPO	$153.38

PLATE PROC LAT HUM 3HL RIGHT

Facility

$11,624.10

Service Code	HCPCS C1713
Hospital Charge Code	8394476
Hospital Revenue Code	278
Min. Negotiated Rate	$2,906.02
Max. Negotiated Rate	$5,812.05
Rate for Payer: Aetna Commercial	$3,487.23
Rate for Payer: Cash Price	$10,229.21
Rate for Payer: Cigna Commercial	$2,906.02
Rate for Payer: Multiplan Auto	$5,812.05
Rate for Payer: Multiplan Commercial	$5,812.05
Rate for Payer: Multiplan Workers Comp	$5,812.05
Rate for Payer: Scott and White EPO/PPO	$5,812.05

PLATE PROC LAT HUM 3HL RIGHT

Facility

$11,624.10

Service Code	HCPCS C1713
Hospital Charge Code	8394476
Hospital Revenue Code	278
Min. Negotiated Rate	$1,046.17
Max. Negotiated Rate	$5,812.05
Rate for Payer: Aetna Commercial	$3,487.23
Rate for Payer: Amerigroup CHIP/Medicaid	$1,046.17
Rate for Payer: BCBS of TX Blue Advantage	$3,487.23
Rate for Payer: BCBS of TX Blue Essentials	$4,184.68
Rate for Payer: BCBS of TX PPO	$4,649.64
Rate for Payer: Cash Price	$10,229.21
Rate for Payer: Multiplan Auto	$5,812.05
Rate for Payer: Multiplan Commercial	$5,812.05
Rate for Payer: Multiplan Workers Comp	$5,812.05
Rate for Payer: Scott and White EPO/PPO	$5,812.05
Rate for Payer: Superior Health Plan EPO	$1,580.88

plate super lateral 4 hole

Facility

$5,916.14

Service Code	HCPCS C1713
Hospital Charge Code	144883
Hospital Revenue Code	278
Min. Negotiated Rate	$532.45
Max. Negotiated Rate	$2,958.07
Rate for Payer: Aetna Commercial	$1,774.84
Rate for Payer: Amerigroup CHIP/Medicaid	$532.45
Rate for Payer: BCBS of TX Blue Advantage	$1,774.84
Rate for Payer: BCBS of TX Blue Essentials	$2,129.81
Rate for Payer: BCBS of TX PPO	$2,366.46
Rate for Payer: Cash Price	$5,206.20
Rate for Payer: Multiplan Auto	$2,958.07
Rate for Payer: Multiplan Commercial	$2,958.07
Rate for Payer: Multiplan Workers Comp	$2,958.07
Rate for Payer: Scott and White EPO/PPO	$2,958.07
Rate for Payer: Superior Health Plan EPO	$804.60

Know your out-of-pocket cost for care.

All Charges