White Rock Medical Center

All Charges

Charge

Type

Setting

Price

plate super lateral 4 hole

Facility

$5,916.14

Service Code	HCPCS C1713
Hospital Charge Code	144883
Hospital Revenue Code	278
Min. Negotiated Rate	$1,479.04
Max. Negotiated Rate	$2,958.07
Rate for Payer: Aetna Commercial	$1,774.84
Rate for Payer: Cash Price	$5,206.20
Rate for Payer: Cigna Commercial	$1,479.04
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

PLATE TIBIAL RIGHT

Facility

$11,050.24

Service Code	HCPCS C1713
Hospital Charge Code	145071
Hospital Revenue Code	278
Min. Negotiated Rate	$994.52
Max. Negotiated Rate	$5,525.12
Rate for Payer: Aetna Commercial	$3,315.07
Rate for Payer: Amerigroup CHIP/Medicaid	$994.52
Rate for Payer: BCBS of TX Blue Advantage	$3,315.07
Rate for Payer: BCBS of TX Blue Essentials	$3,978.09
Rate for Payer: BCBS of TX PPO	$4,420.10
Rate for Payer: Cash Price	$9,724.21
Rate for Payer: Multiplan Auto	$5,525.12
Rate for Payer: Multiplan Commercial	$5,525.12
Rate for Payer: Multiplan Workers Comp	$5,525.12
Rate for Payer: Scott and White EPO/PPO	$5,525.12
Rate for Payer: Superior Health Plan EPO	$1,502.83

PLATE TIBIAL RIGHT

Facility

$11,050.24

Service Code	HCPCS C1713
Hospital Charge Code	145071
Hospital Revenue Code	278
Min. Negotiated Rate	$2,762.56
Max. Negotiated Rate	$5,525.12
Rate for Payer: Aetna Commercial	$3,315.07
Rate for Payer: Cash Price	$9,724.21
Rate for Payer: Cigna Commercial	$2,762.56
Rate for Payer: Multiplan Auto	$5,525.12
Rate for Payer: Multiplan Commercial	$5,525.12
Rate for Payer: Multiplan Workers Comp	$5,525.12
Rate for Payer: Scott and White EPO/PPO	$5,525.12

PLATE VOLAR 10 HOLE SHORT

Facility

$7,180.30

Service Code	HCPCS C1713
Hospital Charge Code	141238
Hospital Revenue Code	278
Min. Negotiated Rate	$1,795.08
Max. Negotiated Rate	$3,590.15
Rate for Payer: Aetna Commercial	$2,154.09
Rate for Payer: Cash Price	$6,318.66
Rate for Payer: Cigna Commercial	$1,795.08
Rate for Payer: Multiplan Auto	$3,590.15
Rate for Payer: Multiplan Commercial	$3,590.15
Rate for Payer: Multiplan Workers Comp	$3,590.15
Rate for Payer: Scott and White EPO/PPO	$3,590.15

PLATE VOLAR 10 HOLE SHORT

Facility

$7,180.30

Service Code	HCPCS C1713
Hospital Charge Code	141238
Hospital Revenue Code	278
Min. Negotiated Rate	$646.23
Max. Negotiated Rate	$3,590.15
Rate for Payer: Aetna Commercial	$2,154.09
Rate for Payer: Amerigroup CHIP/Medicaid	$646.23
Rate for Payer: BCBS of TX Blue Advantage	$2,154.09
Rate for Payer: BCBS of TX Blue Essentials	$2,584.91
Rate for Payer: BCBS of TX PPO	$2,872.12
Rate for Payer: Cash Price	$6,318.66
Rate for Payer: Multiplan Auto	$3,590.15
Rate for Payer: Multiplan Commercial	$3,590.15
Rate for Payer: Multiplan Workers Comp	$3,590.15
Rate for Payer: Scott and White EPO/PPO	$3,590.15
Rate for Payer: Superior Health Plan EPO	$976.52

PLC CATH ART 1ST ORDR

Facility

$2,418.00

Service Code	CPT 36215
Hospital Charge Code	4617835
Hospital Revenue Code	361
Min. Negotiated Rate	$217.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,329.90
Rate for Payer: Amerigroup CHIP/Medicaid	$217.62
Rate for Payer: Cash Price	$2,127.84
Rate for Payer: Cash Price	$2,127.84
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: Scott and White EPO/PPO	$1,209.00
Rate for Payer: Superior Health Plan EPO	$328.85

PLC CATH ART 1ST ORDR

Facility

$2,418.00

Service Code	CPT 36215
Hospital Charge Code	4617835
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,127.84

PLC CATH EXTRM ARTERY

Facility

$1,270.00

Service Code	CPT 36140
Hospital Charge Code	4617860
Hospital Revenue Code	361
Min. Negotiated Rate	$114.30
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$698.50
Rate for Payer: Amerigroup CHIP/Medicaid	$114.30
Rate for Payer: Cash Price	$1,117.60
Rate for Payer: Cash Price	$1,117.60
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: Scott and White EPO/PPO	$635.00
Rate for Payer: Superior Health Plan EPO	$172.72

PLC CATH EXTRM ARTERY

Facility

$1,270.00

Service Code	CPT 36140
Hospital Charge Code	4617860
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,117.60

PLC CATH VEIN 1ST ORDR

Facility

$1,905.00

Service Code	CPT 36011
Hospital Charge Code	4616011
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,676.40

PLC CATH VEIN 1ST ORDR

Facility

$1,905.00

Service Code	CPT 36011
Hospital Charge Code	4616011
Hospital Revenue Code	361
Min. Negotiated Rate	$171.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,047.75
Rate for Payer: Amerigroup CHIP/Medicaid	$171.45
Rate for Payer: Cash Price	$1,676.40
Rate for Payer: Cash Price	$1,676.40
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: Scott and White EPO/PPO	$952.50
Rate for Payer: Superior Health Plan EPO	$259.08

PLC CATH VEIN 2ND ORDR

Facility

$2,105.00

Service Code	CPT 36012
Hospital Charge Code	4616012
Hospital Revenue Code	361
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$1,157.75
Rate for Payer: Amerigroup CHIP/Medicaid	$189.45
Rate for Payer: Cash Price	$1,852.40
Rate for Payer: Cash Price	$1,852.40
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: Scott and White EPO/PPO	$1,052.50
Rate for Payer: Superior Health Plan EPO	$286.28

PLC CATH VEIN 2ND ORDR

Facility

$2,105.00

Service Code	CPT 36012
Hospital Charge Code	4616012
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,852.40

PLC NEPHROSTOMY CATH

Facility

$3,335.00

Service Code	CPT 50432
Hospital Charge Code	4610392
Hospital Revenue Code	361
Min. Negotiated Rate	$41.09
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$2,794.14
Rate for Payer: Amerigroup CHIP/Medicaid	$652.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Amerigroup Medicare	$1,862.76
Rate for Payer: BCBS of TX Blue Advantage	$2,958.49
Rate for Payer: BCBS of TX Blue Essentials	$3,543.10
Rate for Payer: BCBS of TX Medicare	$1,862.76
Rate for Payer: BCBS of TX PPO	$4,464.31
Rate for Payer: Cash Price	$2,934.80
Rate for Payer: Cash Price	$2,934.80
Rate for Payer: Cigna Commercial	$4,219.69
Rate for Payer: Cigna Medicaid	$652.80
Rate for Payer: Cigna Medicare	$1,862.76
Rate for Payer: Employer Direct Commercial	$1,862.76
Rate for Payer: Humana Medicare/TRICARE	$1,862.76
Rate for Payer: Molina CHIP/Medicaid	$652.80
Rate for Payer: Molina Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Molina Medicare	$1,862.76
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	$652.80
Rate for Payer: Scott and White EPO/PPO	$41.09
Rate for Payer: Scott and White Medicare	$1,862.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$652.80
Rate for Payer: Superior Health Plan EPO	$1,862.76
Rate for Payer: Superior Health Plan Medicare	$1,862.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,862.76
Rate for Payer: Universal American Medicare	$1,862.76
Rate for Payer: Wellcare Medicare	$1,862.76
Rate for Payer: Wellmed Medicare	$1,862.76

PLC NEPHROSTOMY CATH

Facility

$3,335.00

Service Code	CPT 50432
Hospital Charge Code	4610392
Hospital Revenue Code	361
Rate for Payer: Cash Price	$2,934.80

PLC VASC CLSURE DEVICE

Facility

$894.00

Service Code	HCPCS G0269
Hospital Charge Code	4610269
Hospital Revenue Code	361
Min. Negotiated Rate	$80.46
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$491.70
Rate for Payer: Amerigroup CHIP/Medicaid	$80.46
Rate for Payer: Cash Price	$786.72
Rate for Payer: Cash Price	$786.72
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: Scott and White EPO/PPO	$447.00
Rate for Payer: Superior Health Plan EPO	$121.58

PLC VASC CLSURE DEVICE

Facility

$894.00

Service Code	HCPCS G0269
Hospital Charge Code	4610269
Hospital Revenue Code	361
Rate for Payer: Cash Price	$786.72

PLEURAL EFFUSION WITH CC

Facility

$18,929.70

Service Code	MSDRG 187
Min. Negotiated Rate	$8,717.62
Max. Negotiated Rate	$18,929.70
Rate for Payer: Aetna Commercial	$11,208.38
Rate for Payer: Aetna Medicare	$14,946.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,964.43
Rate for Payer: Amerigroup Medicare	$9,964.43
Rate for Payer: BCBS of TX Blue Advantage	$9,081.60
Rate for Payer: BCBS of TX Blue Essentials	$10,876.23
Rate for Payer: BCBS of TX Medicare	$9,964.43
Rate for Payer: BCBS of TX PPO	$12,085.16
Rate for Payer: Cigna Commercial	$12,832.34
Rate for Payer: Cigna Medicare	$9,964.43
Rate for Payer: Employer Direct Commercial	$9,964.43
Rate for Payer: Humana Medicare/TRICARE	$9,964.43
Rate for Payer: Molina Dual Medicare/Medicaid	$9,964.43
Rate for Payer: Molina Medicare	$9,964.43
Rate for Payer: Multiplan Auto	$18,929.70
Rate for Payer: Multiplan Commercial	$18,929.70
Rate for Payer: Multiplan Workers Comp	$18,929.70
Rate for Payer: Scott and White EPO/PPO	$8,717.62
Rate for Payer: Scott and White Medicare	$9,964.43
Rate for Payer: Superior Health Plan EPO	$9,964.43
Rate for Payer: Superior Health Plan Medicare	$9,964.43
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,964.43
Rate for Payer: Universal American Medicare	$9,964.43
Rate for Payer: Wellcare Medicare	$9,964.43
Rate for Payer: Wellmed Medicare	$9,964.43

PLEURAL EFFUSION WITH MCC

Facility

$29,489.90

Service Code	MSDRG 186
Min. Negotiated Rate	$13,346.34
Max. Negotiated Rate	$29,489.90
Rate for Payer: Aetna Commercial	$17,461.12
Rate for Payer: Aetna Medicare	$20,895.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,930.66
Rate for Payer: Amerigroup Medicare	$13,930.66
Rate for Payer: BCBS of TX Blue Advantage	$13,346.34
Rate for Payer: BCBS of TX Blue Essentials	$16,092.48
Rate for Payer: BCBS of TX Medicare	$13,930.66
Rate for Payer: BCBS of TX PPO	$17,881.23
Rate for Payer: Cigna Commercial	$19,991.05
Rate for Payer: Cigna Medicare	$13,930.66
Rate for Payer: Employer Direct Commercial	$13,930.66
Rate for Payer: Humana Medicare/TRICARE	$13,930.66
Rate for Payer: Molina Dual Medicare/Medicaid	$13,930.66
Rate for Payer: Molina Medicare	$13,930.66
Rate for Payer: Multiplan Auto	$29,489.90
Rate for Payer: Multiplan Commercial	$29,489.90
Rate for Payer: Multiplan Workers Comp	$29,489.90
Rate for Payer: Scott and White EPO/PPO	$13,580.88
Rate for Payer: Scott and White Medicare	$13,930.66
Rate for Payer: Superior Health Plan EPO	$13,930.66
Rate for Payer: Superior Health Plan Medicare	$13,930.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,930.66
Rate for Payer: Universal American Medicare	$13,930.66
Rate for Payer: Wellcare Medicare	$13,930.66
Rate for Payer: Wellmed Medicare	$13,930.66

PLEURAL EFFUSION WITHOUT CC/MCC

Facility

$14,183.50

Service Code	MSDRG 188
Min. Negotiated Rate	$6,531.88
Max. Negotiated Rate	$14,183.50
Rate for Payer: Aetna Commercial	$8,398.12
Rate for Payer: Aetna Medicare	$12,272.78
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,181.85
Rate for Payer: Amerigroup Medicare	$8,181.85
Rate for Payer: BCBS of TX Blue Advantage	$6,607.38
Rate for Payer: BCBS of TX Blue Essentials	$7,916.74
Rate for Payer: BCBS of TX Medicare	$8,181.85
Rate for Payer: BCBS of TX PPO	$8,796.72
Rate for Payer: Cigna Commercial	$9,614.92
Rate for Payer: Cigna Medicare	$8,181.85
Rate for Payer: Employer Direct Commercial	$8,181.85
Rate for Payer: Humana Medicare/TRICARE	$8,181.85
Rate for Payer: Molina Dual Medicare/Medicaid	$8,181.85
Rate for Payer: Molina Medicare	$8,181.85
Rate for Payer: Multiplan Auto	$14,183.50
Rate for Payer: Multiplan Commercial	$14,183.50
Rate for Payer: Multiplan Workers Comp	$14,183.50
Rate for Payer: Scott and White EPO/PPO	$6,531.88
Rate for Payer: Scott and White Medicare	$8,181.85
Rate for Payer: Superior Health Plan EPO	$8,181.85
Rate for Payer: Superior Health Plan Medicare	$8,181.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,181.85
Rate for Payer: Universal American Medicare	$8,181.85
Rate for Payer: Wellcare Medicare	$8,181.85
Rate for Payer: Wellmed Medicare	$8,181.85

PL GASTRO TUBE W/FLUORO

Facility

$5,522.00

Service Code	CPT 49440
Hospital Charge Code	4619440
Hospital Revenue Code	361
Min. Negotiated Rate	$38.38
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$2,200.00
Rate for Payer: Aetna Medicare	$2,610.33
Rate for Payer: Amerigroup CHIP/Medicaid	$564.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Amerigroup Medicare	$1,740.22
Rate for Payer: BCBS of TX Blue Advantage	$2,600.86
Rate for Payer: BCBS of TX Blue Essentials	$3,114.80
Rate for Payer: BCBS of TX Medicare	$1,740.22
Rate for Payer: BCBS of TX PPO	$3,924.65
Rate for Payer: Cash Price	$4,859.36
Rate for Payer: Cash Price	$4,859.36
Rate for Payer: Cigna Commercial	$3,942.10
Rate for Payer: Cigna Medicaid	$564.97
Rate for Payer: Cigna Medicare	$1,740.22
Rate for Payer: Employer Direct Commercial	$1,740.22
Rate for Payer: Humana Medicare/TRICARE	$1,740.22
Rate for Payer: Molina CHIP/Medicaid	$564.97
Rate for Payer: Molina Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Molina Medicare	$1,740.22
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	$564.97
Rate for Payer: Scott and White EPO/PPO	$38.38
Rate for Payer: Scott and White Medicare	$1,740.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$564.97
Rate for Payer: Superior Health Plan EPO	$1,740.22
Rate for Payer: Superior Health Plan Medicare	$1,740.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,740.22
Rate for Payer: Universal American Medicare	$1,740.22
Rate for Payer: Wellcare Medicare	$1,740.22
Rate for Payer: Wellmed Medicare	$1,740.22

PLT BN MED -- DHF

Facility

$9,872.76

Service Code	HCPCS C1713
Hospital Charge Code	81336752
Hospital Revenue Code	278
Min. Negotiated Rate	$2,468.19
Max. Negotiated Rate	$4,936.38
Rate for Payer: Aetna Commercial	$2,961.83
Rate for Payer: Cash Price	$8,688.03
Rate for Payer: Cigna Commercial	$2,468.19
Rate for Payer: Multiplan Auto	$4,936.38
Rate for Payer: Multiplan Commercial	$4,936.38
Rate for Payer: Multiplan Workers Comp	$4,936.38
Rate for Payer: Scott and White EPO/PPO	$4,936.38

PLT BN MED -- DHF

Facility

$9,872.76

Service Code	HCPCS C1713
Hospital Charge Code	81336752
Hospital Revenue Code	278
Min. Negotiated Rate	$888.55
Max. Negotiated Rate	$4,936.38
Rate for Payer: Aetna Commercial	$2,961.83
Rate for Payer: Amerigroup CHIP/Medicaid	$888.55
Rate for Payer: BCBS of TX Blue Advantage	$2,961.83
Rate for Payer: BCBS of TX Blue Essentials	$3,554.19
Rate for Payer: BCBS of TX PPO	$3,949.10
Rate for Payer: Cash Price	$8,688.03
Rate for Payer: Multiplan Auto	$4,936.38
Rate for Payer: Multiplan Commercial	$4,936.38
Rate for Payer: Multiplan Workers Comp	$4,936.38
Rate for Payer: Scott and White EPO/PPO	$4,936.38
Rate for Payer: Superior Health Plan EPO	$1,342.70

PLT BN SMALL -- DHF

Facility

$4,569.66

Service Code	HCPCS C1713
Hospital Charge Code	81336802
Hospital Revenue Code	278
Min. Negotiated Rate	$411.27
Max. Negotiated Rate	$2,284.83
Rate for Payer: Aetna Commercial	$1,370.90
Rate for Payer: Amerigroup CHIP/Medicaid	$411.27
Rate for Payer: BCBS of TX Blue Advantage	$1,370.90
Rate for Payer: BCBS of TX Blue Essentials	$1,645.08
Rate for Payer: BCBS of TX PPO	$1,827.86
Rate for Payer: Cash Price	$4,021.30
Rate for Payer: Multiplan Auto	$2,284.83
Rate for Payer: Multiplan Commercial	$2,284.83
Rate for Payer: Multiplan Workers Comp	$2,284.83
Rate for Payer: Scott and White EPO/PPO	$2,284.83
Rate for Payer: Superior Health Plan EPO	$621.47

PLT BN SMALL -- DHF

Facility

$4,569.66

Service Code	HCPCS C1713
Hospital Charge Code	81336802
Hospital Revenue Code	278
Min. Negotiated Rate	$1,142.42
Max. Negotiated Rate	$2,284.83
Rate for Payer: Aetna Commercial	$1,370.90
Rate for Payer: Cash Price	$4,021.30
Rate for Payer: Cigna Commercial	$1,142.42
Rate for Payer: Multiplan Auto	$2,284.83
Rate for Payer: Multiplan Commercial	$2,284.83
Rate for Payer: Multiplan Workers Comp	$2,284.83
Rate for Payer: Scott and White EPO/PPO	$2,284.83

Know your out-of-pocket cost for care.

All Charges