White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Placement of occlusive device

Facility

$894.00

Service Code	HCPCS G0269
Hospital Charge Code	991308
Hospital Revenue Code	361
Min. Negotiated Rate	$80.46
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.46
Rate for Payer: BCBS of TX Blue Advantage	$268.20
Rate for Payer: BCBS of TX Blue Essentials	$321.84
Rate for Payer: BCBS of TX PPO	$357.60
Rate for Payer: Cash Price	$607.92
Rate for Payer: Cash Price	$607.92
Rate for Payer: Cigna Medicaid	$643.68
Rate for Payer: Molina CHIP/Medicaid	$643.68
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	$643.68
Rate for Payer: Scott and White EPO/PPO	$447.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$643.68
Rate for Payer: Superior Health Plan EPO	$121.58

Placement of occlusive device

Facility

$894.00

Service Code	HCPCS G0269
Hospital Charge Code	991308
Hospital Revenue Code	361
Rate for Payer: Cash Price	$607.92

Placement of occlusive device

Facility

$894.00

Service Code	HCPCS G0269
Hospital Charge Code	991019
Hospital Revenue Code	361
Min. Negotiated Rate	$80.46
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$80.46
Rate for Payer: BCBS of TX Blue Advantage	$268.20
Rate for Payer: BCBS of TX Blue Essentials	$321.84
Rate for Payer: BCBS of TX PPO	$357.60
Rate for Payer: Cash Price	$607.92
Rate for Payer: Cash Price	$607.92
Rate for Payer: Cigna Medicaid	$643.68
Rate for Payer: Molina CHIP/Medicaid	$643.68
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	$643.68
Rate for Payer: Scott and White EPO/PPO	$447.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$643.68
Rate for Payer: Superior Health Plan EPO	$121.58

Placement of stent percutaneous imaging guidance balloon dilation, catheter exchange catheter removal

Facility

$24,696.00

Service Code	HCPCS 47539
Hospital Charge Code	994161
Hospital Revenue Code	481
Rate for Payer: Cash Price	$16,793.28

Placement of stent percutaneous imaging guidance balloon dilation, catheter exchange catheter removal

Facility

$24,696.00

Service Code	HCPCS 47539
Hospital Charge Code	994161
Hospital Revenue Code	481
Min. Negotiated Rate	$505.46
Max. Negotiated Rate	$17,781.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,222.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$17,781.12
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$17,781.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
Rate for Payer: Multiplan Auto	$16,052.40
Rate for Payer: Multiplan Commercial	$16,052.40
Rate for Payer: Multiplan Workers Comp	$16,052.40
Rate for Payer: Parkland Medicaid	$17,781.12
Rate for Payer: Scott and White EPO/PPO	$505.46
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,781.12
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Placement of stent percutaneous, including diagnostic cholangiography balloon dilation, catheter

Facility

$24,696.00

Service Code	HCPCS 47538
Hospital Charge Code	994162
Hospital Revenue Code	481
Min. Negotiated Rate	$278.45
Max. Negotiated Rate	$17,781.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,222.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$17,781.12
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$17,781.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
Rate for Payer: Multiplan Auto	$16,052.40
Rate for Payer: Multiplan Commercial	$16,052.40
Rate for Payer: Multiplan Workers Comp	$16,052.40
Rate for Payer: Parkland Medicaid	$17,781.12
Rate for Payer: Scott and White EPO/PPO	$278.45
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,781.12
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Placement of stent percutaneous, including diagnostic cholangiography balloon dilation, catheter

Facility

$24,696.00

Service Code	HCPCS 47538
Hospital Charge Code	994162
Hospital Revenue Code	481
Rate for Payer: Cash Price	$16,793.28

Placement of stent(s) into a bile duct, percutaneous, with placement of separate biliary drainage catheter

Facility

$24,696.00

Service Code	HCPCS 47540
Hospital Charge Code	994163
Hospital Revenue Code	481
Min. Negotiated Rate	$520.65
Max. Negotiated Rate	$17,781.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2,222.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Amerigroup Medicare	$6,073.08
Rate for Payer: BCBS of TX Blue Advantage	$8,072.30
Rate for Payer: BCBS of TX Blue Essentials	$9,667.42
Rate for Payer: BCBS of TX Medicare	$6,073.08
Rate for Payer: BCBS of TX PPO	$12,180.95
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cash Price	$16,793.28
Rate for Payer: Cigna Commercial	$12,837.39
Rate for Payer: Cigna Medicaid	$17,781.12
Rate for Payer: Cigna Medicare	$6,073.08
Rate for Payer: Employer Direct Commercial	$6,073.08
Rate for Payer: Humana Medicare/TRICARE	$6,073.08
Rate for Payer: Molina CHIP/Medicaid	$17,781.12
Rate for Payer: Molina Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Molina Medicare	$6,073.08
Rate for Payer: Multiplan Auto	$16,052.40
Rate for Payer: Multiplan Commercial	$16,052.40
Rate for Payer: Multiplan Workers Comp	$16,052.40
Rate for Payer: Parkland Medicaid	$17,781.12
Rate for Payer: Scott and White EPO/PPO	$520.65
Rate for Payer: Scott and White Medicare	$6,073.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,781.12
Rate for Payer: Superior Health Plan EPO	$6,073.08
Rate for Payer: Superior Health Plan Medicare	$6,073.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,073.08
Rate for Payer: Universal American Medicare	$6,073.08
Rate for Payer: Wellcare Medicare	$6,073.08
Rate for Payer: Wellmed Medicare	$6,073.08

Placement of stent(s) into a bile duct, percutaneous, with placement of separate biliary drainage catheter

Facility

$24,696.00

Service Code	HCPCS 47540
Hospital Charge Code	994163
Hospital Revenue Code	481
Rate for Payer: Cash Price	$16,793.28

Plastic repair of salivary duct, sialodochoplasty; primary or simple

Facility

$40,688.40

Service Code	HCPCS 42500
Hospital Charge Code	9900657
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$29,295.65
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cash Price	$27,668.11
Rate for Payer: Cash Price	$27,668.11
Rate for Payer: Cash Price	$27,668.11
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicaid	$29,295.65
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina CHIP/Medicaid	$29,295.65
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$29,295.65
Rate for Payer: Scott and White EPO/PPO	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,295.65
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Plastic repair of salivary duct, sialodochoplasty; primary or simple

Facility

$12,570.48

Service Code	CPT 42500
Hospital Charge Code	36042500
Hospital Revenue Code	360
Min. Negotiated Rate	$1,954.22
Max. Negotiated Rate	$12,570.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,954.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Amerigroup Medicare	$5,946.81
Rate for Payer: BCBS of TX Blue Advantage	$8,100.39
Rate for Payer: BCBS of TX Blue Essentials	$9,701.06
Rate for Payer: BCBS of TX Medicare	$5,946.81
Rate for Payer: BCBS of TX PPO	$12,223.34
Rate for Payer: Cigna Commercial	$12,570.48
Rate for Payer: Cigna Medicare	$5,946.81
Rate for Payer: Employer Direct Commercial	$5,946.81
Rate for Payer: Humana Medicare/TRICARE	$5,946.81
Rate for Payer: Molina Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Molina Medicare	$5,946.81
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	$9,908.12
Rate for Payer: Scott and White Medicare	$5,946.81
Rate for Payer: Superior Health Plan EPO	$5,946.81
Rate for Payer: Superior Health Plan Medicare	$5,946.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$5,946.81
Rate for Payer: Universal American Medicare	$5,946.81
Rate for Payer: Wellcare Medicare	$5,946.81
Rate for Payer: Wellmed Medicare	$5,946.81

Plastic repair of salivary duct, sialodochoplasty; primary or simple

Facility

$40,688.40

Service Code	HCPCS 42500
Hospital Charge Code	9900657
Hospital Revenue Code	360
Rate for Payer: Cash Price	$27,668.11

PLATE 2.4/2.7 MM VA LOCKING LATERAL RIM PATELLA SML

Facility

$22,517.00

Service Code	HCPCS C1776
Hospital Charge Code	146665
Hospital Revenue Code	278
Min. Negotiated Rate	$2,026.53
Max. Negotiated Rate	$16,212.24
Rate for Payer: Amerigroup CHIP/Medicaid	$2,026.53
Rate for Payer: BCBS of TX Blue Advantage	$6,755.10
Rate for Payer: BCBS of TX Blue Essentials	$8,106.12
Rate for Payer: BCBS of TX PPO	$9,006.80
Rate for Payer: Cash Price	$15,311.56
Rate for Payer: Cigna Medicaid	$16,212.24
Rate for Payer: Molina CHIP/Medicaid	$16,212.24
Rate for Payer: Multiplan Auto	$11,258.50
Rate for Payer: Multiplan Commercial	$11,258.50
Rate for Payer: Multiplan Workers Comp	$11,258.50
Rate for Payer: Parkland Medicaid	$16,212.24
Rate for Payer: Scott and White EPO/PPO	$11,258.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,212.24
Rate for Payer: Superior Health Plan EPO	$3,062.31

PLATE 2.4/2.7 MM VA LOCKING LATERAL RIM PATELLA SML

Facility

$22,517.00

Service Code	HCPCS C1776
Hospital Charge Code	146665
Hospital Revenue Code	278
Min. Negotiated Rate	$5,629.25
Max. Negotiated Rate	$11,258.50
Rate for Payer: Cash Price	$15,311.56
Rate for Payer: Cigna Commercial	$5,629.25
Rate for Payer: Multiplan Auto	$11,258.50
Rate for Payer: Multiplan Commercial	$11,258.50
Rate for Payer: Multiplan Workers Comp	$11,258.50
Rate for Payer: Scott and White EPO/PPO	$11,258.50

PLATE 7 HOLE RIGHT

Facility

$19,578.00

Service Code	HCPCS C1776
Hospital Charge Code	8428493
Hospital Revenue Code	278
Min. Negotiated Rate	$1,762.02
Max. Negotiated Rate	$14,096.16
Rate for Payer: Amerigroup CHIP/Medicaid	$1,762.02
Rate for Payer: BCBS of TX Blue Advantage	$5,873.40
Rate for Payer: BCBS of TX Blue Essentials	$7,048.08
Rate for Payer: BCBS of TX PPO	$7,831.20
Rate for Payer: Cash Price	$13,313.04
Rate for Payer: Cigna Medicaid	$14,096.16
Rate for Payer: Molina CHIP/Medicaid	$14,096.16
Rate for Payer: Multiplan Auto	$9,789.00
Rate for Payer: Multiplan Commercial	$9,789.00
Rate for Payer: Multiplan Workers Comp	$9,789.00
Rate for Payer: Parkland Medicaid	$14,096.16
Rate for Payer: Scott and White EPO/PPO	$9,789.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,096.16
Rate for Payer: Superior Health Plan EPO	$2,662.61

PLATE 7 HOLE RIGHT

Facility

$19,578.00

Service Code	HCPCS C1776
Hospital Charge Code	8428493
Hospital Revenue Code	278
Min. Negotiated Rate	$4,894.50
Max. Negotiated Rate	$9,789.00
Rate for Payer: Cash Price	$13,313.04
Rate for Payer: Cigna Commercial	$4,894.50
Rate for Payer: Multiplan Auto	$9,789.00
Rate for Payer: Multiplan Commercial	$9,789.00
Rate for Payer: Multiplan Workers Comp	$9,789.00
Rate for Payer: Scott and White EPO/PPO	$9,789.00

PLATE ACDF 3 LEVEL

Facility

$17,284.00

Service Code	HCPCS C1776
Hospital Charge Code	146225
Hospital Revenue Code	278
Min. Negotiated Rate	$4,321.00
Max. Negotiated Rate	$8,642.00
Rate for Payer: Cash Price	$11,753.12
Rate for Payer: Cigna Commercial	$4,321.00
Rate for Payer: Multiplan Auto	$8,642.00
Rate for Payer: Multiplan Commercial	$8,642.00
Rate for Payer: Multiplan Workers Comp	$8,642.00
Rate for Payer: Scott and White EPO/PPO	$8,642.00

PLATE ACDF 3 LEVEL

Facility

$17,284.00

Service Code	HCPCS C1776
Hospital Charge Code	146225
Hospital Revenue Code	278
Min. Negotiated Rate	$1,555.56
Max. Negotiated Rate	$12,444.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,555.56
Rate for Payer: BCBS of TX Blue Advantage	$5,185.20
Rate for Payer: BCBS of TX Blue Essentials	$6,222.24
Rate for Payer: BCBS of TX PPO	$6,913.60
Rate for Payer: Cash Price	$11,753.12
Rate for Payer: Cigna Medicaid	$12,444.48
Rate for Payer: Molina CHIP/Medicaid	$12,444.48
Rate for Payer: Multiplan Auto	$8,642.00
Rate for Payer: Multiplan Commercial	$8,642.00
Rate for Payer: Multiplan Workers Comp	$8,642.00
Rate for Payer: Parkland Medicaid	$12,444.48
Rate for Payer: Scott and White EPO/PPO	$8,642.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,444.48
Rate for Payer: Superior Health Plan EPO	$2,350.62

plate acdf all levels

Facility

$6,024.00

Service Code	HCPCS C1776
Hospital Charge Code	8672535
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.00
Max. Negotiated Rate	$3,012.00
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Commercial	$1,506.00
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Scott and White EPO/PPO	$3,012.00

plate acdf all levels

Facility

$6,024.00

Service Code	HCPCS C1776
Hospital Charge Code	8672535
Hospital Revenue Code	278
Min. Negotiated Rate	$542.16
Max. Negotiated Rate	$4,337.28
Rate for Payer: Amerigroup CHIP/Medicaid	$542.16
Rate for Payer: BCBS of TX Blue Advantage	$1,807.20
Rate for Payer: BCBS of TX Blue Essentials	$2,168.64
Rate for Payer: BCBS of TX PPO	$2,409.60
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Medicaid	$4,337.28
Rate for Payer: Molina CHIP/Medicaid	$4,337.28
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Parkland Medicaid	$4,337.28
Rate for Payer: Scott and White EPO/PPO	$3,012.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,337.28
Rate for Payer: Superior Health Plan EPO	$819.26

PLATE ACF 2 LEVEL

Facility

$14,458.00

Service Code	HCPCS C1776
Hospital Charge Code	8568967
Hospital Revenue Code	278
Min. Negotiated Rate	$3,614.50
Max. Negotiated Rate	$7,229.00
Rate for Payer: Cash Price	$9,831.44
Rate for Payer: Cigna Commercial	$3,614.50
Rate for Payer: Multiplan Auto	$7,229.00
Rate for Payer: Multiplan Commercial	$7,229.00
Rate for Payer: Multiplan Workers Comp	$7,229.00
Rate for Payer: Scott and White EPO/PPO	$7,229.00

PLATE ACF 2 LEVEL

Facility

$14,458.00

Service Code	HCPCS C1776
Hospital Charge Code	8568967
Hospital Revenue Code	278
Min. Negotiated Rate	$1,301.22
Max. Negotiated Rate	$10,409.76
Rate for Payer: Amerigroup CHIP/Medicaid	$1,301.22
Rate for Payer: BCBS of TX Blue Advantage	$4,337.40
Rate for Payer: BCBS of TX Blue Essentials	$5,204.88
Rate for Payer: BCBS of TX PPO	$5,783.20
Rate for Payer: Cash Price	$9,831.44
Rate for Payer: Cigna Medicaid	$10,409.76
Rate for Payer: Molina CHIP/Medicaid	$10,409.76
Rate for Payer: Multiplan Auto	$7,229.00
Rate for Payer: Multiplan Commercial	$7,229.00
Rate for Payer: Multiplan Workers Comp	$7,229.00
Rate for Payer: Parkland Medicaid	$10,409.76
Rate for Payer: Scott and White EPO/PPO	$7,229.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,409.76
Rate for Payer: Superior Health Plan EPO	$1,966.29

plate acf cover

Facility

$1,325.00

Service Code	HCPCS C1776
Hospital Charge Code	8666512
Hospital Revenue Code	278
Min. Negotiated Rate	$119.25
Max. Negotiated Rate	$954.00
Rate for Payer: Amerigroup CHIP/Medicaid	$119.25
Rate for Payer: BCBS of TX Blue Advantage	$397.50
Rate for Payer: BCBS of TX Blue Essentials	$477.00
Rate for Payer: BCBS of TX PPO	$530.00
Rate for Payer: Cash Price	$901.00
Rate for Payer: Cigna Medicaid	$954.00
Rate for Payer: Molina CHIP/Medicaid	$954.00
Rate for Payer: Multiplan Auto	$662.50
Rate for Payer: Multiplan Commercial	$662.50
Rate for Payer: Multiplan Workers Comp	$662.50
Rate for Payer: Parkland Medicaid	$954.00
Rate for Payer: Scott and White EPO/PPO	$662.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$954.00
Rate for Payer: Superior Health Plan EPO	$180.20

plate acf cover

Facility

$1,325.00

Service Code	HCPCS C1776
Hospital Charge Code	8666512
Hospital Revenue Code	278
Min. Negotiated Rate	$331.25
Max. Negotiated Rate	$662.50
Rate for Payer: Cash Price	$901.00
Rate for Payer: Cigna Commercial	$331.25
Rate for Payer: Multiplan Auto	$662.50
Rate for Payer: Multiplan Commercial	$662.50
Rate for Payer: Multiplan Workers Comp	$662.50
Rate for Payer: Scott and White EPO/PPO	$662.50

PLATE ACIF LEVEL 2 40MM

Facility

$14,458.00

Service Code	HCPCS C1776
Hospital Charge Code	8569067
Hospital Revenue Code	278
Min. Negotiated Rate	$3,614.50
Max. Negotiated Rate	$7,229.00
Rate for Payer: Cash Price	$9,831.44
Rate for Payer: Cigna Commercial	$3,614.50
Rate for Payer: Multiplan Auto	$7,229.00
Rate for Payer: Multiplan Commercial	$7,229.00
Rate for Payer: Multiplan Workers Comp	$7,229.00
Rate for Payer: Scott and White EPO/PPO	$7,229.00

Know your out-of-pocket cost for care.

All Charges