White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PLATE ACIF LEVEL 2 40MM

Facility

$14,458.00

Service Code	HCPCS C1776
Hospital Charge Code	8569067
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 ACP

Facility

$12,048.00

Service Code	HCPCS C1776
Hospital Charge Code	8452479
Hospital Revenue Code	278
Min. Negotiated Rate	$1,084.32
Max. Negotiated Rate	$8,674.56
Rate for Payer: Amerigroup CHIP/Medicaid	$1,084.32
Rate for Payer: BCBS of TX Blue Advantage	$3,614.40
Rate for Payer: BCBS of TX Blue Essentials	$4,337.28
Rate for Payer: BCBS of TX PPO	$4,819.20
Rate for Payer: Cash Price	$8,192.64
Rate for Payer: Cigna Medicaid	$8,674.56
Rate for Payer: Molina CHIP/Medicaid	$8,674.56
Rate for Payer: Multiplan Auto	$6,024.00
Rate for Payer: Multiplan Commercial	$6,024.00
Rate for Payer: Multiplan Workers Comp	$6,024.00
Rate for Payer: Parkland Medicaid	$8,674.56
Rate for Payer: Scott and White EPO/PPO	$6,024.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,674.56
Rate for Payer: Superior Health Plan EPO	$1,638.53

PLATE ACP

Facility

$12,048.00

Service Code	HCPCS C1776
Hospital Charge Code	8452479
Hospital Revenue Code	278
Min. Negotiated Rate	$3,012.00
Max. Negotiated Rate	$6,024.00
Rate for Payer: Cash Price	$8,192.64
Rate for Payer: Cigna Commercial	$3,012.00
Rate for Payer: Multiplan Auto	$6,024.00
Rate for Payer: Multiplan Commercial	$6,024.00
Rate for Payer: Multiplan Workers Comp	$6,024.00
Rate for Payer: Scott and White EPO/PPO	$6,024.00

PLATE ALIF 13MM 2 LINK

Facility

$9,259.00

Service Code	HCPCS C1776
Hospital Charge Code	145977
Hospital Revenue Code	278
Min. Negotiated Rate	$833.31
Max. Negotiated Rate	$6,666.48
Rate for Payer: Amerigroup CHIP/Medicaid	$833.31
Rate for Payer: BCBS of TX Blue Advantage	$2,777.70
Rate for Payer: BCBS of TX Blue Essentials	$3,333.24
Rate for Payer: BCBS of TX PPO	$3,703.60
Rate for Payer: Cash Price	$6,296.12
Rate for Payer: Cigna Medicaid	$6,666.48
Rate for Payer: Molina CHIP/Medicaid	$6,666.48
Rate for Payer: Multiplan Auto	$4,629.50
Rate for Payer: Multiplan Commercial	$4,629.50
Rate for Payer: Multiplan Workers Comp	$4,629.50
Rate for Payer: Parkland Medicaid	$6,666.48
Rate for Payer: Scott and White EPO/PPO	$4,629.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,666.48
Rate for Payer: Superior Health Plan EPO	$1,259.22

PLATE ALIF 13MM 2 LINK

Facility

$9,259.00

Service Code	HCPCS C1776
Hospital Charge Code	145977
Hospital Revenue Code	278
Min. Negotiated Rate	$2,314.75
Max. Negotiated Rate	$4,629.50
Rate for Payer: Cash Price	$6,296.12
Rate for Payer: Cigna Commercial	$2,314.75
Rate for Payer: Multiplan Auto	$4,629.50
Rate for Payer: Multiplan Commercial	$4,629.50
Rate for Payer: Multiplan Workers Comp	$4,629.50
Rate for Payer: Scott and White EPO/PPO	$4,629.50

PLATE ALIF PEEK 32MMX08MMX13MM

Facility

$18,072.00

Service Code	HCPCS C1776
Hospital Charge Code	145336
Hospital Revenue Code	278
Min. Negotiated Rate	$4,518.00
Max. Negotiated Rate	$9,036.00
Rate for Payer: Cash Price	$12,288.96
Rate for Payer: Cigna Commercial	$4,518.00
Rate for Payer: Multiplan Auto	$9,036.00
Rate for Payer: Multiplan Commercial	$9,036.00
Rate for Payer: Multiplan Workers Comp	$9,036.00
Rate for Payer: Scott and White EPO/PPO	$9,036.00

PLATE ALIF PEEK 32MMX08MMX13MM

Facility

$18,072.00

Service Code	HCPCS C1776
Hospital Charge Code	145336
Hospital Revenue Code	278
Min. Negotiated Rate	$1,626.48
Max. Negotiated Rate	$13,011.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,626.48
Rate for Payer: BCBS of TX Blue Advantage	$5,421.60
Rate for Payer: BCBS of TX Blue Essentials	$6,505.92
Rate for Payer: BCBS of TX PPO	$7,228.80
Rate for Payer: Cash Price	$12,288.96
Rate for Payer: Cigna Medicaid	$13,011.84
Rate for Payer: Molina CHIP/Medicaid	$13,011.84
Rate for Payer: Multiplan Auto	$9,036.00
Rate for Payer: Multiplan Commercial	$9,036.00
Rate for Payer: Multiplan Workers Comp	$9,036.00
Rate for Payer: Parkland Medicaid	$13,011.84
Rate for Payer: Scott and White EPO/PPO	$9,036.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,011.84
Rate for Payer: Superior Health Plan EPO	$2,457.79

plate alif peek 39x15x15

Facility

$18,072.00

Service Code	HCPCS C1776
Hospital Charge Code	8618509
Hospital Revenue Code	278
Min. Negotiated Rate	$4,518.00
Max. Negotiated Rate	$9,036.00
Rate for Payer: Cash Price	$12,288.96
Rate for Payer: Cigna Commercial	$4,518.00
Rate for Payer: Multiplan Auto	$9,036.00
Rate for Payer: Multiplan Commercial	$9,036.00
Rate for Payer: Multiplan Workers Comp	$9,036.00
Rate for Payer: Scott and White EPO/PPO	$9,036.00

plate alif peek 39x15x15

Facility

$18,072.00

Service Code	HCPCS C1776
Hospital Charge Code	8618509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,626.48
Max. Negotiated Rate	$13,011.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,626.48
Rate for Payer: BCBS of TX Blue Advantage	$5,421.60
Rate for Payer: BCBS of TX Blue Essentials	$6,505.92
Rate for Payer: BCBS of TX PPO	$7,228.80
Rate for Payer: Cash Price	$12,288.96
Rate for Payer: Cigna Medicaid	$13,011.84
Rate for Payer: Molina CHIP/Medicaid	$13,011.84
Rate for Payer: Multiplan Auto	$9,036.00
Rate for Payer: Multiplan Commercial	$9,036.00
Rate for Payer: Multiplan Workers Comp	$9,036.00
Rate for Payer: Parkland Medicaid	$13,011.84
Rate for Payer: Scott and White EPO/PPO	$9,036.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,011.84
Rate for Payer: Superior Health Plan EPO	$2,457.79

PLATE CERVICAL ACP 34MM

Facility

$19,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8428488
Hospital Revenue Code	278
Min. Negotiated Rate	$1,785.15
Max. Negotiated Rate	$14,281.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,785.15
Rate for Payer: BCBS of TX Blue Advantage	$5,950.50
Rate for Payer: BCBS of TX Blue Essentials	$7,140.60
Rate for Payer: BCBS of TX PPO	$7,934.00
Rate for Payer: Cash Price	$13,487.80
Rate for Payer: Cigna Medicaid	$14,281.20
Rate for Payer: Molina CHIP/Medicaid	$14,281.20
Rate for Payer: Multiplan Auto	$9,917.50
Rate for Payer: Multiplan Commercial	$9,917.50
Rate for Payer: Multiplan Workers Comp	$9,917.50
Rate for Payer: Parkland Medicaid	$14,281.20
Rate for Payer: Scott and White EPO/PPO	$9,917.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,281.20
Rate for Payer: Superior Health Plan EPO	$2,697.56

PLATE CERVICAL ACP 34MM

Facility

$19,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8428488
Hospital Revenue Code	278
Min. Negotiated Rate	$4,958.75
Max. Negotiated Rate	$9,917.50
Rate for Payer: Cash Price	$13,487.80
Rate for Payer: Cigna Commercial	$4,958.75
Rate for Payer: Multiplan Auto	$9,917.50
Rate for Payer: Multiplan Commercial	$9,917.50
Rate for Payer: Multiplan Workers Comp	$9,917.50
Rate for Payer: Scott and White EPO/PPO	$9,917.50

PLATE CERVICAL LVL 3

Facility

$23,140.00

Service Code	HCPCS C1776
Hospital Charge Code	8404459
Hospital Revenue Code	278
Min. Negotiated Rate	$5,785.00
Max. Negotiated Rate	$11,570.00
Rate for Payer: Cash Price	$15,735.20
Rate for Payer: Cigna Commercial	$5,785.00
Rate for Payer: Multiplan Auto	$11,570.00
Rate for Payer: Multiplan Commercial	$11,570.00
Rate for Payer: Multiplan Workers Comp	$11,570.00
Rate for Payer: Scott and White EPO/PPO	$11,570.00

PLATE CERVICAL LVL 3

Facility

$23,140.00

Service Code	HCPCS C1776
Hospital Charge Code	8404459
Hospital Revenue Code	278
Min. Negotiated Rate	$2,082.60
Max. Negotiated Rate	$16,660.80
Rate for Payer: Amerigroup CHIP/Medicaid	$2,082.60
Rate for Payer: BCBS of TX Blue Advantage	$6,942.00
Rate for Payer: BCBS of TX Blue Essentials	$8,330.40
Rate for Payer: BCBS of TX PPO	$9,256.00
Rate for Payer: Cash Price	$15,735.20
Rate for Payer: Cigna Medicaid	$16,660.80
Rate for Payer: Molina CHIP/Medicaid	$16,660.80
Rate for Payer: Multiplan Auto	$11,570.00
Rate for Payer: Multiplan Commercial	$11,570.00
Rate for Payer: Multiplan Workers Comp	$11,570.00
Rate for Payer: Parkland Medicaid	$16,660.80
Rate for Payer: Scott and White EPO/PPO	$11,570.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,660.80
Rate for Payer: Superior Health Plan EPO	$3,147.04

PLATE CHRAMAGAR MRSA 11

Facility

$36.74

Hospital Charge Code	993653
Hospital Revenue Code	270
Rate for Payer: Cash Price	$24.98

PLATE CHRAMAGAR MRSA 11

Facility

$36.74

Hospital Charge Code	993653
Hospital Revenue Code	270
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$26.45
Rate for Payer: Amerigroup CHIP/Medicaid	$3.31
Rate for Payer: BCBS of TX Blue Advantage	$11.02
Rate for Payer: BCBS of TX Blue Essentials	$13.23
Rate for Payer: BCBS of TX PPO	$14.70
Rate for Payer: Cash Price	$24.98
Rate for Payer: Cigna Medicaid	$26.45
Rate for Payer: Molina CHIP/Medicaid	$26.45
Rate for Payer: Multiplan Auto	$23.88
Rate for Payer: Multiplan Commercial	$23.88
Rate for Payer: Multiplan Workers Comp	$23.88
Rate for Payer: Parkland Medicaid	$26.45
Rate for Payer: Scott and White EPO/PPO	$18.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.45
Rate for Payer: Superior Health Plan EPO	$5.00

PLATE DISTAL LATERAL 4 HOLE

Facility

$9,915.66

Service Code	HCPCS C1713
Hospital Charge Code	992149
Hospital Revenue Code	278
Min. Negotiated Rate	$892.41
Max. Negotiated Rate	$7,139.28
Rate for Payer: Amerigroup CHIP/Medicaid	$892.41
Rate for Payer: BCBS of TX Blue Advantage	$2,974.70
Rate for Payer: BCBS of TX Blue Essentials	$3,569.64
Rate for Payer: BCBS of TX PPO	$3,966.26
Rate for Payer: Cash Price	$6,742.65
Rate for Payer: Cigna Medicaid	$7,139.28
Rate for Payer: Molina CHIP/Medicaid	$7,139.28
Rate for Payer: Multiplan Auto	$4,957.83
Rate for Payer: Multiplan Commercial	$4,957.83
Rate for Payer: Multiplan Workers Comp	$4,957.83
Rate for Payer: Parkland Medicaid	$7,139.28
Rate for Payer: Scott and White EPO/PPO	$4,957.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,139.28
Rate for Payer: Superior Health Plan EPO	$1,348.53

PLATE DISTAL LATERAL 4 HOLE

Facility

$9,915.66

Service Code	HCPCS C1713
Hospital Charge Code	992149
Hospital Revenue Code	278
Min. Negotiated Rate	$2,478.91
Max. Negotiated Rate	$4,957.83
Rate for Payer: Cash Price	$6,742.65
Rate for Payer: Cigna Commercial	$2,478.91
Rate for Payer: Multiplan Auto	$4,957.83
Rate for Payer: Multiplan Commercial	$4,957.83
Rate for Payer: Multiplan Workers Comp	$4,957.83
Rate for Payer: Scott and White EPO/PPO	$4,957.83

PLATE DISTAL LATERAL FEMUR 8 HOLE

Facility

$14,176.00

Service Code	HCPCS C1776
Hospital Charge Code	144884
Hospital Revenue Code	278
Min. Negotiated Rate	$3,544.00
Max. Negotiated Rate	$7,088.00
Rate for Payer: Cash Price	$9,639.68
Rate for Payer: Cigna Commercial	$3,544.00
Rate for Payer: Multiplan Auto	$7,088.00
Rate for Payer: Multiplan Commercial	$7,088.00
Rate for Payer: Multiplan Workers Comp	$7,088.00
Rate for Payer: Scott and White EPO/PPO	$7,088.00

PLATE DISTAL LATERAL FEMUR 8 HOLE

Facility

$14,176.00

Service Code	HCPCS C1776
Hospital Charge Code	144884
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.84
Max. Negotiated Rate	$10,206.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,275.84
Rate for Payer: BCBS of TX Blue Advantage	$4,252.80
Rate for Payer: BCBS of TX Blue Essentials	$5,103.36
Rate for Payer: BCBS of TX PPO	$5,670.40
Rate for Payer: Cash Price	$9,639.68
Rate for Payer: Cigna Medicaid	$10,206.72
Rate for Payer: Molina CHIP/Medicaid	$10,206.72
Rate for Payer: Multiplan Auto	$7,088.00
Rate for Payer: Multiplan Commercial	$7,088.00
Rate for Payer: Multiplan Workers Comp	$7,088.00
Rate for Payer: Parkland Medicaid	$10,206.72
Rate for Payer: Scott and White EPO/PPO	$7,088.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,206.72
Rate for Payer: Superior Health Plan EPO	$1,927.94

PLATE DISTAL VOLAR RADIAL

Facility

$5,020.00

Service Code	HCPCS C1776
Hospital Charge Code	8568966
Hospital Revenue Code	278
Min. Negotiated Rate	$451.80
Max. Negotiated Rate	$3,614.40
Rate for Payer: Amerigroup CHIP/Medicaid	$451.80
Rate for Payer: BCBS of TX Blue Advantage	$1,506.00
Rate for Payer: BCBS of TX Blue Essentials	$1,807.20
Rate for Payer: BCBS of TX PPO	$2,008.00
Rate for Payer: Cash Price	$3,413.60
Rate for Payer: Cigna Medicaid	$3,614.40
Rate for Payer: Molina CHIP/Medicaid	$3,614.40
Rate for Payer: Multiplan Auto	$2,510.00
Rate for Payer: Multiplan Commercial	$2,510.00
Rate for Payer: Multiplan Workers Comp	$2,510.00
Rate for Payer: Parkland Medicaid	$3,614.40
Rate for Payer: Scott and White EPO/PPO	$2,510.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,614.40
Rate for Payer: Superior Health Plan EPO	$682.72

PLATE DISTAL VOLAR RADIAL

Facility

$5,020.00

Service Code	HCPCS C1776
Hospital Charge Code	8568966
Hospital Revenue Code	278
Min. Negotiated Rate	$1,255.00
Max. Negotiated Rate	$2,510.00
Rate for Payer: Cash Price	$3,413.60
Rate for Payer: Cigna Commercial	$1,255.00
Rate for Payer: Multiplan Auto	$2,510.00
Rate for Payer: Multiplan Commercial	$2,510.00
Rate for Payer: Multiplan Workers Comp	$2,510.00
Rate for Payer: Scott and White EPO/PPO	$2,510.00

plate fibula distal

Facility

$3,305.00

Service Code	HCPCS C1776
Hospital Charge Code	8702512
Hospital Revenue Code	278
Min. Negotiated Rate	$826.25
Max. Negotiated Rate	$1,652.50
Rate for Payer: Cash Price	$2,247.40
Rate for Payer: Cigna Commercial	$826.25
Rate for Payer: Multiplan Auto	$1,652.50
Rate for Payer: Multiplan Commercial	$1,652.50
Rate for Payer: Multiplan Workers Comp	$1,652.50
Rate for Payer: Scott and White EPO/PPO	$1,652.50

plate fibula distal

Facility

$3,305.00

Service Code	HCPCS C1776
Hospital Charge Code	8702512
Hospital Revenue Code	278
Min. Negotiated Rate	$297.45
Max. Negotiated Rate	$2,379.60
Rate for Payer: Amerigroup CHIP/Medicaid	$297.45
Rate for Payer: BCBS of TX Blue Advantage	$991.50
Rate for Payer: BCBS of TX Blue Essentials	$1,189.80
Rate for Payer: BCBS of TX PPO	$1,322.00
Rate for Payer: Cash Price	$2,247.40
Rate for Payer: Cigna Medicaid	$2,379.60
Rate for Payer: Molina CHIP/Medicaid	$2,379.60
Rate for Payer: Multiplan Auto	$1,652.50
Rate for Payer: Multiplan Commercial	$1,652.50
Rate for Payer: Multiplan Workers Comp	$1,652.50
Rate for Payer: Parkland Medicaid	$2,379.60
Rate for Payer: Scott and White EPO/PPO	$1,652.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,379.60
Rate for Payer: Superior Health Plan EPO	$449.48

PLATE FOREARM 11 HOLE

Facility

$6,958.00

Service Code	HCPCS C1776
Hospital Charge Code	145263
Hospital Revenue Code	278
Min. Negotiated Rate	$626.22
Max. Negotiated Rate	$5,009.76
Rate for Payer: Amerigroup CHIP/Medicaid	$626.22
Rate for Payer: BCBS of TX Blue Advantage	$2,087.40
Rate for Payer: BCBS of TX Blue Essentials	$2,504.88
Rate for Payer: BCBS of TX PPO	$2,783.20
Rate for Payer: Cash Price	$4,731.44
Rate for Payer: Cigna Medicaid	$5,009.76
Rate for Payer: Molina CHIP/Medicaid	$5,009.76
Rate for Payer: Multiplan Auto	$3,479.00
Rate for Payer: Multiplan Commercial	$3,479.00
Rate for Payer: Multiplan Workers Comp	$3,479.00
Rate for Payer: Parkland Medicaid	$5,009.76
Rate for Payer: Scott and White EPO/PPO	$3,479.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,009.76
Rate for Payer: Superior Health Plan EPO	$946.29

PLATE FOREARM 11 HOLE

Facility

$6,958.00

Service Code	HCPCS C1776
Hospital Charge Code	145263
Hospital Revenue Code	278
Min. Negotiated Rate	$1,739.50
Max. Negotiated Rate	$3,479.00
Rate for Payer: Cash Price	$4,731.44
Rate for Payer: Cigna Commercial	$1,739.50
Rate for Payer: Multiplan Auto	$3,479.00
Rate for Payer: Multiplan Commercial	$3,479.00
Rate for Payer: Multiplan Workers Comp	$3,479.00
Rate for Payer: Scott and White EPO/PPO	$3,479.00

Know your out-of-pocket cost for care.

All Charges