White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PLATE HOOK 5 HOLE

Facility

$11,457.83

Service Code	HCPCS C1713
Hospital Charge Code	992134
Hospital Revenue Code	278
Min. Negotiated Rate	$1,031.20
Max. Negotiated Rate	$8,249.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1,031.20
Rate for Payer: BCBS of TX Blue Advantage	$3,437.35
Rate for Payer: BCBS of TX Blue Essentials	$4,124.82
Rate for Payer: BCBS of TX PPO	$4,583.13
Rate for Payer: Cash Price	$7,791.32
Rate for Payer: Cigna Medicaid	$8,249.64
Rate for Payer: Molina CHIP/Medicaid	$8,249.64
Rate for Payer: Multiplan Auto	$5,728.91
Rate for Payer: Multiplan Commercial	$5,728.91
Rate for Payer: Multiplan Workers Comp	$5,728.91
Rate for Payer: Parkland Medicaid	$8,249.64
Rate for Payer: Scott and White EPO/PPO	$5,728.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,249.64
Rate for Payer: Superior Health Plan EPO	$1,558.26

PLATE HOOK 5 HOLE

Facility

$11,457.83

Service Code	HCPCS C1713
Hospital Charge Code	992134
Hospital Revenue Code	278
Min. Negotiated Rate	$2,864.46
Max. Negotiated Rate	$5,728.91
Rate for Payer: Cash Price	$7,791.32
Rate for Payer: Cigna Commercial	$2,864.46
Rate for Payer: Multiplan Auto	$5,728.91
Rate for Payer: Multiplan Commercial	$5,728.91
Rate for Payer: Multiplan Workers Comp	$5,728.91
Rate for Payer: Scott and White EPO/PPO	$5,728.91

PLATE HOOK 5 HOLE RIGHT

Facility

$11,741.00

Service Code	HCPCS C1776
Hospital Charge Code	146724
Hospital Revenue Code	278
Min. Negotiated Rate	$2,935.25
Max. Negotiated Rate	$5,870.50
Rate for Payer: Cash Price	$7,983.88
Rate for Payer: Cigna Commercial	$2,935.25
Rate for Payer: Multiplan Auto	$5,870.50
Rate for Payer: Multiplan Commercial	$5,870.50
Rate for Payer: Multiplan Workers Comp	$5,870.50
Rate for Payer: Scott and White EPO/PPO	$5,870.50

PLATE HOOK 5 HOLE RIGHT

Facility

$11,741.00

Service Code	HCPCS C1776
Hospital Charge Code	146724
Hospital Revenue Code	278
Min. Negotiated Rate	$1,056.69
Max. Negotiated Rate	$8,453.52
Rate for Payer: Amerigroup CHIP/Medicaid	$1,056.69
Rate for Payer: BCBS of TX Blue Advantage	$3,522.30
Rate for Payer: BCBS of TX Blue Essentials	$4,226.76
Rate for Payer: BCBS of TX PPO	$4,696.40
Rate for Payer: Cash Price	$7,983.88
Rate for Payer: Cigna Medicaid	$8,453.52
Rate for Payer: Molina CHIP/Medicaid	$8,453.52
Rate for Payer: Multiplan Auto	$5,870.50
Rate for Payer: Multiplan Commercial	$5,870.50
Rate for Payer: Multiplan Workers Comp	$5,870.50
Rate for Payer: Parkland Medicaid	$8,453.52
Rate for Payer: Scott and White EPO/PPO	$5,870.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,453.52
Rate for Payer: Superior Health Plan EPO	$1,596.78

PLATE HUMERUS

Facility

$11,624.00

Service Code	HCPCS C1776
Hospital Charge Code	8514468
Hospital Revenue Code	278
Min. Negotiated Rate	$2,906.00
Max. Negotiated Rate	$5,812.00
Rate for Payer: Cash Price	$7,904.32
Rate for Payer: Cigna Commercial	$2,906.00
Rate for Payer: Multiplan Auto	$5,812.00
Rate for Payer: Multiplan Commercial	$5,812.00
Rate for Payer: Multiplan Workers Comp	$5,812.00
Rate for Payer: Scott and White EPO/PPO	$5,812.00

PLATE HUMERUS

Facility

$11,624.00

Service Code	HCPCS C1776
Hospital Charge Code	8514468
Hospital Revenue Code	278
Min. Negotiated Rate	$1,046.16
Max. Negotiated Rate	$8,369.28
Rate for Payer: Amerigroup CHIP/Medicaid	$1,046.16
Rate for Payer: BCBS of TX Blue Advantage	$3,487.20
Rate for Payer: BCBS of TX Blue Essentials	$4,184.64
Rate for Payer: BCBS of TX PPO	$4,649.60
Rate for Payer: Cash Price	$7,904.32
Rate for Payer: Cigna Medicaid	$8,369.28
Rate for Payer: Molina CHIP/Medicaid	$8,369.28
Rate for Payer: Multiplan Auto	$5,812.00
Rate for Payer: Multiplan Commercial	$5,812.00
Rate for Payer: Multiplan Workers Comp	$5,812.00
Rate for Payer: Parkland Medicaid	$8,369.28
Rate for Payer: Scott and White EPO/PPO	$5,812.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,369.28
Rate for Payer: Superior Health Plan EPO	$1,580.86

PLATE HUMERUS DISTAL LAT 8 HOLE RT

Facility

$19,962.96

Hospital Charge Code	146506
Hospital Revenue Code	274
Min. Negotiated Rate	$1,796.67
Max. Negotiated Rate	$14,373.33
Rate for Payer: Amerigroup CHIP/Medicaid	$1,796.67
Rate for Payer: BCBS of TX Blue Advantage	$5,988.89
Rate for Payer: BCBS of TX Blue Essentials	$7,186.67
Rate for Payer: BCBS of TX PPO	$7,985.18
Rate for Payer: Cash Price	$13,574.81
Rate for Payer: Cigna Medicaid	$14,373.33
Rate for Payer: Molina CHIP/Medicaid	$14,373.33
Rate for Payer: Multiplan Auto	$9,981.48
Rate for Payer: Multiplan Commercial	$9,981.48
Rate for Payer: Multiplan Workers Comp	$9,981.48
Rate for Payer: Parkland Medicaid	$14,373.33
Rate for Payer: Scott and White EPO/PPO	$9,981.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,373.33
Rate for Payer: Superior Health Plan EPO	$2,714.96

PLATE HUMERUS DISTAL LAT 8 HOLE RT

Facility

$19,962.96

Hospital Charge Code	146506
Hospital Revenue Code	274
Min. Negotiated Rate	$4,990.74
Max. Negotiated Rate	$9,981.48
Rate for Payer: Cash Price	$13,574.81
Rate for Payer: Cigna Commercial	$4,990.74
Rate for Payer: Multiplan Auto	$9,981.48
Rate for Payer: Multiplan Commercial	$9,981.48
Rate for Payer: Multiplan Workers Comp	$9,981.48
Rate for Payer: Scott and White EPO/PPO	$9,981.48

PLATE HUMERUS DISTAL MEDIA

Facility

$4,901.00

Service Code	HCPCS C1776
Hospital Charge Code	144824
Hospital Revenue Code	278
Min. Negotiated Rate	$1,225.25
Max. Negotiated Rate	$2,450.50
Rate for Payer: Cash Price	$3,332.68
Rate for Payer: Cigna Commercial	$1,225.25
Rate for Payer: Multiplan Auto	$2,450.50
Rate for Payer: Multiplan Commercial	$2,450.50
Rate for Payer: Multiplan Workers Comp	$2,450.50
Rate for Payer: Scott and White EPO/PPO	$2,450.50

PLATE HUMERUS DISTAL MEDIA

Facility

$4,901.00

Service Code	HCPCS C1776
Hospital Charge Code	144824
Hospital Revenue Code	278
Min. Negotiated Rate	$441.09
Max. Negotiated Rate	$3,528.72
Rate for Payer: Amerigroup CHIP/Medicaid	$441.09
Rate for Payer: BCBS of TX Blue Advantage	$1,470.30
Rate for Payer: BCBS of TX Blue Essentials	$1,764.36
Rate for Payer: BCBS of TX PPO	$1,960.40
Rate for Payer: Cash Price	$3,332.68
Rate for Payer: Cigna Medicaid	$3,528.72
Rate for Payer: Molina CHIP/Medicaid	$3,528.72
Rate for Payer: Multiplan Auto	$2,450.50
Rate for Payer: Multiplan Commercial	$2,450.50
Rate for Payer: Multiplan Workers Comp	$2,450.50
Rate for Payer: Parkland Medicaid	$3,528.72
Rate for Payer: Scott and White EPO/PPO	$2,450.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,528.72
Rate for Payer: Superior Health Plan EPO	$666.54

PLATE HUMERUS PROX

Facility

$13,413.00

Service Code	HCPCS C1776
Hospital Charge Code	8528469
Hospital Revenue Code	278
Min. Negotiated Rate	$1,207.17
Max. Negotiated Rate	$9,657.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,207.17
Rate for Payer: BCBS of TX Blue Advantage	$4,023.90
Rate for Payer: BCBS of TX Blue Essentials	$4,828.68
Rate for Payer: BCBS of TX PPO	$5,365.20
Rate for Payer: Cash Price	$9,120.84
Rate for Payer: Cigna Medicaid	$9,657.36
Rate for Payer: Molina CHIP/Medicaid	$9,657.36
Rate for Payer: Multiplan Auto	$6,706.50
Rate for Payer: Multiplan Commercial	$6,706.50
Rate for Payer: Multiplan Workers Comp	$6,706.50
Rate for Payer: Parkland Medicaid	$9,657.36
Rate for Payer: Scott and White EPO/PPO	$6,706.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,657.36
Rate for Payer: Superior Health Plan EPO	$1,824.17

PLATE HUMERUS PROX

Facility

$13,413.00

Service Code	HCPCS C1776
Hospital Charge Code	8528469
Hospital Revenue Code	278
Min. Negotiated Rate	$3,353.25
Max. Negotiated Rate	$6,706.50
Rate for Payer: Cash Price	$9,120.84
Rate for Payer: Cigna Commercial	$3,353.25
Rate for Payer: Multiplan Auto	$6,706.50
Rate for Payer: Multiplan Commercial	$6,706.50
Rate for Payer: Multiplan Workers Comp	$6,706.50
Rate for Payer: Scott and White EPO/PPO	$6,706.50

PLATE KIT

Facility

$10,560.04

Service Code	HCPCS C1734
Hospital Charge Code	994122
Hospital Revenue Code	278
Min. Negotiated Rate	$2,640.01
Max. Negotiated Rate	$5,280.02
Rate for Payer: Cash Price	$7,180.83
Rate for Payer: Cigna Commercial	$2,640.01
Rate for Payer: Multiplan Auto	$5,280.02
Rate for Payer: Multiplan Commercial	$5,280.02
Rate for Payer: Multiplan Workers Comp	$5,280.02
Rate for Payer: Scott and White EPO/PPO	$5,280.02

PLATE KIT

Facility

$10,560.04

Service Code	HCPCS C1734
Hospital Charge Code	994122
Hospital Revenue Code	278
Min. Negotiated Rate	$950.40
Max. Negotiated Rate	$7,603.23
Rate for Payer: Amerigroup CHIP/Medicaid	$950.40
Rate for Payer: BCBS of TX Blue Advantage	$3,168.01
Rate for Payer: BCBS of TX Blue Essentials	$3,801.61
Rate for Payer: BCBS of TX PPO	$4,224.02
Rate for Payer: Cash Price	$7,180.83
Rate for Payer: Cigna Medicaid	$7,603.23
Rate for Payer: Molina CHIP/Medicaid	$7,603.23
Rate for Payer: Multiplan Auto	$5,280.02
Rate for Payer: Multiplan Commercial	$5,280.02
Rate for Payer: Multiplan Workers Comp	$5,280.02
Rate for Payer: Parkland Medicaid	$7,603.23
Rate for Payer: Scott and White EPO/PPO	$5,280.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,603.23
Rate for Payer: Superior Health Plan EPO	$1,436.17

PLATE LAPIDUS 3 HOLE STANDARD COMPRESSION

Facility

$9,074.00

Service Code	HCPCS C1776
Hospital Charge Code	146413
Hospital Revenue Code	278
Min. Negotiated Rate	$2,268.50
Max. Negotiated Rate	$4,537.00
Rate for Payer: Cash Price	$6,170.32
Rate for Payer: Cigna Commercial	$2,268.50
Rate for Payer: Multiplan Auto	$4,537.00
Rate for Payer: Multiplan Commercial	$4,537.00
Rate for Payer: Multiplan Workers Comp	$4,537.00
Rate for Payer: Scott and White EPO/PPO	$4,537.00

PLATE LAPIDUS 3 HOLE STANDARD COMPRESSION

Facility

$9,074.00

Service Code	HCPCS C1776
Hospital Charge Code	146413
Hospital Revenue Code	278
Min. Negotiated Rate	$816.66
Max. Negotiated Rate	$6,533.28
Rate for Payer: Amerigroup CHIP/Medicaid	$816.66
Rate for Payer: BCBS of TX Blue Advantage	$2,722.20
Rate for Payer: BCBS of TX Blue Essentials	$3,266.64
Rate for Payer: BCBS of TX PPO	$3,629.60
Rate for Payer: Cash Price	$6,170.32
Rate for Payer: Cigna Medicaid	$6,533.28
Rate for Payer: Molina CHIP/Medicaid	$6,533.28
Rate for Payer: Multiplan Auto	$4,537.00
Rate for Payer: Multiplan Commercial	$4,537.00
Rate for Payer: Multiplan Workers Comp	$4,537.00
Rate for Payer: Parkland Medicaid	$6,533.28
Rate for Payer: Scott and White EPO/PPO	$4,537.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,533.28
Rate for Payer: Superior Health Plan EPO	$1,234.06

Platelet Antibody Profile SO

Facility

$527.00

Service Code	HCPCS 86022
Hospital Charge Code	1701010
Hospital Revenue Code	302
Min. Negotiated Rate	$7.16
Max. Negotiated Rate	$379.44
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	$158.10
Rate for Payer: BCBS of TX Blue Essentials	$189.72
Rate for Payer: BCBS of TX Medicare	$18.37
Rate for Payer: BCBS of TX PPO	$210.80
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cash Price	$358.36
Rate for Payer: Cigna Medicaid	$379.44
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	$379.44
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	$379.44
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	$379.44
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 Antibody Profile SO

Facility

$527.00

Service Code	HCPCS 86022
Hospital Charge Code	1701010
Hospital Revenue Code	302
Rate for Payer: Cash Price	$358.36

Platelet Count

Facility

$177.00

Service Code	HCPCS 85049
Hospital Charge Code	1611870
Hospital Revenue Code	305
Rate for Payer: Cash Price	$120.36

Platelet Count

Facility

$177.00

Service Code	HCPCS 85049
Hospital Charge Code	1611870
Hospital Revenue Code	305
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$127.44
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	$53.10
Rate for Payer: BCBS of TX Blue Essentials	$63.72
Rate for Payer: BCBS of TX Medicare	$4.48
Rate for Payer: BCBS of TX PPO	$70.80
Rate for Payer: Cash Price	$120.36
Rate for Payer: Cash Price	$120.36
Rate for Payer: Cigna Medicaid	$127.44
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	$127.44
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	$127.44
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	$127.44
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

Platelets, each unit

Facility

$303.84

Service Code	HCPCS P9019
Hospital Charge Code	994079
Hospital Revenue Code	391
Rate for Payer: Cash Price	$206.61

Platelets, each unit

Facility

$303.84

Service Code	HCPCS P9019
Hospital Charge Code	994079
Hospital Revenue Code	391
Min. Negotiated Rate	$27.35
Max. Negotiated Rate	$218.76
Rate for Payer: Amerigroup CHIP/Medicaid	$27.35
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$52.28
Rate for Payer: Amerigroup Medicare	$52.28
Rate for Payer: BCBS of TX Blue Advantage	$91.15
Rate for Payer: BCBS of TX Blue Essentials	$109.38
Rate for Payer: BCBS of TX Medicare	$52.28
Rate for Payer: BCBS of TX PPO	$121.54
Rate for Payer: Cash Price	$206.61
Rate for Payer: Cash Price	$206.61
Rate for Payer: Cash Price	$206.61
Rate for Payer: Cigna Commercial	$110.50
Rate for Payer: Cigna Medicaid	$218.76
Rate for Payer: Cigna Medicare	$52.28
Rate for Payer: Employer Direct Commercial	$52.28
Rate for Payer: Humana Medicare/TRICARE	$52.28
Rate for Payer: Molina CHIP/Medicaid	$218.76
Rate for Payer: Molina Dual Medicare/Medicaid	$52.28
Rate for Payer: Molina Medicare	$52.28
Rate for Payer: Multiplan Auto	$197.50
Rate for Payer: Multiplan Commercial	$197.50
Rate for Payer: Multiplan Workers Comp	$197.50
Rate for Payer: Parkland Medicaid	$218.76
Rate for Payer: Scott and White EPO/PPO	$151.92
Rate for Payer: Scott and White Medicare	$52.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$218.76
Rate for Payer: Superior Health Plan EPO	$52.28
Rate for Payer: Superior Health Plan Medicare	$52.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$52.28
Rate for Payer: Universal American Medicare	$52.28
Rate for Payer: Wellcare Medicare	$52.28
Rate for Payer: Wellmed Medicare	$52.28

PLATE LEVEL 1

Facility

$12,048.00

Service Code	HCPCS C1776
Hospital Charge Code	8428494
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 LEVEL 1

Facility

$12,048.00

Service Code	HCPCS C1776
Hospital Charge Code	8428494
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 LEVEL 2

Facility

$14,458.00

Service Code	HCPCS C1776
Hospital Charge Code	8430486
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

Know your out-of-pocket cost for care.

All Charges