White Rock Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LEVEL 2

Facility

$14,458.00

Service Code	HCPCS C1776
Hospital Charge Code	8430486
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 LEVEL 3 #2

Facility

$7,289.00

Service Code	HCPCS C1776
Hospital Charge Code	8492479
Hospital Revenue Code	278
Min. Negotiated Rate	$1,822.25
Max. Negotiated Rate	$3,644.50
Rate for Payer: Cash Price	$4,956.52
Rate for Payer: Cigna Commercial	$1,822.25
Rate for Payer: Multiplan Auto	$3,644.50
Rate for Payer: Multiplan Commercial	$3,644.50
Rate for Payer: Multiplan Workers Comp	$3,644.50
Rate for Payer: Scott and White EPO/PPO	$3,644.50

PLATE LEVEL 3 #2

Facility

$7,289.00

Service Code	HCPCS C1776
Hospital Charge Code	8492479
Hospital Revenue Code	278
Min. Negotiated Rate	$656.01
Max. Negotiated Rate	$5,248.08
Rate for Payer: Amerigroup CHIP/Medicaid	$656.01
Rate for Payer: BCBS of TX Blue Advantage	$2,186.70
Rate for Payer: BCBS of TX Blue Essentials	$2,624.04
Rate for Payer: BCBS of TX PPO	$2,915.60
Rate for Payer: Cash Price	$4,956.52
Rate for Payer: Cigna Medicaid	$5,248.08
Rate for Payer: Molina CHIP/Medicaid	$5,248.08
Rate for Payer: Multiplan Auto	$3,644.50
Rate for Payer: Multiplan Commercial	$3,644.50
Rate for Payer: Multiplan Workers Comp	$3,644.50
Rate for Payer: Parkland Medicaid	$5,248.08
Rate for Payer: Scott and White EPO/PPO	$3,644.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,248.08
Rate for Payer: Superior Health Plan EPO	$991.30

PLATE LEVEL 4 ACP

Facility

$19,277.00

Service Code	HCPCS C1776
Hospital Charge Code	8492478
Hospital Revenue Code	278
Min. Negotiated Rate	$4,819.25
Max. Negotiated Rate	$9,638.50
Rate for Payer: Cash Price	$13,108.36
Rate for Payer: Cigna Commercial	$4,819.25
Rate for Payer: Multiplan Auto	$9,638.50
Rate for Payer: Multiplan Commercial	$9,638.50
Rate for Payer: Multiplan Workers Comp	$9,638.50
Rate for Payer: Scott and White EPO/PPO	$9,638.50

PLATE LEVEL 4 ACP

Facility

$19,277.00

Service Code	HCPCS C1776
Hospital Charge Code	8492478
Hospital Revenue Code	278
Min. Negotiated Rate	$1,734.93
Max. Negotiated Rate	$13,879.44
Rate for Payer: Amerigroup CHIP/Medicaid	$1,734.93
Rate for Payer: BCBS of TX Blue Advantage	$5,783.10
Rate for Payer: BCBS of TX Blue Essentials	$6,939.72
Rate for Payer: BCBS of TX PPO	$7,710.80
Rate for Payer: Cash Price	$13,108.36
Rate for Payer: Cigna Medicaid	$13,879.44
Rate for Payer: Molina CHIP/Medicaid	$13,879.44
Rate for Payer: Multiplan Auto	$9,638.50
Rate for Payer: Multiplan Commercial	$9,638.50
Rate for Payer: Multiplan Workers Comp	$9,638.50
Rate for Payer: Parkland Medicaid	$13,879.44
Rate for Payer: Scott and White EPO/PPO	$9,638.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,879.44
Rate for Payer: Superior Health Plan EPO	$2,621.67

PLATE LOCK COMP NARROW 12 HOLE

Facility

$15,101.00

Service Code	HCPCS C1776
Hospital Charge Code	8406479
Hospital Revenue Code	278
Min. Negotiated Rate	$1,359.09
Max. Negotiated Rate	$10,872.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,359.09
Rate for Payer: BCBS of TX Blue Advantage	$4,530.30
Rate for Payer: BCBS of TX Blue Essentials	$5,436.36
Rate for Payer: BCBS of TX PPO	$6,040.40
Rate for Payer: Cash Price	$10,268.68
Rate for Payer: Cigna Medicaid	$10,872.72
Rate for Payer: Molina CHIP/Medicaid	$10,872.72
Rate for Payer: Multiplan Auto	$7,550.50
Rate for Payer: Multiplan Commercial	$7,550.50
Rate for Payer: Multiplan Workers Comp	$7,550.50
Rate for Payer: Parkland Medicaid	$10,872.72
Rate for Payer: Scott and White EPO/PPO	$7,550.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,872.72
Rate for Payer: Superior Health Plan EPO	$2,053.74

PLATE LOCK COMP NARROW 12 HOLE

Facility

$15,101.00

Service Code	HCPCS C1776
Hospital Charge Code	8406479
Hospital Revenue Code	278
Min. Negotiated Rate	$3,775.25
Max. Negotiated Rate	$7,550.50
Rate for Payer: Cash Price	$10,268.68
Rate for Payer: Cigna Commercial	$3,775.25
Rate for Payer: Multiplan Auto	$7,550.50
Rate for Payer: Multiplan Commercial	$7,550.50
Rate for Payer: Multiplan Workers Comp	$7,550.50
Rate for Payer: Scott and White EPO/PPO	$7,550.50

PLATE LOCKING 9 HOLE

Facility

$6,018.00

Service Code	HCPCS C1776
Hospital Charge Code	145259
Hospital Revenue Code	278
Min. Negotiated Rate	$541.62
Max. Negotiated Rate	$4,332.96
Rate for Payer: Amerigroup CHIP/Medicaid	$541.62
Rate for Payer: BCBS of TX Blue Advantage	$1,805.40
Rate for Payer: BCBS of TX Blue Essentials	$2,166.48
Rate for Payer: BCBS of TX PPO	$2,407.20
Rate for Payer: Cash Price	$4,092.24
Rate for Payer: Cigna Medicaid	$4,332.96
Rate for Payer: Molina CHIP/Medicaid	$4,332.96
Rate for Payer: Multiplan Auto	$3,009.00
Rate for Payer: Multiplan Commercial	$3,009.00
Rate for Payer: Multiplan Workers Comp	$3,009.00
Rate for Payer: Parkland Medicaid	$4,332.96
Rate for Payer: Scott and White EPO/PPO	$3,009.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,332.96
Rate for Payer: Superior Health Plan EPO	$818.45

PLATE LOCKING 9 HOLE

Facility

$6,018.00

Service Code	HCPCS C1776
Hospital Charge Code	145259
Hospital Revenue Code	278
Min. Negotiated Rate	$1,504.50
Max. Negotiated Rate	$3,009.00
Rate for Payer: Cash Price	$4,092.24
Rate for Payer: Cigna Commercial	$1,504.50
Rate for Payer: Multiplan Auto	$3,009.00
Rate for Payer: Multiplan Commercial	$3,009.00
Rate for Payer: Multiplan Workers Comp	$3,009.00
Rate for Payer: Scott and White EPO/PPO	$3,009.00

PLATE LUMBAR 15MM

Facility

$9,036.00

Service Code	HCPCS C1776
Hospital Charge Code	8428498
Hospital Revenue Code	278
Min. Negotiated Rate	$813.24
Max. Negotiated Rate	$6,505.92
Rate for Payer: Amerigroup CHIP/Medicaid	$813.24
Rate for Payer: BCBS of TX Blue Advantage	$2,710.80
Rate for Payer: BCBS of TX Blue Essentials	$3,252.96
Rate for Payer: BCBS of TX PPO	$3,614.40
Rate for Payer: Cash Price	$6,144.48
Rate for Payer: Cigna Medicaid	$6,505.92
Rate for Payer: Molina CHIP/Medicaid	$6,505.92
Rate for Payer: Multiplan Auto	$4,518.00
Rate for Payer: Multiplan Commercial	$4,518.00
Rate for Payer: Multiplan Workers Comp	$4,518.00
Rate for Payer: Parkland Medicaid	$6,505.92
Rate for Payer: Scott and White EPO/PPO	$4,518.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,505.92
Rate for Payer: Superior Health Plan EPO	$1,228.90

PLATE LUMBAR 15MM

Facility

$9,036.00

Service Code	HCPCS C1776
Hospital Charge Code	8428498
Hospital Revenue Code	278
Min. Negotiated Rate	$2,259.00
Max. Negotiated Rate	$4,518.00
Rate for Payer: Cash Price	$6,144.48
Rate for Payer: Cigna Commercial	$2,259.00
Rate for Payer: Multiplan Auto	$4,518.00
Rate for Payer: Multiplan Commercial	$4,518.00
Rate for Payer: Multiplan Workers Comp	$4,518.00
Rate for Payer: Scott and White EPO/PPO	$4,518.00

PLATE NAVICULAR LOCKING RIGHT

Facility

$8,813.00

Service Code	HCPCS C1776
Hospital Charge Code	146437
Hospital Revenue Code	278
Min. Negotiated Rate	$793.17
Max. Negotiated Rate	$6,345.36
Rate for Payer: Amerigroup CHIP/Medicaid	$793.17
Rate for Payer: BCBS of TX Blue Advantage	$2,643.90
Rate for Payer: BCBS of TX Blue Essentials	$3,172.68
Rate for Payer: BCBS of TX PPO	$3,525.20
Rate for Payer: Cash Price	$5,992.84
Rate for Payer: Cigna Medicaid	$6,345.36
Rate for Payer: Molina CHIP/Medicaid	$6,345.36
Rate for Payer: Multiplan Auto	$4,406.50
Rate for Payer: Multiplan Commercial	$4,406.50
Rate for Payer: Multiplan Workers Comp	$4,406.50
Rate for Payer: Parkland Medicaid	$6,345.36
Rate for Payer: Scott and White EPO/PPO	$4,406.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,345.36
Rate for Payer: Superior Health Plan EPO	$1,198.57

PLATE NAVICULAR LOCKING RIGHT

Facility

$8,813.00

Service Code	HCPCS C1776
Hospital Charge Code	146437
Hospital Revenue Code	278
Min. Negotiated Rate	$2,203.25
Max. Negotiated Rate	$4,406.50
Rate for Payer: Cash Price	$5,992.84
Rate for Payer: Cigna Commercial	$2,203.25
Rate for Payer: Multiplan Auto	$4,406.50
Rate for Payer: Multiplan Commercial	$4,406.50
Rate for Payer: Multiplan Workers Comp	$4,406.50
Rate for Payer: Scott and White EPO/PPO	$4,406.50

PLATE OCLECRANON

Facility

$5,404.00

Service Code	HCPCS C1776
Hospital Charge Code	140788
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.00
Max. Negotiated Rate	$2,702.00
Rate for Payer: Cash Price	$3,674.72
Rate for Payer: Cigna Commercial	$1,351.00
Rate for Payer: Multiplan Auto	$2,702.00
Rate for Payer: Multiplan Commercial	$2,702.00
Rate for Payer: Multiplan Workers Comp	$2,702.00
Rate for Payer: Scott and White EPO/PPO	$2,702.00

PLATE OCLECRANON

Facility

$5,404.00

Service Code	HCPCS C1776
Hospital Charge Code	140788
Hospital Revenue Code	278
Min. Negotiated Rate	$486.36
Max. Negotiated Rate	$3,890.88
Rate for Payer: Amerigroup CHIP/Medicaid	$486.36
Rate for Payer: BCBS of TX Blue Advantage	$1,621.20
Rate for Payer: BCBS of TX Blue Essentials	$1,945.44
Rate for Payer: BCBS of TX PPO	$2,161.60
Rate for Payer: Cash Price	$3,674.72
Rate for Payer: Cigna Medicaid	$3,890.88
Rate for Payer: Molina CHIP/Medicaid	$3,890.88
Rate for Payer: Multiplan Auto	$2,702.00
Rate for Payer: Multiplan Commercial	$2,702.00
Rate for Payer: Multiplan Workers Comp	$2,702.00
Rate for Payer: Parkland Medicaid	$3,890.88
Rate for Payer: Scott and White EPO/PPO	$2,702.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,890.88
Rate for Payer: Superior Health Plan EPO	$734.94

PLATE OTHER -- DHF

Facility

$1,128.00

Service Code	HCPCS C1776
Hospital Charge Code	81338436
Hospital Revenue Code	278
Min. Negotiated Rate	$101.52
Max. Negotiated Rate	$812.16
Rate for Payer: Amerigroup CHIP/Medicaid	$101.52
Rate for Payer: BCBS of TX Blue Advantage	$338.40
Rate for Payer: BCBS of TX Blue Essentials	$406.08
Rate for Payer: BCBS of TX PPO	$451.20
Rate for Payer: Cash Price	$767.04
Rate for Payer: Cigna Medicaid	$812.16
Rate for Payer: Molina CHIP/Medicaid	$812.16
Rate for Payer: Multiplan Auto	$564.00
Rate for Payer: Multiplan Commercial	$564.00
Rate for Payer: Multiplan Workers Comp	$564.00
Rate for Payer: Parkland Medicaid	$812.16
Rate for Payer: Scott and White EPO/PPO	$564.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$812.16
Rate for Payer: Superior Health Plan EPO	$153.41

PLATE OTHER -- DHF

Facility

$1,128.00

Service Code	HCPCS C1776
Hospital Charge Code	81338436
Hospital Revenue Code	278
Min. Negotiated Rate	$282.00
Max. Negotiated Rate	$564.00
Rate for Payer: Cash Price	$767.04
Rate for Payer: Cigna Commercial	$282.00
Rate for Payer: Multiplan Auto	$564.00
Rate for Payer: Multiplan Commercial	$564.00
Rate for Payer: Multiplan Workers Comp	$564.00
Rate for Payer: Scott and White EPO/PPO	$564.00

PLATE PROC LAT HUM 3HL RIGHT

Facility

$11,624.00

Service Code	HCPCS C1776
Hospital Charge Code	8394476
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 PROC LAT HUM 3HL RIGHT

Facility

$11,624.00

Service Code	HCPCS C1776
Hospital Charge Code	8394476
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 STD VERSA-FX 3 HOLE

Facility

$3,090.00

Service Code	HCPCS C1776
Hospital Charge Code	146538
Hospital Revenue Code	278
Min. Negotiated Rate	$278.10
Max. Negotiated Rate	$2,224.80
Rate for Payer: Amerigroup CHIP/Medicaid	$278.10
Rate for Payer: BCBS of TX Blue Advantage	$927.00
Rate for Payer: BCBS of TX Blue Essentials	$1,112.40
Rate for Payer: BCBS of TX PPO	$1,236.00
Rate for Payer: Cash Price	$2,101.20
Rate for Payer: Cigna Medicaid	$2,224.80
Rate for Payer: Molina CHIP/Medicaid	$2,224.80
Rate for Payer: Multiplan Auto	$1,545.00
Rate for Payer: Multiplan Commercial	$1,545.00
Rate for Payer: Multiplan Workers Comp	$1,545.00
Rate for Payer: Parkland Medicaid	$2,224.80
Rate for Payer: Scott and White EPO/PPO	$1,545.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,224.80
Rate for Payer: Superior Health Plan EPO	$420.24

PLATE STD VERSA-FX 3 HOLE

Facility

$3,090.00

Service Code	HCPCS C1776
Hospital Charge Code	146538
Hospital Revenue Code	278
Min. Negotiated Rate	$772.50
Max. Negotiated Rate	$1,545.00
Rate for Payer: Cash Price	$2,101.20
Rate for Payer: Cigna Commercial	$772.50
Rate for Payer: Multiplan Auto	$1,545.00
Rate for Payer: Multiplan Commercial	$1,545.00
Rate for Payer: Multiplan Workers Comp	$1,545.00
Rate for Payer: Scott and White EPO/PPO	$1,545.00

plate super lateral 4 hole

Facility

$5,916.00

Service Code	HCPCS C1776
Hospital Charge Code	144883
Hospital Revenue Code	278
Min. Negotiated Rate	$532.44
Max. Negotiated Rate	$4,259.52
Rate for Payer: Amerigroup CHIP/Medicaid	$532.44
Rate for Payer: BCBS of TX Blue Advantage	$1,774.80
Rate for Payer: BCBS of TX Blue Essentials	$2,129.76
Rate for Payer: BCBS of TX PPO	$2,366.40
Rate for Payer: Cash Price	$4,022.88
Rate for Payer: Cigna Medicaid	$4,259.52
Rate for Payer: Molina CHIP/Medicaid	$4,259.52
Rate for Payer: Multiplan Auto	$2,958.00
Rate for Payer: Multiplan Commercial	$2,958.00
Rate for Payer: Multiplan Workers Comp	$2,958.00
Rate for Payer: Parkland Medicaid	$4,259.52
Rate for Payer: Scott and White EPO/PPO	$2,958.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,259.52
Rate for Payer: Superior Health Plan EPO	$804.58

plate super lateral 4 hole

Facility

$5,916.00

Service Code	HCPCS C1776
Hospital Charge Code	144883
Hospital Revenue Code	278
Min. Negotiated Rate	$1,479.00
Max. Negotiated Rate	$2,958.00
Rate for Payer: Cash Price	$4,022.88
Rate for Payer: Cigna Commercial	$1,479.00
Rate for Payer: Multiplan Auto	$2,958.00
Rate for Payer: Multiplan Commercial	$2,958.00
Rate for Payer: Multiplan Workers Comp	$2,958.00
Rate for Payer: Scott and White EPO/PPO	$2,958.00

PLATE TIBIAL RIGHT

Facility

$11,050.00

Service Code	HCPCS C1776
Hospital Charge Code	145071
Hospital Revenue Code	278
Min. Negotiated Rate	$2,762.50
Max. Negotiated Rate	$5,525.00
Rate for Payer: Cash Price	$7,514.00
Rate for Payer: Cigna Commercial	$2,762.50
Rate for Payer: Multiplan Auto	$5,525.00
Rate for Payer: Multiplan Commercial	$5,525.00
Rate for Payer: Multiplan Workers Comp	$5,525.00
Rate for Payer: Scott and White EPO/PPO	$5,525.00

PLATE TIBIAL RIGHT

Facility

$11,050.00

Service Code	HCPCS C1776
Hospital Charge Code	145071
Hospital Revenue Code	278
Min. Negotiated Rate	$994.50
Max. Negotiated Rate	$7,956.00
Rate for Payer: Amerigroup CHIP/Medicaid	$994.50
Rate for Payer: BCBS of TX Blue Advantage	$3,315.00
Rate for Payer: BCBS of TX Blue Essentials	$3,978.00
Rate for Payer: BCBS of TX PPO	$4,420.00
Rate for Payer: Cash Price	$7,514.00
Rate for Payer: Cigna Medicaid	$7,956.00
Rate for Payer: Molina CHIP/Medicaid	$7,956.00
Rate for Payer: Multiplan Auto	$5,525.00
Rate for Payer: Multiplan Commercial	$5,525.00
Rate for Payer: Multiplan Workers Comp	$5,525.00
Rate for Payer: Parkland Medicaid	$7,956.00
Rate for Payer: Scott and White EPO/PPO	$5,525.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,956.00
Rate for Payer: Superior Health Plan EPO	$1,502.80

Know your out-of-pocket cost for care.

All Charges