White Rock Medical Center

All Charges

Charge

Type

Setting

Price

4.5mm x 27.5mm Screw, Fully Threaded

Facility

$2,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992188
Hospital Revenue Code	278
Min. Negotiated Rate	$198.43
Max. Negotiated Rate	$1,587.47
Rate for Payer: Amerigroup CHIP/Medicaid	$198.43
Rate for Payer: BCBS of TX Blue Advantage	$661.45
Rate for Payer: BCBS of TX Blue Essentials	$793.74
Rate for Payer: BCBS of TX PPO	$881.93
Rate for Payer: Cash Price	$1,499.28
Rate for Payer: Cigna Medicaid	$1,587.47
Rate for Payer: Molina CHIP/Medicaid	$1,587.47
Rate for Payer: Multiplan Auto	$1,102.41
Rate for Payer: Multiplan Commercial	$1,102.41
Rate for Payer: Multiplan Workers Comp	$1,102.41
Rate for Payer: Parkland Medicaid	$1,587.47
Rate for Payer: Scott and White EPO/PPO	$1,102.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,587.47
Rate for Payer: Superior Health Plan EPO	$299.86

4.5mm x 27.5mm Screw, Fully Threaded

Facility

$2,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992188
Hospital Revenue Code	278
Min. Negotiated Rate	$551.21
Max. Negotiated Rate	$1,102.41
Rate for Payer: Cash Price	$1,499.28
Rate for Payer: Cigna Commercial	$551.21
Rate for Payer: Multiplan Auto	$1,102.41
Rate for Payer: Multiplan Commercial	$1,102.41
Rate for Payer: Multiplan Workers Comp	$1,102.41
Rate for Payer: Scott and White EPO/PPO	$1,102.41

4.5mm x 30mm Screw, Fully Threaded

Facility

$2,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992187
Hospital Revenue Code	278
Min. Negotiated Rate	$198.43
Max. Negotiated Rate	$1,587.47
Rate for Payer: Amerigroup CHIP/Medicaid	$198.43
Rate for Payer: BCBS of TX Blue Advantage	$661.45
Rate for Payer: BCBS of TX Blue Essentials	$793.74
Rate for Payer: BCBS of TX PPO	$881.93
Rate for Payer: Cash Price	$1,499.28
Rate for Payer: Cigna Medicaid	$1,587.47
Rate for Payer: Molina CHIP/Medicaid	$1,587.47
Rate for Payer: Multiplan Auto	$1,102.41
Rate for Payer: Multiplan Commercial	$1,102.41
Rate for Payer: Multiplan Workers Comp	$1,102.41
Rate for Payer: Parkland Medicaid	$1,587.47
Rate for Payer: Scott and White EPO/PPO	$1,102.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,587.47
Rate for Payer: Superior Health Plan EPO	$299.86

4.5mm x 30mm Screw, Fully Threaded

Facility

$2,204.82

Service Code	HCPCS C1713
Hospital Charge Code	992187
Hospital Revenue Code	278
Min. Negotiated Rate	$551.21
Max. Negotiated Rate	$1,102.41
Rate for Payer: Cash Price	$1,499.28
Rate for Payer: Cigna Commercial	$551.21
Rate for Payer: Multiplan Auto	$1,102.41
Rate for Payer: Multiplan Commercial	$1,102.41
Rate for Payer: Multiplan Workers Comp	$1,102.41
Rate for Payer: Scott and White EPO/PPO	$1,102.41

4.5 X 35 SCREW

Facility

$11,371.08

Service Code	HCPCS C1713
Hospital Charge Code	992385
Hospital Revenue Code	278
Min. Negotiated Rate	$1,023.40
Max. Negotiated Rate	$8,187.18
Rate for Payer: Amerigroup CHIP/Medicaid	$1,023.40
Rate for Payer: BCBS of TX Blue Advantage	$3,411.32
Rate for Payer: BCBS of TX Blue Essentials	$4,093.59
Rate for Payer: BCBS of TX PPO	$4,548.43
Rate for Payer: Cash Price	$7,732.33
Rate for Payer: Cigna Medicaid	$8,187.18
Rate for Payer: Molina CHIP/Medicaid	$8,187.18
Rate for Payer: Multiplan Auto	$5,685.54
Rate for Payer: Multiplan Commercial	$5,685.54
Rate for Payer: Multiplan Workers Comp	$5,685.54
Rate for Payer: Parkland Medicaid	$8,187.18
Rate for Payer: Scott and White EPO/PPO	$5,685.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,187.18
Rate for Payer: Superior Health Plan EPO	$1,546.47

4.5 X 35 SCREW

Facility

$11,371.08

Service Code	HCPCS C1713
Hospital Charge Code	992385
Hospital Revenue Code	278
Min. Negotiated Rate	$2,842.77
Max. Negotiated Rate	$5,685.54
Rate for Payer: Cash Price	$7,732.33
Rate for Payer: Cigna Commercial	$2,842.77
Rate for Payer: Multiplan Auto	$5,685.54
Rate for Payer: Multiplan Commercial	$5,685.54
Rate for Payer: Multiplan Workers Comp	$5,685.54
Rate for Payer: Scott and White EPO/PPO	$5,685.54

46S01645

Facility

$18,971.69

Service Code	HCPCS C1734
Hospital Charge Code	991070
Hospital Revenue Code	278
Min. Negotiated Rate	$4,742.92
Max. Negotiated Rate	$9,485.84
Rate for Payer: Cash Price	$12,900.75
Rate for Payer: Cigna Commercial	$4,742.92
Rate for Payer: Multiplan Auto	$9,485.84
Rate for Payer: Multiplan Commercial	$9,485.84
Rate for Payer: Multiplan Workers Comp	$9,485.84
Rate for Payer: Scott and White EPO/PPO	$9,485.84

46S01645

Facility

$18,971.69

Service Code	HCPCS C1776
Hospital Charge Code	991133
Hospital Revenue Code	278
Min. Negotiated Rate	$4,742.92
Max. Negotiated Rate	$9,485.84
Rate for Payer: Cash Price	$12,900.75
Rate for Payer: Cigna Commercial	$4,742.92
Rate for Payer: Multiplan Auto	$9,485.84
Rate for Payer: Multiplan Commercial	$9,485.84
Rate for Payer: Multiplan Workers Comp	$9,485.84
Rate for Payer: Scott and White EPO/PPO	$9,485.84

46S01645

Facility

$18,971.69

Service Code	HCPCS C1776
Hospital Charge Code	991133
Hospital Revenue Code	278
Min. Negotiated Rate	$1,707.45
Max. Negotiated Rate	$13,659.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1,707.45
Rate for Payer: BCBS of TX Blue Advantage	$5,691.51
Rate for Payer: BCBS of TX Blue Essentials	$6,829.81
Rate for Payer: BCBS of TX PPO	$7,588.68
Rate for Payer: Cash Price	$12,900.75
Rate for Payer: Cigna Medicaid	$13,659.62
Rate for Payer: Molina CHIP/Medicaid	$13,659.62
Rate for Payer: Multiplan Auto	$9,485.84
Rate for Payer: Multiplan Commercial	$9,485.84
Rate for Payer: Multiplan Workers Comp	$9,485.84
Rate for Payer: Parkland Medicaid	$13,659.62
Rate for Payer: Scott and White EPO/PPO	$9,485.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,659.62
Rate for Payer: Superior Health Plan EPO	$2,580.15

46S01645

Facility

$18,971.69

Service Code	HCPCS C1734
Hospital Charge Code	991070
Hospital Revenue Code	278
Min. Negotiated Rate	$1,707.45
Max. Negotiated Rate	$13,659.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1,707.45
Rate for Payer: BCBS of TX Blue Advantage	$5,691.51
Rate for Payer: BCBS of TX Blue Essentials	$6,829.81
Rate for Payer: BCBS of TX PPO	$7,588.68
Rate for Payer: Cash Price	$12,900.75
Rate for Payer: Cigna Medicaid	$13,659.62
Rate for Payer: Molina CHIP/Medicaid	$13,659.62
Rate for Payer: Multiplan Auto	$9,485.84
Rate for Payer: Multiplan Commercial	$9,485.84
Rate for Payer: Multiplan Workers Comp	$9,485.84
Rate for Payer: Parkland Medicaid	$13,659.62
Rate for Payer: Scott and White EPO/PPO	$9,485.84
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,659.62
Rate for Payer: Superior Health Plan EPO	$2,580.15

46S02055

Facility

$28,246.99

Service Code	HCPCS C1734
Hospital Charge Code	991196
Hospital Revenue Code	278
Min. Negotiated Rate	$2,542.23
Max. Negotiated Rate	$20,337.83
Rate for Payer: Amerigroup CHIP/Medicaid	$2,542.23
Rate for Payer: BCBS of TX Blue Advantage	$8,474.10
Rate for Payer: BCBS of TX Blue Essentials	$10,168.92
Rate for Payer: BCBS of TX PPO	$11,298.80
Rate for Payer: Cash Price	$19,207.95
Rate for Payer: Cigna Medicaid	$20,337.83
Rate for Payer: Molina CHIP/Medicaid	$20,337.83
Rate for Payer: Multiplan Auto	$14,123.50
Rate for Payer: Multiplan Commercial	$14,123.50
Rate for Payer: Multiplan Workers Comp	$14,123.50
Rate for Payer: Parkland Medicaid	$20,337.83
Rate for Payer: Scott and White EPO/PPO	$14,123.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,337.83
Rate for Payer: Superior Health Plan EPO	$3,841.59

46S02055

Facility

$28,246.99

Service Code	HCPCS C1734
Hospital Charge Code	991196
Hospital Revenue Code	278
Min. Negotiated Rate	$7,061.75
Max. Negotiated Rate	$14,123.50
Rate for Payer: Cash Price	$19,207.95
Rate for Payer: Cigna Commercial	$7,061.75
Rate for Payer: Multiplan Auto	$14,123.50
Rate for Payer: Multiplan Commercial	$14,123.50
Rate for Payer: Multiplan Workers Comp	$14,123.50
Rate for Payer: Scott and White EPO/PPO	$14,123.50

47S01645 BIOFOAM

Facility

$1,500.00

Service Code	HCPCS C1734
Hospital Charge Code	991153
Hospital Revenue Code	278
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$1,080.00
Rate for Payer: Amerigroup CHIP/Medicaid	$135.00
Rate for Payer: BCBS of TX Blue Advantage	$450.00
Rate for Payer: BCBS of TX Blue Essentials	$540.00
Rate for Payer: BCBS of TX PPO	$600.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cigna Medicaid	$1,080.00
Rate for Payer: Molina CHIP/Medicaid	$1,080.00
Rate for Payer: Multiplan Auto	$750.00
Rate for Payer: Multiplan Commercial	$750.00
Rate for Payer: Multiplan Workers Comp	$750.00
Rate for Payer: Parkland Medicaid	$1,080.00
Rate for Payer: Scott and White EPO/PPO	$750.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,080.00
Rate for Payer: Superior Health Plan EPO	$204.00

47S01645 BIOFOAM

Facility

$1,500.00

Service Code	HCPCS C1734
Hospital Charge Code	991153
Hospital Revenue Code	278
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$750.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cigna Commercial	$375.00
Rate for Payer: Multiplan Auto	$750.00
Rate for Payer: Multiplan Commercial	$750.00
Rate for Payer: Multiplan Workers Comp	$750.00
Rate for Payer: Scott and White EPO/PPO	$750.00

4933-1-0014933-1-1004933-1-200

Facility

$584.33

Service Code	HCPCS C1776
Hospital Charge Code	991098
Hospital Revenue Code	278
Min. Negotiated Rate	$52.59
Max. Negotiated Rate	$420.72
Rate for Payer: Amerigroup CHIP/Medicaid	$52.59
Rate for Payer: BCBS of TX Blue Advantage	$175.30
Rate for Payer: BCBS of TX Blue Essentials	$210.36
Rate for Payer: BCBS of TX PPO	$233.73
Rate for Payer: Cash Price	$397.34
Rate for Payer: Cigna Medicaid	$420.72
Rate for Payer: Molina CHIP/Medicaid	$420.72
Rate for Payer: Multiplan Auto	$292.17
Rate for Payer: Multiplan Commercial	$292.17
Rate for Payer: Multiplan Workers Comp	$292.17
Rate for Payer: Parkland Medicaid	$420.72
Rate for Payer: Scott and White EPO/PPO	$292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$420.72
Rate for Payer: Superior Health Plan EPO	$79.47

4933-1-0014933-1-1004933-1-200

Facility

$584.33

Service Code	HCPCS C1776
Hospital Charge Code	991098
Hospital Revenue Code	278
Min. Negotiated Rate	$146.08
Max. Negotiated Rate	$292.17
Rate for Payer: Cash Price	$397.34
Rate for Payer: Cigna Commercial	$146.08
Rate for Payer: Multiplan Auto	$292.17
Rate for Payer: Multiplan Commercial	$292.17
Rate for Payer: Multiplan Workers Comp	$292.17
Rate for Payer: Scott and White EPO/PPO	$292.17

4933-1-520

Facility

$403.61

Service Code	HCPCS C1734
Hospital Charge Code	991100
Hospital Revenue Code	278
Min. Negotiated Rate	$100.90
Max. Negotiated Rate	$201.81
Rate for Payer: Cash Price	$274.45
Rate for Payer: Cigna Commercial	$100.90
Rate for Payer: Multiplan Auto	$201.81
Rate for Payer: Multiplan Commercial	$201.81
Rate for Payer: Multiplan Workers Comp	$201.81
Rate for Payer: Scott and White EPO/PPO	$201.81

4933-1-520

Facility

$403.61

Service Code	HCPCS C1734
Hospital Charge Code	991100
Hospital Revenue Code	278
Min. Negotiated Rate	$36.32
Max. Negotiated Rate	$290.60
Rate for Payer: Amerigroup CHIP/Medicaid	$36.32
Rate for Payer: BCBS of TX Blue Advantage	$121.08
Rate for Payer: BCBS of TX Blue Essentials	$145.30
Rate for Payer: BCBS of TX PPO	$161.44
Rate for Payer: Cash Price	$274.45
Rate for Payer: Cigna Medicaid	$290.60
Rate for Payer: Molina CHIP/Medicaid	$290.60
Rate for Payer: Multiplan Auto	$201.81
Rate for Payer: Multiplan Commercial	$201.81
Rate for Payer: Multiplan Workers Comp	$201.81
Rate for Payer: Parkland Medicaid	$290.60
Rate for Payer: Scott and White EPO/PPO	$201.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$290.60
Rate for Payer: Superior Health Plan EPO	$54.89

4933-1-560

Facility

$512.04

Service Code	HCPCS C1776
Hospital Charge Code	991101
Hospital Revenue Code	278
Min. Negotiated Rate	$128.01
Max. Negotiated Rate	$256.02
Rate for Payer: Cash Price	$348.19
Rate for Payer: Cigna Commercial	$128.01
Rate for Payer: Multiplan Auto	$256.02
Rate for Payer: Multiplan Commercial	$256.02
Rate for Payer: Multiplan Workers Comp	$256.02
Rate for Payer: Scott and White EPO/PPO	$256.02

4933-1-560

Facility

$512.04

Service Code	HCPCS C1776
Hospital Charge Code	991101
Hospital Revenue Code	278
Min. Negotiated Rate	$46.08
Max. Negotiated Rate	$368.67
Rate for Payer: Amerigroup CHIP/Medicaid	$46.08
Rate for Payer: BCBS of TX Blue Advantage	$153.61
Rate for Payer: BCBS of TX Blue Essentials	$184.33
Rate for Payer: BCBS of TX PPO	$204.82
Rate for Payer: Cash Price	$348.19
Rate for Payer: Cigna Medicaid	$368.67
Rate for Payer: Molina CHIP/Medicaid	$368.67
Rate for Payer: Multiplan Auto	$256.02
Rate for Payer: Multiplan Commercial	$256.02
Rate for Payer: Multiplan Workers Comp	$256.02
Rate for Payer: Parkland Medicaid	$368.67
Rate for Payer: Scott and White EPO/PPO	$256.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.67
Rate for Payer: Superior Health Plan EPO	$69.64

4933-1-701

Facility

$162.65

Service Code	HCPCS C1776
Hospital Charge Code	991102
Hospital Revenue Code	278
Min. Negotiated Rate	$14.64
Max. Negotiated Rate	$117.11
Rate for Payer: Amerigroup CHIP/Medicaid	$14.64
Rate for Payer: BCBS of TX Blue Advantage	$48.80
Rate for Payer: BCBS of TX Blue Essentials	$58.55
Rate for Payer: BCBS of TX PPO	$65.06
Rate for Payer: Cash Price	$110.60
Rate for Payer: Cigna Medicaid	$117.11
Rate for Payer: Molina CHIP/Medicaid	$117.11
Rate for Payer: Multiplan Auto	$81.33
Rate for Payer: Multiplan Commercial	$81.33
Rate for Payer: Multiplan Workers Comp	$81.33
Rate for Payer: Parkland Medicaid	$117.11
Rate for Payer: Scott and White EPO/PPO	$81.33
Rate for Payer: Superior Health Plan CHIP/Medicaid	$117.11
Rate for Payer: Superior Health Plan EPO	$22.12

4933-1-701

Facility

$162.65

Service Code	HCPCS C1776
Hospital Charge Code	991102
Hospital Revenue Code	278
Min. Negotiated Rate	$40.66
Max. Negotiated Rate	$81.33
Rate for Payer: Cash Price	$110.60
Rate for Payer: Cigna Commercial	$40.66
Rate for Payer: Multiplan Auto	$81.33
Rate for Payer: Multiplan Commercial	$81.33
Rate for Payer: Multiplan Workers Comp	$81.33
Rate for Payer: Scott and White EPO/PPO	$81.33

4933-2-1554933-3-155

Facility

$12,132.53

Service Code	HCPCS C1776
Hospital Charge Code	991103
Hospital Revenue Code	278
Min. Negotiated Rate	$3,033.13
Max. Negotiated Rate	$6,066.27
Rate for Payer: Cash Price	$8,250.12
Rate for Payer: Cigna Commercial	$3,033.13
Rate for Payer: Multiplan Auto	$6,066.27
Rate for Payer: Multiplan Commercial	$6,066.27
Rate for Payer: Multiplan Workers Comp	$6,066.27
Rate for Payer: Scott and White EPO/PPO	$6,066.27

4933-2-1554933-3-155

Facility

$12,132.53

Service Code	HCPCS C1776
Hospital Charge Code	991103
Hospital Revenue Code	278
Min. Negotiated Rate	$1,091.93
Max. Negotiated Rate	$8,735.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1,091.93
Rate for Payer: BCBS of TX Blue Advantage	$3,639.76
Rate for Payer: BCBS of TX Blue Essentials	$4,367.71
Rate for Payer: BCBS of TX PPO	$4,853.01
Rate for Payer: Cash Price	$8,250.12
Rate for Payer: Cigna Medicaid	$8,735.42
Rate for Payer: Molina CHIP/Medicaid	$8,735.42
Rate for Payer: Multiplan Auto	$6,066.27
Rate for Payer: Multiplan Commercial	$6,066.27
Rate for Payer: Multiplan Workers Comp	$6,066.27
Rate for Payer: Parkland Medicaid	$8,735.42
Rate for Payer: Scott and White EPO/PPO	$6,066.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,735.42
Rate for Payer: Superior Health Plan EPO	$1,650.02

4933-8-0104933-8-030

Facility

$1,686.75

Service Code	HCPCS C1734
Hospital Charge Code	991104
Hospital Revenue Code	278
Min. Negotiated Rate	$151.81
Max. Negotiated Rate	$1,214.46
Rate for Payer: Amerigroup CHIP/Medicaid	$151.81
Rate for Payer: BCBS of TX Blue Advantage	$506.02
Rate for Payer: BCBS of TX Blue Essentials	$607.23
Rate for Payer: BCBS of TX PPO	$674.70
Rate for Payer: Cash Price	$1,146.99
Rate for Payer: Cigna Medicaid	$1,214.46
Rate for Payer: Molina CHIP/Medicaid	$1,214.46
Rate for Payer: Multiplan Auto	$843.38
Rate for Payer: Multiplan Commercial	$843.38
Rate for Payer: Multiplan Workers Comp	$843.38
Rate for Payer: Parkland Medicaid	$1,214.46
Rate for Payer: Scott and White EPO/PPO	$843.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,214.46
Rate for Payer: Superior Health Plan EPO	$229.40

Know your out-of-pocket cost for care.

All Charges