White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DARCO 7.0 HEADLESS SCREW 32X110 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992270
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DARCO 7.0 HEADLESS SCREW 32X110 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992270
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

DARCO 7.0 HEADLESS SCREW 32X75 DARGO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992304
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DARCO 7.0 HEADLESS SCREW 32X75 DARGO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992304
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

DARCO 7.0 HEADLESS SCREW 32X80 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992388
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DARCO 7.0 HEADLESS SCREW 32X80 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992388
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

DARCO 7.0 HEADLESS SCREW 32 X 85 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	993147
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

DARCO 7.0 HEADLESS SCREW 32 X 85 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	993147
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DARCO 7.0 HEADLESS SCREW 32X85 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992376
Hospital Revenue Code	278
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$3,573.54
Rate for Payer: Amerigroup CHIP/Medicaid	$446.69
Rate for Payer: BCBS of TX Blue Advantage	$1,488.97
Rate for Payer: BCBS of TX Blue Essentials	$1,786.77
Rate for Payer: BCBS of TX PPO	$1,985.30
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Medicaid	$3,573.54
Rate for Payer: Molina CHIP/Medicaid	$3,573.54
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Parkland Medicaid	$3,573.54
Rate for Payer: Scott and White EPO/PPO	$2,481.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,573.54
Rate for Payer: Superior Health Plan EPO	$675.00

DARCO 7.0 HEADLESS SCREW 32X85 DARCO SYSTEM

Facility

$4,963.25

Service Code	HCPCS C1713
Hospital Charge Code	992376
Hospital Revenue Code	278
Min. Negotiated Rate	$1,240.81
Max. Negotiated Rate	$2,481.62
Rate for Payer: Cash Price	$3,375.01
Rate for Payer: Cigna Commercial	$1,240.81
Rate for Payer: Multiplan Auto	$2,481.62
Rate for Payer: Multiplan Commercial	$2,481.62
Rate for Payer: Multiplan Workers Comp	$2,481.62
Rate for Payer: Scott and White EPO/PPO	$2,481.62

DARCO 7.0 HEADLESS SCREW 32X90 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992268
Hospital Revenue Code	278
Min. Negotiated Rate	$406.08
Max. Negotiated Rate	$3,248.68
Rate for Payer: Amerigroup CHIP/Medicaid	$406.08
Rate for Payer: BCBS of TX Blue Advantage	$1,353.62
Rate for Payer: BCBS of TX Blue Essentials	$1,624.34
Rate for Payer: BCBS of TX PPO	$1,804.82
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Medicaid	$3,248.68
Rate for Payer: Molina CHIP/Medicaid	$3,248.68
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Parkland Medicaid	$3,248.68
Rate for Payer: Scott and White EPO/PPO	$2,256.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,248.68
Rate for Payer: Superior Health Plan EPO	$613.64

DARCO 7.0 HEADLESS SCREW 32X90 DARCO SYSTEM

Facility

$4,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992268
Hospital Revenue Code	278
Min. Negotiated Rate	$1,128.01
Max. Negotiated Rate	$2,256.03
Rate for Payer: Cash Price	$3,068.19
Rate for Payer: Cigna Commercial	$1,128.01
Rate for Payer: Multiplan Auto	$2,256.03
Rate for Payer: Multiplan Commercial	$2,256.03
Rate for Payer: Multiplan Workers Comp	$2,256.03
Rate for Payer: Scott and White EPO/PPO	$2,256.03

Darco headed 2.5mm k-wire qty 1 270mm long smooth tip

Facility

$167.98

Service Code	HCPCS C1769
Hospital Charge Code	993399
Hospital Revenue Code	278
Min. Negotiated Rate	$41.99
Max. Negotiated Rate	$83.99
Rate for Payer: Cash Price	$114.23
Rate for Payer: Cigna Commercial	$41.99
Rate for Payer: Multiplan Auto	$83.99
Rate for Payer: Multiplan Commercial	$83.99
Rate for Payer: Multiplan Workers Comp	$83.99
Rate for Payer: Scott and White EPO/PPO	$83.99

Darco headed 2.5mm k-wire qty 1 270mm long smooth tip

Facility

$167.98

Service Code	HCPCS C1769
Hospital Charge Code	993399
Hospital Revenue Code	278
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$120.95
Rate for Payer: Amerigroup CHIP/Medicaid	$15.12
Rate for Payer: BCBS of TX Blue Advantage	$50.39
Rate for Payer: BCBS of TX Blue Essentials	$60.47
Rate for Payer: BCBS of TX PPO	$67.19
Rate for Payer: Cash Price	$114.23
Rate for Payer: Cigna Medicaid	$120.95
Rate for Payer: Molina CHIP/Medicaid	$120.95
Rate for Payer: Multiplan Auto	$83.99
Rate for Payer: Multiplan Commercial	$83.99
Rate for Payer: Multiplan Workers Comp	$83.99
Rate for Payer: Parkland Medicaid	$120.95
Rate for Payer: Scott and White EPO/PPO	$83.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.95
Rate for Payer: Superior Health Plan EPO	$22.85

DARCO HEADED 3.5MM DRILL TIP

Facility

$1,094.14

Hospital Charge Code	993507
Hospital Revenue Code	272
Rate for Payer: Cash Price	$744.02

DARCO HEADED 3.5MM DRILL TIP

Facility

$1,094.14

Hospital Charge Code	993507
Hospital Revenue Code	272
Min. Negotiated Rate	$98.47
Max. Negotiated Rate	$787.78
Rate for Payer: Amerigroup CHIP/Medicaid	$98.47
Rate for Payer: BCBS of TX Blue Advantage	$328.24
Rate for Payer: BCBS of TX Blue Essentials	$393.89
Rate for Payer: BCBS of TX PPO	$437.66
Rate for Payer: Cash Price	$744.02
Rate for Payer: Cigna Medicaid	$787.78
Rate for Payer: Molina CHIP/Medicaid	$787.78
Rate for Payer: Multiplan Auto	$711.19
Rate for Payer: Multiplan Commercial	$711.19
Rate for Payer: Multiplan Workers Comp	$711.19
Rate for Payer: Parkland Medicaid	$787.78
Rate for Payer: Scott and White EPO/PPO	$547.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$787.78
Rate for Payer: Superior Health Plan EPO	$148.80

DARCO HEADED 3MM K-WIRE QTY 1270MM LONG SMOOTH TIP

Facility

$167.98

Service Code	HCPCS C1769
Hospital Charge Code	993165
Hospital Revenue Code	278
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$120.95
Rate for Payer: Amerigroup CHIP/Medicaid	$15.12
Rate for Payer: BCBS of TX Blue Advantage	$50.39
Rate for Payer: BCBS of TX Blue Essentials	$60.47
Rate for Payer: BCBS of TX PPO	$67.19
Rate for Payer: Cash Price	$114.23
Rate for Payer: Cigna Medicaid	$120.95
Rate for Payer: Molina CHIP/Medicaid	$120.95
Rate for Payer: Multiplan Auto	$83.99
Rate for Payer: Multiplan Commercial	$83.99
Rate for Payer: Multiplan Workers Comp	$83.99
Rate for Payer: Parkland Medicaid	$120.95
Rate for Payer: Scott and White EPO/PPO	$83.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.95
Rate for Payer: Superior Health Plan EPO	$22.85

DARCO HEADED 3MM K-WIRE QTY 1270MM LONG SMOOTH TIP

Facility

$167.98

Service Code	HCPCS C1769
Hospital Charge Code	993165
Hospital Revenue Code	278
Min. Negotiated Rate	$41.99
Max. Negotiated Rate	$83.99
Rate for Payer: Cash Price	$114.23
Rate for Payer: Cigna Commercial	$41.99
Rate for Payer: Multiplan Auto	$83.99
Rate for Payer: Multiplan Commercial	$83.99
Rate for Payer: Multiplan Workers Comp	$83.99
Rate for Payer: Scott and White EPO/PPO	$83.99

DARCO HEADED 4.5MM DRILL TIP

Facility

$1,094.14

Hospital Charge Code	993511
Hospital Revenue Code	272
Min. Negotiated Rate	$98.47
Max. Negotiated Rate	$787.78
Rate for Payer: Amerigroup CHIP/Medicaid	$98.47
Rate for Payer: BCBS of TX Blue Advantage	$328.24
Rate for Payer: BCBS of TX Blue Essentials	$393.89
Rate for Payer: BCBS of TX PPO	$437.66
Rate for Payer: Cash Price	$744.02
Rate for Payer: Cigna Medicaid	$787.78
Rate for Payer: Molina CHIP/Medicaid	$787.78
Rate for Payer: Multiplan Auto	$711.19
Rate for Payer: Multiplan Commercial	$711.19
Rate for Payer: Multiplan Workers Comp	$711.19
Rate for Payer: Parkland Medicaid	$787.78
Rate for Payer: Scott and White EPO/PPO	$547.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$787.78
Rate for Payer: Superior Health Plan EPO	$148.80

DARCO HEADED 4.5MM DRILL TIP

Facility

$1,094.14

Hospital Charge Code	993511
Hospital Revenue Code	272
Rate for Payer: Cash Price	$744.02

DARCO HEADED DRILL TIP 5.0MM FOR 7.5MM SCREWS

Facility

$1,451.81

Service Code	HCPCS C1713
Hospital Charge Code	992412
Hospital Revenue Code	278
Min. Negotiated Rate	$362.95
Max. Negotiated Rate	$725.90
Rate for Payer: Cash Price	$987.23
Rate for Payer: Cigna Commercial	$362.95
Rate for Payer: Multiplan Auto	$725.90
Rate for Payer: Multiplan Commercial	$725.90
Rate for Payer: Multiplan Workers Comp	$725.90
Rate for Payer: Scott and White EPO/PPO	$725.90

DARCO HEADED DRILL TIP 5.0MM FOR 7.5MM SCREWS

Facility

$1,451.81

Service Code	HCPCS C1713
Hospital Charge Code	992412
Hospital Revenue Code	278
Min. Negotiated Rate	$130.66
Max. Negotiated Rate	$1,045.30
Rate for Payer: Amerigroup CHIP/Medicaid	$130.66
Rate for Payer: BCBS of TX Blue Advantage	$435.54
Rate for Payer: BCBS of TX Blue Essentials	$522.65
Rate for Payer: BCBS of TX PPO	$580.72
Rate for Payer: Cash Price	$987.23
Rate for Payer: Cigna Medicaid	$1,045.30
Rate for Payer: Molina CHIP/Medicaid	$1,045.30
Rate for Payer: Multiplan Auto	$725.90
Rate for Payer: Multiplan Commercial	$725.90
Rate for Payer: Multiplan Workers Comp	$725.90
Rate for Payer: Parkland Medicaid	$1,045.30
Rate for Payer: Scott and White EPO/PPO	$725.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,045.30
Rate for Payer: Superior Health Plan EPO	$197.45

DARCO HEADED SCR 3.5X36 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992272
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

DARCO HEADED SCR 3.5X36 LONG

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992272
Hospital Revenue Code	278
Min. Negotiated Rate	$117.65
Max. Negotiated Rate	$941.21
Rate for Payer: Amerigroup CHIP/Medicaid	$117.65
Rate for Payer: BCBS of TX Blue Advantage	$392.17
Rate for Payer: BCBS of TX Blue Essentials	$470.60
Rate for Payer: BCBS of TX PPO	$522.89
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Medicaid	$941.21
Rate for Payer: Molina CHIP/Medicaid	$941.21
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Parkland Medicaid	$941.21
Rate for Payer: Scott and White EPO/PPO	$653.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.21
Rate for Payer: Superior Health Plan EPO	$177.78

DARCO HEADED SCR 3.5X38 FULL

Facility

$1,307.23

Service Code	HCPCS C1713
Hospital Charge Code	992326
Hospital Revenue Code	278
Min. Negotiated Rate	$326.81
Max. Negotiated Rate	$653.62
Rate for Payer: Cash Price	$888.92
Rate for Payer: Cigna Commercial	$326.81
Rate for Payer: Multiplan Auto	$653.62
Rate for Payer: Multiplan Commercial	$653.62
Rate for Payer: Multiplan Workers Comp	$653.62
Rate for Payer: Scott and White EPO/PPO	$653.62

Know your out-of-pocket cost for care.

All Charges