White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HEADED SCREW 3.0MM X 22MM DART-FIRE COMPRESSION SCREW

Facility

$1,199.40

Service Code	HCPCS C1713
Hospital Charge Code	992407
Hospital Revenue Code	278
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$863.57
Rate for Payer: Amerigroup CHIP/Medicaid	$107.95
Rate for Payer: BCBS of TX Blue Advantage	$359.82
Rate for Payer: BCBS of TX Blue Essentials	$431.78
Rate for Payer: BCBS of TX PPO	$479.76
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Medicaid	$863.57
Rate for Payer: Molina CHIP/Medicaid	$863.57
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Parkland Medicaid	$863.57
Rate for Payer: Scott and White EPO/PPO	$599.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$863.57
Rate for Payer: Superior Health Plan EPO	$163.12

HEADED SCREW 3.0MM X 34MM DART-FIRE COMPRESSION SCREW

Facility

$1,199.40

Service Code	HCPCS C1713
Hospital Charge Code	992408
Hospital Revenue Code	278
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$863.57
Rate for Payer: Amerigroup CHIP/Medicaid	$107.95
Rate for Payer: BCBS of TX Blue Advantage	$359.82
Rate for Payer: BCBS of TX Blue Essentials	$431.78
Rate for Payer: BCBS of TX PPO	$479.76
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Medicaid	$863.57
Rate for Payer: Molina CHIP/Medicaid	$863.57
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Parkland Medicaid	$863.57
Rate for Payer: Scott and White EPO/PPO	$599.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$863.57
Rate for Payer: Superior Health Plan EPO	$163.12

HEADED SCREW 3.0MM X 34MM DART-FIRE COMPRESSION SCREW

Facility

$1,199.40

Service Code	HCPCS C1713
Hospital Charge Code	992408
Hospital Revenue Code	278
Min. Negotiated Rate	$299.85
Max. Negotiated Rate	$599.70
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Commercial	$299.85
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Scott and White EPO/PPO	$599.70

HEADED SCREW 3.0MM X 36MM DART-FIRE COMPRESSION SCREW

Facility

$1,199.40

Service Code	HCPCS C1713
Hospital Charge Code	992409
Hospital Revenue Code	278
Min. Negotiated Rate	$299.85
Max. Negotiated Rate	$599.70
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Commercial	$299.85
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Scott and White EPO/PPO	$599.70

HEADED SCREW 3.0MM X 36MM DART-FIRE COMPRESSION SCREW

Facility

$1,199.40

Service Code	HCPCS C1713
Hospital Charge Code	992409
Hospital Revenue Code	278
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$863.57
Rate for Payer: Amerigroup CHIP/Medicaid	$107.95
Rate for Payer: BCBS of TX Blue Advantage	$359.82
Rate for Payer: BCBS of TX Blue Essentials	$431.78
Rate for Payer: BCBS of TX PPO	$479.76
Rate for Payer: Cash Price	$815.59
Rate for Payer: Cigna Medicaid	$863.57
Rate for Payer: Molina CHIP/Medicaid	$863.57
Rate for Payer: Multiplan Auto	$599.70
Rate for Payer: Multiplan Commercial	$599.70
Rate for Payer: Multiplan Workers Comp	$599.70
Rate for Payer: Parkland Medicaid	$863.57
Rate for Payer: Scott and White EPO/PPO	$599.70
Rate for Payer: Superior Health Plan CHIP/Medicaid	$863.57
Rate for Payer: Superior Health Plan EPO	$163.12

HEAD FEM 26-42MM HIP BIP UHR COCR UNV

Facility

$3,012.05

Service Code	HCPCS C1734
Hospital Charge Code	992162
Hospital Revenue Code	278
Min. Negotiated Rate	$753.01
Max. Negotiated Rate	$1,506.03
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Commercial	$753.01
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Scott and White EPO/PPO	$1,506.03

HEAD FEM 26-42MM HIP BIP UHR COCR UNV

Facility

$3,012.05

Service Code	HCPCS C1734
Hospital Charge Code	992162
Hospital Revenue Code	278
Min. Negotiated Rate	$271.08
Max. Negotiated Rate	$2,168.68
Rate for Payer: Amerigroup CHIP/Medicaid	$271.08
Rate for Payer: BCBS of TX Blue Advantage	$903.62
Rate for Payer: BCBS of TX Blue Essentials	$1,084.34
Rate for Payer: BCBS of TX PPO	$1,204.82
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Medicaid	$2,168.68
Rate for Payer: Molina CHIP/Medicaid	$2,168.68
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Parkland Medicaid	$2,168.68
Rate for Payer: Scott and White EPO/PPO	$1,506.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,168.68
Rate for Payer: Superior Health Plan EPO	$409.64

HEAD FEM 28-46MM HIP BIP UHR COCR UNV

Facility

$3,012.05

Service Code	HCPCS C1734
Hospital Charge Code	992128
Hospital Revenue Code	278
Min. Negotiated Rate	$271.08
Max. Negotiated Rate	$2,168.68
Rate for Payer: Amerigroup CHIP/Medicaid	$271.08
Rate for Payer: BCBS of TX Blue Advantage	$903.62
Rate for Payer: BCBS of TX Blue Essentials	$1,084.34
Rate for Payer: BCBS of TX PPO	$1,204.82
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Medicaid	$2,168.68
Rate for Payer: Molina CHIP/Medicaid	$2,168.68
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Parkland Medicaid	$2,168.68
Rate for Payer: Scott and White EPO/PPO	$1,506.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,168.68
Rate for Payer: Superior Health Plan EPO	$409.64

HEAD FEM 28-46MM HIP BIP UHR COCR UNV

Facility

$3,012.05

Service Code	HCPCS C1734
Hospital Charge Code	992128
Hospital Revenue Code	278
Min. Negotiated Rate	$753.01
Max. Negotiated Rate	$1,506.03
Rate for Payer: Cash Price	$2,048.19
Rate for Payer: Cigna Commercial	$753.01
Rate for Payer: Multiplan Auto	$1,506.03
Rate for Payer: Multiplan Commercial	$1,506.03
Rate for Payer: Multiplan Workers Comp	$1,506.03
Rate for Payer: Scott and White EPO/PPO	$1,506.03

HEAD FEM -3MM 26MM HIP COCR V40

Facility

$2,710.84

Service Code	HCPCS C1734
Hospital Charge Code	992163
Hospital Revenue Code	278
Min. Negotiated Rate	$243.98
Max. Negotiated Rate	$1,951.80
Rate for Payer: Amerigroup CHIP/Medicaid	$243.98
Rate for Payer: BCBS of TX Blue Advantage	$813.25
Rate for Payer: BCBS of TX Blue Essentials	$975.90
Rate for Payer: BCBS of TX PPO	$1,084.34
Rate for Payer: Cash Price	$1,843.37
Rate for Payer: Cigna Medicaid	$1,951.80
Rate for Payer: Molina CHIP/Medicaid	$1,951.80
Rate for Payer: Multiplan Auto	$1,355.42
Rate for Payer: Multiplan Commercial	$1,355.42
Rate for Payer: Multiplan Workers Comp	$1,355.42
Rate for Payer: Parkland Medicaid	$1,951.80
Rate for Payer: Scott and White EPO/PPO	$1,355.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,951.80
Rate for Payer: Superior Health Plan EPO	$368.67

HEAD FEM -3MM 26MM HIP COCR V40

Facility

$2,710.84

Service Code	HCPCS C1734
Hospital Charge Code	992163
Hospital Revenue Code	278
Min. Negotiated Rate	$677.71
Max. Negotiated Rate	$1,355.42
Rate for Payer: Cash Price	$1,843.37
Rate for Payer: Cigna Commercial	$677.71
Rate for Payer: Multiplan Auto	$1,355.42
Rate for Payer: Multiplan Commercial	$1,355.42
Rate for Payer: Multiplan Workers Comp	$1,355.42
Rate for Payer: Scott and White EPO/PPO	$1,355.42

Headless screw 2.5mm X 18mm Dart-fire compression screw

Facility

$1,536.14

Service Code	HCPCS C1713
Hospital Charge Code	992203
Hospital Revenue Code	278
Min. Negotiated Rate	$384.04
Max. Negotiated Rate	$768.07
Rate for Payer: Cash Price	$1,044.58
Rate for Payer: Cigna Commercial	$384.04
Rate for Payer: Multiplan Auto	$768.07
Rate for Payer: Multiplan Commercial	$768.07
Rate for Payer: Multiplan Workers Comp	$768.07
Rate for Payer: Scott and White EPO/PPO	$768.07

Headless screw 2.5mm X 18mm Dart-fire compression screw

Facility

$1,536.14

Service Code	HCPCS C1713
Hospital Charge Code	992203
Hospital Revenue Code	278
Min. Negotiated Rate	$138.25
Max. Negotiated Rate	$1,106.02
Rate for Payer: Amerigroup CHIP/Medicaid	$138.25
Rate for Payer: BCBS of TX Blue Advantage	$460.84
Rate for Payer: BCBS of TX Blue Essentials	$553.01
Rate for Payer: BCBS of TX PPO	$614.46
Rate for Payer: Cash Price	$1,044.58
Rate for Payer: Cigna Medicaid	$1,106.02
Rate for Payer: Molina CHIP/Medicaid	$1,106.02
Rate for Payer: Multiplan Auto	$768.07
Rate for Payer: Multiplan Commercial	$768.07
Rate for Payer: Multiplan Workers Comp	$768.07
Rate for Payer: Parkland Medicaid	$1,106.02
Rate for Payer: Scott and White EPO/PPO	$768.07
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,106.02
Rate for Payer: Superior Health Plan EPO	$208.92

HEADLESS SCREW 2.5MM X 20MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	993135
Hospital Revenue Code	278
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,149.83
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
Rate for Payer: BCBS of TX Blue Advantage	$479.10
Rate for Payer: BCBS of TX Blue Essentials	$574.92
Rate for Payer: BCBS of TX PPO	$638.80
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Medicaid	$1,149.83
Rate for Payer: Molina CHIP/Medicaid	$1,149.83
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Parkland Medicaid	$1,149.83
Rate for Payer: Scott and White EPO/PPO	$798.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.83
Rate for Payer: Superior Health Plan EPO	$217.19

HEADLESS SCREW 2.5MM X 20MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	993135
Hospital Revenue Code	278
Min. Negotiated Rate	$399.25
Max. Negotiated Rate	$798.50
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Commercial	$399.25
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Scott and White EPO/PPO	$798.50

HEADLESS SCREW 2.5MM X 22MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	992396
Hospital Revenue Code	278
Min. Negotiated Rate	$399.25
Max. Negotiated Rate	$798.50
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Commercial	$399.25
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Scott and White EPO/PPO	$798.50

HEADLESS SCREW 2.5MM X 22MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	992396
Hospital Revenue Code	278
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,149.83
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
Rate for Payer: BCBS of TX Blue Advantage	$479.10
Rate for Payer: BCBS of TX Blue Essentials	$574.92
Rate for Payer: BCBS of TX PPO	$638.80
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Medicaid	$1,149.83
Rate for Payer: Molina CHIP/Medicaid	$1,149.83
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Parkland Medicaid	$1,149.83
Rate for Payer: Scott and White EPO/PPO	$798.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.83
Rate for Payer: Superior Health Plan EPO	$217.19

HEADLESS SCREW 2.5MM X 24MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	993131
Hospital Revenue Code	278
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,149.83
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
Rate for Payer: BCBS of TX Blue Advantage	$479.10
Rate for Payer: BCBS of TX Blue Essentials	$574.92
Rate for Payer: BCBS of TX PPO	$638.80
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Medicaid	$1,149.83
Rate for Payer: Molina CHIP/Medicaid	$1,149.83
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Parkland Medicaid	$1,149.83
Rate for Payer: Scott and White EPO/PPO	$798.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.83
Rate for Payer: Superior Health Plan EPO	$217.19

HEADLESS SCREW 2.5MM X 24MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	993131
Hospital Revenue Code	278
Min. Negotiated Rate	$399.25
Max. Negotiated Rate	$798.50
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Commercial	$399.25
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Scott and White EPO/PPO	$798.50

HEADLESS SCREW 2.5MM X 30MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	992398
Hospital Revenue Code	278
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,149.83
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
Rate for Payer: BCBS of TX Blue Advantage	$479.10
Rate for Payer: BCBS of TX Blue Essentials	$574.92
Rate for Payer: BCBS of TX PPO	$638.80
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Medicaid	$1,149.83
Rate for Payer: Molina CHIP/Medicaid	$1,149.83
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Parkland Medicaid	$1,149.83
Rate for Payer: Scott and White EPO/PPO	$798.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.83
Rate for Payer: Superior Health Plan EPO	$217.19

HEADLESS SCREW 2.5MM X 30MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	992398
Hospital Revenue Code	278
Min. Negotiated Rate	$399.25
Max. Negotiated Rate	$798.50
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Commercial	$399.25
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Scott and White EPO/PPO	$798.50

HEADLESS SCREW 2.5MM X 32MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	993132
Hospital Revenue Code	278
Min. Negotiated Rate	$399.25
Max. Negotiated Rate	$798.50
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Commercial	$399.25
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Scott and White EPO/PPO	$798.50

HEADLESS SCREW 2.5MM X 32MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	993132
Hospital Revenue Code	278
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,149.83
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
Rate for Payer: BCBS of TX Blue Advantage	$479.10
Rate for Payer: BCBS of TX Blue Essentials	$574.92
Rate for Payer: BCBS of TX PPO	$638.80
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Medicaid	$1,149.83
Rate for Payer: Molina CHIP/Medicaid	$1,149.83
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Parkland Medicaid	$1,149.83
Rate for Payer: Scott and White EPO/PPO	$798.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.83
Rate for Payer: Superior Health Plan EPO	$217.19

HEADLESS SCREW 2.5MM X 34MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	992397
Hospital Revenue Code	278
Min. Negotiated Rate	$399.25
Max. Negotiated Rate	$798.50
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Commercial	$399.25
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Scott and White EPO/PPO	$798.50

HEADLESS SCREW 2.5MM X 34MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	992397
Hospital Revenue Code	278
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,149.83
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
Rate for Payer: BCBS of TX Blue Advantage	$479.10
Rate for Payer: BCBS of TX Blue Essentials	$574.92
Rate for Payer: BCBS of TX PPO	$638.80
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Medicaid	$1,149.83
Rate for Payer: Molina CHIP/Medicaid	$1,149.83
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Parkland Medicaid	$1,149.83
Rate for Payer: Scott and White EPO/PPO	$798.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.83
Rate for Payer: Superior Health Plan EPO	$217.19

Know your out-of-pocket cost for care.

All Charges