White Rock Medical Center

All Charges

Charge

Type

Setting

Price

K-WIRE 1.2 X 150MM 150MM LONG SMOOTH TIP

Facility

$167.98

Service Code	HCPCS C1769
Hospital Charge Code	993447
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

K-WIRE 1.2 X 150MM 150MM LONG SMOOTH TIP

Facility

$167.98

Service Code	HCPCS C1769
Hospital Charge Code	993447
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

K-WIRE 1.2 X 150 R3CON

Facility

$114.00

Service Code	HCPCS C1769
Hospital Charge Code	146425
Hospital Revenue Code	278
Min. Negotiated Rate	$10.26
Max. Negotiated Rate	$82.08
Rate for Payer: Amerigroup CHIP/Medicaid	$10.26
Rate for Payer: BCBS of TX Blue Advantage	$34.20
Rate for Payer: BCBS of TX Blue Essentials	$41.04
Rate for Payer: BCBS of TX PPO	$45.60
Rate for Payer: Cash Price	$77.52
Rate for Payer: Cigna Medicaid	$82.08
Rate for Payer: Molina CHIP/Medicaid	$82.08
Rate for Payer: Multiplan Auto	$57.00
Rate for Payer: Multiplan Commercial	$57.00
Rate for Payer: Multiplan Workers Comp	$57.00
Rate for Payer: Parkland Medicaid	$82.08
Rate for Payer: Scott and White EPO/PPO	$57.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$82.08
Rate for Payer: Superior Health Plan EPO	$15.50

K-WIRE 1.2 X 150 R3CON

Facility

$114.00

Service Code	HCPCS C1769
Hospital Charge Code	146425
Hospital Revenue Code	278
Min. Negotiated Rate	$28.50
Max. Negotiated Rate	$57.00
Rate for Payer: Cash Price	$77.52
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Multiplan Auto	$57.00
Rate for Payer: Multiplan Commercial	$57.00
Rate for Payer: Multiplan Workers Comp	$57.00
Rate for Payer: Scott and White EPO/PPO	$57.00

K-WIRE 1.4MM X 228MM

Facility

$122.58

Service Code	HCPCS C1769
Hospital Charge Code	993439
Hospital Revenue Code	278
Min. Negotiated Rate	$30.64
Max. Negotiated Rate	$61.29
Rate for Payer: Cash Price	$83.35
Rate for Payer: Cigna Commercial	$30.64
Rate for Payer: Multiplan Auto	$61.29
Rate for Payer: Multiplan Commercial	$61.29
Rate for Payer: Multiplan Workers Comp	$61.29
Rate for Payer: Scott and White EPO/PPO	$61.29

K-WIRE 1.4MM X 228MM

Facility

$122.58

Service Code	HCPCS C1769
Hospital Charge Code	993439
Hospital Revenue Code	278
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$88.26
Rate for Payer: Amerigroup CHIP/Medicaid	$11.03
Rate for Payer: BCBS of TX Blue Advantage	$36.77
Rate for Payer: BCBS of TX Blue Essentials	$44.13
Rate for Payer: BCBS of TX PPO	$49.03
Rate for Payer: Cash Price	$83.35
Rate for Payer: Cigna Medicaid	$88.26
Rate for Payer: Molina CHIP/Medicaid	$88.26
Rate for Payer: Multiplan Auto	$61.29
Rate for Payer: Multiplan Commercial	$61.29
Rate for Payer: Multiplan Workers Comp	$61.29
Rate for Payer: Parkland Medicaid	$88.26
Rate for Payer: Scott and White EPO/PPO	$61.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.26
Rate for Payer: Superior Health Plan EPO	$16.67

K-wire 1.4 X 150mm Blunt/trocar

Facility

$167.98

Service Code	HCPCS C1769
Hospital Charge Code	993408
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

K-wire 1.4 X 150mm Blunt/trocar

Facility

$167.98

Service Code	HCPCS C1769
Hospital Charge Code	993408
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

K-WIRE 1.6 X 150 SMOOTH R3CON

Facility

$114.00

Service Code	HCPCS C1769
Hospital Charge Code	146421
Hospital Revenue Code	278
Min. Negotiated Rate	$28.50
Max. Negotiated Rate	$57.00
Rate for Payer: Cash Price	$77.52
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Multiplan Auto	$57.00
Rate for Payer: Multiplan Commercial	$57.00
Rate for Payer: Multiplan Workers Comp	$57.00
Rate for Payer: Scott and White EPO/PPO	$57.00

K-WIRE 1.6 X 150 SMOOTH R3CON

Facility

$114.00

Service Code	HCPCS C1769
Hospital Charge Code	146421
Hospital Revenue Code	278
Min. Negotiated Rate	$10.26
Max. Negotiated Rate	$82.08
Rate for Payer: Amerigroup CHIP/Medicaid	$10.26
Rate for Payer: BCBS of TX Blue Advantage	$34.20
Rate for Payer: BCBS of TX Blue Essentials	$41.04
Rate for Payer: BCBS of TX PPO	$45.60
Rate for Payer: Cash Price	$77.52
Rate for Payer: Cigna Medicaid	$82.08
Rate for Payer: Molina CHIP/Medicaid	$82.08
Rate for Payer: Multiplan Auto	$57.00
Rate for Payer: Multiplan Commercial	$57.00
Rate for Payer: Multiplan Workers Comp	$57.00
Rate for Payer: Parkland Medicaid	$82.08
Rate for Payer: Scott and White EPO/PPO	$57.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$82.08
Rate for Payer: Superior Health Plan EPO	$15.50

K-WIRE 2.5MM X 150MM

Facility

$326.88

Service Code	HCPCS C1769
Hospital Charge Code	993555
Hospital Revenue Code	278
Min. Negotiated Rate	$29.42
Max. Negotiated Rate	$235.35
Rate for Payer: Amerigroup CHIP/Medicaid	$29.42
Rate for Payer: BCBS of TX Blue Advantage	$98.06
Rate for Payer: BCBS of TX Blue Essentials	$117.68
Rate for Payer: BCBS of TX PPO	$130.75
Rate for Payer: Cash Price	$222.28
Rate for Payer: Cigna Medicaid	$235.35
Rate for Payer: Molina CHIP/Medicaid	$235.35
Rate for Payer: Multiplan Auto	$163.44
Rate for Payer: Multiplan Commercial	$163.44
Rate for Payer: Multiplan Workers Comp	$163.44
Rate for Payer: Parkland Medicaid	$235.35
Rate for Payer: Scott and White EPO/PPO	$163.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$235.35
Rate for Payer: Superior Health Plan EPO	$44.46

K-WIRE 2.5MM X 150MM

Facility

$326.88

Service Code	HCPCS C1769
Hospital Charge Code	993555
Hospital Revenue Code	278
Min. Negotiated Rate	$81.72
Max. Negotiated Rate	$163.44
Rate for Payer: Cash Price	$222.28
Rate for Payer: Cigna Commercial	$81.72
Rate for Payer: Multiplan Auto	$163.44
Rate for Payer: Multiplan Commercial	$163.44
Rate for Payer: Multiplan Workers Comp	$163.44
Rate for Payer: Scott and White EPO/PPO	$163.44

K WIRE 3.2MM

Facility

$1,034.00

Service Code	HCPCS C1769
Hospital Charge Code	122780
Hospital Revenue Code	278
Min. Negotiated Rate	$258.50
Max. Negotiated Rate	$517.00
Rate for Payer: Cash Price	$703.12
Rate for Payer: Cigna Commercial	$258.50
Rate for Payer: Multiplan Auto	$517.00
Rate for Payer: Multiplan Commercial	$517.00
Rate for Payer: Multiplan Workers Comp	$517.00
Rate for Payer: Scott and White EPO/PPO	$517.00

K WIRE 3.2MM

Facility

$1,034.00

Service Code	HCPCS C1769
Hospital Charge Code	122780
Hospital Revenue Code	278
Min. Negotiated Rate	$93.06
Max. Negotiated Rate	$744.48
Rate for Payer: Amerigroup CHIP/Medicaid	$93.06
Rate for Payer: BCBS of TX Blue Advantage	$310.20
Rate for Payer: BCBS of TX Blue Essentials	$372.24
Rate for Payer: BCBS of TX PPO	$413.60
Rate for Payer: Cash Price	$703.12
Rate for Payer: Cigna Medicaid	$744.48
Rate for Payer: Molina CHIP/Medicaid	$744.48
Rate for Payer: Multiplan Auto	$517.00
Rate for Payer: Multiplan Commercial	$517.00
Rate for Payer: Multiplan Workers Comp	$517.00
Rate for Payer: Parkland Medicaid	$744.48
Rate for Payer: Scott and White EPO/PPO	$517.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$744.48
Rate for Payer: Superior Health Plan EPO	$140.62

K-WIRE 3.2 X 450 MM STERILE

Facility

$1,192.77

Service Code	HCPCS C1769
Hospital Charge Code	993141
Hospital Revenue Code	278
Min. Negotiated Rate	$107.35
Max. Negotiated Rate	$858.79
Rate for Payer: Amerigroup CHIP/Medicaid	$107.35
Rate for Payer: BCBS of TX Blue Advantage	$357.83
Rate for Payer: BCBS of TX Blue Essentials	$429.40
Rate for Payer: BCBS of TX PPO	$477.11
Rate for Payer: Cash Price	$811.08
Rate for Payer: Cigna Medicaid	$858.79
Rate for Payer: Molina CHIP/Medicaid	$858.79
Rate for Payer: Multiplan Auto	$596.38
Rate for Payer: Multiplan Commercial	$596.38
Rate for Payer: Multiplan Workers Comp	$596.38
Rate for Payer: Parkland Medicaid	$858.79
Rate for Payer: Scott and White EPO/PPO	$596.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$858.79
Rate for Payer: Superior Health Plan EPO	$162.22

K-WIRE 3.2 X 450 MM STERILE

Facility

$1,192.77

Service Code	HCPCS C1769
Hospital Charge Code	993141
Hospital Revenue Code	278
Min. Negotiated Rate	$298.19
Max. Negotiated Rate	$596.38
Rate for Payer: Cash Price	$811.08
Rate for Payer: Cigna Commercial	$298.19
Rate for Payer: Multiplan Auto	$596.38
Rate for Payer: Multiplan Commercial	$596.38
Rate for Payer: Multiplan Workers Comp	$596.38
Rate for Payer: Scott and White EPO/PPO	$596.38

K-WIRE 3mmX285mm STERILE

Facility

$862.60

Service Code	HCPCS C1769
Hospital Charge Code	993474
Hospital Revenue Code	278
Min. Negotiated Rate	$215.65
Max. Negotiated Rate	$431.30
Rate for Payer: Cash Price	$586.57
Rate for Payer: Cigna Commercial	$215.65
Rate for Payer: Multiplan Auto	$431.30
Rate for Payer: Multiplan Commercial	$431.30
Rate for Payer: Multiplan Workers Comp	$431.30
Rate for Payer: Scott and White EPO/PPO	$431.30

K-WIRE 3mmX285mm STERILE

Facility

$862.60

Service Code	HCPCS C1769
Hospital Charge Code	993474
Hospital Revenue Code	278
Min. Negotiated Rate	$77.63
Max. Negotiated Rate	$621.07
Rate for Payer: Amerigroup CHIP/Medicaid	$77.63
Rate for Payer: BCBS of TX Blue Advantage	$258.78
Rate for Payer: BCBS of TX Blue Essentials	$310.54
Rate for Payer: BCBS of TX PPO	$345.04
Rate for Payer: Cash Price	$586.57
Rate for Payer: Cigna Medicaid	$621.07
Rate for Payer: Molina CHIP/Medicaid	$621.07
Rate for Payer: Multiplan Auto	$431.30
Rate for Payer: Multiplan Commercial	$431.30
Rate for Payer: Multiplan Workers Comp	$431.30
Rate for Payer: Parkland Medicaid	$621.07
Rate for Payer: Scott and White EPO/PPO	$431.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$621.07
Rate for Payer: Superior Health Plan EPO	$117.31

k wire access 3.2x3s 2x350mm

Facility

$848.00

Service Code	HCPCS C1769
Hospital Charge Code	8720596
Hospital Revenue Code	278
Min. Negotiated Rate	$76.32
Max. Negotiated Rate	$610.56
Rate for Payer: Amerigroup CHIP/Medicaid	$76.32
Rate for Payer: BCBS of TX Blue Advantage	$254.40
Rate for Payer: BCBS of TX Blue Essentials	$305.28
Rate for Payer: BCBS of TX PPO	$339.20
Rate for Payer: Cash Price	$576.64
Rate for Payer: Cigna Medicaid	$610.56
Rate for Payer: Molina CHIP/Medicaid	$610.56
Rate for Payer: Multiplan Auto	$424.00
Rate for Payer: Multiplan Commercial	$424.00
Rate for Payer: Multiplan Workers Comp	$424.00
Rate for Payer: Parkland Medicaid	$610.56
Rate for Payer: Scott and White EPO/PPO	$424.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$610.56
Rate for Payer: Superior Health Plan EPO	$115.33

k wire access 3.2x3s 2x350mm

Facility

$848.00

Service Code	HCPCS C1769
Hospital Charge Code	8720596
Hospital Revenue Code	278
Min. Negotiated Rate	$212.00
Max. Negotiated Rate	$424.00
Rate for Payer: Cash Price	$576.64
Rate for Payer: Cigna Commercial	$212.00
Rate for Payer: Multiplan Auto	$424.00
Rate for Payer: Multiplan Commercial	$424.00
Rate for Payer: Multiplan Workers Comp	$424.00
Rate for Payer: Scott and White EPO/PPO	$424.00

K WIRE -- DHF

Facility

$549.00

Service Code	HCPCS C1769
Hospital Charge Code	81329500
Hospital Revenue Code	278
Min. Negotiated Rate	$49.41
Max. Negotiated Rate	$395.28
Rate for Payer: Amerigroup CHIP/Medicaid	$49.41
Rate for Payer: BCBS of TX Blue Advantage	$164.70
Rate for Payer: BCBS of TX Blue Essentials	$197.64
Rate for Payer: BCBS of TX PPO	$219.60
Rate for Payer: Cash Price	$373.32
Rate for Payer: Cigna Medicaid	$395.28
Rate for Payer: Molina CHIP/Medicaid	$395.28
Rate for Payer: Multiplan Auto	$274.50
Rate for Payer: Multiplan Commercial	$274.50
Rate for Payer: Multiplan Workers Comp	$274.50
Rate for Payer: Parkland Medicaid	$395.28
Rate for Payer: Scott and White EPO/PPO	$274.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$395.28
Rate for Payer: Superior Health Plan EPO	$74.66

K WIRE -- DHF

Facility

$549.00

Service Code	HCPCS C1769
Hospital Charge Code	81329500
Hospital Revenue Code	278
Min. Negotiated Rate	$137.25
Max. Negotiated Rate	$274.50
Rate for Payer: Cash Price	$373.32
Rate for Payer: Cigna Commercial	$137.25
Rate for Payer: Multiplan Auto	$274.50
Rate for Payer: Multiplan Commercial	$274.50
Rate for Payer: Multiplan Workers Comp	$274.50
Rate for Payer: Scott and White EPO/PPO	$274.50

k wire lag screw 62s 620mm

Facility

$887.00

Service Code	HCPCS C1713
Hospital Charge Code	8720595
Hospital Revenue Code	278
Min. Negotiated Rate	$221.75
Max. Negotiated Rate	$443.50
Rate for Payer: Cash Price	$603.16
Rate for Payer: Cigna Commercial	$221.75
Rate for Payer: Multiplan Auto	$443.50
Rate for Payer: Multiplan Commercial	$443.50
Rate for Payer: Multiplan Workers Comp	$443.50
Rate for Payer: Scott and White EPO/PPO	$443.50

k wire lag screw 62s 620mm

Facility

$887.00

Service Code	HCPCS C1713
Hospital Charge Code	8720595
Hospital Revenue Code	278
Min. Negotiated Rate	$79.83
Max. Negotiated Rate	$638.64
Rate for Payer: Amerigroup CHIP/Medicaid	$79.83
Rate for Payer: BCBS of TX Blue Advantage	$266.10
Rate for Payer: BCBS of TX Blue Essentials	$319.32
Rate for Payer: BCBS of TX PPO	$354.80
Rate for Payer: Cash Price	$603.16
Rate for Payer: Cigna Medicaid	$638.64
Rate for Payer: Molina CHIP/Medicaid	$638.64
Rate for Payer: Multiplan Auto	$443.50
Rate for Payer: Multiplan Commercial	$443.50
Rate for Payer: Multiplan Workers Comp	$443.50
Rate for Payer: Parkland Medicaid	$638.64
Rate for Payer: Scott and White EPO/PPO	$443.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$638.64
Rate for Payer: Superior Health Plan EPO	$120.63

K-WIRE SS 1.6 X 127MM NS

Facility

$171.61

Service Code	HCPCS C1769
Hospital Charge Code	993173
Hospital Revenue Code	278
Min. Negotiated Rate	$15.44
Max. Negotiated Rate	$123.56
Rate for Payer: Amerigroup CHIP/Medicaid	$15.44
Rate for Payer: BCBS of TX Blue Advantage	$51.48
Rate for Payer: BCBS of TX Blue Essentials	$61.78
Rate for Payer: BCBS of TX PPO	$68.64
Rate for Payer: Cash Price	$116.69
Rate for Payer: Cigna Medicaid	$123.56
Rate for Payer: Molina CHIP/Medicaid	$123.56
Rate for Payer: Multiplan Auto	$85.81
Rate for Payer: Multiplan Commercial	$85.81
Rate for Payer: Multiplan Workers Comp	$85.81
Rate for Payer: Parkland Medicaid	$123.56
Rate for Payer: Scott and White EPO/PPO	$85.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.56
Rate for Payer: Superior Health Plan EPO	$23.34

Know your out-of-pocket cost for care.

All Charges