White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Local/Sedation, per interval cumulative, 15 Minutes

Facility

$2,105.00

Hospital Charge Code	9900034
Hospital Revenue Code	370
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$1,515.60
Rate for Payer: Amerigroup CHIP/Medicaid	$189.45
Rate for Payer: BCBS of TX Blue Advantage	$631.50
Rate for Payer: BCBS of TX Blue Essentials	$757.80
Rate for Payer: BCBS of TX PPO	$842.00
Rate for Payer: Cash Price	$1,431.40
Rate for Payer: Cigna Medicaid	$1,515.60
Rate for Payer: Molina CHIP/Medicaid	$1,515.60
Rate for Payer: Multiplan Auto	$1,368.25
Rate for Payer: Multiplan Commercial	$1,368.25
Rate for Payer: Multiplan Workers Comp	$1,368.25
Rate for Payer: Parkland Medicaid	$1,515.60
Rate for Payer: Scott and White EPO/PPO	$1,052.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,515.60
Rate for Payer: Superior Health Plan EPO	$286.28

Local/Sedation, per interval cumulative, 15 Minutes

Facility

$2,105.00

Hospital Charge Code	9900034
Hospital Revenue Code	370
Rate for Payer: Cash Price	$1,431.40

Local/Sedation, per unit cumulative, 15 Minutes

Facility

$625.00

Hospital Charge Code	9900035
Hospital Revenue Code	370
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$450.00
Rate for Payer: Amerigroup CHIP/Medicaid	$56.25
Rate for Payer: BCBS of TX Blue Advantage	$187.50
Rate for Payer: BCBS of TX Blue Essentials	$225.00
Rate for Payer: BCBS of TX PPO	$250.00
Rate for Payer: Cash Price	$425.00
Rate for Payer: Cigna Medicaid	$450.00
Rate for Payer: Molina CHIP/Medicaid	$450.00
Rate for Payer: Multiplan Auto	$406.25
Rate for Payer: Multiplan Commercial	$406.25
Rate for Payer: Multiplan Workers Comp	$406.25
Rate for Payer: Parkland Medicaid	$450.00
Rate for Payer: Scott and White EPO/PPO	$312.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$450.00
Rate for Payer: Superior Health Plan EPO	$85.00

Local/Sedation, per unit cumulative, 15 Minutes

Facility

$625.00

Hospital Charge Code	9900035
Hospital Revenue Code	370
Rate for Payer: Cash Price	$425.00

LOCK, CONTAINER, TAMPREVDNT, STEAM, ORNG C

Facility

$0.70

Hospital Charge Code	993016
Hospital Revenue Code	270
Rate for Payer: Cash Price	$0.48

LOCK, CONTAINER, TAMPREVDNT, STEAM, ORNG C

Facility

$0.70

Hospital Charge Code	993016
Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.50
Rate for Payer: Amerigroup CHIP/Medicaid	$0.06
Rate for Payer: BCBS of TX Blue Advantage	$0.21
Rate for Payer: BCBS of TX Blue Essentials	$0.25
Rate for Payer: BCBS of TX PPO	$0.28
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cigna Medicaid	$0.50
Rate for Payer: Molina CHIP/Medicaid	$0.50
Rate for Payer: Multiplan Auto	$0.46
Rate for Payer: Multiplan Commercial	$0.46
Rate for Payer: Multiplan Workers Comp	$0.46
Rate for Payer: Parkland Medicaid	$0.50
Rate for Payer: Scott and White EPO/PPO	$0.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$0.50
Rate for Payer: Superior Health Plan EPO	$0.10

LOCKING SCREW

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992173
Hospital Revenue Code	278
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$1,270.84
Rate for Payer: Amerigroup CHIP/Medicaid	$158.86
Rate for Payer: BCBS of TX Blue Advantage	$529.52
Rate for Payer: BCBS of TX Blue Essentials	$635.42
Rate for Payer: BCBS of TX PPO	$706.02
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Medicaid	$1,270.84
Rate for Payer: Molina CHIP/Medicaid	$1,270.84
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Parkland Medicaid	$1,270.84
Rate for Payer: Scott and White EPO/PPO	$882.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.84
Rate for Payer: Superior Health Plan EPO	$240.05

LOCKING SCREW

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992173
Hospital Revenue Code	278
Min. Negotiated Rate	$441.26
Max. Negotiated Rate	$882.53
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Commercial	$441.26
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Scott and White EPO/PPO	$882.53

Locking screw 2.7 X 18L

Facility

$1,054.22

Service Code	HCPCS C1713
Hospital Charge Code	992172
Hospital Revenue Code	278
Min. Negotiated Rate	$94.88
Max. Negotiated Rate	$759.04
Rate for Payer: Amerigroup CHIP/Medicaid	$94.88
Rate for Payer: BCBS of TX Blue Advantage	$316.27
Rate for Payer: BCBS of TX Blue Essentials	$379.52
Rate for Payer: BCBS of TX PPO	$421.69
Rate for Payer: Cash Price	$716.87
Rate for Payer: Cigna Medicaid	$759.04
Rate for Payer: Molina CHIP/Medicaid	$759.04
Rate for Payer: Multiplan Auto	$527.11
Rate for Payer: Multiplan Commercial	$527.11
Rate for Payer: Multiplan Workers Comp	$527.11
Rate for Payer: Parkland Medicaid	$759.04
Rate for Payer: Scott and White EPO/PPO	$527.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$759.04
Rate for Payer: Superior Health Plan EPO	$143.37

Locking screw 2.7 X 18L

Facility

$1,054.22

Service Code	HCPCS C1713
Hospital Charge Code	992172
Hospital Revenue Code	278
Min. Negotiated Rate	$263.56
Max. Negotiated Rate	$527.11
Rate for Payer: Cash Price	$716.87
Rate for Payer: Cigna Commercial	$263.56
Rate for Payer: Multiplan Auto	$527.11
Rate for Payer: Multiplan Commercial	$527.11
Rate for Payer: Multiplan Workers Comp	$527.11
Rate for Payer: Scott and White EPO/PPO	$527.11

LOCKING SCREW 3.5 X 10MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$1,837.35

Service Code	HCPCS C1713
Hospital Charge Code	992325
Hospital Revenue Code	278
Min. Negotiated Rate	$459.34
Max. Negotiated Rate	$918.67
Rate for Payer: Cash Price	$1,249.40
Rate for Payer: Cigna Commercial	$459.34
Rate for Payer: Multiplan Auto	$918.67
Rate for Payer: Multiplan Commercial	$918.67
Rate for Payer: Multiplan Workers Comp	$918.67
Rate for Payer: Scott and White EPO/PPO	$918.67

LOCKING SCREW 3.5 X 10MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$1,837.35

Service Code	HCPCS C1713
Hospital Charge Code	992325
Hospital Revenue Code	278
Min. Negotiated Rate	$165.36
Max. Negotiated Rate	$1,322.89
Rate for Payer: Amerigroup CHIP/Medicaid	$165.36
Rate for Payer: BCBS of TX Blue Advantage	$551.21
Rate for Payer: BCBS of TX Blue Essentials	$661.45
Rate for Payer: BCBS of TX PPO	$734.94
Rate for Payer: Cash Price	$1,249.40
Rate for Payer: Cigna Medicaid	$1,322.89
Rate for Payer: Molina CHIP/Medicaid	$1,322.89
Rate for Payer: Multiplan Auto	$918.67
Rate for Payer: Multiplan Commercial	$918.67
Rate for Payer: Multiplan Workers Comp	$918.67
Rate for Payer: Parkland Medicaid	$1,322.89
Rate for Payer: Scott and White EPO/PPO	$918.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,322.89
Rate for Payer: Superior Health Plan EPO	$249.88

LOCKING SCREW 3.5 X 12MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$1,837.35

Service Code	HCPCS C1713
Hospital Charge Code	992329
Hospital Revenue Code	278
Min. Negotiated Rate	$459.34
Max. Negotiated Rate	$918.67
Rate for Payer: Cash Price	$1,249.40
Rate for Payer: Cigna Commercial	$459.34
Rate for Payer: Multiplan Auto	$918.67
Rate for Payer: Multiplan Commercial	$918.67
Rate for Payer: Multiplan Workers Comp	$918.67
Rate for Payer: Scott and White EPO/PPO	$918.67

LOCKING SCREW 3.5 X 12MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$1,837.35

Service Code	HCPCS C1713
Hospital Charge Code	992329
Hospital Revenue Code	278
Min. Negotiated Rate	$165.36
Max. Negotiated Rate	$1,322.89
Rate for Payer: Amerigroup CHIP/Medicaid	$165.36
Rate for Payer: BCBS of TX Blue Advantage	$551.21
Rate for Payer: BCBS of TX Blue Essentials	$661.45
Rate for Payer: BCBS of TX PPO	$734.94
Rate for Payer: Cash Price	$1,249.40
Rate for Payer: Cigna Medicaid	$1,322.89
Rate for Payer: Molina CHIP/Medicaid	$1,322.89
Rate for Payer: Multiplan Auto	$918.67
Rate for Payer: Multiplan Commercial	$918.67
Rate for Payer: Multiplan Workers Comp	$918.67
Rate for Payer: Parkland Medicaid	$1,322.89
Rate for Payer: Scott and White EPO/PPO	$918.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,322.89
Rate for Payer: Superior Health Plan EPO	$249.88

LOCKING SCREW 3.5 X 16MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$5,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992379
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.01
Max. Negotiated Rate	$2,756.03
Rate for Payer: Cash Price	$3,748.19
Rate for Payer: Cigna Commercial	$1,378.01
Rate for Payer: Multiplan Auto	$2,756.03
Rate for Payer: Multiplan Commercial	$2,756.03
Rate for Payer: Multiplan Workers Comp	$2,756.03
Rate for Payer: Scott and White EPO/PPO	$2,756.03

LOCKING SCREW 3.5 X 16MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$5,512.05

Service Code	HCPCS C1713
Hospital Charge Code	992379
Hospital Revenue Code	278
Min. Negotiated Rate	$496.08
Max. Negotiated Rate	$3,968.68
Rate for Payer: Amerigroup CHIP/Medicaid	$496.08
Rate for Payer: BCBS of TX Blue Advantage	$1,653.62
Rate for Payer: BCBS of TX Blue Essentials	$1,984.34
Rate for Payer: BCBS of TX PPO	$2,204.82
Rate for Payer: Cash Price	$3,748.19
Rate for Payer: Cigna Medicaid	$3,968.68
Rate for Payer: Molina CHIP/Medicaid	$3,968.68
Rate for Payer: Multiplan Auto	$2,756.03
Rate for Payer: Multiplan Commercial	$2,756.03
Rate for Payer: Multiplan Workers Comp	$2,756.03
Rate for Payer: Parkland Medicaid	$3,968.68
Rate for Payer: Scott and White EPO/PPO	$2,756.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,968.68
Rate for Payer: Superior Health Plan EPO	$749.64

LOCKING SCREW 3.5 X 18MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$1,837.35

Service Code	HCPCS C1713
Hospital Charge Code	992380
Hospital Revenue Code	278
Min. Negotiated Rate	$165.36
Max. Negotiated Rate	$1,322.89
Rate for Payer: Amerigroup CHIP/Medicaid	$165.36
Rate for Payer: BCBS of TX Blue Advantage	$551.21
Rate for Payer: BCBS of TX Blue Essentials	$661.45
Rate for Payer: BCBS of TX PPO	$734.94
Rate for Payer: Cash Price	$1,249.40
Rate for Payer: Cigna Medicaid	$1,322.89
Rate for Payer: Molina CHIP/Medicaid	$1,322.89
Rate for Payer: Multiplan Auto	$918.67
Rate for Payer: Multiplan Commercial	$918.67
Rate for Payer: Multiplan Workers Comp	$918.67
Rate for Payer: Parkland Medicaid	$1,322.89
Rate for Payer: Scott and White EPO/PPO	$918.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,322.89
Rate for Payer: Superior Health Plan EPO	$249.88

LOCKING SCREW 3.5 X 18MM ORTHOLOC 3DI PLATING SYSTEM

Facility

$1,837.35

Service Code	HCPCS C1713
Hospital Charge Code	992380
Hospital Revenue Code	278
Min. Negotiated Rate	$459.34
Max. Negotiated Rate	$918.67
Rate for Payer: Cash Price	$1,249.40
Rate for Payer: Cigna Commercial	$459.34
Rate for Payer: Multiplan Auto	$918.67
Rate for Payer: Multiplan Commercial	$918.67
Rate for Payer: Multiplan Workers Comp	$918.67
Rate for Payer: Scott and White EPO/PPO	$918.67

LOCKING THIRO TUBULAR PLATE, SS, 7H

Facility

$2,560.24

Service Code	HCPCS C1734
Hospital Charge Code	992252
Hospital Revenue Code	278
Min. Negotiated Rate	$230.42
Max. Negotiated Rate	$1,843.37
Rate for Payer: Amerigroup CHIP/Medicaid	$230.42
Rate for Payer: BCBS of TX Blue Advantage	$768.07
Rate for Payer: BCBS of TX Blue Essentials	$921.69
Rate for Payer: BCBS of TX PPO	$1,024.10
Rate for Payer: Cash Price	$1,740.96
Rate for Payer: Cigna Medicaid	$1,843.37
Rate for Payer: Molina CHIP/Medicaid	$1,843.37
Rate for Payer: Multiplan Auto	$1,280.12
Rate for Payer: Multiplan Commercial	$1,280.12
Rate for Payer: Multiplan Workers Comp	$1,280.12
Rate for Payer: Parkland Medicaid	$1,843.37
Rate for Payer: Scott and White EPO/PPO	$1,280.12
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,843.37
Rate for Payer: Superior Health Plan EPO	$348.19

LOCKING THIRO TUBULAR PLATE, SS, 7H

Facility

$2,560.24

Service Code	HCPCS C1734
Hospital Charge Code	992252
Hospital Revenue Code	278
Min. Negotiated Rate	$640.06
Max. Negotiated Rate	$1,280.12
Rate for Payer: Cash Price	$1,740.96
Rate for Payer: Cigna Commercial	$640.06
Rate for Payer: Multiplan Auto	$1,280.12
Rate for Payer: Multiplan Commercial	$1,280.12
Rate for Payer: Multiplan Workers Comp	$1,280.12
Rate for Payer: Scott and White EPO/PPO	$1,280.12

LOCK SCREW SQUARE 2.7MM X 12MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992314
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.52
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Scott and White EPO/PPO	$379.52

LOCK SCREW SQUARE 2.7MM X 12MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992314
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.51
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.62
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Medicaid	$546.51
Rate for Payer: Molina CHIP/Medicaid	$546.51
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Parkland Medicaid	$546.51
Rate for Payer: Scott and White EPO/PPO	$379.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.51
Rate for Payer: Superior Health Plan EPO	$103.23

LOCK SCREW SQUARE 2.7MM X 13MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992315
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.52
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Scott and White EPO/PPO	$379.52

LOCK SCREW SQUARE 2.7MM X 13MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992315
Hospital Revenue Code	278
Min. Negotiated Rate	$68.31
Max. Negotiated Rate	$546.51
Rate for Payer: Amerigroup CHIP/Medicaid	$68.31
Rate for Payer: BCBS of TX Blue Advantage	$227.71
Rate for Payer: BCBS of TX Blue Essentials	$273.25
Rate for Payer: BCBS of TX PPO	$303.62
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Medicaid	$546.51
Rate for Payer: Molina CHIP/Medicaid	$546.51
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Parkland Medicaid	$546.51
Rate for Payer: Scott and White EPO/PPO	$379.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$546.51
Rate for Payer: Superior Health Plan EPO	$103.23

LOCK SCREW SQUARE 2.7MM X 14MM

Facility

$759.04

Service Code	HCPCS C1713
Hospital Charge Code	992316
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$379.52
Rate for Payer: Cash Price	$516.15
Rate for Payer: Cigna Commercial	$189.76
Rate for Payer: Multiplan Auto	$379.52
Rate for Payer: Multiplan Commercial	$379.52
Rate for Payer: Multiplan Workers Comp	$379.52
Rate for Payer: Scott and White EPO/PPO	$379.52

Know your out-of-pocket cost for care.

All Charges