White Rock Medical Center

All Charges

Charge

Type

Setting

Price

screw poly avant

Facility

$4,819.28

Service Code	HCPCS C1713
Hospital Charge Code	8708540
Hospital Revenue Code	278
Min. Negotiated Rate	$1,204.82
Max. Negotiated Rate	$2,409.64
Rate for Payer: Aetna Commercial	$1,445.78
Rate for Payer: Cash Price	$4,240.97
Rate for Payer: Cigna Commercial	$1,204.82
Rate for Payer: Multiplan Auto	$2,409.64
Rate for Payer: Multiplan Commercial	$2,409.64
Rate for Payer: Multiplan Workers Comp	$2,409.64
Rate for Payer: Scott and White EPO/PPO	$2,409.64

SCREW POLY AVANT

Facility

$6,927.10

Service Code	HCPCS C1713
Hospital Charge Code	8504494
Hospital Revenue Code	278
Min. Negotiated Rate	$1,731.78
Max. Negotiated Rate	$3,463.55
Rate for Payer: Aetna Commercial	$2,078.13
Rate for Payer: Cash Price	$6,095.85
Rate for Payer: Cigna Commercial	$1,731.78
Rate for Payer: Multiplan Auto	$3,463.55
Rate for Payer: Multiplan Commercial	$3,463.55
Rate for Payer: Multiplan Workers Comp	$3,463.55
Rate for Payer: Scott and White EPO/PPO	$3,463.55

SCREW POLY AVANT

Facility

$6,927.10

Service Code	HCPCS C1713
Hospital Charge Code	8504494
Hospital Revenue Code	278
Min. Negotiated Rate	$623.44
Max. Negotiated Rate	$3,463.55
Rate for Payer: Aetna Commercial	$2,078.13
Rate for Payer: Amerigroup CHIP/Medicaid	$623.44
Rate for Payer: BCBS of TX Blue Advantage	$2,078.13
Rate for Payer: BCBS of TX Blue Essentials	$2,493.76
Rate for Payer: BCBS of TX PPO	$2,770.84
Rate for Payer: Cash Price	$6,095.85
Rate for Payer: Multiplan Auto	$3,463.55
Rate for Payer: Multiplan Commercial	$3,463.55
Rate for Payer: Multiplan Workers Comp	$3,463.55
Rate for Payer: Scott and White EPO/PPO	$3,463.55
Rate for Payer: Superior Health Plan EPO	$942.09

SCREW POLYAXIAL

Facility

$5,722.89

Service Code	HCPCS C1713
Hospital Charge Code	8420453
Hospital Revenue Code	278
Min. Negotiated Rate	$515.06
Max. Negotiated Rate	$2,861.44
Rate for Payer: Aetna Commercial	$1,716.87
Rate for Payer: Amerigroup CHIP/Medicaid	$515.06
Rate for Payer: BCBS of TX Blue Advantage	$1,716.87
Rate for Payer: BCBS of TX Blue Essentials	$2,060.24
Rate for Payer: BCBS of TX PPO	$2,289.16
Rate for Payer: Cash Price	$5,036.14
Rate for Payer: Multiplan Auto	$2,861.44
Rate for Payer: Multiplan Commercial	$2,861.44
Rate for Payer: Multiplan Workers Comp	$2,861.44
Rate for Payer: Scott and White EPO/PPO	$2,861.44
Rate for Payer: Superior Health Plan EPO	$778.31

SCREW POLYAXIAL

Facility

$5,722.89

Service Code	HCPCS C1713
Hospital Charge Code	8420453
Hospital Revenue Code	278
Min. Negotiated Rate	$1,430.72
Max. Negotiated Rate	$2,861.44
Rate for Payer: Aetna Commercial	$1,716.87
Rate for Payer: Cash Price	$5,036.14
Rate for Payer: Cigna Commercial	$1,430.72
Rate for Payer: Multiplan Auto	$2,861.44
Rate for Payer: Multiplan Commercial	$2,861.44
Rate for Payer: Multiplan Workers Comp	$2,861.44
Rate for Payer: Scott and White EPO/PPO	$2,861.44

SCREW POLYAXIAL 6.4 X 40 SLOK

Facility

$18,554.22

Service Code	HCPCS C1713
Hospital Charge Code	8406458
Hospital Revenue Code	278
Min. Negotiated Rate	$4,638.56
Max. Negotiated Rate	$9,277.11
Rate for Payer: Aetna Commercial	$5,566.27
Rate for Payer: Cash Price	$16,327.71
Rate for Payer: Cigna Commercial	$4,638.56
Rate for Payer: Multiplan Auto	$9,277.11
Rate for Payer: Multiplan Commercial	$9,277.11
Rate for Payer: Multiplan Workers Comp	$9,277.11
Rate for Payer: Scott and White EPO/PPO	$9,277.11

SCREW POLYAXIAL 6.4 X 40 SLOK

Facility

$18,554.22

Service Code	HCPCS C1713
Hospital Charge Code	8406458
Hospital Revenue Code	278
Min. Negotiated Rate	$1,669.88
Max. Negotiated Rate	$9,277.11
Rate for Payer: Aetna Commercial	$5,566.27
Rate for Payer: Amerigroup CHIP/Medicaid	$1,669.88
Rate for Payer: BCBS of TX Blue Advantage	$5,566.27
Rate for Payer: BCBS of TX Blue Essentials	$6,679.52
Rate for Payer: BCBS of TX PPO	$7,421.69
Rate for Payer: Cash Price	$16,327.71
Rate for Payer: Multiplan Auto	$9,277.11
Rate for Payer: Multiplan Commercial	$9,277.11
Rate for Payer: Multiplan Workers Comp	$9,277.11
Rate for Payer: Scott and White EPO/PPO	$9,277.11
Rate for Payer: Superior Health Plan EPO	$2,523.37

SCREW POLYAXIAL 6.5 X 35 SLOK

Facility

$7,831.33

Service Code	HCPCS C1713
Hospital Charge Code	8404477
Hospital Revenue Code	278
Min. Negotiated Rate	$1,957.83
Max. Negotiated Rate	$3,915.66
Rate for Payer: Aetna Commercial	$2,349.40
Rate for Payer: Cash Price	$6,891.57
Rate for Payer: Cigna Commercial	$1,957.83
Rate for Payer: Multiplan Auto	$3,915.66
Rate for Payer: Multiplan Commercial	$3,915.66
Rate for Payer: Multiplan Workers Comp	$3,915.66
Rate for Payer: Scott and White EPO/PPO	$3,915.66

SCREW POLYAXIAL 6.5 X 35 SLOK

Facility

$7,831.33

Service Code	HCPCS C1713
Hospital Charge Code	8404477
Hospital Revenue Code	278
Min. Negotiated Rate	$704.82
Max. Negotiated Rate	$3,915.66
Rate for Payer: Aetna Commercial	$2,349.40
Rate for Payer: Amerigroup CHIP/Medicaid	$704.82
Rate for Payer: BCBS of TX Blue Advantage	$2,349.40
Rate for Payer: BCBS of TX Blue Essentials	$2,819.28
Rate for Payer: BCBS of TX PPO	$3,132.53
Rate for Payer: Cash Price	$6,891.57
Rate for Payer: Multiplan Auto	$3,915.66
Rate for Payer: Multiplan Commercial	$3,915.66
Rate for Payer: Multiplan Workers Comp	$3,915.66
Rate for Payer: Scott and White EPO/PPO	$3,915.66
Rate for Payer: Superior Health Plan EPO	$1,065.06

SCREW SELF DRILL VARIABLE 4.0 14

Facility

$1,859.50

Service Code	HCPCS C1713
Hospital Charge Code	8404458
Hospital Revenue Code	278
Min. Negotiated Rate	$464.88
Max. Negotiated Rate	$929.75
Rate for Payer: Aetna Commercial	$557.85
Rate for Payer: Cash Price	$1,636.36
Rate for Payer: Cigna Commercial	$464.88
Rate for Payer: Multiplan Auto	$929.75
Rate for Payer: Multiplan Commercial	$929.75
Rate for Payer: Multiplan Workers Comp	$929.75
Rate for Payer: Scott and White EPO/PPO	$929.75

SCREW SELF DRILL VARIABLE 4.0 14

Facility

$1,859.50

Service Code	HCPCS C1713
Hospital Charge Code	8404458
Hospital Revenue Code	278
Min. Negotiated Rate	$167.36
Max. Negotiated Rate	$929.75
Rate for Payer: Aetna Commercial	$557.85
Rate for Payer: Amerigroup CHIP/Medicaid	$167.36
Rate for Payer: BCBS of TX Blue Advantage	$557.85
Rate for Payer: BCBS of TX Blue Essentials	$669.42
Rate for Payer: BCBS of TX PPO	$743.80
Rate for Payer: Cash Price	$1,636.36
Rate for Payer: Multiplan Auto	$929.75
Rate for Payer: Multiplan Commercial	$929.75
Rate for Payer: Multiplan Workers Comp	$929.75
Rate for Payer: Scott and White EPO/PPO	$929.75
Rate for Payer: Superior Health Plan EPO	$252.89

SCREW SELF TAPPING

Facility

$1,325.30

Service Code	HCPCS C1713
Hospital Charge Code	8492476
Hospital Revenue Code	278
Min. Negotiated Rate	$331.32
Max. Negotiated Rate	$662.65
Rate for Payer: Aetna Commercial	$397.59
Rate for Payer: Cash Price	$1,166.26
Rate for Payer: Cigna Commercial	$331.32
Rate for Payer: Multiplan Auto	$662.65
Rate for Payer: Multiplan Commercial	$662.65
Rate for Payer: Multiplan Workers Comp	$662.65
Rate for Payer: Scott and White EPO/PPO	$662.65

SCREW SELF TAPPING

Facility

$1,325.30

Service Code	HCPCS C1713
Hospital Charge Code	8492476
Hospital Revenue Code	278
Min. Negotiated Rate	$119.28
Max. Negotiated Rate	$662.65
Rate for Payer: Aetna Commercial	$397.59
Rate for Payer: Amerigroup CHIP/Medicaid	$119.28
Rate for Payer: BCBS of TX Blue Advantage	$397.59
Rate for Payer: BCBS of TX Blue Essentials	$477.11
Rate for Payer: BCBS of TX PPO	$530.12
Rate for Payer: Cash Price	$1,166.26
Rate for Payer: Multiplan Auto	$662.65
Rate for Payer: Multiplan Commercial	$662.65
Rate for Payer: Multiplan Workers Comp	$662.65
Rate for Payer: Scott and White EPO/PPO	$662.65
Rate for Payer: Superior Health Plan EPO	$180.24

SCREW SET

Facility

$301.20

Service Code	HCPCS C1713
Hospital Charge Code	8504491
Hospital Revenue Code	278
Min. Negotiated Rate	$27.11
Max. Negotiated Rate	$150.60
Rate for Payer: Aetna Commercial	$90.36
Rate for Payer: Amerigroup CHIP/Medicaid	$27.11
Rate for Payer: BCBS of TX Blue Advantage	$90.36
Rate for Payer: BCBS of TX Blue Essentials	$108.43
Rate for Payer: BCBS of TX PPO	$120.48
Rate for Payer: Cash Price	$265.06
Rate for Payer: Multiplan Auto	$150.60
Rate for Payer: Multiplan Commercial	$150.60
Rate for Payer: Multiplan Workers Comp	$150.60
Rate for Payer: Scott and White EPO/PPO	$150.60
Rate for Payer: Superior Health Plan EPO	$40.96

SCREW SET

Facility

$301.20

Service Code	HCPCS C1713
Hospital Charge Code	8504491
Hospital Revenue Code	278
Min. Negotiated Rate	$75.30
Max. Negotiated Rate	$150.60
Rate for Payer: Aetna Commercial	$90.36
Rate for Payer: Cash Price	$265.06
Rate for Payer: Cigna Commercial	$75.30
Rate for Payer: Multiplan Auto	$150.60
Rate for Payer: Multiplan Commercial	$150.60
Rate for Payer: Multiplan Workers Comp	$150.60
Rate for Payer: Scott and White EPO/PPO	$150.60

screw set spine

Facility

$753.01

Service Code	HCPCS C1713
Hospital Charge Code	8666517
Hospital Revenue Code	278
Min. Negotiated Rate	$67.77
Max. Negotiated Rate	$376.50
Rate for Payer: Aetna Commercial	$225.90
Rate for Payer: Amerigroup CHIP/Medicaid	$67.77
Rate for Payer: BCBS of TX Blue Advantage	$225.90
Rate for Payer: BCBS of TX Blue Essentials	$271.08
Rate for Payer: BCBS of TX PPO	$301.20
Rate for Payer: Cash Price	$662.65
Rate for Payer: Multiplan Auto	$376.50
Rate for Payer: Multiplan Commercial	$376.50
Rate for Payer: Multiplan Workers Comp	$376.50
Rate for Payer: Scott and White EPO/PPO	$376.50
Rate for Payer: Superior Health Plan EPO	$102.41

screw set spine

Facility

$753.01

Service Code	HCPCS C1713
Hospital Charge Code	8666517
Hospital Revenue Code	278
Min. Negotiated Rate	$188.25
Max. Negotiated Rate	$376.50
Rate for Payer: Aetna Commercial	$225.90
Rate for Payer: Cash Price	$662.65
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Multiplan Auto	$376.50
Rate for Payer: Multiplan Commercial	$376.50
Rate for Payer: Multiplan Workers Comp	$376.50
Rate for Payer: Scott and White EPO/PPO	$376.50

SCREW SLOK POLYAXIAL PEDICLE

Facility

$7,831.33

Service Code	HCPCS C1713
Hospital Charge Code	8394464
Hospital Revenue Code	278
Min. Negotiated Rate	$704.82
Max. Negotiated Rate	$3,915.66
Rate for Payer: Aetna Commercial	$2,349.40
Rate for Payer: Amerigroup CHIP/Medicaid	$704.82
Rate for Payer: BCBS of TX Blue Advantage	$2,349.40
Rate for Payer: BCBS of TX Blue Essentials	$2,819.28
Rate for Payer: BCBS of TX PPO	$3,132.53
Rate for Payer: Cash Price	$6,891.57
Rate for Payer: Multiplan Auto	$3,915.66
Rate for Payer: Multiplan Commercial	$3,915.66
Rate for Payer: Multiplan Workers Comp	$3,915.66
Rate for Payer: Scott and White EPO/PPO	$3,915.66
Rate for Payer: Superior Health Plan EPO	$1,065.06

SCREW SLOK POLYAXIAL PEDICLE

Facility

$7,831.33

Service Code	HCPCS C1713
Hospital Charge Code	8394464
Hospital Revenue Code	278
Min. Negotiated Rate	$1,957.83
Max. Negotiated Rate	$3,915.66
Rate for Payer: Aetna Commercial	$2,349.40
Rate for Payer: Cash Price	$6,891.57
Rate for Payer: Cigna Commercial	$1,957.83
Rate for Payer: Multiplan Auto	$3,915.66
Rate for Payer: Multiplan Commercial	$3,915.66
Rate for Payer: Multiplan Workers Comp	$3,915.66
Rate for Payer: Scott and White EPO/PPO	$3,915.66

SCREW SPECIALITY TYPEI -- DHF

Facility

$135.85

Service Code	HCPCS C1713
Hospital Charge Code	81362667
Hospital Revenue Code	278
Min. Negotiated Rate	$12.23
Max. Negotiated Rate	$67.92
Rate for Payer: Aetna Commercial	$40.76
Rate for Payer: Amerigroup CHIP/Medicaid	$12.23
Rate for Payer: BCBS of TX Blue Advantage	$40.76
Rate for Payer: BCBS of TX Blue Essentials	$48.91
Rate for Payer: BCBS of TX PPO	$54.34
Rate for Payer: Cash Price	$119.55
Rate for Payer: Multiplan Auto	$67.92
Rate for Payer: Multiplan Commercial	$67.92
Rate for Payer: Multiplan Workers Comp	$67.92
Rate for Payer: Scott and White EPO/PPO	$67.92
Rate for Payer: Superior Health Plan EPO	$18.48

SCREW SPECIALITY TYPEI -- DHF

Facility

$135.85

Service Code	HCPCS C1713
Hospital Charge Code	81362667
Hospital Revenue Code	278
Min. Negotiated Rate	$33.96
Max. Negotiated Rate	$67.92
Rate for Payer: Aetna Commercial	$40.76
Rate for Payer: Cash Price	$119.55
Rate for Payer: Cigna Commercial	$33.96
Rate for Payer: Multiplan Auto	$67.92
Rate for Payer: Multiplan Commercial	$67.92
Rate for Payer: Multiplan Workers Comp	$67.92
Rate for Payer: Scott and White EPO/PPO	$67.92

SCREW SPECIALITY TYPEII -- DHF

Facility

$5,259.59

Service Code	HCPCS C1713
Hospital Charge Code	81362675
Hospital Revenue Code	278
Min. Negotiated Rate	$1,314.90
Max. Negotiated Rate	$2,629.80
Rate for Payer: Aetna Commercial	$1,577.88
Rate for Payer: Cash Price	$4,628.44
Rate for Payer: Cigna Commercial	$1,314.90
Rate for Payer: Multiplan Auto	$2,629.80
Rate for Payer: Multiplan Commercial	$2,629.80
Rate for Payer: Multiplan Workers Comp	$2,629.80
Rate for Payer: Scott and White EPO/PPO	$2,629.80

SCREW SPECIALITY TYPEII -- DHF

Facility

$5,259.59

Service Code	HCPCS C1713
Hospital Charge Code	81362675
Hospital Revenue Code	278
Min. Negotiated Rate	$473.36
Max. Negotiated Rate	$2,629.80
Rate for Payer: Aetna Commercial	$1,577.88
Rate for Payer: Amerigroup CHIP/Medicaid	$473.36
Rate for Payer: BCBS of TX Blue Advantage	$1,577.88
Rate for Payer: BCBS of TX Blue Essentials	$1,893.45
Rate for Payer: BCBS of TX PPO	$2,103.84
Rate for Payer: Cash Price	$4,628.44
Rate for Payer: Multiplan Auto	$2,629.80
Rate for Payer: Multiplan Commercial	$2,629.80
Rate for Payer: Multiplan Workers Comp	$2,629.80
Rate for Payer: Scott and White EPO/PPO	$2,629.80
Rate for Payer: Superior Health Plan EPO	$715.30

screw talon distal fix lag

Facility

$4,819.28

Service Code	HCPCS C1713
Hospital Charge Code	8720591
Hospital Revenue Code	278
Min. Negotiated Rate	$1,204.82
Max. Negotiated Rate	$2,409.64
Rate for Payer: Aetna Commercial	$1,445.78
Rate for Payer: Cash Price	$4,240.97
Rate for Payer: Cigna Commercial	$1,204.82
Rate for Payer: Multiplan Auto	$2,409.64
Rate for Payer: Multiplan Commercial	$2,409.64
Rate for Payer: Multiplan Workers Comp	$2,409.64
Rate for Payer: Scott and White EPO/PPO	$2,409.64

screw talon distal fix lag

Facility

$4,819.28

Service Code	HCPCS C1713
Hospital Charge Code	8720591
Hospital Revenue Code	278
Min. Negotiated Rate	$433.74
Max. Negotiated Rate	$2,409.64
Rate for Payer: Aetna Commercial	$1,445.78
Rate for Payer: Amerigroup CHIP/Medicaid	$433.74
Rate for Payer: BCBS of TX Blue Advantage	$1,445.78
Rate for Payer: BCBS of TX Blue Essentials	$1,734.94
Rate for Payer: BCBS of TX PPO	$1,927.71
Rate for Payer: Cash Price	$4,240.97
Rate for Payer: Multiplan Auto	$2,409.64
Rate for Payer: Multiplan Commercial	$2,409.64
Rate for Payer: Multiplan Workers Comp	$2,409.64
Rate for Payer: Scott and White EPO/PPO	$2,409.64
Rate for Payer: Superior Health Plan EPO	$655.42

Know your out-of-pocket cost for care.

All Charges