White Rock Medical Center

All Charges

Charge

Type

Setting

Price

screw titanium 5.0 l3

Facility

$2,096.39

Service Code	HCPCS C1713
Hospital Charge Code	8720605
Hospital Revenue Code	278
Min. Negotiated Rate	$524.10
Max. Negotiated Rate	$1,048.20
Rate for Payer: Aetna Commercial	$628.92
Rate for Payer: Cash Price	$1,844.82
Rate for Payer: Cigna Commercial	$524.10
Rate for Payer: Multiplan Auto	$1,048.20
Rate for Payer: Multiplan Commercial	$1,048.20
Rate for Payer: Multiplan Workers Comp	$1,048.20
Rate for Payer: Scott and White EPO/PPO	$1,048.20

screw titanium 5.0 l3

Facility

$2,096.39

Service Code	HCPCS C1713
Hospital Charge Code	8720605
Hospital Revenue Code	278
Min. Negotiated Rate	$188.68
Max. Negotiated Rate	$1,048.20
Rate for Payer: Aetna Commercial	$628.92
Rate for Payer: Amerigroup CHIP/Medicaid	$188.68
Rate for Payer: BCBS of TX Blue Advantage	$628.92
Rate for Payer: BCBS of TX Blue Essentials	$754.70
Rate for Payer: BCBS of TX PPO	$838.56
Rate for Payer: Cash Price	$1,844.82
Rate for Payer: Multiplan Auto	$1,048.20
Rate for Payer: Multiplan Commercial	$1,048.20
Rate for Payer: Multiplan Workers Comp	$1,048.20
Rate for Payer: Scott and White EPO/PPO	$1,048.20
Rate for Payer: Superior Health Plan EPO	$285.11

SCREW VAULT 4.0 X 25MM

Facility

$2,108.43

Service Code	HCPCS C1713
Hospital Charge Code	8394459
Hospital Revenue Code	278
Min. Negotiated Rate	$527.11
Max. Negotiated Rate	$1,054.22
Rate for Payer: Aetna Commercial	$632.53
Rate for Payer: Cash Price	$1,855.42
Rate for Payer: Cigna Commercial	$527.11
Rate for Payer: Multiplan Auto	$1,054.22
Rate for Payer: Multiplan Commercial	$1,054.22
Rate for Payer: Multiplan Workers Comp	$1,054.22
Rate for Payer: Scott and White EPO/PPO	$1,054.22

SCREW VAULT 4.0 X 25MM

Facility

$2,108.43

Service Code	HCPCS C1713
Hospital Charge Code	8394459
Hospital Revenue Code	278
Min. Negotiated Rate	$189.76
Max. Negotiated Rate	$1,054.22
Rate for Payer: Aetna Commercial	$632.53
Rate for Payer: Amerigroup CHIP/Medicaid	$189.76
Rate for Payer: BCBS of TX Blue Advantage	$632.53
Rate for Payer: BCBS of TX Blue Essentials	$759.03
Rate for Payer: BCBS of TX PPO	$843.37
Rate for Payer: Cash Price	$1,855.42
Rate for Payer: Multiplan Auto	$1,054.22
Rate for Payer: Multiplan Commercial	$1,054.22
Rate for Payer: Multiplan Workers Comp	$1,054.22
Rate for Payer: Scott and White EPO/PPO	$1,054.22
Rate for Payer: Superior Health Plan EPO	$286.75

SCRW BN 81360059 -- DHF

Facility

$2,829.29

Service Code	HCPCS C1713
Hospital Charge Code	81360059
Hospital Revenue Code	278
Min. Negotiated Rate	$254.64
Max. Negotiated Rate	$1,414.64
Rate for Payer: Aetna Commercial	$848.79
Rate for Payer: Amerigroup CHIP/Medicaid	$254.64
Rate for Payer: BCBS of TX Blue Advantage	$848.79
Rate for Payer: BCBS of TX Blue Essentials	$1,018.54
Rate for Payer: BCBS of TX PPO	$1,131.72
Rate for Payer: Cash Price	$2,489.78
Rate for Payer: Multiplan Auto	$1,414.64
Rate for Payer: Multiplan Commercial	$1,414.64
Rate for Payer: Multiplan Workers Comp	$1,414.64
Rate for Payer: Scott and White EPO/PPO	$1,414.64
Rate for Payer: Superior Health Plan EPO	$384.78

SCRW BN 81360059 -- DHF

Facility

$2,829.29

Service Code	HCPCS C1713
Hospital Charge Code	81360059
Hospital Revenue Code	278
Min. Negotiated Rate	$707.32
Max. Negotiated Rate	$1,414.64
Rate for Payer: Aetna Commercial	$848.79
Rate for Payer: Cash Price	$2,489.78
Rate for Payer: Cigna Commercial	$707.32
Rate for Payer: Multiplan Auto	$1,414.64
Rate for Payer: Multiplan Commercial	$1,414.64
Rate for Payer: Multiplan Workers Comp	$1,414.64
Rate for Payer: Scott and White EPO/PPO	$1,414.64

SCRW BN 81360067 -- DHF

Facility

$273.80

Service Code	HCPCS C1713
Hospital Charge Code	81360067
Hospital Revenue Code	278
Min. Negotiated Rate	$68.45
Max. Negotiated Rate	$136.90
Rate for Payer: Aetna Commercial	$82.14
Rate for Payer: Cash Price	$240.94
Rate for Payer: Cigna Commercial	$68.45
Rate for Payer: Multiplan Auto	$136.90
Rate for Payer: Multiplan Commercial	$136.90
Rate for Payer: Multiplan Workers Comp	$136.90
Rate for Payer: Scott and White EPO/PPO	$136.90

SCRW BN 81360067 -- DHF

Facility

$273.80

Service Code	HCPCS C1713
Hospital Charge Code	81360067
Hospital Revenue Code	278
Min. Negotiated Rate	$24.64
Max. Negotiated Rate	$136.90
Rate for Payer: Aetna Commercial	$82.14
Rate for Payer: Amerigroup CHIP/Medicaid	$24.64
Rate for Payer: BCBS of TX Blue Advantage	$82.14
Rate for Payer: BCBS of TX Blue Essentials	$98.57
Rate for Payer: BCBS of TX PPO	$109.52
Rate for Payer: Cash Price	$240.94
Rate for Payer: Multiplan Auto	$136.90
Rate for Payer: Multiplan Commercial	$136.90
Rate for Payer: Multiplan Workers Comp	$136.90
Rate for Payer: Scott and White EPO/PPO	$136.90
Rate for Payer: Superior Health Plan EPO	$37.24

SCRW CANCL -- DHF

Facility

$3,355.50

Service Code	HCPCS C1713
Hospital Charge Code	81360208
Hospital Revenue Code	278
Min. Negotiated Rate	$302.00
Max. Negotiated Rate	$1,677.75
Rate for Payer: Aetna Commercial	$1,006.65
Rate for Payer: Amerigroup CHIP/Medicaid	$302.00
Rate for Payer: BCBS of TX Blue Advantage	$1,006.65
Rate for Payer: BCBS of TX Blue Essentials	$1,207.98
Rate for Payer: BCBS of TX PPO	$1,342.20
Rate for Payer: Cash Price	$2,952.84
Rate for Payer: Multiplan Auto	$1,677.75
Rate for Payer: Multiplan Commercial	$1,677.75
Rate for Payer: Multiplan Workers Comp	$1,677.75
Rate for Payer: Scott and White EPO/PPO	$1,677.75
Rate for Payer: Superior Health Plan EPO	$456.35

SCRW CANCL -- DHF

Facility

$3,355.50

Service Code	HCPCS C1713
Hospital Charge Code	81360208
Hospital Revenue Code	278
Min. Negotiated Rate	$838.88
Max. Negotiated Rate	$1,677.75
Rate for Payer: Aetna Commercial	$1,006.65
Rate for Payer: Cash Price	$2,952.84
Rate for Payer: Cigna Commercial	$838.88
Rate for Payer: Multiplan Auto	$1,677.75
Rate for Payer: Multiplan Commercial	$1,677.75
Rate for Payer: Multiplan Workers Comp	$1,677.75
Rate for Payer: Scott and White EPO/PPO	$1,677.75

SCRW CANN -- DHF

Facility

$3,795.61

Service Code	HCPCS C1713
Hospital Charge Code	81360307
Hospital Revenue Code	278
Min. Negotiated Rate	$341.60
Max. Negotiated Rate	$1,897.80
Rate for Payer: Aetna Commercial	$1,138.68
Rate for Payer: Amerigroup CHIP/Medicaid	$341.60
Rate for Payer: BCBS of TX Blue Advantage	$1,138.68
Rate for Payer: BCBS of TX Blue Essentials	$1,366.42
Rate for Payer: BCBS of TX PPO	$1,518.24
Rate for Payer: Cash Price	$3,340.14
Rate for Payer: Multiplan Auto	$1,897.80
Rate for Payer: Multiplan Commercial	$1,897.80
Rate for Payer: Multiplan Workers Comp	$1,897.80
Rate for Payer: Scott and White EPO/PPO	$1,897.80
Rate for Payer: Superior Health Plan EPO	$516.20

SCRW CANN -- DHF

Facility

$3,795.61

Service Code	HCPCS C1713
Hospital Charge Code	81360307
Hospital Revenue Code	278
Min. Negotiated Rate	$948.90
Max. Negotiated Rate	$1,897.80
Rate for Payer: Aetna Commercial	$1,138.68
Rate for Payer: Cash Price	$3,340.14
Rate for Payer: Cigna Commercial	$948.90
Rate for Payer: Multiplan Auto	$1,897.80
Rate for Payer: Multiplan Commercial	$1,897.80
Rate for Payer: Multiplan Workers Comp	$1,897.80
Rate for Payer: Scott and White EPO/PPO	$1,897.80

SCRW COMPRESS 81360505 -- DHF

Facility

$1,540.24

Service Code	HCPCS C1713
Hospital Charge Code	81360505
Hospital Revenue Code	278
Min. Negotiated Rate	$385.06
Max. Negotiated Rate	$770.12
Rate for Payer: Aetna Commercial	$462.07
Rate for Payer: Cash Price	$1,355.41
Rate for Payer: Cigna Commercial	$385.06
Rate for Payer: Multiplan Auto	$770.12
Rate for Payer: Multiplan Commercial	$770.12
Rate for Payer: Multiplan Workers Comp	$770.12
Rate for Payer: Scott and White EPO/PPO	$770.12

SCRW COMPRESS 81360505 -- DHF

Facility

$1,540.24

Service Code	HCPCS C1713
Hospital Charge Code	81360505
Hospital Revenue Code	278
Min. Negotiated Rate	$138.62
Max. Negotiated Rate	$770.12
Rate for Payer: Aetna Commercial	$462.07
Rate for Payer: Amerigroup CHIP/Medicaid	$138.62
Rate for Payer: BCBS of TX Blue Advantage	$462.07
Rate for Payer: BCBS of TX Blue Essentials	$554.49
Rate for Payer: BCBS of TX PPO	$616.10
Rate for Payer: Cash Price	$1,355.41
Rate for Payer: Multiplan Auto	$770.12
Rate for Payer: Multiplan Commercial	$770.12
Rate for Payer: Multiplan Workers Comp	$770.12
Rate for Payer: Scott and White EPO/PPO	$770.12
Rate for Payer: Superior Health Plan EPO	$209.47

SCRW COMPRESS 81360554 -- DHF

Facility

$241.36

Service Code	HCPCS C1713
Hospital Charge Code	81360554
Hospital Revenue Code	278
Min. Negotiated Rate	$21.72
Max. Negotiated Rate	$120.68
Rate for Payer: Aetna Commercial	$72.41
Rate for Payer: Amerigroup CHIP/Medicaid	$21.72
Rate for Payer: BCBS of TX Blue Advantage	$72.41
Rate for Payer: BCBS of TX Blue Essentials	$86.89
Rate for Payer: BCBS of TX PPO	$96.54
Rate for Payer: Cash Price	$212.40
Rate for Payer: Multiplan Auto	$120.68
Rate for Payer: Multiplan Commercial	$120.68
Rate for Payer: Multiplan Workers Comp	$120.68
Rate for Payer: Scott and White EPO/PPO	$120.68
Rate for Payer: Superior Health Plan EPO	$32.82

SCRW COMPRESS 81360554 -- DHF

Facility

$241.36

Service Code	HCPCS C1713
Hospital Charge Code	81360554
Hospital Revenue Code	278
Min. Negotiated Rate	$60.34
Max. Negotiated Rate	$120.68
Rate for Payer: Aetna Commercial	$72.41
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cigna Commercial	$60.34
Rate for Payer: Multiplan Auto	$120.68
Rate for Payer: Multiplan Commercial	$120.68
Rate for Payer: Multiplan Workers Comp	$120.68
Rate for Payer: Scott and White EPO/PPO	$120.68

SCRW CORTICAL -- DHF

Facility

$662.72

Service Code	HCPCS C1713
Hospital Charge Code	81360711
Hospital Revenue Code	278
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$331.36
Rate for Payer: Aetna Commercial	$198.82
Rate for Payer: Amerigroup CHIP/Medicaid	$59.64
Rate for Payer: BCBS of TX Blue Advantage	$198.82
Rate for Payer: BCBS of TX Blue Essentials	$238.58
Rate for Payer: BCBS of TX PPO	$265.09
Rate for Payer: Cash Price	$583.19
Rate for Payer: Multiplan Auto	$331.36
Rate for Payer: Multiplan Commercial	$331.36
Rate for Payer: Multiplan Workers Comp	$331.36
Rate for Payer: Scott and White EPO/PPO	$331.36
Rate for Payer: Superior Health Plan EPO	$90.13

SCRW CORTICAL -- DHF

Facility

$662.72

Service Code	HCPCS C1713
Hospital Charge Code	81360711
Hospital Revenue Code	278
Min. Negotiated Rate	$165.68
Max. Negotiated Rate	$331.36
Rate for Payer: Aetna Commercial	$198.82
Rate for Payer: Cash Price	$583.19
Rate for Payer: Cigna Commercial	$165.68
Rate for Payer: Multiplan Auto	$331.36
Rate for Payer: Multiplan Commercial	$331.36
Rate for Payer: Multiplan Workers Comp	$331.36
Rate for Payer: Scott and White EPO/PPO	$331.36

SCRW CORTX -- DHF

Facility

$297.52

Service Code	HCPCS C1713
Hospital Charge Code	81360679
Hospital Revenue Code	278
Min. Negotiated Rate	$74.38
Max. Negotiated Rate	$148.76
Rate for Payer: Aetna Commercial	$89.26
Rate for Payer: Cash Price	$261.82
Rate for Payer: Cigna Commercial	$74.38
Rate for Payer: Multiplan Auto	$148.76
Rate for Payer: Multiplan Commercial	$148.76
Rate for Payer: Multiplan Workers Comp	$148.76
Rate for Payer: Scott and White EPO/PPO	$148.76

SCRW CORTX -- DHF

Facility

$297.52

Service Code	HCPCS C1713
Hospital Charge Code	81360679
Hospital Revenue Code	278
Min. Negotiated Rate	$26.78
Max. Negotiated Rate	$148.76
Rate for Payer: Aetna Commercial	$89.26
Rate for Payer: Amerigroup CHIP/Medicaid	$26.78
Rate for Payer: BCBS of TX Blue Advantage	$89.26
Rate for Payer: BCBS of TX Blue Essentials	$107.11
Rate for Payer: BCBS of TX PPO	$119.01
Rate for Payer: Cash Price	$261.82
Rate for Payer: Multiplan Auto	$148.76
Rate for Payer: Multiplan Commercial	$148.76
Rate for Payer: Multiplan Workers Comp	$148.76
Rate for Payer: Scott and White EPO/PPO	$148.76
Rate for Payer: Superior Health Plan EPO	$40.46

SCRW INTRAFIX ADVNC BR SHTH -- DHF

Facility

$7,446.28

Service Code	HCPCS C1713
Hospital Charge Code	81361883
Hospital Revenue Code	278
Min. Negotiated Rate	$1,861.57
Max. Negotiated Rate	$3,723.14
Rate for Payer: Aetna Commercial	$2,233.88
Rate for Payer: Cash Price	$6,552.73
Rate for Payer: Cigna Commercial	$1,861.57
Rate for Payer: Multiplan Auto	$3,723.14
Rate for Payer: Multiplan Commercial	$3,723.14
Rate for Payer: Multiplan Workers Comp	$3,723.14
Rate for Payer: Scott and White EPO/PPO	$3,723.14

SCRW INTRAFIX ADVNC BR SHTH -- DHF

Facility

$7,446.28

Service Code	HCPCS C1713
Hospital Charge Code	81361883
Hospital Revenue Code	278
Min. Negotiated Rate	$670.17
Max. Negotiated Rate	$3,723.14
Rate for Payer: Aetna Commercial	$2,233.88
Rate for Payer: Amerigroup CHIP/Medicaid	$670.17
Rate for Payer: BCBS of TX Blue Advantage	$2,233.88
Rate for Payer: BCBS of TX Blue Essentials	$2,680.66
Rate for Payer: BCBS of TX PPO	$2,978.51
Rate for Payer: Cash Price	$6,552.73
Rate for Payer: Multiplan Auto	$3,723.14
Rate for Payer: Multiplan Commercial	$3,723.14
Rate for Payer: Multiplan Workers Comp	$3,723.14
Rate for Payer: Scott and White EPO/PPO	$3,723.14
Rate for Payer: Superior Health Plan EPO	$1,012.69

SCRW LCK SLF TAP -- DHF

Facility

$942.14

Service Code	HCPCS C1713
Hospital Charge Code	81361990
Hospital Revenue Code	278
Min. Negotiated Rate	$235.54
Max. Negotiated Rate	$471.07
Rate for Payer: Aetna Commercial	$282.64
Rate for Payer: Cash Price	$829.08
Rate for Payer: Cigna Commercial	$235.54
Rate for Payer: Multiplan Auto	$471.07
Rate for Payer: Multiplan Commercial	$471.07
Rate for Payer: Multiplan Workers Comp	$471.07
Rate for Payer: Scott and White EPO/PPO	$471.07

SCRW LCK SLF TAP -- DHF

Facility

$942.14

Service Code	HCPCS C1713
Hospital Charge Code	81361990
Hospital Revenue Code	278
Min. Negotiated Rate	$84.79
Max. Negotiated Rate	$471.07
Rate for Payer: Aetna Commercial	$282.64
Rate for Payer: Amerigroup CHIP/Medicaid	$84.79
Rate for Payer: BCBS of TX Blue Advantage	$282.64
Rate for Payer: BCBS of TX Blue Essentials	$339.17
Rate for Payer: BCBS of TX PPO	$376.86
Rate for Payer: Cash Price	$829.08
Rate for Payer: Multiplan Auto	$471.07
Rate for Payer: Multiplan Commercial	$471.07
Rate for Payer: Multiplan Workers Comp	$471.07
Rate for Payer: Scott and White EPO/PPO	$471.07
Rate for Payer: Superior Health Plan EPO	$128.13

SCRW LCK TIT -- DHF

Facility

$845.37

Service Code	HCPCS C1713
Hospital Charge Code	81361941
Hospital Revenue Code	278
Min. Negotiated Rate	$76.08
Max. Negotiated Rate	$422.68
Rate for Payer: Aetna Commercial	$253.61
Rate for Payer: Amerigroup CHIP/Medicaid	$76.08
Rate for Payer: BCBS of TX Blue Advantage	$253.61
Rate for Payer: BCBS of TX Blue Essentials	$304.33
Rate for Payer: BCBS of TX PPO	$338.15
Rate for Payer: Cash Price	$743.93
Rate for Payer: Multiplan Auto	$422.68
Rate for Payer: Multiplan Commercial	$422.68
Rate for Payer: Multiplan Workers Comp	$422.68
Rate for Payer: Scott and White EPO/PPO	$422.68
Rate for Payer: Superior Health Plan EPO	$114.97

Know your out-of-pocket cost for care.

All Charges