White Rock Medical Center

All Charges

Charge

Type

Setting

Price

scopolamine 1.3 mg TD Film, ER

Facility

$62.35

Service Code	HCPCS J3490
Hospital Charge Code	78876081
Hospital Revenue Code	250
Rate for Payer: Cash Price	$42.40

Screening test of visual acuity, quantitative, bilateral

Facility

$32.30

Service Code	HCPCS 99173
Hospital Charge Code	994128
Hospital Revenue Code	761
Rate for Payer: Cash Price	$21.96

Screening test of visual acuity, quantitative, bilateral

Facility

$32.30

Service Code	HCPCS 99173
Hospital Charge Code	994128
Hospital Revenue Code	761
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$50.00
Rate for Payer: Amerigroup CHIP/Medicaid	$2.91
Rate for Payer: BCBS of TX Blue Advantage	$38.00
Rate for Payer: BCBS of TX Blue Essentials	$45.00
Rate for Payer: BCBS of TX PPO	$50.00
Rate for Payer: Cash Price	$21.96
Rate for Payer: Cash Price	$21.96
Rate for Payer: Cigna Medicaid	$23.26
Rate for Payer: Molina CHIP/Medicaid	$23.26
Rate for Payer: Multiplan Auto	$21.00
Rate for Payer: Multiplan Commercial	$21.00
Rate for Payer: Multiplan Workers Comp	$21.00
Rate for Payer: Parkland Medicaid	$23.26
Rate for Payer: Scott and White EPO/PPO	$16.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$23.26
Rate for Payer: Superior Health Plan EPO	$4.39

SCREW

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992136
Hospital Revenue Code	278
Min. Negotiated Rate	$159.64
Max. Negotiated Rate	$319.27
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Commercial	$159.64
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Scott and White EPO/PPO	$319.27

SCREW

Facility

$638.55

Service Code	HCPCS C1713
Hospital Charge Code	992136
Hospital Revenue Code	278
Min. Negotiated Rate	$57.47
Max. Negotiated Rate	$459.76
Rate for Payer: Amerigroup CHIP/Medicaid	$57.47
Rate for Payer: BCBS of TX Blue Advantage	$191.56
Rate for Payer: BCBS of TX Blue Essentials	$229.88
Rate for Payer: BCBS of TX PPO	$255.42
Rate for Payer: Cash Price	$434.21
Rate for Payer: Cigna Medicaid	$459.76
Rate for Payer: Molina CHIP/Medicaid	$459.76
Rate for Payer: Multiplan Auto	$319.27
Rate for Payer: Multiplan Commercial	$319.27
Rate for Payer: Multiplan Workers Comp	$319.27
Rate for Payer: Parkland Medicaid	$459.76
Rate for Payer: Scott and White EPO/PPO	$319.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$459.76
Rate for Payer: Superior Health Plan EPO	$86.84

SCREW 3.5MM HEX HEAD

Facility

$936.00

Service Code	HCPCS C1713
Hospital Charge Code	144886
Hospital Revenue Code	278
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$468.00
Rate for Payer: Cash Price	$636.48
Rate for Payer: Cigna Commercial	$234.00
Rate for Payer: Multiplan Auto	$468.00
Rate for Payer: Multiplan Commercial	$468.00
Rate for Payer: Multiplan Workers Comp	$468.00
Rate for Payer: Scott and White EPO/PPO	$468.00

SCREW 3.5MM HEX HEAD

Facility

$936.00

Service Code	HCPCS C1713
Hospital Charge Code	144886
Hospital Revenue Code	278
Min. Negotiated Rate	$84.24
Max. Negotiated Rate	$673.92
Rate for Payer: Amerigroup CHIP/Medicaid	$84.24
Rate for Payer: BCBS of TX Blue Advantage	$280.80
Rate for Payer: BCBS of TX Blue Essentials	$336.96
Rate for Payer: BCBS of TX PPO	$374.40
Rate for Payer: Cash Price	$636.48
Rate for Payer: Cigna Medicaid	$673.92
Rate for Payer: Molina CHIP/Medicaid	$673.92
Rate for Payer: Multiplan Auto	$468.00
Rate for Payer: Multiplan Commercial	$468.00
Rate for Payer: Multiplan Workers Comp	$468.00
Rate for Payer: Parkland Medicaid	$673.92
Rate for Payer: Scott and White EPO/PPO	$468.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$673.92
Rate for Payer: Superior Health Plan EPO	$127.30

SCREW 602685 602680 602675

Facility

$2,246.99

Service Code	HCPCS C1713
Hospital Charge Code	994086
Hospital Revenue Code	278
Min. Negotiated Rate	$202.23
Max. Negotiated Rate	$1,617.83
Rate for Payer: Amerigroup CHIP/Medicaid	$202.23
Rate for Payer: BCBS of TX Blue Advantage	$674.10
Rate for Payer: BCBS of TX Blue Essentials	$808.92
Rate for Payer: BCBS of TX PPO	$898.80
Rate for Payer: Cash Price	$1,527.95
Rate for Payer: Cigna Medicaid	$1,617.83
Rate for Payer: Molina CHIP/Medicaid	$1,617.83
Rate for Payer: Multiplan Auto	$1,123.49
Rate for Payer: Multiplan Commercial	$1,123.49
Rate for Payer: Multiplan Workers Comp	$1,123.49
Rate for Payer: Parkland Medicaid	$1,617.83
Rate for Payer: Scott and White EPO/PPO	$1,123.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,617.83
Rate for Payer: Superior Health Plan EPO	$305.59

SCREW 602685 602680 602675

Facility

$2,246.99

Service Code	HCPCS C1713
Hospital Charge Code	994086
Hospital Revenue Code	278
Min. Negotiated Rate	$561.75
Max. Negotiated Rate	$1,123.49
Rate for Payer: Cash Price	$1,527.95
Rate for Payer: Cigna Commercial	$561.75
Rate for Payer: Multiplan Auto	$1,123.49
Rate for Payer: Multiplan Commercial	$1,123.49
Rate for Payer: Multiplan Workers Comp	$1,123.49
Rate for Payer: Scott and White EPO/PPO	$1,123.49

SCREW ACF 4.0 SELF DRILLING SDV40

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8420463
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

SCREW ACF 4.0 SELF DRILLING SDV40

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8420463
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

SCREW ACIFSLF DRL FXD 4.0X16

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8568969
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

SCREW ACIFSLF DRL FXD 4.0X16

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8568969
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

SCREW ACIF SLF DRL FXD 4X12

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8568968
Hospital Revenue Code	278
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$753.00
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Commercial	$376.50
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Scott and White EPO/PPO	$753.00

SCREW ACIF SLF DRL FXD 4X12

Facility

$1,506.00

Service Code	HCPCS C1713
Hospital Charge Code	8568968
Hospital Revenue Code	278
Min. Negotiated Rate	$135.54
Max. Negotiated Rate	$1,084.32
Rate for Payer: Amerigroup CHIP/Medicaid	$135.54
Rate for Payer: BCBS of TX Blue Advantage	$451.80
Rate for Payer: BCBS of TX Blue Essentials	$542.16
Rate for Payer: BCBS of TX PPO	$602.40
Rate for Payer: Cash Price	$1,024.08
Rate for Payer: Cigna Medicaid	$1,084.32
Rate for Payer: Molina CHIP/Medicaid	$1,084.32
Rate for Payer: Multiplan Auto	$753.00
Rate for Payer: Multiplan Commercial	$753.00
Rate for Payer: Multiplan Workers Comp	$753.00
Rate for Payer: Parkland Medicaid	$1,084.32
Rate for Payer: Scott and White EPO/PPO	$753.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,084.32
Rate for Payer: Superior Health Plan EPO	$204.82

SCREW BN TAP CORTICAL 4.5X48NL 661748

Facility

$276.00

Service Code	HCPCS C1713
Hospital Charge Code	145155
Hospital Revenue Code	278
Min. Negotiated Rate	$24.84
Max. Negotiated Rate	$198.72
Rate for Payer: Amerigroup CHIP/Medicaid	$24.84
Rate for Payer: BCBS of TX Blue Advantage	$82.80
Rate for Payer: BCBS of TX Blue Essentials	$99.36
Rate for Payer: BCBS of TX PPO	$110.40
Rate for Payer: Cash Price	$187.68
Rate for Payer: Cigna Medicaid	$198.72
Rate for Payer: Molina CHIP/Medicaid	$198.72
Rate for Payer: Multiplan Auto	$138.00
Rate for Payer: Multiplan Commercial	$138.00
Rate for Payer: Multiplan Workers Comp	$138.00
Rate for Payer: Parkland Medicaid	$198.72
Rate for Payer: Scott and White EPO/PPO	$138.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$198.72
Rate for Payer: Superior Health Plan EPO	$37.54

SCREW BN TAP CORTICAL 4.5X48NL 661748

Facility

$276.00

Service Code	HCPCS C1713
Hospital Charge Code	145155
Hospital Revenue Code	278
Min. Negotiated Rate	$69.00
Max. Negotiated Rate	$138.00
Rate for Payer: Cash Price	$187.68
Rate for Payer: Cigna Commercial	$69.00
Rate for Payer: Multiplan Auto	$138.00
Rate for Payer: Multiplan Commercial	$138.00
Rate for Payer: Multiplan Workers Comp	$138.00
Rate for Payer: Scott and White EPO/PPO	$138.00

screw bone full thread

Facility

$518.00

Service Code	HCPCS C1713
Hospital Charge Code	8702510
Hospital Revenue Code	278
Min. Negotiated Rate	$46.62
Max. Negotiated Rate	$372.96
Rate for Payer: Amerigroup CHIP/Medicaid	$46.62
Rate for Payer: BCBS of TX Blue Advantage	$155.40
Rate for Payer: BCBS of TX Blue Essentials	$186.48
Rate for Payer: BCBS of TX PPO	$207.20
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cigna Medicaid	$372.96
Rate for Payer: Molina CHIP/Medicaid	$372.96
Rate for Payer: Multiplan Auto	$259.00
Rate for Payer: Multiplan Commercial	$259.00
Rate for Payer: Multiplan Workers Comp	$259.00
Rate for Payer: Parkland Medicaid	$372.96
Rate for Payer: Scott and White EPO/PPO	$259.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$372.96
Rate for Payer: Superior Health Plan EPO	$70.45

screw bone full thread

Facility

$518.00

Service Code	HCPCS C1713
Hospital Charge Code	8702510
Hospital Revenue Code	278
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$259.00
Rate for Payer: Cash Price	$352.24
Rate for Payer: Cigna Commercial	$129.50
Rate for Payer: Multiplan Auto	$259.00
Rate for Payer: Multiplan Commercial	$259.00
Rate for Payer: Multiplan Workers Comp	$259.00
Rate for Payer: Scott and White EPO/PPO	$259.00

SCREW BONE LOCKING

Facility

$1,845.00

Service Code	HCPCS C1713
Hospital Charge Code	8428501
Hospital Revenue Code	278
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$922.50
Rate for Payer: Cash Price	$1,254.60
Rate for Payer: Cigna Commercial	$461.25
Rate for Payer: Multiplan Auto	$922.50
Rate for Payer: Multiplan Commercial	$922.50
Rate for Payer: Multiplan Workers Comp	$922.50
Rate for Payer: Scott and White EPO/PPO	$922.50

SCREW BONE LOCKING

Facility

$1,845.00

Service Code	HCPCS C1713
Hospital Charge Code	8428501
Hospital Revenue Code	278
Min. Negotiated Rate	$166.05
Max. Negotiated Rate	$1,328.40
Rate for Payer: Amerigroup CHIP/Medicaid	$166.05
Rate for Payer: BCBS of TX Blue Advantage	$553.50
Rate for Payer: BCBS of TX Blue Essentials	$664.20
Rate for Payer: BCBS of TX PPO	$738.00
Rate for Payer: Cash Price	$1,254.60
Rate for Payer: Cigna Medicaid	$1,328.40
Rate for Payer: Molina CHIP/Medicaid	$1,328.40
Rate for Payer: Multiplan Auto	$922.50
Rate for Payer: Multiplan Commercial	$922.50
Rate for Payer: Multiplan Workers Comp	$922.50
Rate for Payer: Parkland Medicaid	$1,328.40
Rate for Payer: Scott and White EPO/PPO	$922.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,328.40
Rate for Payer: Superior Health Plan EPO	$250.92

SCREW BONE T8 FULL THREAD 2.7X12

Facility

$699.00

Service Code	HCPCS C1713
Hospital Charge Code	145594
Hospital Revenue Code	278
Min. Negotiated Rate	$62.91
Max. Negotiated Rate	$503.28
Rate for Payer: Amerigroup CHIP/Medicaid	$62.91
Rate for Payer: BCBS of TX Blue Advantage	$209.70
Rate for Payer: BCBS of TX Blue Essentials	$251.64
Rate for Payer: BCBS of TX PPO	$279.60
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cigna Medicaid	$503.28
Rate for Payer: Molina CHIP/Medicaid	$503.28
Rate for Payer: Multiplan Auto	$349.50
Rate for Payer: Multiplan Commercial	$349.50
Rate for Payer: Multiplan Workers Comp	$349.50
Rate for Payer: Parkland Medicaid	$503.28
Rate for Payer: Scott and White EPO/PPO	$349.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$503.28
Rate for Payer: Superior Health Plan EPO	$95.06

SCREW BONE T8 FULL THREAD 2.7X12

Facility

$699.00

Service Code	HCPCS C1713
Hospital Charge Code	145594
Hospital Revenue Code	278
Min. Negotiated Rate	$174.75
Max. Negotiated Rate	$349.50
Rate for Payer: Cash Price	$475.32
Rate for Payer: Cigna Commercial	$174.75
Rate for Payer: Multiplan Auto	$349.50
Rate for Payer: Multiplan Commercial	$349.50
Rate for Payer: Multiplan Workers Comp	$349.50
Rate for Payer: Scott and White EPO/PPO	$349.50

SCREW CANCELLOUS6.0X80 608080

Facility

$249.00

Service Code	HCPCS C1713
Hospital Charge Code	145153
Hospital Revenue Code	278
Min. Negotiated Rate	$22.41
Max. Negotiated Rate	$179.28
Rate for Payer: Amerigroup CHIP/Medicaid	$22.41
Rate for Payer: BCBS of TX Blue Advantage	$74.70
Rate for Payer: BCBS of TX Blue Essentials	$89.64
Rate for Payer: BCBS of TX PPO	$99.60
Rate for Payer: Cash Price	$169.32
Rate for Payer: Cigna Medicaid	$179.28
Rate for Payer: Molina CHIP/Medicaid	$179.28
Rate for Payer: Multiplan Auto	$124.50
Rate for Payer: Multiplan Commercial	$124.50
Rate for Payer: Multiplan Workers Comp	$124.50
Rate for Payer: Parkland Medicaid	$179.28
Rate for Payer: Scott and White EPO/PPO	$124.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$179.28
Rate for Payer: Superior Health Plan EPO	$33.86

SCREW CANCELLOUS6.0X80 608080

Facility

$249.00

Service Code	HCPCS C1713
Hospital Charge Code	145153
Hospital Revenue Code	278
Min. Negotiated Rate	$62.25
Max. Negotiated Rate	$124.50
Rate for Payer: Cash Price	$169.32
Rate for Payer: Cigna Commercial	$62.25
Rate for Payer: Multiplan Auto	$124.50
Rate for Payer: Multiplan Commercial	$124.50
Rate for Payer: Multiplan Workers Comp	$124.50
Rate for Payer: Scott and White EPO/PPO	$124.50

Know your out-of-pocket cost for care.

All Charges