White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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 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 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 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 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

SCREW CANCELLOUS 6MM F/T

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	145596
Hospital Revenue Code	278
Min. Negotiated Rate	$77.50
Max. Negotiated Rate	$155.00
Rate for Payer: Cash Price	$210.80
Rate for Payer: Cigna Commercial	$77.50
Rate for Payer: Multiplan Auto	$155.00
Rate for Payer: Multiplan Commercial	$155.00
Rate for Payer: Multiplan Workers Comp	$155.00
Rate for Payer: Scott and White EPO/PPO	$155.00

SCREW CANCELLOUS 6MM F/T

Facility

$310.00

Service Code	HCPCS C1713
Hospital Charge Code	145596
Hospital Revenue Code	278
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$223.20
Rate for Payer: Amerigroup CHIP/Medicaid	$27.90
Rate for Payer: BCBS of TX Blue Advantage	$93.00
Rate for Payer: BCBS of TX Blue Essentials	$111.60
Rate for Payer: BCBS of TX PPO	$124.00
Rate for Payer: Cash Price	$210.80
Rate for Payer: Cigna Medicaid	$223.20
Rate for Payer: Molina CHIP/Medicaid	$223.20
Rate for Payer: Multiplan Auto	$155.00
Rate for Payer: Multiplan Commercial	$155.00
Rate for Payer: Multiplan Workers Comp	$155.00
Rate for Payer: Parkland Medicaid	$223.20
Rate for Payer: Scott and White EPO/PPO	$155.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$223.20
Rate for Payer: Superior Health Plan EPO	$42.16

SCREW CANN ASNIS III

Facility

$1,424.00

Service Code	HCPCS C1713
Hospital Charge Code	144885
Hospital Revenue Code	278
Min. Negotiated Rate	$128.16
Max. Negotiated Rate	$1,025.28
Rate for Payer: Amerigroup CHIP/Medicaid	$128.16
Rate for Payer: BCBS of TX Blue Advantage	$427.20
Rate for Payer: BCBS of TX Blue Essentials	$512.64
Rate for Payer: BCBS of TX PPO	$569.60
Rate for Payer: Cash Price	$968.32
Rate for Payer: Cigna Medicaid	$1,025.28
Rate for Payer: Molina CHIP/Medicaid	$1,025.28
Rate for Payer: Multiplan Auto	$712.00
Rate for Payer: Multiplan Commercial	$712.00
Rate for Payer: Multiplan Workers Comp	$712.00
Rate for Payer: Parkland Medicaid	$1,025.28
Rate for Payer: Scott and White EPO/PPO	$712.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,025.28
Rate for Payer: Superior Health Plan EPO	$193.66

SCREW CANN ASNIS III

Facility

$1,424.00

Service Code	HCPCS C1713
Hospital Charge Code	144885
Hospital Revenue Code	278
Min. Negotiated Rate	$356.00
Max. Negotiated Rate	$712.00
Rate for Payer: Cash Price	$968.32
Rate for Payer: Cigna Commercial	$356.00
Rate for Payer: Multiplan Auto	$712.00
Rate for Payer: Multiplan Commercial	$712.00
Rate for Payer: Multiplan Workers Comp	$712.00
Rate for Payer: Scott and White EPO/PPO	$712.00

SCREW CANN -- DHF

Facility

$1,225.00

Service Code	HCPCS C1713
Hospital Charge Code	81360315
Hospital Revenue Code	278
Min. Negotiated Rate	$306.25
Max. Negotiated Rate	$612.50
Rate for Payer: Cash Price	$833.00
Rate for Payer: Cigna Commercial	$306.25
Rate for Payer: Multiplan Auto	$612.50
Rate for Payer: Multiplan Commercial	$612.50
Rate for Payer: Multiplan Workers Comp	$612.50
Rate for Payer: Scott and White EPO/PPO	$612.50

SCREW CANN -- DHF

Facility

$1,225.00

Service Code	HCPCS C1713
Hospital Charge Code	81360315
Hospital Revenue Code	278
Min. Negotiated Rate	$110.25
Max. Negotiated Rate	$882.00
Rate for Payer: Amerigroup CHIP/Medicaid	$110.25
Rate for Payer: BCBS of TX Blue Advantage	$367.50
Rate for Payer: BCBS of TX Blue Essentials	$441.00
Rate for Payer: BCBS of TX PPO	$490.00
Rate for Payer: Cash Price	$833.00
Rate for Payer: Cigna Medicaid	$882.00
Rate for Payer: Molina CHIP/Medicaid	$882.00
Rate for Payer: Multiplan Auto	$612.50
Rate for Payer: Multiplan Commercial	$612.50
Rate for Payer: Multiplan Workers Comp	$612.50
Rate for Payer: Parkland Medicaid	$882.00
Rate for Payer: Scott and White EPO/PPO	$612.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$882.00
Rate for Payer: Superior Health Plan EPO	$166.60

SCREW CANNULATED

Facility

$2,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992140
Hospital Revenue Code	278
Min. Negotiated Rate	$585.84
Max. Negotiated Rate	$1,171.68
Rate for Payer: Cash Price	$1,593.49
Rate for Payer: Cigna Commercial	$585.84
Rate for Payer: Multiplan Auto	$1,171.68
Rate for Payer: Multiplan Commercial	$1,171.68
Rate for Payer: Multiplan Workers Comp	$1,171.68
Rate for Payer: Scott and White EPO/PPO	$1,171.68

SCREW CANNULATED

Facility

$2,343.37

Service Code	HCPCS C1713
Hospital Charge Code	992140
Hospital Revenue Code	278
Min. Negotiated Rate	$210.90
Max. Negotiated Rate	$1,687.23
Rate for Payer: Amerigroup CHIP/Medicaid	$210.90
Rate for Payer: BCBS of TX Blue Advantage	$703.01
Rate for Payer: BCBS of TX Blue Essentials	$843.61
Rate for Payer: BCBS of TX PPO	$937.35
Rate for Payer: Cash Price	$1,593.49
Rate for Payer: Cigna Medicaid	$1,687.23
Rate for Payer: Molina CHIP/Medicaid	$1,687.23
Rate for Payer: Multiplan Auto	$1,171.68
Rate for Payer: Multiplan Commercial	$1,171.68
Rate for Payer: Multiplan Workers Comp	$1,171.68
Rate for Payer: Parkland Medicaid	$1,687.23
Rate for Payer: Scott and White EPO/PPO	$1,171.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,687.23
Rate for Payer: Superior Health Plan EPO	$318.70

screw cannulated 4.0

Facility

$895.00

Service Code	HCPCS C1713
Hospital Charge Code	8654506
Hospital Revenue Code	278
Min. Negotiated Rate	$80.55
Max. Negotiated Rate	$644.40
Rate for Payer: Amerigroup CHIP/Medicaid	$80.55
Rate for Payer: BCBS of TX Blue Advantage	$268.50
Rate for Payer: BCBS of TX Blue Essentials	$322.20
Rate for Payer: BCBS of TX PPO	$358.00
Rate for Payer: Cash Price	$608.60
Rate for Payer: Cigna Medicaid	$644.40
Rate for Payer: Molina CHIP/Medicaid	$644.40
Rate for Payer: Multiplan Auto	$447.50
Rate for Payer: Multiplan Commercial	$447.50
Rate for Payer: Multiplan Workers Comp	$447.50
Rate for Payer: Parkland Medicaid	$644.40
Rate for Payer: Scott and White EPO/PPO	$447.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$644.40
Rate for Payer: Superior Health Plan EPO	$121.72

screw cannulated 4.0

Facility

$895.00

Service Code	HCPCS C1713
Hospital Charge Code	8654506
Hospital Revenue Code	278
Min. Negotiated Rate	$223.75
Max. Negotiated Rate	$447.50
Rate for Payer: Cash Price	$608.60
Rate for Payer: Cigna Commercial	$223.75
Rate for Payer: Multiplan Auto	$447.50
Rate for Payer: Multiplan Commercial	$447.50
Rate for Payer: Multiplan Workers Comp	$447.50
Rate for Payer: Scott and White EPO/PPO	$447.50

SCREW CANNULATED 4.0 X 28MM

Facility

$1,226.00

Service Code	HCPCS C1713
Hospital Charge Code	146436
Hospital Revenue Code	278
Min. Negotiated Rate	$110.34
Max. Negotiated Rate	$882.72
Rate for Payer: Amerigroup CHIP/Medicaid	$110.34
Rate for Payer: BCBS of TX Blue Advantage	$367.80
Rate for Payer: BCBS of TX Blue Essentials	$441.36
Rate for Payer: BCBS of TX PPO	$490.40
Rate for Payer: Cash Price	$833.68
Rate for Payer: Cigna Medicaid	$882.72
Rate for Payer: Molina CHIP/Medicaid	$882.72
Rate for Payer: Multiplan Auto	$613.00
Rate for Payer: Multiplan Commercial	$613.00
Rate for Payer: Multiplan Workers Comp	$613.00
Rate for Payer: Parkland Medicaid	$882.72
Rate for Payer: Scott and White EPO/PPO	$613.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$882.72
Rate for Payer: Superior Health Plan EPO	$166.74

SCREW CANNULATED 4.0 X 28MM

Facility

$1,226.00

Service Code	HCPCS C1713
Hospital Charge Code	146436
Hospital Revenue Code	278
Min. Negotiated Rate	$306.50
Max. Negotiated Rate	$613.00
Rate for Payer: Cash Price	$833.68
Rate for Payer: Cigna Commercial	$306.50
Rate for Payer: Multiplan Auto	$613.00
Rate for Payer: Multiplan Commercial	$613.00
Rate for Payer: Multiplan Workers Comp	$613.00
Rate for Payer: Scott and White EPO/PPO	$613.00

SCREW CANNULATED 6.5X100

Facility

$1,397.00

Service Code	HCPCS C1713
Hospital Charge Code	8562501
Hospital Revenue Code	278
Min. Negotiated Rate	$125.73
Max. Negotiated Rate	$1,005.84
Rate for Payer: Amerigroup CHIP/Medicaid	$125.73
Rate for Payer: BCBS of TX Blue Advantage	$419.10
Rate for Payer: BCBS of TX Blue Essentials	$502.92
Rate for Payer: BCBS of TX PPO	$558.80
Rate for Payer: Cash Price	$949.96
Rate for Payer: Cigna Medicaid	$1,005.84
Rate for Payer: Molina CHIP/Medicaid	$1,005.84
Rate for Payer: Multiplan Auto	$698.50
Rate for Payer: Multiplan Commercial	$698.50
Rate for Payer: Multiplan Workers Comp	$698.50
Rate for Payer: Parkland Medicaid	$1,005.84
Rate for Payer: Scott and White EPO/PPO	$698.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,005.84
Rate for Payer: Superior Health Plan EPO	$189.99

SCREW CANNULATED 6.5X100

Facility

$1,397.00

Service Code	HCPCS C1713
Hospital Charge Code	8562501
Hospital Revenue Code	278
Min. Negotiated Rate	$349.25
Max. Negotiated Rate	$698.50
Rate for Payer: Cash Price	$949.96
Rate for Payer: Cigna Commercial	$349.25
Rate for Payer: Multiplan Auto	$698.50
Rate for Payer: Multiplan Commercial	$698.50
Rate for Payer: Multiplan Workers Comp	$698.50
Rate for Payer: Scott and White EPO/PPO	$698.50

SCREW CANNULATED 6.5X90

Facility

$1,410.00

Service Code	HCPCS C1713
Hospital Charge Code	8562502
Hospital Revenue Code	278
Min. Negotiated Rate	$352.50
Max. Negotiated Rate	$705.00
Rate for Payer: Cash Price	$958.80
Rate for Payer: Cigna Commercial	$352.50
Rate for Payer: Multiplan Auto	$705.00
Rate for Payer: Multiplan Commercial	$705.00
Rate for Payer: Multiplan Workers Comp	$705.00
Rate for Payer: Scott and White EPO/PPO	$705.00

Know your out-of-pocket cost for care.

All Charges