White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 -- 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 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 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

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 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

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 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	$126.90
Max. Negotiated Rate	$1,015.20
Rate for Payer: Amerigroup CHIP/Medicaid	$126.90
Rate for Payer: BCBS of TX Blue Advantage	$423.00
Rate for Payer: BCBS of TX Blue Essentials	$507.60
Rate for Payer: BCBS of TX PPO	$564.00
Rate for Payer: Cash Price	$958.80
Rate for Payer: Cigna Medicaid	$1,015.20
Rate for Payer: Molina CHIP/Medicaid	$1,015.20
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: Parkland Medicaid	$1,015.20
Rate for Payer: Scott and White EPO/PPO	$705.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,015.20
Rate for Payer: Superior Health Plan EPO	$191.76

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

SCREW CANNULATED 6.5 X 95

Facility

$1,828.00

Service Code	HCPCS C1713
Hospital Charge Code	140603
Hospital Revenue Code	278
Min. Negotiated Rate	$164.52
Max. Negotiated Rate	$1,316.16
Rate for Payer: Amerigroup CHIP/Medicaid	$164.52
Rate for Payer: BCBS of TX Blue Advantage	$548.40
Rate for Payer: BCBS of TX Blue Essentials	$658.08
Rate for Payer: BCBS of TX PPO	$731.20
Rate for Payer: Cash Price	$1,243.04
Rate for Payer: Cigna Medicaid	$1,316.16
Rate for Payer: Molina CHIP/Medicaid	$1,316.16
Rate for Payer: Multiplan Auto	$914.00
Rate for Payer: Multiplan Commercial	$914.00
Rate for Payer: Multiplan Workers Comp	$914.00
Rate for Payer: Parkland Medicaid	$1,316.16
Rate for Payer: Scott and White EPO/PPO	$914.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,316.16
Rate for Payer: Superior Health Plan EPO	$248.61

SCREW CANNULATED 6.5 X 95

Facility

$1,828.00

Service Code	HCPCS C1713
Hospital Charge Code	140603
Hospital Revenue Code	278
Min. Negotiated Rate	$457.00
Max. Negotiated Rate	$914.00
Rate for Payer: Cash Price	$1,243.04
Rate for Payer: Cigna Commercial	$457.00
Rate for Payer: Multiplan Auto	$914.00
Rate for Payer: Multiplan Commercial	$914.00
Rate for Payer: Multiplan Workers Comp	$914.00
Rate for Payer: Scott and White EPO/PPO	$914.00

SCREW CANNULATED COMP HEADLESS

Facility

$2,417.00

Service Code	HCPCS C1713
Hospital Charge Code	8612540
Hospital Revenue Code	278
Min. Negotiated Rate	$604.25
Max. Negotiated Rate	$1,208.50
Rate for Payer: Cash Price	$1,643.56
Rate for Payer: Cigna Commercial	$604.25
Rate for Payer: Multiplan Auto	$1,208.50
Rate for Payer: Multiplan Commercial	$1,208.50
Rate for Payer: Multiplan Workers Comp	$1,208.50
Rate for Payer: Scott and White EPO/PPO	$1,208.50

SCREW CANNULATED COMP HEADLESS

Facility

$2,417.00

Service Code	HCPCS C1713
Hospital Charge Code	8612540
Hospital Revenue Code	278
Min. Negotiated Rate	$217.53
Max. Negotiated Rate	$1,740.24
Rate for Payer: Amerigroup CHIP/Medicaid	$217.53
Rate for Payer: BCBS of TX Blue Advantage	$725.10
Rate for Payer: BCBS of TX Blue Essentials	$870.12
Rate for Payer: BCBS of TX PPO	$966.80
Rate for Payer: Cash Price	$1,643.56
Rate for Payer: Cigna Medicaid	$1,740.24
Rate for Payer: Molina CHIP/Medicaid	$1,740.24
Rate for Payer: Multiplan Auto	$1,208.50
Rate for Payer: Multiplan Commercial	$1,208.50
Rate for Payer: Multiplan Workers Comp	$1,208.50
Rate for Payer: Parkland Medicaid	$1,740.24
Rate for Payer: Scott and White EPO/PPO	$1,208.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,740.24
Rate for Payer: Superior Health Plan EPO	$328.71

SCREW CANNULATED COMPRESSION

Facility

$1,811.00

Service Code	HCPCS C1713
Hospital Charge Code	146478
Hospital Revenue Code	278
Min. Negotiated Rate	$452.75
Max. Negotiated Rate	$905.50
Rate for Payer: Cash Price	$1,231.48
Rate for Payer: Cigna Commercial	$452.75
Rate for Payer: Multiplan Auto	$905.50
Rate for Payer: Multiplan Commercial	$905.50
Rate for Payer: Multiplan Workers Comp	$905.50
Rate for Payer: Scott and White EPO/PPO	$905.50

SCREW CANNULATED COMPRESSION

Facility

$1,811.00

Service Code	HCPCS C1713
Hospital Charge Code	146478
Hospital Revenue Code	278
Min. Negotiated Rate	$162.99
Max. Negotiated Rate	$1,303.92
Rate for Payer: Amerigroup CHIP/Medicaid	$162.99
Rate for Payer: BCBS of TX Blue Advantage	$543.30
Rate for Payer: BCBS of TX Blue Essentials	$651.96
Rate for Payer: BCBS of TX PPO	$724.40
Rate for Payer: Cash Price	$1,231.48
Rate for Payer: Cigna Medicaid	$1,303.92
Rate for Payer: Molina CHIP/Medicaid	$1,303.92
Rate for Payer: Multiplan Auto	$905.50
Rate for Payer: Multiplan Commercial	$905.50
Rate for Payer: Multiplan Workers Comp	$905.50
Rate for Payer: Parkland Medicaid	$1,303.92
Rate for Payer: Scott and White EPO/PPO	$905.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,303.92
Rate for Payer: Superior Health Plan EPO	$246.30

SCREW CANNULATED HEADED 2.0

Facility

$1,958.00

Service Code	HCPCS C1713
Hospital Charge Code	145184
Hospital Revenue Code	278
Min. Negotiated Rate	$176.22
Max. Negotiated Rate	$1,409.76
Rate for Payer: Amerigroup CHIP/Medicaid	$176.22
Rate for Payer: BCBS of TX Blue Advantage	$587.40
Rate for Payer: BCBS of TX Blue Essentials	$704.88
Rate for Payer: BCBS of TX PPO	$783.20
Rate for Payer: Cash Price	$1,331.44
Rate for Payer: Cigna Medicaid	$1,409.76
Rate for Payer: Molina CHIP/Medicaid	$1,409.76
Rate for Payer: Multiplan Auto	$979.00
Rate for Payer: Multiplan Commercial	$979.00
Rate for Payer: Multiplan Workers Comp	$979.00
Rate for Payer: Parkland Medicaid	$1,409.76
Rate for Payer: Scott and White EPO/PPO	$979.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,409.76
Rate for Payer: Superior Health Plan EPO	$266.29

SCREW CANNULATED HEADED 2.0

Facility

$1,958.00

Service Code	HCPCS C1713
Hospital Charge Code	145184
Hospital Revenue Code	278
Min. Negotiated Rate	$489.50
Max. Negotiated Rate	$979.00
Rate for Payer: Cash Price	$1,331.44
Rate for Payer: Cigna Commercial	$489.50
Rate for Payer: Multiplan Auto	$979.00
Rate for Payer: Multiplan Commercial	$979.00
Rate for Payer: Multiplan Workers Comp	$979.00
Rate for Payer: Scott and White EPO/PPO	$979.00

SCREW CANNULATED II

Facility

$6,925.00

Service Code	HCPCS C1713
Hospital Charge Code	8510471
Hospital Revenue Code	278
Min. Negotiated Rate	$1,731.25
Max. Negotiated Rate	$3,462.50
Rate for Payer: Cash Price	$4,709.00
Rate for Payer: Cigna Commercial	$1,731.25
Rate for Payer: Multiplan Auto	$3,462.50
Rate for Payer: Multiplan Commercial	$3,462.50
Rate for Payer: Multiplan Workers Comp	$3,462.50
Rate for Payer: Scott and White EPO/PPO	$3,462.50

Know your out-of-pocket cost for care.

All Charges