White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 6.5 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

SCREW CANNULATED II

Facility

$6,925.00

Service Code	HCPCS C1713
Hospital Charge Code	8510471
Hospital Revenue Code	278
Min. Negotiated Rate	$623.25
Max. Negotiated Rate	$4,986.00
Rate for Payer: Amerigroup CHIP/Medicaid	$623.25
Rate for Payer: BCBS of TX Blue Advantage	$2,077.50
Rate for Payer: BCBS of TX Blue Essentials	$2,493.00
Rate for Payer: BCBS of TX PPO	$2,770.00
Rate for Payer: Cash Price	$4,709.00
Rate for Payer: Cigna Medicaid	$4,986.00
Rate for Payer: Molina CHIP/Medicaid	$4,986.00
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: Parkland Medicaid	$4,986.00
Rate for Payer: Scott and White EPO/PPO	$3,462.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,986.00
Rate for Payer: Superior Health Plan EPO	$941.80

SCREW CANNULATED III

Facility

$2,417.00

Service Code	HCPCS C1713
Hospital Charge Code	8512489
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 III

Facility

$2,417.00

Service Code	HCPCS C1713
Hospital Charge Code	8512489
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 CENTER 6.5MM

Facility

$602.00

Service Code	HCPCS C1713
Hospital Charge Code	8504479
Hospital Revenue Code	278
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$301.00
Rate for Payer: Cash Price	$409.36
Rate for Payer: Cigna Commercial	$150.50
Rate for Payer: Multiplan Auto	$301.00
Rate for Payer: Multiplan Commercial	$301.00
Rate for Payer: Multiplan Workers Comp	$301.00
Rate for Payer: Scott and White EPO/PPO	$301.00

SCREW CENTER 6.5MM

Facility

$602.00

Service Code	HCPCS C1713
Hospital Charge Code	8504479
Hospital Revenue Code	278
Min. Negotiated Rate	$54.18
Max. Negotiated Rate	$433.44
Rate for Payer: Amerigroup CHIP/Medicaid	$54.18
Rate for Payer: BCBS of TX Blue Advantage	$180.60
Rate for Payer: BCBS of TX Blue Essentials	$216.72
Rate for Payer: BCBS of TX PPO	$240.80
Rate for Payer: Cash Price	$409.36
Rate for Payer: Cigna Medicaid	$433.44
Rate for Payer: Molina CHIP/Medicaid	$433.44
Rate for Payer: Multiplan Auto	$301.00
Rate for Payer: Multiplan Commercial	$301.00
Rate for Payer: Multiplan Workers Comp	$301.00
Rate for Payer: Parkland Medicaid	$433.44
Rate for Payer: Scott and White EPO/PPO	$301.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.44
Rate for Payer: Superior Health Plan EPO	$81.87

SCREW COMPRESSION 1818-0001

Facility

$1,208.00

Service Code	HCPCS C1713
Hospital Charge Code	145504
Hospital Revenue Code	278
Min. Negotiated Rate	$108.72
Max. Negotiated Rate	$869.76
Rate for Payer: Amerigroup CHIP/Medicaid	$108.72
Rate for Payer: BCBS of TX Blue Advantage	$362.40
Rate for Payer: BCBS of TX Blue Essentials	$434.88
Rate for Payer: BCBS of TX PPO	$483.20
Rate for Payer: Cash Price	$821.44
Rate for Payer: Cigna Medicaid	$869.76
Rate for Payer: Molina CHIP/Medicaid	$869.76
Rate for Payer: Multiplan Auto	$604.00
Rate for Payer: Multiplan Commercial	$604.00
Rate for Payer: Multiplan Workers Comp	$604.00
Rate for Payer: Parkland Medicaid	$869.76
Rate for Payer: Scott and White EPO/PPO	$604.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$869.76
Rate for Payer: Superior Health Plan EPO	$164.29

SCREW COMPRESSION 1818-0001

Facility

$1,208.00

Service Code	HCPCS C1713
Hospital Charge Code	145504
Hospital Revenue Code	278
Min. Negotiated Rate	$302.00
Max. Negotiated Rate	$604.00
Rate for Payer: Cash Price	$821.44
Rate for Payer: Cigna Commercial	$302.00
Rate for Payer: Multiplan Auto	$604.00
Rate for Payer: Multiplan Commercial	$604.00
Rate for Payer: Multiplan Workers Comp	$604.00
Rate for Payer: Scott and White EPO/PPO	$604.00

SCREW COMPRESSION CANN HEADLESS 5.0 X 36

Facility

$2,417.00

Service Code	HCPCS C1713
Hospital Charge Code	8504488
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 COMPRESSION CANN HEADLESS 5.0 X 36

Facility

$2,417.00

Service Code	HCPCS C1713
Hospital Charge Code	8504488
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 CORT 5X34MM AFFIXUS DIST

Facility

$1,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146544
Hospital Revenue Code	278
Min. Negotiated Rate	$109.98
Max. Negotiated Rate	$879.84
Rate for Payer: Amerigroup CHIP/Medicaid	$109.98
Rate for Payer: BCBS of TX Blue Advantage	$366.60
Rate for Payer: BCBS of TX Blue Essentials	$439.92
Rate for Payer: BCBS of TX PPO	$488.80
Rate for Payer: Cash Price	$830.96
Rate for Payer: Cigna Medicaid	$879.84
Rate for Payer: Molina CHIP/Medicaid	$879.84
Rate for Payer: Multiplan Auto	$611.00
Rate for Payer: Multiplan Commercial	$611.00
Rate for Payer: Multiplan Workers Comp	$611.00
Rate for Payer: Parkland Medicaid	$879.84
Rate for Payer: Scott and White EPO/PPO	$611.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$879.84
Rate for Payer: Superior Health Plan EPO	$166.19

SCREW CORT 5X34MM AFFIXUS DIST

Facility

$1,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146544
Hospital Revenue Code	278
Min. Negotiated Rate	$305.50
Max. Negotiated Rate	$611.00
Rate for Payer: Cash Price	$830.96
Rate for Payer: Cigna Commercial	$305.50
Rate for Payer: Multiplan Auto	$611.00
Rate for Payer: Multiplan Commercial	$611.00
Rate for Payer: Multiplan Workers Comp	$611.00
Rate for Payer: Scott and White EPO/PPO	$611.00

SCREW CORT 5X40MM AFFIXUS DIST

Facility

$1,283.00

Service Code	HCPCS C1713
Hospital Charge Code	146675
Hospital Revenue Code	278
Min. Negotiated Rate	$320.75
Max. Negotiated Rate	$641.50
Rate for Payer: Cash Price	$872.44
Rate for Payer: Cigna Commercial	$320.75
Rate for Payer: Multiplan Auto	$641.50
Rate for Payer: Multiplan Commercial	$641.50
Rate for Payer: Multiplan Workers Comp	$641.50
Rate for Payer: Scott and White EPO/PPO	$641.50

SCREW CORT 5X40MM AFFIXUS DIST

Facility

$1,283.00

Service Code	HCPCS C1713
Hospital Charge Code	146675
Hospital Revenue Code	278
Min. Negotiated Rate	$115.47
Max. Negotiated Rate	$923.76
Rate for Payer: Amerigroup CHIP/Medicaid	$115.47
Rate for Payer: BCBS of TX Blue Advantage	$384.90
Rate for Payer: BCBS of TX Blue Essentials	$461.88
Rate for Payer: BCBS of TX PPO	$513.20
Rate for Payer: Cash Price	$872.44
Rate for Payer: Cigna Medicaid	$923.76
Rate for Payer: Molina CHIP/Medicaid	$923.76
Rate for Payer: Multiplan Auto	$641.50
Rate for Payer: Multiplan Commercial	$641.50
Rate for Payer: Multiplan Workers Comp	$641.50
Rate for Payer: Parkland Medicaid	$923.76
Rate for Payer: Scott and White EPO/PPO	$641.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$923.76
Rate for Payer: Superior Health Plan EPO	$174.49

SCREW CORTEX 5.00 MM

Facility

$1,235.00

Service Code	HCPCS C1713
Hospital Charge Code	125837
Hospital Revenue Code	278
Min. Negotiated Rate	$111.15
Max. Negotiated Rate	$889.20
Rate for Payer: Amerigroup CHIP/Medicaid	$111.15
Rate for Payer: BCBS of TX Blue Advantage	$370.50
Rate for Payer: BCBS of TX Blue Essentials	$444.60
Rate for Payer: BCBS of TX PPO	$494.00
Rate for Payer: Cash Price	$839.80
Rate for Payer: Cigna Medicaid	$889.20
Rate for Payer: Molina CHIP/Medicaid	$889.20
Rate for Payer: Multiplan Auto	$617.50
Rate for Payer: Multiplan Commercial	$617.50
Rate for Payer: Multiplan Workers Comp	$617.50
Rate for Payer: Parkland Medicaid	$889.20
Rate for Payer: Scott and White EPO/PPO	$617.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$889.20
Rate for Payer: Superior Health Plan EPO	$167.96

SCREW CORTEX 5.00 MM

Facility

$1,235.00

Service Code	HCPCS C1713
Hospital Charge Code	125837
Hospital Revenue Code	278
Min. Negotiated Rate	$308.75
Max. Negotiated Rate	$617.50
Rate for Payer: Cash Price	$839.80
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Multiplan Auto	$617.50
Rate for Payer: Multiplan Commercial	$617.50
Rate for Payer: Multiplan Workers Comp	$617.50
Rate for Payer: Scott and White EPO/PPO	$617.50

Know your out-of-pocket cost for care.

All Charges