White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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 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 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 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 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	$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 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 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

SCREW CORTICAL

Facility

$3,058.00

Service Code	HCPCS C1713
Hospital Charge Code	8428497
Hospital Revenue Code	278
Min. Negotiated Rate	$275.22
Max. Negotiated Rate	$2,201.76
Rate for Payer: Amerigroup CHIP/Medicaid	$275.22
Rate for Payer: BCBS of TX Blue Advantage	$917.40
Rate for Payer: BCBS of TX Blue Essentials	$1,100.88
Rate for Payer: BCBS of TX PPO	$1,223.20
Rate for Payer: Cash Price	$2,079.44
Rate for Payer: Cigna Medicaid	$2,201.76
Rate for Payer: Molina CHIP/Medicaid	$2,201.76
Rate for Payer: Multiplan Auto	$1,529.00
Rate for Payer: Multiplan Commercial	$1,529.00
Rate for Payer: Multiplan Workers Comp	$1,529.00
Rate for Payer: Parkland Medicaid	$2,201.76
Rate for Payer: Scott and White EPO/PPO	$1,529.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,201.76
Rate for Payer: Superior Health Plan EPO	$415.89

SCREW CORTICAL

Facility

$3,058.00

Service Code	HCPCS C1713
Hospital Charge Code	8428497
Hospital Revenue Code	278
Min. Negotiated Rate	$764.50
Max. Negotiated Rate	$1,529.00
Rate for Payer: Cash Price	$2,079.44
Rate for Payer: Cigna Commercial	$764.50
Rate for Payer: Multiplan Auto	$1,529.00
Rate for Payer: Multiplan Commercial	$1,529.00
Rate for Payer: Multiplan Workers Comp	$1,529.00
Rate for Payer: Scott and White EPO/PPO	$1,529.00

SCREW CORTICAL 3.5MM X 28

Facility

$416.00

Service Code	HCPCS C1713
Hospital Charge Code	145265
Hospital Revenue Code	278
Min. Negotiated Rate	$104.00
Max. Negotiated Rate	$208.00
Rate for Payer: Cash Price	$282.88
Rate for Payer: Cigna Commercial	$104.00
Rate for Payer: Multiplan Auto	$208.00
Rate for Payer: Multiplan Commercial	$208.00
Rate for Payer: Multiplan Workers Comp	$208.00
Rate for Payer: Scott and White EPO/PPO	$208.00

SCREW CORTICAL 3.5MM X 28

Facility

$416.00

Service Code	HCPCS C1713
Hospital Charge Code	145265
Hospital Revenue Code	278
Min. Negotiated Rate	$37.44
Max. Negotiated Rate	$299.52
Rate for Payer: Amerigroup CHIP/Medicaid	$37.44
Rate for Payer: BCBS of TX Blue Advantage	$124.80
Rate for Payer: BCBS of TX Blue Essentials	$149.76
Rate for Payer: BCBS of TX PPO	$166.40
Rate for Payer: Cash Price	$282.88
Rate for Payer: Cigna Medicaid	$299.52
Rate for Payer: Molina CHIP/Medicaid	$299.52
Rate for Payer: Multiplan Auto	$208.00
Rate for Payer: Multiplan Commercial	$208.00
Rate for Payer: Multiplan Workers Comp	$208.00
Rate for Payer: Parkland Medicaid	$299.52
Rate for Payer: Scott and White EPO/PPO	$208.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$299.52
Rate for Payer: Superior Health Plan EPO	$56.58

SCREW CORTICAL 3.5 X 20

Facility

$355.00

Service Code	HCPCS C1713
Hospital Charge Code	145264
Hospital Revenue Code	278
Min. Negotiated Rate	$88.75
Max. Negotiated Rate	$177.50
Rate for Payer: Cash Price	$241.40
Rate for Payer: Cigna Commercial	$88.75
Rate for Payer: Multiplan Auto	$177.50
Rate for Payer: Multiplan Commercial	$177.50
Rate for Payer: Multiplan Workers Comp	$177.50
Rate for Payer: Scott and White EPO/PPO	$177.50

SCREW CORTICAL 3.5 X 20

Facility

$355.00

Service Code	HCPCS C1713
Hospital Charge Code	145264
Hospital Revenue Code	278
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$255.60
Rate for Payer: Amerigroup CHIP/Medicaid	$31.95
Rate for Payer: BCBS of TX Blue Advantage	$106.50
Rate for Payer: BCBS of TX Blue Essentials	$127.80
Rate for Payer: BCBS of TX PPO	$142.00
Rate for Payer: Cash Price	$241.40
Rate for Payer: Cigna Medicaid	$255.60
Rate for Payer: Molina CHIP/Medicaid	$255.60
Rate for Payer: Multiplan Auto	$177.50
Rate for Payer: Multiplan Commercial	$177.50
Rate for Payer: Multiplan Workers Comp	$177.50
Rate for Payer: Parkland Medicaid	$255.60
Rate for Payer: Scott and White EPO/PPO	$177.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$255.60
Rate for Payer: Superior Health Plan EPO	$48.28

SCREW CORTICAL 3.5 X 22

Facility

$355.00

Service Code	HCPCS C1713
Hospital Charge Code	145266
Hospital Revenue Code	278
Min. Negotiated Rate	$88.75
Max. Negotiated Rate	$177.50
Rate for Payer: Cash Price	$241.40
Rate for Payer: Cigna Commercial	$88.75
Rate for Payer: Multiplan Auto	$177.50
Rate for Payer: Multiplan Commercial	$177.50
Rate for Payer: Multiplan Workers Comp	$177.50
Rate for Payer: Scott and White EPO/PPO	$177.50

SCREW CORTICAL 3.5 X 22

Facility

$355.00

Service Code	HCPCS C1713
Hospital Charge Code	145266
Hospital Revenue Code	278
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$255.60
Rate for Payer: Amerigroup CHIP/Medicaid	$31.95
Rate for Payer: BCBS of TX Blue Advantage	$106.50
Rate for Payer: BCBS of TX Blue Essentials	$127.80
Rate for Payer: BCBS of TX PPO	$142.00
Rate for Payer: Cash Price	$241.40
Rate for Payer: Cigna Medicaid	$255.60
Rate for Payer: Molina CHIP/Medicaid	$255.60
Rate for Payer: Multiplan Auto	$177.50
Rate for Payer: Multiplan Commercial	$177.50
Rate for Payer: Multiplan Workers Comp	$177.50
Rate for Payer: Parkland Medicaid	$255.60
Rate for Payer: Scott and White EPO/PPO	$177.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$255.60
Rate for Payer: Superior Health Plan EPO	$48.28

SCREW CORTICAL 3.5X 24

Facility

$355.00

Service Code	HCPCS C1713
Hospital Charge Code	145267
Hospital Revenue Code	278
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$255.60
Rate for Payer: Amerigroup CHIP/Medicaid	$31.95
Rate for Payer: BCBS of TX Blue Advantage	$106.50
Rate for Payer: BCBS of TX Blue Essentials	$127.80
Rate for Payer: BCBS of TX PPO	$142.00
Rate for Payer: Cash Price	$241.40
Rate for Payer: Cigna Medicaid	$255.60
Rate for Payer: Molina CHIP/Medicaid	$255.60
Rate for Payer: Multiplan Auto	$177.50
Rate for Payer: Multiplan Commercial	$177.50
Rate for Payer: Multiplan Workers Comp	$177.50
Rate for Payer: Parkland Medicaid	$255.60
Rate for Payer: Scott and White EPO/PPO	$177.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$255.60
Rate for Payer: Superior Health Plan EPO	$48.28

SCREW CORTICAL 3.5X 24

Facility

$355.00

Service Code	HCPCS C1713
Hospital Charge Code	145267
Hospital Revenue Code	278
Min. Negotiated Rate	$88.75
Max. Negotiated Rate	$177.50
Rate for Payer: Cash Price	$241.40
Rate for Payer: Cigna Commercial	$88.75
Rate for Payer: Multiplan Auto	$177.50
Rate for Payer: Multiplan Commercial	$177.50
Rate for Payer: Multiplan Workers Comp	$177.50
Rate for Payer: Scott and White EPO/PPO	$177.50

Know your out-of-pocket cost for care.

All Charges