White Rock Medical Center

All Charges

Charge

Type

Setting

Price

screw intfr compositcp 30

Facility

$1,680.00

Service Code	HCPCS C1713
Hospital Charge Code	126020
Hospital Revenue Code	278
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$1,209.60
Rate for Payer: Amerigroup CHIP/Medicaid	$151.20
Rate for Payer: BCBS of TX Blue Advantage	$504.00
Rate for Payer: BCBS of TX Blue Essentials	$604.80
Rate for Payer: BCBS of TX PPO	$672.00
Rate for Payer: Cash Price	$1,142.40
Rate for Payer: Cigna Medicaid	$1,209.60
Rate for Payer: Molina CHIP/Medicaid	$1,209.60
Rate for Payer: Multiplan Auto	$840.00
Rate for Payer: Multiplan Commercial	$840.00
Rate for Payer: Multiplan Workers Comp	$840.00
Rate for Payer: Parkland Medicaid	$1,209.60
Rate for Payer: Scott and White EPO/PPO	$840.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,209.60
Rate for Payer: Superior Health Plan EPO	$228.48

SCREW LAG 10.5X100MM HIP

Facility

$4,222.00

Service Code	HCPCS C1713
Hospital Charge Code	126111
Hospital Revenue Code	278
Min. Negotiated Rate	$379.98
Max. Negotiated Rate	$3,039.84
Rate for Payer: Amerigroup CHIP/Medicaid	$379.98
Rate for Payer: BCBS of TX Blue Advantage	$1,266.60
Rate for Payer: BCBS of TX Blue Essentials	$1,519.92
Rate for Payer: BCBS of TX PPO	$1,688.80
Rate for Payer: Cash Price	$2,870.96
Rate for Payer: Cigna Medicaid	$3,039.84
Rate for Payer: Molina CHIP/Medicaid	$3,039.84
Rate for Payer: Multiplan Auto	$2,111.00
Rate for Payer: Multiplan Commercial	$2,111.00
Rate for Payer: Multiplan Workers Comp	$2,111.00
Rate for Payer: Parkland Medicaid	$3,039.84
Rate for Payer: Scott and White EPO/PPO	$2,111.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,039.84
Rate for Payer: Superior Health Plan EPO	$574.19

SCREW LAG 10.5X100MM HIP

Facility

$4,222.00

Service Code	HCPCS C1713
Hospital Charge Code	126111
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.50
Max. Negotiated Rate	$2,111.00
Rate for Payer: Cash Price	$2,870.96
Rate for Payer: Cigna Commercial	$1,055.50
Rate for Payer: Multiplan Auto	$2,111.00
Rate for Payer: Multiplan Commercial	$2,111.00
Rate for Payer: Multiplan Workers Comp	$2,111.00
Rate for Payer: Scott and White EPO/PPO	$2,111.00

SCREW LAG 10.5X105MM HIP

Facility

$4,433.00

Service Code	HCPCS C1713
Hospital Charge Code	126112
Hospital Revenue Code	278
Min. Negotiated Rate	$398.97
Max. Negotiated Rate	$3,191.76
Rate for Payer: Amerigroup CHIP/Medicaid	$398.97
Rate for Payer: BCBS of TX Blue Advantage	$1,329.90
Rate for Payer: BCBS of TX Blue Essentials	$1,595.88
Rate for Payer: BCBS of TX PPO	$1,773.20
Rate for Payer: Cash Price	$3,014.44
Rate for Payer: Cigna Medicaid	$3,191.76
Rate for Payer: Molina CHIP/Medicaid	$3,191.76
Rate for Payer: Multiplan Auto	$2,216.50
Rate for Payer: Multiplan Commercial	$2,216.50
Rate for Payer: Multiplan Workers Comp	$2,216.50
Rate for Payer: Parkland Medicaid	$3,191.76
Rate for Payer: Scott and White EPO/PPO	$2,216.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,191.76
Rate for Payer: Superior Health Plan EPO	$602.89

SCREW LAG 10.5X105MM HIP

Facility

$4,433.00

Service Code	HCPCS C1713
Hospital Charge Code	126112
Hospital Revenue Code	278
Min. Negotiated Rate	$1,108.25
Max. Negotiated Rate	$2,216.50
Rate for Payer: Cash Price	$3,014.44
Rate for Payer: Cigna Commercial	$1,108.25
Rate for Payer: Multiplan Auto	$2,216.50
Rate for Payer: Multiplan Commercial	$2,216.50
Rate for Payer: Multiplan Workers Comp	$2,216.50
Rate for Payer: Scott and White EPO/PPO	$2,216.50

SCREW LAG 10.5X80MM TI TROCH IM NL STRL

Facility

$5,048.19

Service Code	HCPCS C1713
Hospital Charge Code	992156
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.05
Max. Negotiated Rate	$2,524.09
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Commercial	$1,262.05
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Scott and White EPO/PPO	$2,524.09

SCREW LAG 10.5X80MM TI TROCH IM NL STRL

Facility

$5,048.19

Service Code	HCPCS C1713
Hospital Charge Code	992156
Hospital Revenue Code	278
Min. Negotiated Rate	$454.34
Max. Negotiated Rate	$3,634.70
Rate for Payer: Amerigroup CHIP/Medicaid	$454.34
Rate for Payer: BCBS of TX Blue Advantage	$1,514.46
Rate for Payer: BCBS of TX Blue Essentials	$1,817.35
Rate for Payer: BCBS of TX PPO	$2,019.28
Rate for Payer: Cash Price	$3,432.77
Rate for Payer: Cigna Medicaid	$3,634.70
Rate for Payer: Molina CHIP/Medicaid	$3,634.70
Rate for Payer: Multiplan Auto	$2,524.09
Rate for Payer: Multiplan Commercial	$2,524.09
Rate for Payer: Multiplan Workers Comp	$2,524.09
Rate for Payer: Parkland Medicaid	$3,634.70
Rate for Payer: Scott and White EPO/PPO	$2,524.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,634.70
Rate for Payer: Superior Health Plan EPO	$686.55

SCREW LAG AFFIXUS 95MM

Facility

$4,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146583
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.50
Max. Negotiated Rate	$2,111.00
Rate for Payer: Cash Price	$2,870.96
Rate for Payer: Cigna Commercial	$1,055.50
Rate for Payer: Multiplan Auto	$2,111.00
Rate for Payer: Multiplan Commercial	$2,111.00
Rate for Payer: Multiplan Workers Comp	$2,111.00
Rate for Payer: Scott and White EPO/PPO	$2,111.00

SCREW LAG AFFIXUS 95MM

Facility

$4,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146583
Hospital Revenue Code	278
Min. Negotiated Rate	$379.98
Max. Negotiated Rate	$3,039.84
Rate for Payer: Amerigroup CHIP/Medicaid	$379.98
Rate for Payer: BCBS of TX Blue Advantage	$1,266.60
Rate for Payer: BCBS of TX Blue Essentials	$1,519.92
Rate for Payer: BCBS of TX PPO	$1,688.80
Rate for Payer: Cash Price	$2,870.96
Rate for Payer: Cigna Medicaid	$3,039.84
Rate for Payer: Molina CHIP/Medicaid	$3,039.84
Rate for Payer: Multiplan Auto	$2,111.00
Rate for Payer: Multiplan Commercial	$2,111.00
Rate for Payer: Multiplan Workers Comp	$2,111.00
Rate for Payer: Parkland Medicaid	$3,039.84
Rate for Payer: Scott and White EPO/PPO	$2,111.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,039.84
Rate for Payer: Superior Health Plan EPO	$574.19

screw lag proxfemur 90mm

Facility

$4,718.00

Service Code	HCPCS C1713
Hospital Charge Code	8720604
Hospital Revenue Code	278
Min. Negotiated Rate	$1,179.50
Max. Negotiated Rate	$2,359.00
Rate for Payer: Cash Price	$3,208.24
Rate for Payer: Cigna Commercial	$1,179.50
Rate for Payer: Multiplan Auto	$2,359.00
Rate for Payer: Multiplan Commercial	$2,359.00
Rate for Payer: Multiplan Workers Comp	$2,359.00
Rate for Payer: Scott and White EPO/PPO	$2,359.00

screw lag proxfemur 90mm

Facility

$4,718.00

Service Code	HCPCS C1713
Hospital Charge Code	8720604
Hospital Revenue Code	278
Min. Negotiated Rate	$424.62
Max. Negotiated Rate	$3,396.96
Rate for Payer: Amerigroup CHIP/Medicaid	$424.62
Rate for Payer: BCBS of TX Blue Advantage	$1,415.40
Rate for Payer: BCBS of TX Blue Essentials	$1,698.48
Rate for Payer: BCBS of TX PPO	$1,887.20
Rate for Payer: Cash Price	$3,208.24
Rate for Payer: Cigna Medicaid	$3,396.96
Rate for Payer: Molina CHIP/Medicaid	$3,396.96
Rate for Payer: Multiplan Auto	$2,359.00
Rate for Payer: Multiplan Commercial	$2,359.00
Rate for Payer: Multiplan Workers Comp	$2,359.00
Rate for Payer: Parkland Medicaid	$3,396.96
Rate for Payer: Scott and White EPO/PPO	$2,359.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,396.96
Rate for Payer: Superior Health Plan EPO	$641.65

SCREW LAG TALON DISTAL FIX

Facility

$1,196.00

Service Code	HCPCS C1713
Hospital Charge Code	145158
Hospital Revenue Code	278
Min. Negotiated Rate	$299.00
Max. Negotiated Rate	$598.00
Rate for Payer: Cash Price	$813.28
Rate for Payer: Cigna Commercial	$299.00
Rate for Payer: Multiplan Auto	$598.00
Rate for Payer: Multiplan Commercial	$598.00
Rate for Payer: Multiplan Workers Comp	$598.00
Rate for Payer: Scott and White EPO/PPO	$598.00

SCREW LAG TALON DISTAL FIX

Facility

$1,196.00

Service Code	HCPCS C1713
Hospital Charge Code	145158
Hospital Revenue Code	278
Min. Negotiated Rate	$107.64
Max. Negotiated Rate	$861.12
Rate for Payer: Amerigroup CHIP/Medicaid	$107.64
Rate for Payer: BCBS of TX Blue Advantage	$358.80
Rate for Payer: BCBS of TX Blue Essentials	$430.56
Rate for Payer: BCBS of TX PPO	$478.40
Rate for Payer: Cash Price	$813.28
Rate for Payer: Cigna Medicaid	$861.12
Rate for Payer: Molina CHIP/Medicaid	$861.12
Rate for Payer: Multiplan Auto	$598.00
Rate for Payer: Multiplan Commercial	$598.00
Rate for Payer: Multiplan Workers Comp	$598.00
Rate for Payer: Parkland Medicaid	$861.12
Rate for Payer: Scott and White EPO/PPO	$598.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$861.12
Rate for Payer: Superior Health Plan EPO	$162.66

SCREW LAG TALON DISTAL FX

Facility

$4,819.00

Service Code	HCPCS C1713
Hospital Charge Code	145226
Hospital Revenue Code	278
Min. Negotiated Rate	$433.71
Max. Negotiated Rate	$3,469.68
Rate for Payer: Amerigroup CHIP/Medicaid	$433.71
Rate for Payer: BCBS of TX Blue Advantage	$1,445.70
Rate for Payer: BCBS of TX Blue Essentials	$1,734.84
Rate for Payer: BCBS of TX PPO	$1,927.60
Rate for Payer: Cash Price	$3,276.92
Rate for Payer: Cigna Medicaid	$3,469.68
Rate for Payer: Molina CHIP/Medicaid	$3,469.68
Rate for Payer: Multiplan Auto	$2,409.50
Rate for Payer: Multiplan Commercial	$2,409.50
Rate for Payer: Multiplan Workers Comp	$2,409.50
Rate for Payer: Parkland Medicaid	$3,469.68
Rate for Payer: Scott and White EPO/PPO	$2,409.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,469.68
Rate for Payer: Superior Health Plan EPO	$655.38

SCREW LAG TALON DISTAL FX

Facility

$4,819.00

Service Code	HCPCS C1713
Hospital Charge Code	145226
Hospital Revenue Code	278
Min. Negotiated Rate	$1,204.75
Max. Negotiated Rate	$2,409.50
Rate for Payer: Cash Price	$3,276.92
Rate for Payer: Cigna Commercial	$1,204.75
Rate for Payer: Multiplan Auto	$2,409.50
Rate for Payer: Multiplan Commercial	$2,409.50
Rate for Payer: Multiplan Workers Comp	$2,409.50
Rate for Payer: Scott and White EPO/PPO	$2,409.50

SCREW LAG TI 10.5 X 85MM

Facility

$3,432.00

Service Code	HCPCS C1713
Hospital Charge Code	8694515
Hospital Revenue Code	278
Min. Negotiated Rate	$858.00
Max. Negotiated Rate	$1,716.00
Rate for Payer: Cash Price	$2,333.76
Rate for Payer: Cigna Commercial	$858.00
Rate for Payer: Multiplan Auto	$1,716.00
Rate for Payer: Multiplan Commercial	$1,716.00
Rate for Payer: Multiplan Workers Comp	$1,716.00
Rate for Payer: Scott and White EPO/PPO	$1,716.00

SCREW LAG TI 10.5 X 85MM

Facility

$3,432.00

Service Code	HCPCS C1713
Hospital Charge Code	8694515
Hospital Revenue Code	278
Min. Negotiated Rate	$308.88
Max. Negotiated Rate	$2,471.04
Rate for Payer: Amerigroup CHIP/Medicaid	$308.88
Rate for Payer: BCBS of TX Blue Advantage	$1,029.60
Rate for Payer: BCBS of TX Blue Essentials	$1,235.52
Rate for Payer: BCBS of TX PPO	$1,372.80
Rate for Payer: Cash Price	$2,333.76
Rate for Payer: Cigna Medicaid	$2,471.04
Rate for Payer: Molina CHIP/Medicaid	$2,471.04
Rate for Payer: Multiplan Auto	$1,716.00
Rate for Payer: Multiplan Commercial	$1,716.00
Rate for Payer: Multiplan Workers Comp	$1,716.00
Rate for Payer: Parkland Medicaid	$2,471.04
Rate for Payer: Scott and White EPO/PPO	$1,716.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,471.04
Rate for Payer: Superior Health Plan EPO	$466.75

SCREW LAG TI TROCH IM NAIL 10.5 X 95MM STERILE

Facility

$3,517.00

Service Code	HCPCS C1713
Hospital Charge Code	125737
Hospital Revenue Code	278
Min. Negotiated Rate	$879.25
Max. Negotiated Rate	$1,758.50
Rate for Payer: Cash Price	$2,391.56
Rate for Payer: Cigna Commercial	$879.25
Rate for Payer: Multiplan Auto	$1,758.50
Rate for Payer: Multiplan Commercial	$1,758.50
Rate for Payer: Multiplan Workers Comp	$1,758.50
Rate for Payer: Scott and White EPO/PPO	$1,758.50

SCREW LAG TI TROCH IM NAIL 10.5 X 95MM STERILE

Facility

$3,517.00

Service Code	HCPCS C1713
Hospital Charge Code	125737
Hospital Revenue Code	278
Min. Negotiated Rate	$316.53
Max. Negotiated Rate	$2,532.24
Rate for Payer: Amerigroup CHIP/Medicaid	$316.53
Rate for Payer: BCBS of TX Blue Advantage	$1,055.10
Rate for Payer: BCBS of TX Blue Essentials	$1,266.12
Rate for Payer: BCBS of TX PPO	$1,406.80
Rate for Payer: Cash Price	$2,391.56
Rate for Payer: Cigna Medicaid	$2,532.24
Rate for Payer: Molina CHIP/Medicaid	$2,532.24
Rate for Payer: Multiplan Auto	$1,758.50
Rate for Payer: Multiplan Commercial	$1,758.50
Rate for Payer: Multiplan Workers Comp	$1,758.50
Rate for Payer: Parkland Medicaid	$2,532.24
Rate for Payer: Scott and White EPO/PPO	$1,758.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,532.24
Rate for Payer: Superior Health Plan EPO	$478.31

SCREW LAG TI TROCH IM NL STRL10.5 X 90MM

Facility

$3,516.85

Hospital Charge Code	125736
Hospital Revenue Code	273
Min. Negotiated Rate	$316.52
Max. Negotiated Rate	$2,532.13
Rate for Payer: Amerigroup CHIP/Medicaid	$316.52
Rate for Payer: BCBS of TX Blue Advantage	$1,055.06
Rate for Payer: BCBS of TX Blue Essentials	$1,266.07
Rate for Payer: BCBS of TX PPO	$1,406.74
Rate for Payer: Cash Price	$2,391.46
Rate for Payer: Cigna Medicaid	$2,532.13
Rate for Payer: Molina CHIP/Medicaid	$2,532.13
Rate for Payer: Multiplan Auto	$2,285.95
Rate for Payer: Multiplan Commercial	$2,285.95
Rate for Payer: Multiplan Workers Comp	$2,285.95
Rate for Payer: Parkland Medicaid	$2,532.13
Rate for Payer: Scott and White EPO/PPO	$1,758.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,532.13
Rate for Payer: Superior Health Plan EPO	$478.29

SCREW LAG TI TROCH IM NL STRL10.5 X 90MM

Facility

$3,516.85

Hospital Charge Code	125736
Hospital Revenue Code	273
Rate for Payer: Cash Price	$2,391.46

SCREW LAG VERSAFIX 12.7MM

Facility

$2,037.00

Service Code	HCPCS C1713
Hospital Charge Code	142601
Hospital Revenue Code	278
Min. Negotiated Rate	$509.25
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$1,385.16
Rate for Payer: Cigna Commercial	$509.25
Rate for Payer: Multiplan Auto	$1,018.50
Rate for Payer: Multiplan Commercial	$1,018.50
Rate for Payer: Multiplan Workers Comp	$1,018.50
Rate for Payer: Scott and White EPO/PPO	$1,018.50

SCREW LAG VERSAFIX 12.7MM

Facility

$2,037.00

Service Code	HCPCS C1713
Hospital Charge Code	142601
Hospital Revenue Code	278
Min. Negotiated Rate	$183.33
Max. Negotiated Rate	$1,466.64
Rate for Payer: Amerigroup CHIP/Medicaid	$183.33
Rate for Payer: BCBS of TX Blue Advantage	$611.10
Rate for Payer: BCBS of TX Blue Essentials	$733.32
Rate for Payer: BCBS of TX PPO	$814.80
Rate for Payer: Cash Price	$1,385.16
Rate for Payer: Cigna Medicaid	$1,466.64
Rate for Payer: Molina CHIP/Medicaid	$1,466.64
Rate for Payer: Multiplan Auto	$1,018.50
Rate for Payer: Multiplan Commercial	$1,018.50
Rate for Payer: Multiplan Workers Comp	$1,018.50
Rate for Payer: Parkland Medicaid	$1,466.64
Rate for Payer: Scott and White EPO/PPO	$1,018.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,466.64
Rate for Payer: Superior Health Plan EPO	$277.03

SCREW LAG ZIMMER NATURAL NAIL 10.5 X 95

Facility

$3,571.00

Service Code	HCPCS C1713
Hospital Charge Code	146542
Hospital Revenue Code	278
Min. Negotiated Rate	$892.75
Max. Negotiated Rate	$1,785.50
Rate for Payer: Cash Price	$2,428.28
Rate for Payer: Cigna Commercial	$892.75
Rate for Payer: Multiplan Auto	$1,785.50
Rate for Payer: Multiplan Commercial	$1,785.50
Rate for Payer: Multiplan Workers Comp	$1,785.50
Rate for Payer: Scott and White EPO/PPO	$1,785.50

SCREW LAG ZIMMER NATURAL NAIL 10.5 X 95

Facility

$3,571.00

Service Code	HCPCS C1713
Hospital Charge Code	146542
Hospital Revenue Code	278
Min. Negotiated Rate	$321.39
Max. Negotiated Rate	$2,571.12
Rate for Payer: Amerigroup CHIP/Medicaid	$321.39
Rate for Payer: BCBS of TX Blue Advantage	$1,071.30
Rate for Payer: BCBS of TX Blue Essentials	$1,285.56
Rate for Payer: BCBS of TX PPO	$1,428.40
Rate for Payer: Cash Price	$2,428.28
Rate for Payer: Cigna Medicaid	$2,571.12
Rate for Payer: Molina CHIP/Medicaid	$2,571.12
Rate for Payer: Multiplan Auto	$1,785.50
Rate for Payer: Multiplan Commercial	$1,785.50
Rate for Payer: Multiplan Workers Comp	$1,785.50
Rate for Payer: Parkland Medicaid	$2,571.12
Rate for Payer: Scott and White EPO/PPO	$1,785.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,571.12
Rate for Payer: Superior Health Plan EPO	$485.66

Know your out-of-pocket cost for care.

All Charges