White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SCREW FENESTRATED STERILE 85MM

Facility

$10,562.00

Service Code	HCPCS C1713
Hospital Charge Code	146296
Hospital Revenue Code	278
Min. Negotiated Rate	$950.58
Max. Negotiated Rate	$7,604.64
Rate for Payer: Amerigroup CHIP/Medicaid	$950.58
Rate for Payer: BCBS of TX Blue Advantage	$3,168.60
Rate for Payer: BCBS of TX Blue Essentials	$3,802.32
Rate for Payer: BCBS of TX PPO	$4,224.80
Rate for Payer: Cash Price	$7,182.16
Rate for Payer: Cigna Medicaid	$7,604.64
Rate for Payer: Molina CHIP/Medicaid	$7,604.64
Rate for Payer: Multiplan Auto	$5,281.00
Rate for Payer: Multiplan Commercial	$5,281.00
Rate for Payer: Multiplan Workers Comp	$5,281.00
Rate for Payer: Parkland Medicaid	$7,604.64
Rate for Payer: Scott and White EPO/PPO	$5,281.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,604.64
Rate for Payer: Superior Health Plan EPO	$1,436.43

SCREW HEADLESS 3.0 MM X 26MM

Facility

$2,410.00

Service Code	HCPCS C1713
Hospital Charge Code	145140
Hospital Revenue Code	278
Min. Negotiated Rate	$216.90
Max. Negotiated Rate	$1,735.20
Rate for Payer: Amerigroup CHIP/Medicaid	$216.90
Rate for Payer: BCBS of TX Blue Advantage	$723.00
Rate for Payer: BCBS of TX Blue Essentials	$867.60
Rate for Payer: BCBS of TX PPO	$964.00
Rate for Payer: Cash Price	$1,638.80
Rate for Payer: Cigna Medicaid	$1,735.20
Rate for Payer: Molina CHIP/Medicaid	$1,735.20
Rate for Payer: Multiplan Auto	$1,205.00
Rate for Payer: Multiplan Commercial	$1,205.00
Rate for Payer: Multiplan Workers Comp	$1,205.00
Rate for Payer: Parkland Medicaid	$1,735.20
Rate for Payer: Scott and White EPO/PPO	$1,205.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,735.20
Rate for Payer: Superior Health Plan EPO	$327.76

SCREW HEADLESS 3.0 MM X 26MM

Facility

$2,410.00

Service Code	HCPCS C1713
Hospital Charge Code	145140
Hospital Revenue Code	278
Min. Negotiated Rate	$602.50
Max. Negotiated Rate	$1,205.00
Rate for Payer: Cash Price	$1,638.80
Rate for Payer: Cigna Commercial	$602.50
Rate for Payer: Multiplan Auto	$1,205.00
Rate for Payer: Multiplan Commercial	$1,205.00
Rate for Payer: Multiplan Workers Comp	$1,205.00
Rate for Payer: Scott and White EPO/PPO	$1,205.00

screw interference

Facility

$2,825.00

Service Code	HCPCS C1713
Hospital Charge Code	145056
Hospital Revenue Code	278
Min. Negotiated Rate	$706.25
Max. Negotiated Rate	$1,412.50
Rate for Payer: Cash Price	$1,921.00
Rate for Payer: Cigna Commercial	$706.25
Rate for Payer: Multiplan Auto	$1,412.50
Rate for Payer: Multiplan Commercial	$1,412.50
Rate for Payer: Multiplan Workers Comp	$1,412.50
Rate for Payer: Scott and White EPO/PPO	$1,412.50

screw interference

Facility

$2,825.00

Service Code	HCPCS C1713
Hospital Charge Code	145056
Hospital Revenue Code	278
Min. Negotiated Rate	$254.25
Max. Negotiated Rate	$2,034.00
Rate for Payer: Amerigroup CHIP/Medicaid	$254.25
Rate for Payer: BCBS of TX Blue Advantage	$847.50
Rate for Payer: BCBS of TX Blue Essentials	$1,017.00
Rate for Payer: BCBS of TX PPO	$1,130.00
Rate for Payer: Cash Price	$1,921.00
Rate for Payer: Cigna Medicaid	$2,034.00
Rate for Payer: Molina CHIP/Medicaid	$2,034.00
Rate for Payer: Multiplan Auto	$1,412.50
Rate for Payer: Multiplan Commercial	$1,412.50
Rate for Payer: Multiplan Workers Comp	$1,412.50
Rate for Payer: Parkland Medicaid	$2,034.00
Rate for Payer: Scott and White EPO/PPO	$1,412.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,034.00
Rate for Payer: Superior Health Plan EPO	$384.20

SCREW INTERFERENCE GENESYS MATRYX

Facility

$1,475.00

Service Code	HCPCS C1713
Hospital Charge Code	146151
Hospital Revenue Code	278
Min. Negotiated Rate	$368.75
Max. Negotiated Rate	$737.50
Rate for Payer: Cash Price	$1,003.00
Rate for Payer: Cigna Commercial	$368.75
Rate for Payer: Multiplan Auto	$737.50
Rate for Payer: Multiplan Commercial	$737.50
Rate for Payer: Multiplan Workers Comp	$737.50
Rate for Payer: Scott and White EPO/PPO	$737.50

SCREW INTERFERENCE GENESYS MATRYX

Facility

$1,475.00

Service Code	HCPCS C1713
Hospital Charge Code	146151
Hospital Revenue Code	278
Min. Negotiated Rate	$132.75
Max. Negotiated Rate	$1,062.00
Rate for Payer: Amerigroup CHIP/Medicaid	$132.75
Rate for Payer: BCBS of TX Blue Advantage	$442.50
Rate for Payer: BCBS of TX Blue Essentials	$531.00
Rate for Payer: BCBS of TX PPO	$590.00
Rate for Payer: Cash Price	$1,003.00
Rate for Payer: Cigna Medicaid	$1,062.00
Rate for Payer: Molina CHIP/Medicaid	$1,062.00
Rate for Payer: Multiplan Auto	$737.50
Rate for Payer: Multiplan Commercial	$737.50
Rate for Payer: Multiplan Workers Comp	$737.50
Rate for Payer: Parkland Medicaid	$1,062.00
Rate for Payer: Scott and White EPO/PPO	$737.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,062.00
Rate for Payer: Superior Health Plan EPO	$200.60

SCREW INTERFERENCE GENESYS MATRYX 8.0 X 25

Facility

$2,605.30

Service Code	HCPCS C1713
Hospital Charge Code	992122
Hospital Revenue Code	278
Min. Negotiated Rate	$651.33
Max. Negotiated Rate	$1,302.65
Rate for Payer: Cash Price	$1,771.60
Rate for Payer: Cigna Commercial	$651.33
Rate for Payer: Multiplan Auto	$1,302.65
Rate for Payer: Multiplan Commercial	$1,302.65
Rate for Payer: Multiplan Workers Comp	$1,302.65
Rate for Payer: Scott and White EPO/PPO	$1,302.65

SCREW INTERFERENCE GENESYS MATRYX 8.0 X 25

Facility

$2,605.30

Service Code	HCPCS C1713
Hospital Charge Code	992122
Hospital Revenue Code	278
Min. Negotiated Rate	$234.48
Max. Negotiated Rate	$1,875.82
Rate for Payer: Amerigroup CHIP/Medicaid	$234.48
Rate for Payer: BCBS of TX Blue Advantage	$781.59
Rate for Payer: BCBS of TX Blue Essentials	$937.91
Rate for Payer: BCBS of TX PPO	$1,042.12
Rate for Payer: Cash Price	$1,771.60
Rate for Payer: Cigna Medicaid	$1,875.82
Rate for Payer: Molina CHIP/Medicaid	$1,875.82
Rate for Payer: Multiplan Auto	$1,302.65
Rate for Payer: Multiplan Commercial	$1,302.65
Rate for Payer: Multiplan Workers Comp	$1,302.65
Rate for Payer: Parkland Medicaid	$1,875.82
Rate for Payer: Scott and White EPO/PPO	$1,302.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,875.82
Rate for Payer: Superior Health Plan EPO	$354.32

screw intfr compositcp 30

Facility

$1,680.00

Service Code	HCPCS C1713
Hospital Charge Code	126020
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$840.00
Rate for Payer: Cash Price	$1,142.40
Rate for Payer: Cigna Commercial	$420.00
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: Scott and White EPO/PPO	$840.00

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	$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 10.5X100MM 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 10.5X105MM 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	$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 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

Know your out-of-pocket cost for care.

All Charges