White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SCREW LCK 3.5X14MM

Facility

$1,398.00

Service Code	HCPCS C1713
Hospital Charge Code	125930
Hospital Revenue Code	278
Min. Negotiated Rate	$349.50
Max. Negotiated Rate	$699.00
Rate for Payer: Cash Price	$950.64
Rate for Payer: Cigna Commercial	$349.50
Rate for Payer: Multiplan Auto	$699.00
Rate for Payer: Multiplan Commercial	$699.00
Rate for Payer: Multiplan Workers Comp	$699.00
Rate for Payer: Scott and White EPO/PPO	$699.00

SCREW LCK 3.5X14MM

Facility

$1,398.00

Service Code	HCPCS C1713
Hospital Charge Code	125930
Hospital Revenue Code	278
Min. Negotiated Rate	$125.82
Max. Negotiated Rate	$1,006.56
Rate for Payer: Amerigroup CHIP/Medicaid	$125.82
Rate for Payer: BCBS of TX Blue Advantage	$419.40
Rate for Payer: BCBS of TX Blue Essentials	$503.28
Rate for Payer: BCBS of TX PPO	$559.20
Rate for Payer: Cash Price	$950.64
Rate for Payer: Cigna Medicaid	$1,006.56
Rate for Payer: Molina CHIP/Medicaid	$1,006.56
Rate for Payer: Multiplan Auto	$699.00
Rate for Payer: Multiplan Commercial	$699.00
Rate for Payer: Multiplan Workers Comp	$699.00
Rate for Payer: Parkland Medicaid	$1,006.56
Rate for Payer: Scott and White EPO/PPO	$699.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,006.56
Rate for Payer: Superior Health Plan EPO	$190.13

SCREW LCK 5X34MM TI TIB T25 STRDRV STRL

Facility

$3,562.00

Service Code	HCPCS C1713
Hospital Charge Code	124841
Hospital Revenue Code	278
Min. Negotiated Rate	$320.58
Max. Negotiated Rate	$2,564.64
Rate for Payer: Amerigroup CHIP/Medicaid	$320.58
Rate for Payer: BCBS of TX Blue Advantage	$1,068.60
Rate for Payer: BCBS of TX Blue Essentials	$1,282.32
Rate for Payer: BCBS of TX PPO	$1,424.80
Rate for Payer: Cash Price	$2,422.16
Rate for Payer: Cigna Medicaid	$2,564.64
Rate for Payer: Molina CHIP/Medicaid	$2,564.64
Rate for Payer: Multiplan Auto	$1,781.00
Rate for Payer: Multiplan Commercial	$1,781.00
Rate for Payer: Multiplan Workers Comp	$1,781.00
Rate for Payer: Parkland Medicaid	$2,564.64
Rate for Payer: Scott and White EPO/PPO	$1,781.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,564.64
Rate for Payer: Superior Health Plan EPO	$484.43

SCREW LCK 5X34MM TI TIB T25 STRDRV STRL

Facility

$3,562.00

Service Code	HCPCS C1713
Hospital Charge Code	124841
Hospital Revenue Code	278
Min. Negotiated Rate	$890.50
Max. Negotiated Rate	$1,781.00
Rate for Payer: Cash Price	$2,422.16
Rate for Payer: Cigna Commercial	$890.50
Rate for Payer: Multiplan Auto	$1,781.00
Rate for Payer: Multiplan Commercial	$1,781.00
Rate for Payer: Multiplan Workers Comp	$1,781.00
Rate for Payer: Scott and White EPO/PPO	$1,781.00

SCREW LCK 5X35MM T2 TI PROX HUM F-T

Facility

$1,171.00

Service Code	HCPCS C1713
Hospital Charge Code	125723
Hospital Revenue Code	278
Min. Negotiated Rate	$292.75
Max. Negotiated Rate	$585.50
Rate for Payer: Cash Price	$796.28
Rate for Payer: Cigna Commercial	$292.75
Rate for Payer: Multiplan Auto	$585.50
Rate for Payer: Multiplan Commercial	$585.50
Rate for Payer: Multiplan Workers Comp	$585.50
Rate for Payer: Scott and White EPO/PPO	$585.50

SCREW LCK 5X35MM T2 TI PROX HUM F-T

Facility

$1,171.00

Service Code	HCPCS C1713
Hospital Charge Code	125723
Hospital Revenue Code	278
Min. Negotiated Rate	$105.39
Max. Negotiated Rate	$843.12
Rate for Payer: Amerigroup CHIP/Medicaid	$105.39
Rate for Payer: BCBS of TX Blue Advantage	$351.30
Rate for Payer: BCBS of TX Blue Essentials	$421.56
Rate for Payer: BCBS of TX PPO	$468.40
Rate for Payer: Cash Price	$796.28
Rate for Payer: Cigna Medicaid	$843.12
Rate for Payer: Molina CHIP/Medicaid	$843.12
Rate for Payer: Multiplan Auto	$585.50
Rate for Payer: Multiplan Commercial	$585.50
Rate for Payer: Multiplan Workers Comp	$585.50
Rate for Payer: Parkland Medicaid	$843.12
Rate for Payer: Scott and White EPO/PPO	$585.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$843.12
Rate for Payer: Superior Health Plan EPO	$159.26

SCREW LCK 5X50MM T2 TI PROX HUM F-T

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992151
Hospital Revenue Code	278
Min. Negotiated Rate	$441.26
Max. Negotiated Rate	$882.53
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Commercial	$441.26
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Scott and White EPO/PPO	$882.53

SCREW LCK 5X50MM T2 TI PROX HUM F-T

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992151
Hospital Revenue Code	278
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$1,270.84
Rate for Payer: Amerigroup CHIP/Medicaid	$158.86
Rate for Payer: BCBS of TX Blue Advantage	$529.52
Rate for Payer: BCBS of TX Blue Essentials	$635.42
Rate for Payer: BCBS of TX PPO	$706.02
Rate for Payer: Cash Price	$1,200.24
Rate for Payer: Cigna Medicaid	$1,270.84
Rate for Payer: Molina CHIP/Medicaid	$1,270.84
Rate for Payer: Multiplan Auto	$882.53
Rate for Payer: Multiplan Commercial	$882.53
Rate for Payer: Multiplan Workers Comp	$882.53
Rate for Payer: Parkland Medicaid	$1,270.84
Rate for Payer: Scott and White EPO/PPO	$882.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,270.84
Rate for Payer: Superior Health Plan EPO	$240.05

SCREW LCKG T8 FULL THD 2.7MM/22MM

Facility

$1,054.22

Service Code	HCPCS C1713
Hospital Charge Code	992102
Hospital Revenue Code	278
Min. Negotiated Rate	$94.88
Max. Negotiated Rate	$759.04
Rate for Payer: Amerigroup CHIP/Medicaid	$94.88
Rate for Payer: BCBS of TX Blue Advantage	$316.27
Rate for Payer: BCBS of TX Blue Essentials	$379.52
Rate for Payer: BCBS of TX PPO	$421.69
Rate for Payer: Cash Price	$716.87
Rate for Payer: Cigna Medicaid	$759.04
Rate for Payer: Molina CHIP/Medicaid	$759.04
Rate for Payer: Multiplan Auto	$527.11
Rate for Payer: Multiplan Commercial	$527.11
Rate for Payer: Multiplan Workers Comp	$527.11
Rate for Payer: Parkland Medicaid	$759.04
Rate for Payer: Scott and White EPO/PPO	$527.11
Rate for Payer: Superior Health Plan CHIP/Medicaid	$759.04
Rate for Payer: Superior Health Plan EPO	$143.37

SCREW LCKG T8 FULL THD 2.7MM/22MM

Facility

$1,054.22

Service Code	HCPCS C1713
Hospital Charge Code	992102
Hospital Revenue Code	278
Min. Negotiated Rate	$263.56
Max. Negotiated Rate	$527.11
Rate for Payer: Cash Price	$716.87
Rate for Payer: Cigna Commercial	$263.56
Rate for Payer: Multiplan Auto	$527.11
Rate for Payer: Multiplan Commercial	$527.11
Rate for Payer: Multiplan Workers Comp	$527.11
Rate for Payer: Scott and White EPO/PPO	$527.11

SCREW LOCKING 2.7 X 10

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	141469
Hospital Revenue Code	278
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$598.50
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Commercial	$299.25
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Scott and White EPO/PPO	$598.50

SCREW LOCKING 2.7 X 10

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	141469
Hospital Revenue Code	278
Min. Negotiated Rate	$107.73
Max. Negotiated Rate	$861.84
Rate for Payer: Amerigroup CHIP/Medicaid	$107.73
Rate for Payer: BCBS of TX Blue Advantage	$359.10
Rate for Payer: BCBS of TX Blue Essentials	$430.92
Rate for Payer: BCBS of TX PPO	$478.80
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Medicaid	$861.84
Rate for Payer: Molina CHIP/Medicaid	$861.84
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Parkland Medicaid	$861.84
Rate for Payer: Scott and White EPO/PPO	$598.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$861.84
Rate for Payer: Superior Health Plan EPO	$162.79

SCREW LOCKING 2.7 X 12

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132388
Hospital Revenue Code	278
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$598.50
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Commercial	$299.25
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Scott and White EPO/PPO	$598.50

SCREW LOCKING 2.7 X 12

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	132388
Hospital Revenue Code	278
Min. Negotiated Rate	$107.73
Max. Negotiated Rate	$861.84
Rate for Payer: Amerigroup CHIP/Medicaid	$107.73
Rate for Payer: BCBS of TX Blue Advantage	$359.10
Rate for Payer: BCBS of TX Blue Essentials	$430.92
Rate for Payer: BCBS of TX PPO	$478.80
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Medicaid	$861.84
Rate for Payer: Molina CHIP/Medicaid	$861.84
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Parkland Medicaid	$861.84
Rate for Payer: Scott and White EPO/PPO	$598.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$861.84
Rate for Payer: Superior Health Plan EPO	$162.79

SCREW LOCKING 2.7 X 26

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	145164
Hospital Revenue Code	278
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$598.50
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Commercial	$299.25
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Scott and White EPO/PPO	$598.50

SCREW LOCKING 2.7 X 26

Facility

$1,197.00

Service Code	HCPCS C1713
Hospital Charge Code	145164
Hospital Revenue Code	278
Min. Negotiated Rate	$107.73
Max. Negotiated Rate	$861.84
Rate for Payer: Amerigroup CHIP/Medicaid	$107.73
Rate for Payer: BCBS of TX Blue Advantage	$359.10
Rate for Payer: BCBS of TX Blue Essentials	$430.92
Rate for Payer: BCBS of TX PPO	$478.80
Rate for Payer: Cash Price	$813.96
Rate for Payer: Cigna Medicaid	$861.84
Rate for Payer: Molina CHIP/Medicaid	$861.84
Rate for Payer: Multiplan Auto	$598.50
Rate for Payer: Multiplan Commercial	$598.50
Rate for Payer: Multiplan Workers Comp	$598.50
Rate for Payer: Parkland Medicaid	$861.84
Rate for Payer: Scott and White EPO/PPO	$598.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$861.84
Rate for Payer: Superior Health Plan EPO	$162.79

SCREW LOCKING 5.0X 37.5

Facility

$873.00

Service Code	HCPCS C1713
Hospital Charge Code	145473
Hospital Revenue Code	278
Min. Negotiated Rate	$218.25
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$593.64
Rate for Payer: Cigna Commercial	$218.25
Rate for Payer: Multiplan Auto	$436.50
Rate for Payer: Multiplan Commercial	$436.50
Rate for Payer: Multiplan Workers Comp	$436.50
Rate for Payer: Scott and White EPO/PPO	$436.50

SCREW LOCKING 5.0X 37.5

Facility

$873.00

Service Code	HCPCS C1713
Hospital Charge Code	145473
Hospital Revenue Code	278
Min. Negotiated Rate	$78.57
Max. Negotiated Rate	$628.56
Rate for Payer: Amerigroup CHIP/Medicaid	$78.57
Rate for Payer: BCBS of TX Blue Advantage	$261.90
Rate for Payer: BCBS of TX Blue Essentials	$314.28
Rate for Payer: BCBS of TX PPO	$349.20
Rate for Payer: Cash Price	$593.64
Rate for Payer: Cigna Medicaid	$628.56
Rate for Payer: Molina CHIP/Medicaid	$628.56
Rate for Payer: Multiplan Auto	$436.50
Rate for Payer: Multiplan Commercial	$436.50
Rate for Payer: Multiplan Workers Comp	$436.50
Rate for Payer: Parkland Medicaid	$628.56
Rate for Payer: Scott and White EPO/PPO	$436.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$628.56
Rate for Payer: Superior Health Plan EPO	$118.73

SCREW LOCKING 5.0X42

Facility

$1,235.00

Service Code	HCPCS C1713
Hospital Charge Code	145423
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 LOCKING 5.0X42

Facility

$1,235.00

Service Code	HCPCS C1713
Hospital Charge Code	145423
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 LOCKING 5MM

Facility

$1,235.00

Service Code	HCPCS C1713
Hospital Charge Code	132406
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 LOCKING 5MM

Facility

$1,235.00

Service Code	HCPCS C1713
Hospital Charge Code	132406
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 LOCKING CORTICAL 3.5 X 18

Facility

$898.00

Service Code	HCPCS C1713
Hospital Charge Code	145270
Hospital Revenue Code	278
Min. Negotiated Rate	$224.50
Max. Negotiated Rate	$449.00
Rate for Payer: Cash Price	$610.64
Rate for Payer: Cigna Commercial	$224.50
Rate for Payer: Multiplan Auto	$449.00
Rate for Payer: Multiplan Commercial	$449.00
Rate for Payer: Multiplan Workers Comp	$449.00
Rate for Payer: Scott and White EPO/PPO	$449.00

SCREW LOCKING CORTICAL 3.5 X 18

Facility

$898.00

Service Code	HCPCS C1713
Hospital Charge Code	145270
Hospital Revenue Code	278
Min. Negotiated Rate	$80.82
Max. Negotiated Rate	$646.56
Rate for Payer: Amerigroup CHIP/Medicaid	$80.82
Rate for Payer: BCBS of TX Blue Advantage	$269.40
Rate for Payer: BCBS of TX Blue Essentials	$323.28
Rate for Payer: BCBS of TX PPO	$359.20
Rate for Payer: Cash Price	$610.64
Rate for Payer: Cigna Medicaid	$646.56
Rate for Payer: Molina CHIP/Medicaid	$646.56
Rate for Payer: Multiplan Auto	$449.00
Rate for Payer: Multiplan Commercial	$449.00
Rate for Payer: Multiplan Workers Comp	$449.00
Rate for Payer: Parkland Medicaid	$646.56
Rate for Payer: Scott and White EPO/PPO	$449.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$646.56
Rate for Payer: Superior Health Plan EPO	$122.13

SCREW LOCKING CORTICAL 3.5 X 20

Facility

$898.00

Service Code	HCPCS C1713
Hospital Charge Code	145269
Hospital Revenue Code	278
Min. Negotiated Rate	$80.82
Max. Negotiated Rate	$646.56
Rate for Payer: Amerigroup CHIP/Medicaid	$80.82
Rate for Payer: BCBS of TX Blue Advantage	$269.40
Rate for Payer: BCBS of TX Blue Essentials	$323.28
Rate for Payer: BCBS of TX PPO	$359.20
Rate for Payer: Cash Price	$610.64
Rate for Payer: Cigna Medicaid	$646.56
Rate for Payer: Molina CHIP/Medicaid	$646.56
Rate for Payer: Multiplan Auto	$449.00
Rate for Payer: Multiplan Commercial	$449.00
Rate for Payer: Multiplan Workers Comp	$449.00
Rate for Payer: Parkland Medicaid	$646.56
Rate for Payer: Scott and White EPO/PPO	$449.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$646.56
Rate for Payer: Superior Health Plan EPO	$122.13

Know your out-of-pocket cost for care.

All Charges