White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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 5.0X 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 5.0X42

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	$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 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 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 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 20

Facility

$898.00

Service Code	HCPCS C1713
Hospital Charge Code	145269
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 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

SCREW LOCKING CORTICAL 3.5 X22

Facility

$898.00

Service Code	HCPCS C1713
Hospital Charge Code	145268
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 X22

Facility

$898.00

Service Code	HCPCS C1713
Hospital Charge Code	145268
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 24

Facility

$898.00

Service Code	HCPCS C1713
Hospital Charge Code	145271
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 24

Facility

$898.00

Service Code	HCPCS C1713
Hospital Charge Code	145271
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 EVO AUTOBAHN 5MM X 27.5

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146677
Hospital Revenue Code	278
Min. Negotiated Rate	$546.25
Max. Negotiated Rate	$1,092.50
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Commercial	$546.25
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Scott and White EPO/PPO	$1,092.50

SCREW LOCKING EVO AUTOBAHN 5MM X 27.5

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146677
Hospital Revenue Code	278
Min. Negotiated Rate	$196.65
Max. Negotiated Rate	$1,573.20
Rate for Payer: Amerigroup CHIP/Medicaid	$196.65
Rate for Payer: BCBS of TX Blue Advantage	$655.50
Rate for Payer: BCBS of TX Blue Essentials	$786.60
Rate for Payer: BCBS of TX PPO	$874.00
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Medicaid	$1,573.20
Rate for Payer: Molina CHIP/Medicaid	$1,573.20
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Parkland Medicaid	$1,573.20
Rate for Payer: Scott and White EPO/PPO	$1,092.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,573.20
Rate for Payer: Superior Health Plan EPO	$297.16

SCREW LOCKING EVO AUTOBAHN 5MM X 32.5

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146679
Hospital Revenue Code	278
Min. Negotiated Rate	$196.65
Max. Negotiated Rate	$1,573.20
Rate for Payer: Amerigroup CHIP/Medicaid	$196.65
Rate for Payer: BCBS of TX Blue Advantage	$655.50
Rate for Payer: BCBS of TX Blue Essentials	$786.60
Rate for Payer: BCBS of TX PPO	$874.00
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Medicaid	$1,573.20
Rate for Payer: Molina CHIP/Medicaid	$1,573.20
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Parkland Medicaid	$1,573.20
Rate for Payer: Scott and White EPO/PPO	$1,092.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,573.20
Rate for Payer: Superior Health Plan EPO	$297.16

SCREW LOCKING EVO AUTOBAHN 5MM X 32.5

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146679
Hospital Revenue Code	278
Min. Negotiated Rate	$546.25
Max. Negotiated Rate	$1,092.50
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Commercial	$546.25
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Scott and White EPO/PPO	$1,092.50

SCREW LOCKING EVO AUTOBAHN 5MM X 40

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146680
Hospital Revenue Code	278
Min. Negotiated Rate	$546.25
Max. Negotiated Rate	$1,092.50
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Commercial	$546.25
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Scott and White EPO/PPO	$1,092.50

SCREW LOCKING EVO AUTOBAHN 5MM X 40

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146680
Hospital Revenue Code	278
Min. Negotiated Rate	$196.65
Max. Negotiated Rate	$1,573.20
Rate for Payer: Amerigroup CHIP/Medicaid	$196.65
Rate for Payer: BCBS of TX Blue Advantage	$655.50
Rate for Payer: BCBS of TX Blue Essentials	$786.60
Rate for Payer: BCBS of TX PPO	$874.00
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Medicaid	$1,573.20
Rate for Payer: Molina CHIP/Medicaid	$1,573.20
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Parkland Medicaid	$1,573.20
Rate for Payer: Scott and White EPO/PPO	$1,092.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,573.20
Rate for Payer: Superior Health Plan EPO	$297.16

SCREW LOCKING EVO AUTOBAHN 5MM X 50

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146681
Hospital Revenue Code	278
Min. Negotiated Rate	$196.65
Max. Negotiated Rate	$1,573.20
Rate for Payer: Amerigroup CHIP/Medicaid	$196.65
Rate for Payer: BCBS of TX Blue Advantage	$655.50
Rate for Payer: BCBS of TX Blue Essentials	$786.60
Rate for Payer: BCBS of TX PPO	$874.00
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Medicaid	$1,573.20
Rate for Payer: Molina CHIP/Medicaid	$1,573.20
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Parkland Medicaid	$1,573.20
Rate for Payer: Scott and White EPO/PPO	$1,092.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,573.20
Rate for Payer: Superior Health Plan EPO	$297.16

SCREW LOCKING EVO AUTOBAHN 5MM X 50

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146681
Hospital Revenue Code	278
Min. Negotiated Rate	$546.25
Max. Negotiated Rate	$1,092.50
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Commercial	$546.25
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Scott and White EPO/PPO	$1,092.50

SCREW LOCKING EVO AUTOBAHN 5MM X 53

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146682
Hospital Revenue Code	278
Min. Negotiated Rate	$196.65
Max. Negotiated Rate	$1,573.20
Rate for Payer: Amerigroup CHIP/Medicaid	$196.65
Rate for Payer: BCBS of TX Blue Advantage	$655.50
Rate for Payer: BCBS of TX Blue Essentials	$786.60
Rate for Payer: BCBS of TX PPO	$874.00
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Medicaid	$1,573.20
Rate for Payer: Molina CHIP/Medicaid	$1,573.20
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Parkland Medicaid	$1,573.20
Rate for Payer: Scott and White EPO/PPO	$1,092.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,573.20
Rate for Payer: Superior Health Plan EPO	$297.16

SCREW LOCKING EVO AUTOBAHN 5MM X 53

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146682
Hospital Revenue Code	278
Min. Negotiated Rate	$546.25
Max. Negotiated Rate	$1,092.50
Rate for Payer: Cash Price	$1,485.80
Rate for Payer: Cigna Commercial	$546.25
Rate for Payer: Multiplan Auto	$1,092.50
Rate for Payer: Multiplan Commercial	$1,092.50
Rate for Payer: Multiplan Workers Comp	$1,092.50
Rate for Payer: Scott and White EPO/PPO	$1,092.50

Know your out-of-pocket cost for care.

All Charges