White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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	$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 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 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 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 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 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 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 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 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 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 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

SCREW LOCKING EVO AUTOBAHN 5MM X 60

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146683
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 60

Facility

$2,185.00

Service Code	HCPCS C1713
Hospital Charge Code	146683
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 F/T T2 4MM X 40MM

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992158
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 LOCKING F/T T2 4MM X 40MM

Facility

$1,765.06

Service Code	HCPCS C1713
Hospital Charge Code	992158
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 locking f/t t2 5x37mm

Facility

$886.00

Service Code	HCPCS C1713
Hospital Charge Code	8694514
Hospital Revenue Code	278
Min. Negotiated Rate	$79.74
Max. Negotiated Rate	$637.92
Rate for Payer: Amerigroup CHIP/Medicaid	$79.74
Rate for Payer: BCBS of TX Blue Advantage	$265.80
Rate for Payer: BCBS of TX Blue Essentials	$318.96
Rate for Payer: BCBS of TX PPO	$354.40
Rate for Payer: Cash Price	$602.48
Rate for Payer: Cigna Medicaid	$637.92
Rate for Payer: Molina CHIP/Medicaid	$637.92
Rate for Payer: Multiplan Auto	$443.00
Rate for Payer: Multiplan Commercial	$443.00
Rate for Payer: Multiplan Workers Comp	$443.00
Rate for Payer: Parkland Medicaid	$637.92
Rate for Payer: Scott and White EPO/PPO	$443.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$637.92
Rate for Payer: Superior Health Plan EPO	$120.50

screw locking f/t t2 5x37mm

Facility

$886.00

Service Code	HCPCS C1713
Hospital Charge Code	8694514
Hospital Revenue Code	278
Min. Negotiated Rate	$221.50
Max. Negotiated Rate	$443.00
Rate for Payer: Cash Price	$602.48
Rate for Payer: Cigna Commercial	$221.50
Rate for Payer: Multiplan Auto	$443.00
Rate for Payer: Multiplan Commercial	$443.00
Rate for Payer: Multiplan Workers Comp	$443.00
Rate for Payer: Scott and White EPO/PPO	$443.00

SCREW LOCKING T10 FULL THREAD 3.5 X 40

Facility

$1,366.00

Service Code	HCPCS C1713
Hospital Charge Code	146507
Hospital Revenue Code	278
Min. Negotiated Rate	$122.94
Max. Negotiated Rate	$983.52
Rate for Payer: Amerigroup CHIP/Medicaid	$122.94
Rate for Payer: BCBS of TX Blue Advantage	$409.80
Rate for Payer: BCBS of TX Blue Essentials	$491.76
Rate for Payer: BCBS of TX PPO	$546.40
Rate for Payer: Cash Price	$928.88
Rate for Payer: Cigna Medicaid	$983.52
Rate for Payer: Molina CHIP/Medicaid	$983.52
Rate for Payer: Multiplan Auto	$683.00
Rate for Payer: Multiplan Commercial	$683.00
Rate for Payer: Multiplan Workers Comp	$683.00
Rate for Payer: Parkland Medicaid	$983.52
Rate for Payer: Scott and White EPO/PPO	$683.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$983.52
Rate for Payer: Superior Health Plan EPO	$185.78

SCREW LOCKING T10 FULL THREAD 3.5 X 40

Facility

$1,366.00

Service Code	HCPCS C1713
Hospital Charge Code	146507
Hospital Revenue Code	278
Min. Negotiated Rate	$341.50
Max. Negotiated Rate	$683.00
Rate for Payer: Cash Price	$928.88
Rate for Payer: Cigna Commercial	$341.50
Rate for Payer: Multiplan Auto	$683.00
Rate for Payer: Multiplan Commercial	$683.00
Rate for Payer: Multiplan Workers Comp	$683.00
Rate for Payer: Scott and White EPO/PPO	$683.00

SCREW LOCKING T10 FULL THREAD 3.5 X 48

Facility

$1,366.00

Service Code	HCPCS C1713
Hospital Charge Code	146508
Hospital Revenue Code	278
Min. Negotiated Rate	$341.50
Max. Negotiated Rate	$683.00
Rate for Payer: Cash Price	$928.88
Rate for Payer: Cigna Commercial	$341.50
Rate for Payer: Multiplan Auto	$683.00
Rate for Payer: Multiplan Commercial	$683.00
Rate for Payer: Multiplan Workers Comp	$683.00
Rate for Payer: Scott and White EPO/PPO	$683.00

SCREW LOCKING T10 FULL THREAD 3.5 X 48

Facility

$1,366.00

Service Code	HCPCS C1713
Hospital Charge Code	146508
Hospital Revenue Code	278
Min. Negotiated Rate	$122.94
Max. Negotiated Rate	$983.52
Rate for Payer: Amerigroup CHIP/Medicaid	$122.94
Rate for Payer: BCBS of TX Blue Advantage	$409.80
Rate for Payer: BCBS of TX Blue Essentials	$491.76
Rate for Payer: BCBS of TX PPO	$546.40
Rate for Payer: Cash Price	$928.88
Rate for Payer: Cigna Medicaid	$983.52
Rate for Payer: Molina CHIP/Medicaid	$983.52
Rate for Payer: Multiplan Auto	$683.00
Rate for Payer: Multiplan Commercial	$683.00
Rate for Payer: Multiplan Workers Comp	$683.00
Rate for Payer: Parkland Medicaid	$983.52
Rate for Payer: Scott and White EPO/PPO	$683.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$983.52
Rate for Payer: Superior Health Plan EPO	$185.78

Know your out-of-pocket cost for care.

All Charges