White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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 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 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 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 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 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 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 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

screw locking vault

Facility

$4,518.00

Service Code	HCPCS C1713
Hospital Charge Code	8394469
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.50
Max. Negotiated Rate	$2,259.00
Rate for Payer: Cash Price	$3,072.24
Rate for Payer: Cigna Commercial	$1,129.50
Rate for Payer: Multiplan Auto	$2,259.00
Rate for Payer: Multiplan Commercial	$2,259.00
Rate for Payer: Multiplan Workers Comp	$2,259.00
Rate for Payer: Scott and White EPO/PPO	$2,259.00

screw locking vault

Facility

$4,518.00

Service Code	HCPCS C1713
Hospital Charge Code	8394469
Hospital Revenue Code	278
Min. Negotiated Rate	$406.62
Max. Negotiated Rate	$3,252.96
Rate for Payer: Amerigroup CHIP/Medicaid	$406.62
Rate for Payer: BCBS of TX Blue Advantage	$1,355.40
Rate for Payer: BCBS of TX Blue Essentials	$1,626.48
Rate for Payer: BCBS of TX PPO	$1,807.20
Rate for Payer: Cash Price	$3,072.24
Rate for Payer: Cigna Medicaid	$3,252.96
Rate for Payer: Molina CHIP/Medicaid	$3,252.96
Rate for Payer: Multiplan Auto	$2,259.00
Rate for Payer: Multiplan Commercial	$2,259.00
Rate for Payer: Multiplan Workers Comp	$2,259.00
Rate for Payer: Parkland Medicaid	$3,252.96
Rate for Payer: Scott and White EPO/PPO	$2,259.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,252.96
Rate for Payer: Superior Health Plan EPO	$614.45

SCREW LO PRO 2.7X16

Facility

$389.00

Service Code	HCPCS C1713
Hospital Charge Code	145498
Hospital Revenue Code	278
Min. Negotiated Rate	$97.25
Max. Negotiated Rate	$194.50
Rate for Payer: Cash Price	$264.52
Rate for Payer: Cigna Commercial	$97.25
Rate for Payer: Multiplan Auto	$194.50
Rate for Payer: Multiplan Commercial	$194.50
Rate for Payer: Multiplan Workers Comp	$194.50
Rate for Payer: Scott and White EPO/PPO	$194.50

SCREW LO PRO 2.7X16

Facility

$389.00

Service Code	HCPCS C1713
Hospital Charge Code	145498
Hospital Revenue Code	278
Min. Negotiated Rate	$35.01
Max. Negotiated Rate	$280.08
Rate for Payer: Amerigroup CHIP/Medicaid	$35.01
Rate for Payer: BCBS of TX Blue Advantage	$116.70
Rate for Payer: BCBS of TX Blue Essentials	$140.04
Rate for Payer: BCBS of TX PPO	$155.60
Rate for Payer: Cash Price	$264.52
Rate for Payer: Cigna Medicaid	$280.08
Rate for Payer: Molina CHIP/Medicaid	$280.08
Rate for Payer: Multiplan Auto	$194.50
Rate for Payer: Multiplan Commercial	$194.50
Rate for Payer: Multiplan Workers Comp	$194.50
Rate for Payer: Parkland Medicaid	$280.08
Rate for Payer: Scott and White EPO/PPO	$194.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.08
Rate for Payer: Superior Health Plan EPO	$52.90

screw milagro interference

Facility

$2,693.00

Service Code	HCPCS C1713
Hospital Charge Code	8612544
Hospital Revenue Code	278
Min. Negotiated Rate	$242.37
Max. Negotiated Rate	$1,938.96
Rate for Payer: Amerigroup CHIP/Medicaid	$242.37
Rate for Payer: BCBS of TX Blue Advantage	$807.90
Rate for Payer: BCBS of TX Blue Essentials	$969.48
Rate for Payer: BCBS of TX PPO	$1,077.20
Rate for Payer: Cash Price	$1,831.24
Rate for Payer: Cigna Medicaid	$1,938.96
Rate for Payer: Molina CHIP/Medicaid	$1,938.96
Rate for Payer: Multiplan Auto	$1,346.50
Rate for Payer: Multiplan Commercial	$1,346.50
Rate for Payer: Multiplan Workers Comp	$1,346.50
Rate for Payer: Parkland Medicaid	$1,938.96
Rate for Payer: Scott and White EPO/PPO	$1,346.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,938.96
Rate for Payer: Superior Health Plan EPO	$366.25

screw milagro interference

Facility

$2,693.00

Service Code	HCPCS C1713
Hospital Charge Code	8612544
Hospital Revenue Code	278
Min. Negotiated Rate	$673.25
Max. Negotiated Rate	$1,346.50
Rate for Payer: Cash Price	$1,831.24
Rate for Payer: Cigna Commercial	$673.25
Rate for Payer: Multiplan Auto	$1,346.50
Rate for Payer: Multiplan Commercial	$1,346.50
Rate for Payer: Multiplan Workers Comp	$1,346.50
Rate for Payer: Scott and White EPO/PPO	$1,346.50

SCREW MINI MONSTER CANNULATED SHORT THREAD 4.0 X 46

Facility

$1,463.00

Service Code	HCPCS C1713
Hospital Charge Code	146422
Hospital Revenue Code	278
Min. Negotiated Rate	$365.75
Max. Negotiated Rate	$731.50
Rate for Payer: Cash Price	$994.84
Rate for Payer: Cigna Commercial	$365.75
Rate for Payer: Multiplan Auto	$731.50
Rate for Payer: Multiplan Commercial	$731.50
Rate for Payer: Multiplan Workers Comp	$731.50
Rate for Payer: Scott and White EPO/PPO	$731.50

SCREW MINI MONSTER CANNULATED SHORT THREAD 4.0 X 46

Facility

$1,463.00

Service Code	HCPCS C1713
Hospital Charge Code	146422
Hospital Revenue Code	278
Min. Negotiated Rate	$131.67
Max. Negotiated Rate	$1,053.36
Rate for Payer: Amerigroup CHIP/Medicaid	$131.67
Rate for Payer: BCBS of TX Blue Advantage	$438.90
Rate for Payer: BCBS of TX Blue Essentials	$526.68
Rate for Payer: BCBS of TX PPO	$585.20
Rate for Payer: Cash Price	$994.84
Rate for Payer: Cigna Medicaid	$1,053.36
Rate for Payer: Molina CHIP/Medicaid	$1,053.36
Rate for Payer: Multiplan Auto	$731.50
Rate for Payer: Multiplan Commercial	$731.50
Rate for Payer: Multiplan Workers Comp	$731.50
Rate for Payer: Parkland Medicaid	$1,053.36
Rate for Payer: Scott and White EPO/PPO	$731.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,053.36
Rate for Payer: Superior Health Plan EPO	$198.97

SCREW NATURAL NAIL 5.0MM

Facility

$1,281.79

Hospital Charge Code	146543
Hospital Revenue Code	271
Min. Negotiated Rate	$115.36
Max. Negotiated Rate	$922.89
Rate for Payer: Amerigroup CHIP/Medicaid	$115.36
Rate for Payer: BCBS of TX Blue Advantage	$384.54
Rate for Payer: BCBS of TX Blue Essentials	$461.44
Rate for Payer: BCBS of TX PPO	$512.72
Rate for Payer: Cash Price	$871.62
Rate for Payer: Cigna Medicaid	$922.89
Rate for Payer: Molina CHIP/Medicaid	$922.89
Rate for Payer: Multiplan Auto	$833.16
Rate for Payer: Multiplan Commercial	$833.16
Rate for Payer: Multiplan Workers Comp	$833.16
Rate for Payer: Parkland Medicaid	$922.89
Rate for Payer: Scott and White EPO/PPO	$640.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$922.89
Rate for Payer: Superior Health Plan EPO	$174.32

SCREW NATURAL NAIL 5.0MM

Facility

$1,281.79

Hospital Charge Code	146543
Hospital Revenue Code	271
Rate for Payer: Cash Price	$871.62

SCREW NON LOCKING 2.7MM X 14

Facility

$497.00

Service Code	HCPCS C1713
Hospital Charge Code	8576468
Hospital Revenue Code	278
Min. Negotiated Rate	$44.73
Max. Negotiated Rate	$357.84
Rate for Payer: Amerigroup CHIP/Medicaid	$44.73
Rate for Payer: BCBS of TX Blue Advantage	$149.10
Rate for Payer: BCBS of TX Blue Essentials	$178.92
Rate for Payer: BCBS of TX PPO	$198.80
Rate for Payer: Cash Price	$337.96
Rate for Payer: Cigna Medicaid	$357.84
Rate for Payer: Molina CHIP/Medicaid	$357.84
Rate for Payer: Multiplan Auto	$248.50
Rate for Payer: Multiplan Commercial	$248.50
Rate for Payer: Multiplan Workers Comp	$248.50
Rate for Payer: Parkland Medicaid	$357.84
Rate for Payer: Scott and White EPO/PPO	$248.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$357.84
Rate for Payer: Superior Health Plan EPO	$67.59

SCREW NON LOCKING 2.7MM X 14

Facility

$497.00

Service Code	HCPCS C1713
Hospital Charge Code	8576468
Hospital Revenue Code	278
Min. Negotiated Rate	$124.25
Max. Negotiated Rate	$248.50
Rate for Payer: Cash Price	$337.96
Rate for Payer: Cigna Commercial	$124.25
Rate for Payer: Multiplan Auto	$248.50
Rate for Payer: Multiplan Commercial	$248.50
Rate for Payer: Multiplan Workers Comp	$248.50
Rate for Payer: Scott and White EPO/PPO	$248.50

SCREW NON LOCKING 2.7MM X 16

Facility

$497.00

Service Code	HCPCS C1713
Hospital Charge Code	8576469
Hospital Revenue Code	278
Min. Negotiated Rate	$44.73
Max. Negotiated Rate	$357.84
Rate for Payer: Amerigroup CHIP/Medicaid	$44.73
Rate for Payer: BCBS of TX Blue Advantage	$149.10
Rate for Payer: BCBS of TX Blue Essentials	$178.92
Rate for Payer: BCBS of TX PPO	$198.80
Rate for Payer: Cash Price	$337.96
Rate for Payer: Cigna Medicaid	$357.84
Rate for Payer: Molina CHIP/Medicaid	$357.84
Rate for Payer: Multiplan Auto	$248.50
Rate for Payer: Multiplan Commercial	$248.50
Rate for Payer: Multiplan Workers Comp	$248.50
Rate for Payer: Parkland Medicaid	$357.84
Rate for Payer: Scott and White EPO/PPO	$248.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$357.84
Rate for Payer: Superior Health Plan EPO	$67.59

SCREW NON LOCKING 2.7MM X 16

Facility

$497.00

Service Code	HCPCS C1713
Hospital Charge Code	8576469
Hospital Revenue Code	278
Min. Negotiated Rate	$124.25
Max. Negotiated Rate	$248.50
Rate for Payer: Cash Price	$337.96
Rate for Payer: Cigna Commercial	$124.25
Rate for Payer: Multiplan Auto	$248.50
Rate for Payer: Multiplan Commercial	$248.50
Rate for Payer: Multiplan Workers Comp	$248.50
Rate for Payer: Scott and White EPO/PPO	$248.50

SCREW NON LOCKING 2.7MM X 18

Facility

$497.00

Service Code	HCPCS C1713
Hospital Charge Code	8576475
Hospital Revenue Code	278
Min. Negotiated Rate	$124.25
Max. Negotiated Rate	$248.50
Rate for Payer: Cash Price	$337.96
Rate for Payer: Cigna Commercial	$124.25
Rate for Payer: Multiplan Auto	$248.50
Rate for Payer: Multiplan Commercial	$248.50
Rate for Payer: Multiplan Workers Comp	$248.50
Rate for Payer: Scott and White EPO/PPO	$248.50

Know your out-of-pocket cost for care.

All Charges