White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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 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 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	$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 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 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
Rate for Payer: Cash Price	$871.62

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 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 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 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 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 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

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	$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 3.5 X48MM

Facility

$7,896.00

Service Code	HCPCS C1713
Hospital Charge Code	145070
Hospital Revenue Code	278
Min. Negotiated Rate	$1,974.00
Max. Negotiated Rate	$3,948.00
Rate for Payer: Cash Price	$5,369.28
Rate for Payer: Cigna Commercial	$1,974.00
Rate for Payer: Multiplan Auto	$3,948.00
Rate for Payer: Multiplan Commercial	$3,948.00
Rate for Payer: Multiplan Workers Comp	$3,948.00
Rate for Payer: Scott and White EPO/PPO	$3,948.00

SCREW NON LOCKING 3.5 X48MM

Facility

$7,896.00

Service Code	HCPCS C1713
Hospital Charge Code	145070
Hospital Revenue Code	278
Min. Negotiated Rate	$710.64
Max. Negotiated Rate	$5,685.12
Rate for Payer: Amerigroup CHIP/Medicaid	$710.64
Rate for Payer: BCBS of TX Blue Advantage	$2,368.80
Rate for Payer: BCBS of TX Blue Essentials	$2,842.56
Rate for Payer: BCBS of TX PPO	$3,158.40
Rate for Payer: Cash Price	$5,369.28
Rate for Payer: Cigna Medicaid	$5,685.12
Rate for Payer: Molina CHIP/Medicaid	$5,685.12
Rate for Payer: Multiplan Auto	$3,948.00
Rate for Payer: Multiplan Commercial	$3,948.00
Rate for Payer: Multiplan Workers Comp	$3,948.00
Rate for Payer: Parkland Medicaid	$5,685.12
Rate for Payer: Scott and White EPO/PPO	$3,948.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,685.12
Rate for Payer: Superior Health Plan EPO	$1,073.86

screw pedicle 5.5 x 45

Facility

$6,024.00

Service Code	HCPCS C1713
Hospital Charge Code	8666511
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.00
Max. Negotiated Rate	$3,012.00
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Commercial	$1,506.00
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Scott and White EPO/PPO	$3,012.00

screw pedicle 5.5 x 45

Facility

$6,024.00

Service Code	HCPCS C1713
Hospital Charge Code	8666511
Hospital Revenue Code	278
Min. Negotiated Rate	$542.16
Max. Negotiated Rate	$4,337.28
Rate for Payer: Amerigroup CHIP/Medicaid	$542.16
Rate for Payer: BCBS of TX Blue Advantage	$1,807.20
Rate for Payer: BCBS of TX Blue Essentials	$2,168.64
Rate for Payer: BCBS of TX PPO	$2,409.60
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Medicaid	$4,337.28
Rate for Payer: Molina CHIP/Medicaid	$4,337.28
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Parkland Medicaid	$4,337.28
Rate for Payer: Scott and White EPO/PPO	$3,012.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,337.28
Rate for Payer: Superior Health Plan EPO	$819.26

screw pedicle 6.5 x 40

Facility

$6,024.00

Service Code	HCPCS C1713
Hospital Charge Code	8666518
Hospital Revenue Code	278
Min. Negotiated Rate	$1,506.00
Max. Negotiated Rate	$3,012.00
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Commercial	$1,506.00
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Scott and White EPO/PPO	$3,012.00

screw pedicle 6.5 x 40

Facility

$6,024.00

Service Code	HCPCS C1713
Hospital Charge Code	8666518
Hospital Revenue Code	278
Min. Negotiated Rate	$542.16
Max. Negotiated Rate	$4,337.28
Rate for Payer: Amerigroup CHIP/Medicaid	$542.16
Rate for Payer: BCBS of TX Blue Advantage	$1,807.20
Rate for Payer: BCBS of TX Blue Essentials	$2,168.64
Rate for Payer: BCBS of TX PPO	$2,409.60
Rate for Payer: Cash Price	$4,096.32
Rate for Payer: Cigna Medicaid	$4,337.28
Rate for Payer: Molina CHIP/Medicaid	$4,337.28
Rate for Payer: Multiplan Auto	$3,012.00
Rate for Payer: Multiplan Commercial	$3,012.00
Rate for Payer: Multiplan Workers Comp	$3,012.00
Rate for Payer: Parkland Medicaid	$4,337.28
Rate for Payer: Scott and White EPO/PPO	$3,012.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,337.28
Rate for Payer: Superior Health Plan EPO	$819.26

screw poly avant

Facility

$4,819.00

Service Code	HCPCS C1713
Hospital Charge Code	8708540
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 poly avant

Facility

$4,819.00

Service Code	HCPCS C1713
Hospital Charge Code	8708540
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

SCREW POLY AVANT

Facility

$6,927.00

Service Code	HCPCS C1713
Hospital Charge Code	8504494
Hospital Revenue Code	278
Min. Negotiated Rate	$623.43
Max. Negotiated Rate	$4,987.44
Rate for Payer: Amerigroup CHIP/Medicaid	$623.43
Rate for Payer: BCBS of TX Blue Advantage	$2,078.10
Rate for Payer: BCBS of TX Blue Essentials	$2,493.72
Rate for Payer: BCBS of TX PPO	$2,770.80
Rate for Payer: Cash Price	$4,710.36
Rate for Payer: Cigna Medicaid	$4,987.44
Rate for Payer: Molina CHIP/Medicaid	$4,987.44
Rate for Payer: Multiplan Auto	$3,463.50
Rate for Payer: Multiplan Commercial	$3,463.50
Rate for Payer: Multiplan Workers Comp	$3,463.50
Rate for Payer: Parkland Medicaid	$4,987.44
Rate for Payer: Scott and White EPO/PPO	$3,463.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,987.44
Rate for Payer: Superior Health Plan EPO	$942.07

Know your out-of-pocket cost for care.

All Charges