White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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 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 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 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 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

$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

$6,927.00

Service Code	HCPCS C1713
Hospital Charge Code	8504494
Hospital Revenue Code	278
Min. Negotiated Rate	$1,731.75
Max. Negotiated Rate	$3,463.50
Rate for Payer: Cash Price	$4,710.36
Rate for Payer: Cigna Commercial	$1,731.75
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: Scott and White EPO/PPO	$3,463.50

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

SCREW POLYAXIAL

Facility

$5,723.00

Service Code	HCPCS C1713
Hospital Charge Code	8420453
Hospital Revenue Code	278
Min. Negotiated Rate	$515.07
Max. Negotiated Rate	$4,120.56
Rate for Payer: Amerigroup CHIP/Medicaid	$515.07
Rate for Payer: BCBS of TX Blue Advantage	$1,716.90
Rate for Payer: BCBS of TX Blue Essentials	$2,060.28
Rate for Payer: BCBS of TX PPO	$2,289.20
Rate for Payer: Cash Price	$3,891.64
Rate for Payer: Cigna Medicaid	$4,120.56
Rate for Payer: Molina CHIP/Medicaid	$4,120.56
Rate for Payer: Multiplan Auto	$2,861.50
Rate for Payer: Multiplan Commercial	$2,861.50
Rate for Payer: Multiplan Workers Comp	$2,861.50
Rate for Payer: Parkland Medicaid	$4,120.56
Rate for Payer: Scott and White EPO/PPO	$2,861.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,120.56
Rate for Payer: Superior Health Plan EPO	$778.33

SCREW POLYAXIAL

Facility

$5,723.00

Service Code	HCPCS C1713
Hospital Charge Code	8420453
Hospital Revenue Code	278
Min. Negotiated Rate	$1,430.75
Max. Negotiated Rate	$2,861.50
Rate for Payer: Cash Price	$3,891.64
Rate for Payer: Cigna Commercial	$1,430.75
Rate for Payer: Multiplan Auto	$2,861.50
Rate for Payer: Multiplan Commercial	$2,861.50
Rate for Payer: Multiplan Workers Comp	$2,861.50
Rate for Payer: Scott and White EPO/PPO	$2,861.50

SCREW POLYAXIAL 6.4 X 40 SLOK

Facility

$18,554.00

Service Code	HCPCS C1713
Hospital Charge Code	8406458
Hospital Revenue Code	278
Min. Negotiated Rate	$4,638.50
Max. Negotiated Rate	$9,277.00
Rate for Payer: Cash Price	$12,616.72
Rate for Payer: Cigna Commercial	$4,638.50
Rate for Payer: Multiplan Auto	$9,277.00
Rate for Payer: Multiplan Commercial	$9,277.00
Rate for Payer: Multiplan Workers Comp	$9,277.00
Rate for Payer: Scott and White EPO/PPO	$9,277.00

SCREW POLYAXIAL 6.4 X 40 SLOK

Facility

$18,554.00

Service Code	HCPCS C1713
Hospital Charge Code	8406458
Hospital Revenue Code	278
Min. Negotiated Rate	$1,669.86
Max. Negotiated Rate	$13,358.88
Rate for Payer: Amerigroup CHIP/Medicaid	$1,669.86
Rate for Payer: BCBS of TX Blue Advantage	$5,566.20
Rate for Payer: BCBS of TX Blue Essentials	$6,679.44
Rate for Payer: BCBS of TX PPO	$7,421.60
Rate for Payer: Cash Price	$12,616.72
Rate for Payer: Cigna Medicaid	$13,358.88
Rate for Payer: Molina CHIP/Medicaid	$13,358.88
Rate for Payer: Multiplan Auto	$9,277.00
Rate for Payer: Multiplan Commercial	$9,277.00
Rate for Payer: Multiplan Workers Comp	$9,277.00
Rate for Payer: Parkland Medicaid	$13,358.88
Rate for Payer: Scott and White EPO/PPO	$9,277.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,358.88
Rate for Payer: Superior Health Plan EPO	$2,523.34

SCREW POLYAXIAL 6.5 X 35 SLOK

Facility

$7,831.00

Service Code	HCPCS C1713
Hospital Charge Code	8404477
Hospital Revenue Code	278
Min. Negotiated Rate	$1,957.75
Max. Negotiated Rate	$3,915.50
Rate for Payer: Cash Price	$5,325.08
Rate for Payer: Cigna Commercial	$1,957.75
Rate for Payer: Multiplan Auto	$3,915.50
Rate for Payer: Multiplan Commercial	$3,915.50
Rate for Payer: Multiplan Workers Comp	$3,915.50
Rate for Payer: Scott and White EPO/PPO	$3,915.50

SCREW POLYAXIAL 6.5 X 35 SLOK

Facility

$7,831.00

Service Code	HCPCS C1713
Hospital Charge Code	8404477
Hospital Revenue Code	278
Min. Negotiated Rate	$704.79
Max. Negotiated Rate	$5,638.32
Rate for Payer: Amerigroup CHIP/Medicaid	$704.79
Rate for Payer: BCBS of TX Blue Advantage	$2,349.30
Rate for Payer: BCBS of TX Blue Essentials	$2,819.16
Rate for Payer: BCBS of TX PPO	$3,132.40
Rate for Payer: Cash Price	$5,325.08
Rate for Payer: Cigna Medicaid	$5,638.32
Rate for Payer: Molina CHIP/Medicaid	$5,638.32
Rate for Payer: Multiplan Auto	$3,915.50
Rate for Payer: Multiplan Commercial	$3,915.50
Rate for Payer: Multiplan Workers Comp	$3,915.50
Rate for Payer: Parkland Medicaid	$5,638.32
Rate for Payer: Scott and White EPO/PPO	$3,915.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,638.32
Rate for Payer: Superior Health Plan EPO	$1,065.02

SCREW POLYAXIAL 7.5X40

Facility

$7,831.00

Service Code	HCPCS C1713
Hospital Charge Code	8394464
Hospital Revenue Code	278
Min. Negotiated Rate	$1,957.75
Max. Negotiated Rate	$3,915.50
Rate for Payer: Cash Price	$5,325.08
Rate for Payer: Cigna Commercial	$1,957.75
Rate for Payer: Multiplan Auto	$3,915.50
Rate for Payer: Multiplan Commercial	$3,915.50
Rate for Payer: Multiplan Workers Comp	$3,915.50
Rate for Payer: Scott and White EPO/PPO	$3,915.50

SCREW POLYAXIAL 7.5X40

Facility

$7,831.00

Service Code	HCPCS C1713
Hospital Charge Code	8394464
Hospital Revenue Code	278
Min. Negotiated Rate	$704.79
Max. Negotiated Rate	$5,638.32
Rate for Payer: Amerigroup CHIP/Medicaid	$704.79
Rate for Payer: BCBS of TX Blue Advantage	$2,349.30
Rate for Payer: BCBS of TX Blue Essentials	$2,819.16
Rate for Payer: BCBS of TX PPO	$3,132.40
Rate for Payer: Cash Price	$5,325.08
Rate for Payer: Cigna Medicaid	$5,638.32
Rate for Payer: Molina CHIP/Medicaid	$5,638.32
Rate for Payer: Multiplan Auto	$3,915.50
Rate for Payer: Multiplan Commercial	$3,915.50
Rate for Payer: Multiplan Workers Comp	$3,915.50
Rate for Payer: Parkland Medicaid	$5,638.32
Rate for Payer: Scott and White EPO/PPO	$3,915.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,638.32
Rate for Payer: Superior Health Plan EPO	$1,065.02

SCREW R3CON LOCKING SCREW 3.5 X 16

Facility

$1,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146415
Hospital Revenue Code	278
Min. Negotiated Rate	$305.50
Max. Negotiated Rate	$611.00
Rate for Payer: Cash Price	$830.96
Rate for Payer: Cigna Commercial	$305.50
Rate for Payer: Multiplan Auto	$611.00
Rate for Payer: Multiplan Commercial	$611.00
Rate for Payer: Multiplan Workers Comp	$611.00
Rate for Payer: Scott and White EPO/PPO	$611.00

SCREW R3CON LOCKING SCREW 3.5 X 16

Facility

$1,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146415
Hospital Revenue Code	278
Min. Negotiated Rate	$109.98
Max. Negotiated Rate	$879.84
Rate for Payer: Amerigroup CHIP/Medicaid	$109.98
Rate for Payer: BCBS of TX Blue Advantage	$366.60
Rate for Payer: BCBS of TX Blue Essentials	$439.92
Rate for Payer: BCBS of TX PPO	$488.80
Rate for Payer: Cash Price	$830.96
Rate for Payer: Cigna Medicaid	$879.84
Rate for Payer: Molina CHIP/Medicaid	$879.84
Rate for Payer: Multiplan Auto	$611.00
Rate for Payer: Multiplan Commercial	$611.00
Rate for Payer: Multiplan Workers Comp	$611.00
Rate for Payer: Parkland Medicaid	$879.84
Rate for Payer: Scott and White EPO/PPO	$611.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$879.84
Rate for Payer: Superior Health Plan EPO	$166.19

SCREW R3CON LOCKING SCREW 3.5 X 18

Facility

$1,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146414
Hospital Revenue Code	278
Min. Negotiated Rate	$305.50
Max. Negotiated Rate	$611.00
Rate for Payer: Cash Price	$830.96
Rate for Payer: Cigna Commercial	$305.50
Rate for Payer: Multiplan Auto	$611.00
Rate for Payer: Multiplan Commercial	$611.00
Rate for Payer: Multiplan Workers Comp	$611.00
Rate for Payer: Scott and White EPO/PPO	$611.00

SCREW R3CON LOCKING SCREW 3.5 X 18

Facility

$1,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146414
Hospital Revenue Code	278
Min. Negotiated Rate	$109.98
Max. Negotiated Rate	$879.84
Rate for Payer: Amerigroup CHIP/Medicaid	$109.98
Rate for Payer: BCBS of TX Blue Advantage	$366.60
Rate for Payer: BCBS of TX Blue Essentials	$439.92
Rate for Payer: BCBS of TX PPO	$488.80
Rate for Payer: Cash Price	$830.96
Rate for Payer: Cigna Medicaid	$879.84
Rate for Payer: Molina CHIP/Medicaid	$879.84
Rate for Payer: Multiplan Auto	$611.00
Rate for Payer: Multiplan Commercial	$611.00
Rate for Payer: Multiplan Workers Comp	$611.00
Rate for Payer: Parkland Medicaid	$879.84
Rate for Payer: Scott and White EPO/PPO	$611.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$879.84
Rate for Payer: Superior Health Plan EPO	$166.19

SCREW R3CON NON LOCKING 3.5 X 14

Facility

$889.00

Service Code	HCPCS C1713
Hospital Charge Code	145416
Hospital Revenue Code	278
Min. Negotiated Rate	$80.01
Max. Negotiated Rate	$640.08
Rate for Payer: Amerigroup CHIP/Medicaid	$80.01
Rate for Payer: BCBS of TX Blue Advantage	$266.70
Rate for Payer: BCBS of TX Blue Essentials	$320.04
Rate for Payer: BCBS of TX PPO	$355.60
Rate for Payer: Cash Price	$604.52
Rate for Payer: Cigna Medicaid	$640.08
Rate for Payer: Molina CHIP/Medicaid	$640.08
Rate for Payer: Multiplan Auto	$444.50
Rate for Payer: Multiplan Commercial	$444.50
Rate for Payer: Multiplan Workers Comp	$444.50
Rate for Payer: Parkland Medicaid	$640.08
Rate for Payer: Scott and White EPO/PPO	$444.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$640.08
Rate for Payer: Superior Health Plan EPO	$120.90

SCREW R3CON NON LOCKING 3.5 X 14

Facility

$889.00

Service Code	HCPCS C1713
Hospital Charge Code	145416
Hospital Revenue Code	278
Min. Negotiated Rate	$222.25
Max. Negotiated Rate	$444.50
Rate for Payer: Cash Price	$604.52
Rate for Payer: Cigna Commercial	$222.25
Rate for Payer: Multiplan Auto	$444.50
Rate for Payer: Multiplan Commercial	$444.50
Rate for Payer: Multiplan Workers Comp	$444.50
Rate for Payer: Scott and White EPO/PPO	$444.50

Know your out-of-pocket cost for care.

All Charges