White Rock Medical Center

All Charges

Charge

Type

Setting

Price

screw set spine

Facility

$753.00

Service Code	HCPCS C1713
Hospital Charge Code	8666517
Hospital Revenue Code	278
Min. Negotiated Rate	$67.77
Max. Negotiated Rate	$542.16
Rate for Payer: Amerigroup CHIP/Medicaid	$67.77
Rate for Payer: BCBS of TX Blue Advantage	$225.90
Rate for Payer: BCBS of TX Blue Essentials	$271.08
Rate for Payer: BCBS of TX PPO	$301.20
Rate for Payer: Cash Price	$512.04
Rate for Payer: Cigna Medicaid	$542.16
Rate for Payer: Molina CHIP/Medicaid	$542.16
Rate for Payer: Multiplan Auto	$376.50
Rate for Payer: Multiplan Commercial	$376.50
Rate for Payer: Multiplan Workers Comp	$376.50
Rate for Payer: Parkland Medicaid	$542.16
Rate for Payer: Scott and White EPO/PPO	$376.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$542.16
Rate for Payer: Superior Health Plan EPO	$102.41

screw set spine

Facility

$753.00

Service Code	HCPCS C1713
Hospital Charge Code	8666517
Hospital Revenue Code	278
Min. Negotiated Rate	$188.25
Max. Negotiated Rate	$376.50
Rate for Payer: Cash Price	$512.04
Rate for Payer: Cigna Commercial	$188.25
Rate for Payer: Multiplan Auto	$376.50
Rate for Payer: Multiplan Commercial	$376.50
Rate for Payer: Multiplan Workers Comp	$376.50
Rate for Payer: Scott and White EPO/PPO	$376.50

SCREW SPECIALITY TYPEI -- DHF

Facility

$136.00

Service Code	HCPCS C1713
Hospital Charge Code	81362667
Hospital Revenue Code	278
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$68.00
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Commercial	$34.00
Rate for Payer: Multiplan Auto	$68.00
Rate for Payer: Multiplan Commercial	$68.00
Rate for Payer: Multiplan Workers Comp	$68.00
Rate for Payer: Scott and White EPO/PPO	$68.00

SCREW SPECIALITY TYPEI -- DHF

Facility

$136.00

Service Code	HCPCS C1713
Hospital Charge Code	81362667
Hospital Revenue Code	278
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$97.92
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
Rate for Payer: Multiplan Auto	$68.00
Rate for Payer: Multiplan Commercial	$68.00
Rate for Payer: Multiplan Workers Comp	$68.00
Rate for Payer: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$68.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

SCREW SPECIALITY TYPEII -- DHF

Facility

$5,260.00

Service Code	HCPCS C1713
Hospital Charge Code	81362675
Hospital Revenue Code	278
Min. Negotiated Rate	$473.40
Max. Negotiated Rate	$3,787.20
Rate for Payer: Amerigroup CHIP/Medicaid	$473.40
Rate for Payer: BCBS of TX Blue Advantage	$1,578.00
Rate for Payer: BCBS of TX Blue Essentials	$1,893.60
Rate for Payer: BCBS of TX PPO	$2,104.00
Rate for Payer: Cash Price	$3,576.80
Rate for Payer: Cigna Medicaid	$3,787.20
Rate for Payer: Molina CHIP/Medicaid	$3,787.20
Rate for Payer: Multiplan Auto	$2,630.00
Rate for Payer: Multiplan Commercial	$2,630.00
Rate for Payer: Multiplan Workers Comp	$2,630.00
Rate for Payer: Parkland Medicaid	$3,787.20
Rate for Payer: Scott and White EPO/PPO	$2,630.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,787.20
Rate for Payer: Superior Health Plan EPO	$715.36

SCREW SPECIALITY TYPEII -- DHF

Facility

$5,260.00

Service Code	HCPCS C1713
Hospital Charge Code	81362675
Hospital Revenue Code	278
Min. Negotiated Rate	$1,315.00
Max. Negotiated Rate	$2,630.00
Rate for Payer: Cash Price	$3,576.80
Rate for Payer: Cigna Commercial	$1,315.00
Rate for Payer: Multiplan Auto	$2,630.00
Rate for Payer: Multiplan Commercial	$2,630.00
Rate for Payer: Multiplan Workers Comp	$2,630.00
Rate for Payer: Scott and White EPO/PPO	$2,630.00

screw talon distal fix lag

Facility

$4,819.00

Service Code	HCPCS C1713
Hospital Charge Code	8720591
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 talon distal fix lag

Facility

$4,819.00

Service Code	HCPCS C1713
Hospital Charge Code	8720591
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 Talon Distal Fx Lag

Facility

$4,819.00

Service Code	HCPCS C1713
Hospital Charge Code	145820
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 Talon Distal Fx Lag

Facility

$4,819.00

Service Code	HCPCS C1713
Hospital Charge Code	145820
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 TITAN CARBOFIX 50MMXL42.5

Facility

$2,096.00

Service Code	HCPCS C1713
Hospital Charge Code	145338
Hospital Revenue Code	278
Min. Negotiated Rate	$524.00
Max. Negotiated Rate	$1,048.00
Rate for Payer: Cash Price	$1,425.28
Rate for Payer: Cigna Commercial	$524.00
Rate for Payer: Multiplan Auto	$1,048.00
Rate for Payer: Multiplan Commercial	$1,048.00
Rate for Payer: Multiplan Workers Comp	$1,048.00
Rate for Payer: Scott and White EPO/PPO	$1,048.00

SCREW TITAN CARBOFIX 50MMXL42.5

Facility

$2,096.00

Service Code	HCPCS C1713
Hospital Charge Code	145338
Hospital Revenue Code	278
Min. Negotiated Rate	$188.64
Max. Negotiated Rate	$1,509.12
Rate for Payer: Amerigroup CHIP/Medicaid	$188.64
Rate for Payer: BCBS of TX Blue Advantage	$628.80
Rate for Payer: BCBS of TX Blue Essentials	$754.56
Rate for Payer: BCBS of TX PPO	$838.40
Rate for Payer: Cash Price	$1,425.28
Rate for Payer: Cigna Medicaid	$1,509.12
Rate for Payer: Molina CHIP/Medicaid	$1,509.12
Rate for Payer: Multiplan Auto	$1,048.00
Rate for Payer: Multiplan Commercial	$1,048.00
Rate for Payer: Multiplan Workers Comp	$1,048.00
Rate for Payer: Parkland Medicaid	$1,509.12
Rate for Payer: Scott and White EPO/PPO	$1,048.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,509.12
Rate for Payer: Superior Health Plan EPO	$285.06

screw titanium 5.0 l3

Facility

$2,096.00

Service Code	HCPCS C1713
Hospital Charge Code	8720605
Hospital Revenue Code	278
Min. Negotiated Rate	$188.64
Max. Negotiated Rate	$1,509.12
Rate for Payer: Amerigroup CHIP/Medicaid	$188.64
Rate for Payer: BCBS of TX Blue Advantage	$628.80
Rate for Payer: BCBS of TX Blue Essentials	$754.56
Rate for Payer: BCBS of TX PPO	$838.40
Rate for Payer: Cash Price	$1,425.28
Rate for Payer: Cigna Medicaid	$1,509.12
Rate for Payer: Molina CHIP/Medicaid	$1,509.12
Rate for Payer: Multiplan Auto	$1,048.00
Rate for Payer: Multiplan Commercial	$1,048.00
Rate for Payer: Multiplan Workers Comp	$1,048.00
Rate for Payer: Parkland Medicaid	$1,509.12
Rate for Payer: Scott and White EPO/PPO	$1,048.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,509.12
Rate for Payer: Superior Health Plan EPO	$285.06

screw titanium 5.0 l3

Facility

$2,096.00

Service Code	HCPCS C1713
Hospital Charge Code	8720605
Hospital Revenue Code	278
Min. Negotiated Rate	$524.00
Max. Negotiated Rate	$1,048.00
Rate for Payer: Cash Price	$1,425.28
Rate for Payer: Cigna Commercial	$524.00
Rate for Payer: Multiplan Auto	$1,048.00
Rate for Payer: Multiplan Commercial	$1,048.00
Rate for Payer: Multiplan Workers Comp	$1,048.00
Rate for Payer: Scott and White EPO/PPO	$1,048.00

SCREW VA LCK 2.7X14MM S/T T8 STRDRV RCS

Facility

$1,599.00

Service Code	HCPCS C1713
Hospital Charge Code	125249
Hospital Revenue Code	278
Min. Negotiated Rate	$399.75
Max. Negotiated Rate	$799.50
Rate for Payer: Cash Price	$1,087.32
Rate for Payer: Cigna Commercial	$399.75
Rate for Payer: Multiplan Auto	$799.50
Rate for Payer: Multiplan Commercial	$799.50
Rate for Payer: Multiplan Workers Comp	$799.50
Rate for Payer: Scott and White EPO/PPO	$799.50

SCREW VA LCK 2.7X14MM S/T T8 STRDRV RCS

Facility

$1,599.00

Service Code	HCPCS C1713
Hospital Charge Code	125249
Hospital Revenue Code	278
Min. Negotiated Rate	$143.91
Max. Negotiated Rate	$1,151.28
Rate for Payer: Amerigroup CHIP/Medicaid	$143.91
Rate for Payer: BCBS of TX Blue Advantage	$479.70
Rate for Payer: BCBS of TX Blue Essentials	$575.64
Rate for Payer: BCBS of TX PPO	$639.60
Rate for Payer: Cash Price	$1,087.32
Rate for Payer: Cigna Medicaid	$1,151.28
Rate for Payer: Molina CHIP/Medicaid	$1,151.28
Rate for Payer: Multiplan Auto	$799.50
Rate for Payer: Multiplan Commercial	$799.50
Rate for Payer: Multiplan Workers Comp	$799.50
Rate for Payer: Parkland Medicaid	$1,151.28
Rate for Payer: Scott and White EPO/PPO	$799.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,151.28
Rate for Payer: Superior Health Plan EPO	$217.46

SCREW VA LCK 2.7X16MM S/T T8 STRDRV RCS

Facility

$1,599.00

Service Code	HCPCS C1713
Hospital Charge Code	125250
Hospital Revenue Code	278
Min. Negotiated Rate	$143.91
Max. Negotiated Rate	$1,151.28
Rate for Payer: Amerigroup CHIP/Medicaid	$143.91
Rate for Payer: BCBS of TX Blue Advantage	$479.70
Rate for Payer: BCBS of TX Blue Essentials	$575.64
Rate for Payer: BCBS of TX PPO	$639.60
Rate for Payer: Cash Price	$1,087.32
Rate for Payer: Cigna Medicaid	$1,151.28
Rate for Payer: Molina CHIP/Medicaid	$1,151.28
Rate for Payer: Multiplan Auto	$799.50
Rate for Payer: Multiplan Commercial	$799.50
Rate for Payer: Multiplan Workers Comp	$799.50
Rate for Payer: Parkland Medicaid	$1,151.28
Rate for Payer: Scott and White EPO/PPO	$799.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,151.28
Rate for Payer: Superior Health Plan EPO	$217.46

SCREW VA LCK 2.7X16MM S/T T8 STRDRV RCS

Facility

$1,599.00

Service Code	HCPCS C1713
Hospital Charge Code	125250
Hospital Revenue Code	278
Min. Negotiated Rate	$399.75
Max. Negotiated Rate	$799.50
Rate for Payer: Cash Price	$1,087.32
Rate for Payer: Cigna Commercial	$399.75
Rate for Payer: Multiplan Auto	$799.50
Rate for Payer: Multiplan Commercial	$799.50
Rate for Payer: Multiplan Workers Comp	$799.50
Rate for Payer: Scott and White EPO/PPO	$799.50

SCREW VARIABLE ANGLE LOCKING 2.7X18MM SELF TAPPING T8 STARDRIVE RECESS

Facility

$1,598.00

Service Code	HCPCS C1713
Hospital Charge Code	125251
Hospital Revenue Code	278
Min. Negotiated Rate	$143.82
Max. Negotiated Rate	$1,150.56
Rate for Payer: Amerigroup CHIP/Medicaid	$143.82
Rate for Payer: BCBS of TX Blue Advantage	$479.40
Rate for Payer: BCBS of TX Blue Essentials	$575.28
Rate for Payer: BCBS of TX PPO	$639.20
Rate for Payer: Cash Price	$1,086.64
Rate for Payer: Cigna Medicaid	$1,150.56
Rate for Payer: Molina CHIP/Medicaid	$1,150.56
Rate for Payer: Multiplan Auto	$799.00
Rate for Payer: Multiplan Commercial	$799.00
Rate for Payer: Multiplan Workers Comp	$799.00
Rate for Payer: Parkland Medicaid	$1,150.56
Rate for Payer: Scott and White EPO/PPO	$799.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,150.56
Rate for Payer: Superior Health Plan EPO	$217.33

SCREW VARIABLE ANGLE LOCKING 2.7X18MM SELF TAPPING T8 STARDRIVE RECESS

Facility

$1,598.00

Service Code	HCPCS C1713
Hospital Charge Code	125251
Hospital Revenue Code	278
Min. Negotiated Rate	$399.50
Max. Negotiated Rate	$799.00
Rate for Payer: Cash Price	$1,086.64
Rate for Payer: Cigna Commercial	$399.50
Rate for Payer: Multiplan Auto	$799.00
Rate for Payer: Multiplan Commercial	$799.00
Rate for Payer: Multiplan Workers Comp	$799.00
Rate for Payer: Scott and White EPO/PPO	$799.00

SCREW VARIABLE ANGLE LOCKING 2.7X20M SELF TAPPING T8 STARDRIVE RECESS

Facility

$1,599.00

Service Code	HCPCS C1713
Hospital Charge Code	125252
Hospital Revenue Code	278
Min. Negotiated Rate	$399.75
Max. Negotiated Rate	$799.50
Rate for Payer: Cash Price	$1,087.32
Rate for Payer: Cigna Commercial	$399.75
Rate for Payer: Multiplan Auto	$799.50
Rate for Payer: Multiplan Commercial	$799.50
Rate for Payer: Multiplan Workers Comp	$799.50
Rate for Payer: Scott and White EPO/PPO	$799.50

SCREW VARIABLE ANGLE LOCKING 2.7X20M SELF TAPPING T8 STARDRIVE RECESS

Facility

$1,599.00

Service Code	HCPCS C1713
Hospital Charge Code	125252
Hospital Revenue Code	278
Min. Negotiated Rate	$143.91
Max. Negotiated Rate	$1,151.28
Rate for Payer: Amerigroup CHIP/Medicaid	$143.91
Rate for Payer: BCBS of TX Blue Advantage	$479.70
Rate for Payer: BCBS of TX Blue Essentials	$575.64
Rate for Payer: BCBS of TX PPO	$639.60
Rate for Payer: Cash Price	$1,087.32
Rate for Payer: Cigna Medicaid	$1,151.28
Rate for Payer: Molina CHIP/Medicaid	$1,151.28
Rate for Payer: Multiplan Auto	$799.50
Rate for Payer: Multiplan Commercial	$799.50
Rate for Payer: Multiplan Workers Comp	$799.50
Rate for Payer: Parkland Medicaid	$1,151.28
Rate for Payer: Scott and White EPO/PPO	$799.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,151.28
Rate for Payer: Superior Health Plan EPO	$217.46

SCREW VAULT 4.0 X 25MM

Facility

$2,108.00

Service Code	HCPCS C1713
Hospital Charge Code	8394459
Hospital Revenue Code	278
Min. Negotiated Rate	$189.72
Max. Negotiated Rate	$1,517.76
Rate for Payer: Amerigroup CHIP/Medicaid	$189.72
Rate for Payer: BCBS of TX Blue Advantage	$632.40
Rate for Payer: BCBS of TX Blue Essentials	$758.88
Rate for Payer: BCBS of TX PPO	$843.20
Rate for Payer: Cash Price	$1,433.44
Rate for Payer: Cigna Medicaid	$1,517.76
Rate for Payer: Molina CHIP/Medicaid	$1,517.76
Rate for Payer: Multiplan Auto	$1,054.00
Rate for Payer: Multiplan Commercial	$1,054.00
Rate for Payer: Multiplan Workers Comp	$1,054.00
Rate for Payer: Parkland Medicaid	$1,517.76
Rate for Payer: Scott and White EPO/PPO	$1,054.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,517.76
Rate for Payer: Superior Health Plan EPO	$286.69

SCREW VAULT 4.0 X 25MM

Facility

$2,108.00

Service Code	HCPCS C1713
Hospital Charge Code	8394459
Hospital Revenue Code	278
Min. Negotiated Rate	$527.00
Max. Negotiated Rate	$1,054.00
Rate for Payer: Cash Price	$1,433.44
Rate for Payer: Cigna Commercial	$527.00
Rate for Payer: Multiplan Auto	$1,054.00
Rate for Payer: Multiplan Commercial	$1,054.00
Rate for Payer: Multiplan Workers Comp	$1,054.00
Rate for Payer: Scott and White EPO/PPO	$1,054.00

SCRUB, BACTOSHIELD CHG 4% 4OZ

Facility

$10.27

Hospital Charge Code	992953
Hospital Revenue Code	270
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$7.39
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: BCBS of TX Blue Advantage	$3.08
Rate for Payer: BCBS of TX Blue Essentials	$3.70
Rate for Payer: BCBS of TX PPO	$4.11
Rate for Payer: Cash Price	$6.98
Rate for Payer: Cigna Medicaid	$7.39
Rate for Payer: Molina CHIP/Medicaid	$7.39
Rate for Payer: Multiplan Auto	$6.68
Rate for Payer: Multiplan Commercial	$6.68
Rate for Payer: Multiplan Workers Comp	$6.68
Rate for Payer: Parkland Medicaid	$7.39
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7.39
Rate for Payer: Superior Health Plan EPO	$1.40

Know your out-of-pocket cost for care.

All Charges