White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SCREW R3CON NON LOCKING 3.5 X 16

Facility

$889.00

Service Code	HCPCS C1713
Hospital Charge Code	146417
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

SCREW R3CON NON LOCKING 3.5 X 16

Facility

$889.00

Service Code	HCPCS C1713
Hospital Charge Code	146417
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 4.2 X 16

Facility

$1,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146418
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 4.2 X 16

Facility

$1,222.00

Service Code	HCPCS C1713
Hospital Charge Code	146418
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 SELF DRILL VARIABLE 4.0 14

Facility

$1,860.00

Service Code	HCPCS C1713
Hospital Charge Code	8404458
Hospital Revenue Code	278
Min. Negotiated Rate	$167.40
Max. Negotiated Rate	$1,339.20
Rate for Payer: Amerigroup CHIP/Medicaid	$167.40
Rate for Payer: BCBS of TX Blue Advantage	$558.00
Rate for Payer: BCBS of TX Blue Essentials	$669.60
Rate for Payer: BCBS of TX PPO	$744.00
Rate for Payer: Cash Price	$1,264.80
Rate for Payer: Cigna Medicaid	$1,339.20
Rate for Payer: Molina CHIP/Medicaid	$1,339.20
Rate for Payer: Multiplan Auto	$930.00
Rate for Payer: Multiplan Commercial	$930.00
Rate for Payer: Multiplan Workers Comp	$930.00
Rate for Payer: Parkland Medicaid	$1,339.20
Rate for Payer: Scott and White EPO/PPO	$930.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,339.20
Rate for Payer: Superior Health Plan EPO	$252.96

SCREW SELF DRILL VARIABLE 4.0 14

Facility

$1,860.00

Service Code	HCPCS C1713
Hospital Charge Code	8404458
Hospital Revenue Code	278
Min. Negotiated Rate	$465.00
Max. Negotiated Rate	$930.00
Rate for Payer: Cash Price	$1,264.80
Rate for Payer: Cigna Commercial	$465.00
Rate for Payer: Multiplan Auto	$930.00
Rate for Payer: Multiplan Commercial	$930.00
Rate for Payer: Multiplan Workers Comp	$930.00
Rate for Payer: Scott and White EPO/PPO	$930.00

SCREW SELF TAPPING

Facility

$1,325.00

Service Code	HCPCS C1713
Hospital Charge Code	8492476
Hospital Revenue Code	278
Min. Negotiated Rate	$119.25
Max. Negotiated Rate	$954.00
Rate for Payer: Amerigroup CHIP/Medicaid	$119.25
Rate for Payer: BCBS of TX Blue Advantage	$397.50
Rate for Payer: BCBS of TX Blue Essentials	$477.00
Rate for Payer: BCBS of TX PPO	$530.00
Rate for Payer: Cash Price	$901.00
Rate for Payer: Cigna Medicaid	$954.00
Rate for Payer: Molina CHIP/Medicaid	$954.00
Rate for Payer: Multiplan Auto	$662.50
Rate for Payer: Multiplan Commercial	$662.50
Rate for Payer: Multiplan Workers Comp	$662.50
Rate for Payer: Parkland Medicaid	$954.00
Rate for Payer: Scott and White EPO/PPO	$662.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$954.00
Rate for Payer: Superior Health Plan EPO	$180.20

SCREW SELF TAPPING

Facility

$1,325.00

Service Code	HCPCS C1713
Hospital Charge Code	8492476
Hospital Revenue Code	278
Min. Negotiated Rate	$331.25
Max. Negotiated Rate	$662.50
Rate for Payer: Cash Price	$901.00
Rate for Payer: Cigna Commercial	$331.25
Rate for Payer: Multiplan Auto	$662.50
Rate for Payer: Multiplan Commercial	$662.50
Rate for Payer: Multiplan Workers Comp	$662.50
Rate for Payer: Scott and White EPO/PPO	$662.50

SCREW SET

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8504491
Hospital Revenue Code	278
Min. Negotiated Rate	$75.25
Max. Negotiated Rate	$150.50
Rate for Payer: Cash Price	$204.68
Rate for Payer: Cigna Commercial	$75.25
Rate for Payer: Multiplan Auto	$150.50
Rate for Payer: Multiplan Commercial	$150.50
Rate for Payer: Multiplan Workers Comp	$150.50
Rate for Payer: Scott and White EPO/PPO	$150.50

SCREW SET

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8504491
Hospital Revenue Code	278
Min. Negotiated Rate	$27.09
Max. Negotiated Rate	$216.72
Rate for Payer: Amerigroup CHIP/Medicaid	$27.09
Rate for Payer: BCBS of TX Blue Advantage	$90.30
Rate for Payer: BCBS of TX Blue Essentials	$108.36
Rate for Payer: BCBS of TX PPO	$120.40
Rate for Payer: Cash Price	$204.68
Rate for Payer: Cigna Medicaid	$216.72
Rate for Payer: Molina CHIP/Medicaid	$216.72
Rate for Payer: Multiplan Auto	$150.50
Rate for Payer: Multiplan Commercial	$150.50
Rate for Payer: Multiplan Workers Comp	$150.50
Rate for Payer: Parkland Medicaid	$216.72
Rate for Payer: Scott and White EPO/PPO	$150.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$216.72
Rate for Payer: Superior Health Plan EPO	$40.94

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 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 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 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 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	$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 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 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	$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 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 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

Know your out-of-pocket cost for care.

All Charges