White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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 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

SCRUB, BACTOSHIELD CHG 4% 4OZ

Facility

$10.27

Hospital Charge Code	992953
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.98

SCRW BN 81360059 -- DHF

Facility

$2,829.00

Service Code	HCPCS C1713
Hospital Charge Code	81360059
Hospital Revenue Code	278
Min. Negotiated Rate	$707.25
Max. Negotiated Rate	$1,414.50
Rate for Payer: Cash Price	$1,923.72
Rate for Payer: Cigna Commercial	$707.25
Rate for Payer: Multiplan Auto	$1,414.50
Rate for Payer: Multiplan Commercial	$1,414.50
Rate for Payer: Multiplan Workers Comp	$1,414.50
Rate for Payer: Scott and White EPO/PPO	$1,414.50

SCRW BN 81360059 -- DHF

Facility

$2,829.00

Service Code	HCPCS C1713
Hospital Charge Code	81360059
Hospital Revenue Code	278
Min. Negotiated Rate	$254.61
Max. Negotiated Rate	$2,036.88
Rate for Payer: Amerigroup CHIP/Medicaid	$254.61
Rate for Payer: BCBS of TX Blue Advantage	$848.70
Rate for Payer: BCBS of TX Blue Essentials	$1,018.44
Rate for Payer: BCBS of TX PPO	$1,131.60
Rate for Payer: Cash Price	$1,923.72
Rate for Payer: Cigna Medicaid	$2,036.88
Rate for Payer: Molina CHIP/Medicaid	$2,036.88
Rate for Payer: Multiplan Auto	$1,414.50
Rate for Payer: Multiplan Commercial	$1,414.50
Rate for Payer: Multiplan Workers Comp	$1,414.50
Rate for Payer: Parkland Medicaid	$2,036.88
Rate for Payer: Scott and White EPO/PPO	$1,414.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,036.88
Rate for Payer: Superior Health Plan EPO	$384.74

SCRW BN 81360067 -- DHF

Facility

$274.00

Service Code	HCPCS C1713
Hospital Charge Code	81360067
Hospital Revenue Code	278
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$137.00
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cigna Commercial	$68.50
Rate for Payer: Multiplan Auto	$137.00
Rate for Payer: Multiplan Commercial	$137.00
Rate for Payer: Multiplan Workers Comp	$137.00
Rate for Payer: Scott and White EPO/PPO	$137.00

SCRW BN 81360067 -- DHF

Facility

$274.00

Service Code	HCPCS C1713
Hospital Charge Code	81360067
Hospital Revenue Code	278
Min. Negotiated Rate	$24.66
Max. Negotiated Rate	$197.28
Rate for Payer: Amerigroup CHIP/Medicaid	$24.66
Rate for Payer: BCBS of TX Blue Advantage	$82.20
Rate for Payer: BCBS of TX Blue Essentials	$98.64
Rate for Payer: BCBS of TX PPO	$109.60
Rate for Payer: Cash Price	$186.32
Rate for Payer: Cigna Medicaid	$197.28
Rate for Payer: Molina CHIP/Medicaid	$197.28
Rate for Payer: Multiplan Auto	$137.00
Rate for Payer: Multiplan Commercial	$137.00
Rate for Payer: Multiplan Workers Comp	$137.00
Rate for Payer: Parkland Medicaid	$197.28
Rate for Payer: Scott and White EPO/PPO	$137.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$197.28
Rate for Payer: Superior Health Plan EPO	$37.26

SCRW CANCL -- DHF

Facility

$3,356.00

Service Code	HCPCS C1713
Hospital Charge Code	81360208
Hospital Revenue Code	278
Min. Negotiated Rate	$839.00
Max. Negotiated Rate	$1,678.00
Rate for Payer: Cash Price	$2,282.08
Rate for Payer: Cigna Commercial	$839.00
Rate for Payer: Multiplan Auto	$1,678.00
Rate for Payer: Multiplan Commercial	$1,678.00
Rate for Payer: Multiplan Workers Comp	$1,678.00
Rate for Payer: Scott and White EPO/PPO	$1,678.00

SCRW CANCL -- DHF

Facility

$3,356.00

Service Code	HCPCS C1713
Hospital Charge Code	81360208
Hospital Revenue Code	278
Min. Negotiated Rate	$302.04
Max. Negotiated Rate	$2,416.32
Rate for Payer: Amerigroup CHIP/Medicaid	$302.04
Rate for Payer: BCBS of TX Blue Advantage	$1,006.80
Rate for Payer: BCBS of TX Blue Essentials	$1,208.16
Rate for Payer: BCBS of TX PPO	$1,342.40
Rate for Payer: Cash Price	$2,282.08
Rate for Payer: Cigna Medicaid	$2,416.32
Rate for Payer: Molina CHIP/Medicaid	$2,416.32
Rate for Payer: Multiplan Auto	$1,678.00
Rate for Payer: Multiplan Commercial	$1,678.00
Rate for Payer: Multiplan Workers Comp	$1,678.00
Rate for Payer: Parkland Medicaid	$2,416.32
Rate for Payer: Scott and White EPO/PPO	$1,678.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,416.32
Rate for Payer: Superior Health Plan EPO	$456.42

SCRW CANN -- DHF

Facility

$3,796.00

Service Code	HCPCS C1713
Hospital Charge Code	81360307
Hospital Revenue Code	278
Min. Negotiated Rate	$341.64
Max. Negotiated Rate	$2,733.12
Rate for Payer: Amerigroup CHIP/Medicaid	$341.64
Rate for Payer: BCBS of TX Blue Advantage	$1,138.80
Rate for Payer: BCBS of TX Blue Essentials	$1,366.56
Rate for Payer: BCBS of TX PPO	$1,518.40
Rate for Payer: Cash Price	$2,581.28
Rate for Payer: Cigna Medicaid	$2,733.12
Rate for Payer: Molina CHIP/Medicaid	$2,733.12
Rate for Payer: Multiplan Auto	$1,898.00
Rate for Payer: Multiplan Commercial	$1,898.00
Rate for Payer: Multiplan Workers Comp	$1,898.00
Rate for Payer: Parkland Medicaid	$2,733.12
Rate for Payer: Scott and White EPO/PPO	$1,898.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,733.12
Rate for Payer: Superior Health Plan EPO	$516.26

SCRW CANN -- DHF

Facility

$3,796.00

Service Code	HCPCS C1713
Hospital Charge Code	81360307
Hospital Revenue Code	278
Min. Negotiated Rate	$949.00
Max. Negotiated Rate	$1,898.00
Rate for Payer: Cash Price	$2,581.28
Rate for Payer: Cigna Commercial	$949.00
Rate for Payer: Multiplan Auto	$1,898.00
Rate for Payer: Multiplan Commercial	$1,898.00
Rate for Payer: Multiplan Workers Comp	$1,898.00
Rate for Payer: Scott and White EPO/PPO	$1,898.00

SCRW COMPRESS 81360505 -- DHF

Facility

$1,540.00

Service Code	HCPCS C1713
Hospital Charge Code	81360505
Hospital Revenue Code	278
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$770.00
Rate for Payer: Cash Price	$1,047.20
Rate for Payer: Cigna Commercial	$385.00
Rate for Payer: Multiplan Auto	$770.00
Rate for Payer: Multiplan Commercial	$770.00
Rate for Payer: Multiplan Workers Comp	$770.00
Rate for Payer: Scott and White EPO/PPO	$770.00

SCRW COMPRESS 81360505 -- DHF

Facility

$1,540.00

Service Code	HCPCS C1713
Hospital Charge Code	81360505
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$1,108.80
Rate for Payer: Amerigroup CHIP/Medicaid	$138.60
Rate for Payer: BCBS of TX Blue Advantage	$462.00
Rate for Payer: BCBS of TX Blue Essentials	$554.40
Rate for Payer: BCBS of TX PPO	$616.00
Rate for Payer: Cash Price	$1,047.20
Rate for Payer: Cigna Medicaid	$1,108.80
Rate for Payer: Molina CHIP/Medicaid	$1,108.80
Rate for Payer: Multiplan Auto	$770.00
Rate for Payer: Multiplan Commercial	$770.00
Rate for Payer: Multiplan Workers Comp	$770.00
Rate for Payer: Parkland Medicaid	$1,108.80
Rate for Payer: Scott and White EPO/PPO	$770.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,108.80
Rate for Payer: Superior Health Plan EPO	$209.44

SCRW COMPRESS 81360554 -- DHF

Facility

$241.00

Service Code	HCPCS C1713
Hospital Charge Code	81360554
Hospital Revenue Code	278
Min. Negotiated Rate	$21.69
Max. Negotiated Rate	$173.52
Rate for Payer: Amerigroup CHIP/Medicaid	$21.69
Rate for Payer: BCBS of TX Blue Advantage	$72.30
Rate for Payer: BCBS of TX Blue Essentials	$86.76
Rate for Payer: BCBS of TX PPO	$96.40
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cigna Medicaid	$173.52
Rate for Payer: Molina CHIP/Medicaid	$173.52
Rate for Payer: Multiplan Auto	$120.50
Rate for Payer: Multiplan Commercial	$120.50
Rate for Payer: Multiplan Workers Comp	$120.50
Rate for Payer: Parkland Medicaid	$173.52
Rate for Payer: Scott and White EPO/PPO	$120.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$173.52
Rate for Payer: Superior Health Plan EPO	$32.78

SCRW COMPRESS 81360554 -- DHF

Facility

$241.00

Service Code	HCPCS C1713
Hospital Charge Code	81360554
Hospital Revenue Code	278
Min. Negotiated Rate	$60.25
Max. Negotiated Rate	$120.50
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cigna Commercial	$60.25
Rate for Payer: Multiplan Auto	$120.50
Rate for Payer: Multiplan Commercial	$120.50
Rate for Payer: Multiplan Workers Comp	$120.50
Rate for Payer: Scott and White EPO/PPO	$120.50

SCRW CORTICAL -- DHF

Facility

$663.00

Service Code	HCPCS C1713
Hospital Charge Code	81360711
Hospital Revenue Code	278
Min. Negotiated Rate	$59.67
Max. Negotiated Rate	$477.36
Rate for Payer: Amerigroup CHIP/Medicaid	$59.67
Rate for Payer: BCBS of TX Blue Advantage	$198.90
Rate for Payer: BCBS of TX Blue Essentials	$238.68
Rate for Payer: BCBS of TX PPO	$265.20
Rate for Payer: Cash Price	$450.84
Rate for Payer: Cigna Medicaid	$477.36
Rate for Payer: Molina CHIP/Medicaid	$477.36
Rate for Payer: Multiplan Auto	$331.50
Rate for Payer: Multiplan Commercial	$331.50
Rate for Payer: Multiplan Workers Comp	$331.50
Rate for Payer: Parkland Medicaid	$477.36
Rate for Payer: Scott and White EPO/PPO	$331.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$477.36
Rate for Payer: Superior Health Plan EPO	$90.17

SCRW CORTICAL -- DHF

Facility

$663.00

Service Code	HCPCS C1713
Hospital Charge Code	81360711
Hospital Revenue Code	278
Min. Negotiated Rate	$165.75
Max. Negotiated Rate	$331.50
Rate for Payer: Cash Price	$450.84
Rate for Payer: Cigna Commercial	$165.75
Rate for Payer: Multiplan Auto	$331.50
Rate for Payer: Multiplan Commercial	$331.50
Rate for Payer: Multiplan Workers Comp	$331.50
Rate for Payer: Scott and White EPO/PPO	$331.50

Know your out-of-pocket cost for care.

All Charges