White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MENISCUS CUTTER -- DHF

Facility

$274.09

Hospital Charge Code	81753105
Hospital Revenue Code	272
Rate for Payer: Cash Price	$241.20

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC

Facility

$18,912.60

Service Code	MSDRG 760
Min. Negotiated Rate	$7,561.98
Max. Negotiated Rate	$18,912.60
Rate for Payer: Aetna Commercial	$11,198.25
Rate for Payer: Aetna Medicare	$14,937.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9,958.02
Rate for Payer: Amerigroup Medicare	$9,958.02
Rate for Payer: BCBS of TX Blue Advantage	$7,561.98
Rate for Payer: BCBS of TX Blue Essentials	$8,995.07
Rate for Payer: BCBS of TX Medicare	$9,958.02
Rate for Payer: BCBS of TX PPO	$9,994.91
Rate for Payer: Cigna Commercial	$12,820.75
Rate for Payer: Cigna Medicare	$9,958.02
Rate for Payer: Employer Direct Commercial	$9,958.02
Rate for Payer: Humana Medicare/TRICARE	$9,958.02
Rate for Payer: Molina Dual Medicare/Medicaid	$9,958.02
Rate for Payer: Molina Medicare	$9,958.02
Rate for Payer: Multiplan Auto	$18,912.60
Rate for Payer: Multiplan Commercial	$18,912.60
Rate for Payer: Multiplan Workers Comp	$18,912.60
Rate for Payer: Scott and White EPO/PPO	$8,709.75
Rate for Payer: Scott and White Medicare	$9,958.02
Rate for Payer: Superior Health Plan EPO	$9,958.02
Rate for Payer: Superior Health Plan Medicare	$9,958.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$9,958.02
Rate for Payer: Universal American Medicare	$9,958.02
Rate for Payer: Wellcare Medicare	$9,958.02
Rate for Payer: Wellmed Medicare	$9,958.02

MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$11,506.40

Service Code	MSDRG 761
Min. Negotiated Rate	$4,780.74
Max. Negotiated Rate	$11,506.40
Rate for Payer: Aetna Commercial	$6,813.00
Rate for Payer: Aetna Medicare	$10,764.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,176.38
Rate for Payer: Amerigroup Medicare	$7,176.38
Rate for Payer: BCBS of TX Blue Advantage	$4,780.74
Rate for Payer: BCBS of TX Blue Essentials	$5,669.26
Rate for Payer: BCBS of TX Medicare	$7,176.38
Rate for Payer: BCBS of TX PPO	$6,299.42
Rate for Payer: Cigna Commercial	$7,800.13
Rate for Payer: Cigna Medicare	$7,176.38
Rate for Payer: Employer Direct Commercial	$7,176.38
Rate for Payer: Humana Medicare/TRICARE	$7,176.38
Rate for Payer: Molina Dual Medicare/Medicaid	$7,176.38
Rate for Payer: Molina Medicare	$7,176.38
Rate for Payer: Multiplan Auto	$11,506.40
Rate for Payer: Multiplan Commercial	$11,506.40
Rate for Payer: Multiplan Workers Comp	$11,506.40
Rate for Payer: Scott and White EPO/PPO	$5,299.00
Rate for Payer: Scott and White Medicare	$7,176.38
Rate for Payer: Superior Health Plan EPO	$7,176.38
Rate for Payer: Superior Health Plan Medicare	$7,176.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,176.38
Rate for Payer: Universal American Medicare	$7,176.38
Rate for Payer: Wellcare Medicare	$7,176.38
Rate for Payer: Wellmed Medicare	$7,176.38

meperidine 25 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2175
Hospital Charge Code	5200
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.64
Rate for Payer: BCBS of TX Blue Essentials	$3.17
Rate for Payer: BCBS of TX PPO	$3.51
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

meperidine 25 mg/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J2175
Hospital Charge Code	5200
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

Mercury, Blood SO

Facility

$82.00

Service Code	CPT 83825
Hospital Charge Code	1703230
Hospital Revenue Code	301
Rate for Payer: Cash Price	$72.16

Mercury, Blood SO

Facility

$82.00

Service Code	CPT 83825
Hospital Charge Code	1703230
Hospital Revenue Code	301
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$53.30
Rate for Payer: Aetna Commercial	$17.08
Rate for Payer: Aetna Medicare	$24.39
Rate for Payer: Amerigroup CHIP/Medicaid	$6.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.26
Rate for Payer: Amerigroup Medicare	$16.26
Rate for Payer: BCBS of TX Blue Advantage	$26.83
Rate for Payer: BCBS of TX Blue Essentials	$32.19
Rate for Payer: BCBS of TX Medicare	$16.26
Rate for Payer: BCBS of TX PPO	$35.93
Rate for Payer: Cash Price	$72.16
Rate for Payer: Cash Price	$72.16
Rate for Payer: Cigna Medicaid	$16.26
Rate for Payer: Cigna Medicare	$16.26
Rate for Payer: Employer Direct Commercial	$16.26
Rate for Payer: Humana Medicare/TRICARE	$16.26
Rate for Payer: Molina CHIP/Medicaid	$16.26
Rate for Payer: Molina Dual Medicare/Medicaid	$16.26
Rate for Payer: Molina Medicare	$16.26
Rate for Payer: Multiplan Auto	$53.30
Rate for Payer: Multiplan Commercial	$53.30
Rate for Payer: Multiplan Workers Comp	$53.30
Rate for Payer: Parkland Medicaid	$16.26
Rate for Payer: Scott and White EPO/PPO	$20.32
Rate for Payer: Scott and White Medicare	$16.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.26
Rate for Payer: Superior Health Plan EPO	$16.26
Rate for Payer: Superior Health Plan Medicare	$16.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.26
Rate for Payer: Universal American Medicare	$16.26
Rate for Payer: Wellcare Medicare	$16.26
Rate for Payer: Wellmed Medicare	$16.26

meropenem 1000 mg IV Inj

Facility

$128.00

Service Code	HCPCS J2185
Hospital Charge Code	77686249
Hospital Revenue Code	636
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$3.20
Rate for Payer: BCBS of TX Blue Essentials	$3.85
Rate for Payer: BCBS of TX PPO	$4.27
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

meropenem 1000 mg IV Inj

Facility

$128.00

Service Code	HCPCS J2185
Hospital Charge Code	77686249
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

meropenem 500 mg and NS; 100 mL connect

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	79477223
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

meropenem 500 mg and NS; 100 mL connect

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	79477223
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$83.20
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan EPO	$17.41

MESH GORTEX DUAL 8X12 -- DHF

Facility

$5,612.78

Service Code	HCPCS C1781
Hospital Charge Code	81420622
Hospital Revenue Code	278
Min. Negotiated Rate	$505.15
Max. Negotiated Rate	$2,806.39
Rate for Payer: Aetna Commercial	$1,683.83
Rate for Payer: Amerigroup CHIP/Medicaid	$505.15
Rate for Payer: BCBS of TX Blue Advantage	$1,683.83
Rate for Payer: BCBS of TX Blue Essentials	$2,020.60
Rate for Payer: BCBS of TX PPO	$2,245.11
Rate for Payer: Cash Price	$4,939.25
Rate for Payer: Multiplan Auto	$2,806.39
Rate for Payer: Multiplan Commercial	$2,806.39
Rate for Payer: Multiplan Workers Comp	$2,806.39
Rate for Payer: Scott and White EPO/PPO	$2,806.39
Rate for Payer: Superior Health Plan EPO	$763.34

MESH GORTEX DUAL 8X12 -- DHF

Facility

$5,612.78

Service Code	HCPCS C1781
Hospital Charge Code	81420622
Hospital Revenue Code	278
Min. Negotiated Rate	$1,403.20
Max. Negotiated Rate	$2,806.39
Rate for Payer: Aetna Commercial	$1,683.83
Rate for Payer: Cash Price	$4,939.25
Rate for Payer: Cigna Commercial	$1,403.20
Rate for Payer: Multiplan Auto	$2,806.39
Rate for Payer: Multiplan Commercial	$2,806.39
Rate for Payer: Multiplan Workers Comp	$2,806.39
Rate for Payer: Scott and White EPO/PPO	$2,806.39

MESH HERNIA COMPOSITE -- DHF

Facility

$6,514.04

Service Code	HCPCS C1781
Hospital Charge Code	40240681
Hospital Revenue Code	278
Min. Negotiated Rate	$586.26
Max. Negotiated Rate	$3,257.02
Rate for Payer: Aetna Commercial	$1,954.21
Rate for Payer: Amerigroup CHIP/Medicaid	$586.26
Rate for Payer: BCBS of TX Blue Advantage	$1,954.21
Rate for Payer: BCBS of TX Blue Essentials	$2,345.05
Rate for Payer: BCBS of TX PPO	$2,605.62
Rate for Payer: Cash Price	$5,732.36
Rate for Payer: Multiplan Auto	$3,257.02
Rate for Payer: Multiplan Commercial	$3,257.02
Rate for Payer: Multiplan Workers Comp	$3,257.02
Rate for Payer: Scott and White EPO/PPO	$3,257.02
Rate for Payer: Superior Health Plan EPO	$885.91

MESH HERNIA COMPOSITE -- DHF

Facility

$6,514.04

Service Code	HCPCS C1781
Hospital Charge Code	40240681
Hospital Revenue Code	278
Min. Negotiated Rate	$1,628.51
Max. Negotiated Rate	$3,257.02
Rate for Payer: Aetna Commercial	$1,954.21
Rate for Payer: Cash Price	$5,732.36
Rate for Payer: Cigna Commercial	$1,628.51
Rate for Payer: Multiplan Auto	$3,257.02
Rate for Payer: Multiplan Commercial	$3,257.02
Rate for Payer: Multiplan Workers Comp	$3,257.02
Rate for Payer: Scott and White EPO/PPO	$3,257.02

MESH, HERNIA LIGHTWEIGHT PARTIALLY ABSRB 10CM -- DHF

Facility

$3,256.94

Service Code	HCPCS C1781
Hospital Charge Code	82401993
Hospital Revenue Code	278
Min. Negotiated Rate	$293.12
Max. Negotiated Rate	$1,628.47
Rate for Payer: Aetna Commercial	$977.08
Rate for Payer: Amerigroup CHIP/Medicaid	$293.12
Rate for Payer: BCBS of TX Blue Advantage	$977.08
Rate for Payer: BCBS of TX Blue Essentials	$1,172.50
Rate for Payer: BCBS of TX PPO	$1,302.78
Rate for Payer: Cash Price	$2,866.11
Rate for Payer: Multiplan Auto	$1,628.47
Rate for Payer: Multiplan Commercial	$1,628.47
Rate for Payer: Multiplan Workers Comp	$1,628.47
Rate for Payer: Scott and White EPO/PPO	$1,628.47
Rate for Payer: Superior Health Plan EPO	$442.94

MESH, HERNIA LIGHTWEIGHT PARTIALLY ABSRB 10CM -- DHF

Facility

$3,256.94

Service Code	HCPCS C1781
Hospital Charge Code	82401993
Hospital Revenue Code	278
Min. Negotiated Rate	$814.24
Max. Negotiated Rate	$1,628.47
Rate for Payer: Aetna Commercial	$977.08
Rate for Payer: Cash Price	$2,866.11
Rate for Payer: Cigna Commercial	$814.24
Rate for Payer: Multiplan Auto	$1,628.47
Rate for Payer: Multiplan Commercial	$1,628.47
Rate for Payer: Multiplan Workers Comp	$1,628.47
Rate for Payer: Scott and White EPO/PPO	$1,628.47

Mesh hernia proceed 20x25 cm pvdh1

Facility

$8,751.92

Service Code	HCPCS C1781
Hospital Charge Code	8602525
Hospital Revenue Code	278
Min. Negotiated Rate	$2,187.98
Max. Negotiated Rate	$4,375.96
Rate for Payer: Aetna Commercial	$2,625.58
Rate for Payer: Cash Price	$7,701.69
Rate for Payer: Cigna Commercial	$2,187.98
Rate for Payer: Multiplan Auto	$4,375.96
Rate for Payer: Multiplan Commercial	$4,375.96
Rate for Payer: Multiplan Workers Comp	$4,375.96
Rate for Payer: Scott and White EPO/PPO	$4,375.96

Mesh hernia proceed 20x25 cm pvdh1

Facility

$8,751.92

Service Code	HCPCS C1781
Hospital Charge Code	8602525
Hospital Revenue Code	278
Min. Negotiated Rate	$787.67
Max. Negotiated Rate	$4,375.96
Rate for Payer: Aetna Commercial	$2,625.58
Rate for Payer: Amerigroup CHIP/Medicaid	$787.67
Rate for Payer: BCBS of TX Blue Advantage	$2,625.58
Rate for Payer: BCBS of TX Blue Essentials	$3,150.69
Rate for Payer: BCBS of TX PPO	$3,500.77
Rate for Payer: Cash Price	$7,701.69
Rate for Payer: Multiplan Auto	$4,375.96
Rate for Payer: Multiplan Commercial	$4,375.96
Rate for Payer: Multiplan Workers Comp	$4,375.96
Rate for Payer: Scott and White EPO/PPO	$4,375.96
Rate for Payer: Superior Health Plan EPO	$1,190.26

MESH HERNIA ULTRAPRO UHSL

Facility

$1,680.73

Service Code	HCPCS C1781
Hospital Charge Code	118929
Hospital Revenue Code	278
Min. Negotiated Rate	$151.27
Max. Negotiated Rate	$840.36
Rate for Payer: Aetna Commercial	$504.22
Rate for Payer: Amerigroup CHIP/Medicaid	$151.27
Rate for Payer: BCBS of TX Blue Advantage	$504.22
Rate for Payer: BCBS of TX Blue Essentials	$605.06
Rate for Payer: BCBS of TX PPO	$672.29
Rate for Payer: Cash Price	$1,479.04
Rate for Payer: Multiplan Auto	$840.36
Rate for Payer: Multiplan Commercial	$840.36
Rate for Payer: Multiplan Workers Comp	$840.36
Rate for Payer: Scott and White EPO/PPO	$840.36
Rate for Payer: Superior Health Plan EPO	$228.58

MESH HERNIA ULTRAPRO UHSL

Facility

$1,680.73

Service Code	HCPCS C1781
Hospital Charge Code	118929
Hospital Revenue Code	278
Min. Negotiated Rate	$420.18
Max. Negotiated Rate	$840.36
Rate for Payer: Aetna Commercial	$504.22
Rate for Payer: Cash Price	$1,479.04
Rate for Payer: Cigna Commercial	$420.18
Rate for Payer: Multiplan Auto	$840.36
Rate for Payer: Multiplan Commercial	$840.36
Rate for Payer: Multiplan Workers Comp	$840.36
Rate for Payer: Scott and White EPO/PPO	$840.36

MESH, LAPARASCOPIC SELF FIX 15X10 LFT ANATOMICAL -- DHF

Facility

$3,490.48

Service Code	HCPCS C1781
Hospital Charge Code	40240954
Hospital Revenue Code	278
Min. Negotiated Rate	$872.62
Max. Negotiated Rate	$1,745.24
Rate for Payer: Aetna Commercial	$1,047.14
Rate for Payer: Cash Price	$3,071.62
Rate for Payer: Cigna Commercial	$872.62
Rate for Payer: Multiplan Auto	$1,745.24
Rate for Payer: Multiplan Commercial	$1,745.24
Rate for Payer: Multiplan Workers Comp	$1,745.24
Rate for Payer: Scott and White EPO/PPO	$1,745.24

MESH, LAPARASCOPIC SELF FIX 15X10 LFT ANATOMICAL -- DHF

Facility

$3,490.48

Service Code	HCPCS C1781
Hospital Charge Code	40240954
Hospital Revenue Code	278
Min. Negotiated Rate	$314.14
Max. Negotiated Rate	$1,745.24
Rate for Payer: Aetna Commercial	$1,047.14
Rate for Payer: Amerigroup CHIP/Medicaid	$314.14
Rate for Payer: BCBS of TX Blue Advantage	$1,047.14
Rate for Payer: BCBS of TX Blue Essentials	$1,256.57
Rate for Payer: BCBS of TX PPO	$1,396.19
Rate for Payer: Cash Price	$3,071.62
Rate for Payer: Multiplan Auto	$1,745.24
Rate for Payer: Multiplan Commercial	$1,745.24
Rate for Payer: Multiplan Workers Comp	$1,745.24
Rate for Payer: Scott and White EPO/PPO	$1,745.24
Rate for Payer: Superior Health Plan EPO	$474.71

MESH, LAPARASCOPIC SELF FIX 15X10 RGT ANATOMICAL -- DHF

Facility

$3,490.48

Service Code	HCPCS C1781
Hospital Charge Code	40240954
Hospital Revenue Code	278
Min. Negotiated Rate	$872.62
Max. Negotiated Rate	$1,745.24
Rate for Payer: Aetna Commercial	$1,047.14
Rate for Payer: Cash Price	$3,071.62
Rate for Payer: Cigna Commercial	$872.62
Rate for Payer: Multiplan Auto	$1,745.24
Rate for Payer: Multiplan Commercial	$1,745.24
Rate for Payer: Multiplan Workers Comp	$1,745.24
Rate for Payer: Scott and White EPO/PPO	$1,745.24

MESH, LAPARASCOPIC SELF FIX 15X10 RGT ANATOMICAL -- DHF

Facility

$3,490.48

Service Code	HCPCS C1781
Hospital Charge Code	40240954
Hospital Revenue Code	278
Min. Negotiated Rate	$314.14
Max. Negotiated Rate	$1,745.24
Rate for Payer: Aetna Commercial	$1,047.14
Rate for Payer: Amerigroup CHIP/Medicaid	$314.14
Rate for Payer: BCBS of TX Blue Advantage	$1,047.14
Rate for Payer: BCBS of TX Blue Essentials	$1,256.57
Rate for Payer: BCBS of TX PPO	$1,396.19
Rate for Payer: Cash Price	$3,071.62
Rate for Payer: Multiplan Auto	$1,745.24
Rate for Payer: Multiplan Commercial	$1,745.24
Rate for Payer: Multiplan Workers Comp	$1,745.24
Rate for Payer: Scott and White EPO/PPO	$1,745.24
Rate for Payer: Superior Health Plan EPO	$474.71

Know your out-of-pocket cost for care.

All Charges