White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MESH PHASIZ SEPRA 4X4

Facility

$11,234.93

Service Code	HCPCS C1781
Hospital Charge Code	8528468
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.73
Max. Negotiated Rate	$5,617.46
Rate for Payer: Aetna Commercial	$3,370.48
Rate for Payer: Cash Price	$9,886.74
Rate for Payer: Cigna Commercial	$2,808.73
Rate for Payer: Multiplan Auto	$5,617.46
Rate for Payer: Multiplan Commercial	$5,617.46
Rate for Payer: Multiplan Workers Comp	$5,617.46
Rate for Payer: Scott and White EPO/PPO	$5,617.46

MESH PHASIZ SEPRA 4X4

Facility

$11,234.93

Service Code	HCPCS C1781
Hospital Charge Code	8528468
Hospital Revenue Code	278
Min. Negotiated Rate	$1,011.14
Max. Negotiated Rate	$5,617.46
Rate for Payer: Aetna Commercial	$3,370.48
Rate for Payer: Amerigroup CHIP/Medicaid	$1,011.14
Rate for Payer: BCBS of TX Blue Advantage	$3,370.48
Rate for Payer: BCBS of TX Blue Essentials	$4,044.57
Rate for Payer: BCBS of TX PPO	$4,493.97
Rate for Payer: Cash Price	$9,886.74
Rate for Payer: Multiplan Auto	$5,617.46
Rate for Payer: Multiplan Commercial	$5,617.46
Rate for Payer: Multiplan Workers Comp	$5,617.46
Rate for Payer: Scott and White EPO/PPO	$5,617.46
Rate for Payer: Superior Health Plan EPO	$1,527.95

MESH, POLYPOLENE FLAT 3X6"

Facility

$319.27

Service Code	HCPCS C1781
Hospital Charge Code	8574471
Hospital Revenue Code	278
Min. Negotiated Rate	$28.73
Max. Negotiated Rate	$159.64
Rate for Payer: Aetna Commercial	$95.78
Rate for Payer: Amerigroup CHIP/Medicaid	$28.73
Rate for Payer: BCBS of TX Blue Advantage	$95.78
Rate for Payer: BCBS of TX Blue Essentials	$114.94
Rate for Payer: BCBS of TX PPO	$127.71
Rate for Payer: Cash Price	$280.96
Rate for Payer: Multiplan Auto	$159.64
Rate for Payer: Multiplan Commercial	$159.64
Rate for Payer: Multiplan Workers Comp	$159.64
Rate for Payer: Scott and White EPO/PPO	$159.64
Rate for Payer: Superior Health Plan EPO	$43.42

MESH, POLYPOLENE FLAT 3X6"

Facility

$319.27

Service Code	HCPCS C1781
Hospital Charge Code	8574471
Hospital Revenue Code	278
Min. Negotiated Rate	$79.82
Max. Negotiated Rate	$159.64
Rate for Payer: Aetna Commercial	$95.78
Rate for Payer: Cash Price	$280.96
Rate for Payer: Cigna Commercial	$79.82
Rate for Payer: Multiplan Auto	$159.64
Rate for Payer: Multiplan Commercial	$159.64
Rate for Payer: Multiplan Workers Comp	$159.64
Rate for Payer: Scott and White EPO/PPO	$159.64

MESH, POLYPROPYLENE KNITTED PERFIX PLUG LARGE -- DHF

Facility

$2,115.70

Service Code	HCPCS C1781
Hospital Charge Code	40241994
Hospital Revenue Code	278
Min. Negotiated Rate	$528.92
Max. Negotiated Rate	$1,057.85
Rate for Payer: Aetna Commercial	$634.71
Rate for Payer: Cash Price	$1,861.82
Rate for Payer: Cigna Commercial	$528.92
Rate for Payer: Multiplan Auto	$1,057.85
Rate for Payer: Multiplan Commercial	$1,057.85
Rate for Payer: Multiplan Workers Comp	$1,057.85
Rate for Payer: Scott and White EPO/PPO	$1,057.85

MESH, POLYPROPYLENE KNITTED PERFIX PLUG LARGE -- DHF

Facility

$2,115.70

Service Code	HCPCS C1781
Hospital Charge Code	40241994
Hospital Revenue Code	278
Min. Negotiated Rate	$190.41
Max. Negotiated Rate	$1,057.85
Rate for Payer: Aetna Commercial	$634.71
Rate for Payer: Amerigroup CHIP/Medicaid	$190.41
Rate for Payer: BCBS of TX Blue Advantage	$634.71
Rate for Payer: BCBS of TX Blue Essentials	$761.65
Rate for Payer: BCBS of TX PPO	$846.28
Rate for Payer: Cash Price	$1,861.82
Rate for Payer: Multiplan Auto	$1,057.85
Rate for Payer: Multiplan Commercial	$1,057.85
Rate for Payer: Multiplan Workers Comp	$1,057.85
Rate for Payer: Scott and White EPO/PPO	$1,057.85
Rate for Payer: Superior Health Plan EPO	$287.74

MESH, POLYPROPYLENE KNITTED PERFIX PLUG MEDIUM -- DHF

Facility

$1,658.19

Service Code	HCPCS C1781
Hospital Charge Code	81420853
Hospital Revenue Code	278
Min. Negotiated Rate	$414.55
Max. Negotiated Rate	$829.10
Rate for Payer: Aetna Commercial	$497.46
Rate for Payer: Cash Price	$1,459.21
Rate for Payer: Cigna Commercial	$414.55
Rate for Payer: Multiplan Auto	$829.10
Rate for Payer: Multiplan Commercial	$829.10
Rate for Payer: Multiplan Workers Comp	$829.10
Rate for Payer: Scott and White EPO/PPO	$829.10

MESH, POLYPROPYLENE KNITTED PERFIX PLUG MEDIUM -- DHF

Facility

$1,658.19

Service Code	HCPCS C1781
Hospital Charge Code	81420853
Hospital Revenue Code	278
Min. Negotiated Rate	$149.24
Max. Negotiated Rate	$829.10
Rate for Payer: Aetna Commercial	$497.46
Rate for Payer: Amerigroup CHIP/Medicaid	$149.24
Rate for Payer: BCBS of TX Blue Advantage	$497.46
Rate for Payer: BCBS of TX Blue Essentials	$596.95
Rate for Payer: BCBS of TX PPO	$663.28
Rate for Payer: Cash Price	$1,459.21
Rate for Payer: Multiplan Auto	$829.10
Rate for Payer: Multiplan Commercial	$829.10
Rate for Payer: Multiplan Workers Comp	$829.10
Rate for Payer: Scott and White EPO/PPO	$829.10
Rate for Payer: Superior Health Plan EPO	$225.51

mesh proceed ventral patch pvpm

Facility

$2,852.83

Service Code	HCPCS C1781
Hospital Charge Code	8618508
Hospital Revenue Code	278
Min. Negotiated Rate	$256.75
Max. Negotiated Rate	$1,426.42
Rate for Payer: Aetna Commercial	$855.85
Rate for Payer: Amerigroup CHIP/Medicaid	$256.75
Rate for Payer: BCBS of TX Blue Advantage	$855.85
Rate for Payer: BCBS of TX Blue Essentials	$1,027.02
Rate for Payer: BCBS of TX PPO	$1,141.13
Rate for Payer: Cash Price	$2,510.49
Rate for Payer: Multiplan Auto	$1,426.42
Rate for Payer: Multiplan Commercial	$1,426.42
Rate for Payer: Multiplan Workers Comp	$1,426.42
Rate for Payer: Scott and White EPO/PPO	$1,426.42
Rate for Payer: Superior Health Plan EPO	$387.98

mesh proceed ventral patch pvpm

Facility

$2,852.83

Service Code	HCPCS C1781
Hospital Charge Code	8618508
Hospital Revenue Code	278
Min. Negotiated Rate	$713.21
Max. Negotiated Rate	$1,426.42
Rate for Payer: Aetna Commercial	$855.85
Rate for Payer: Cash Price	$2,510.49
Rate for Payer: Cigna Commercial	$713.21
Rate for Payer: Multiplan Auto	$1,426.42
Rate for Payer: Multiplan Commercial	$1,426.42
Rate for Payer: Multiplan Workers Comp	$1,426.42
Rate for Payer: Scott and White EPO/PPO	$1,426.42

MESH PROGRIP PARIETEX RT ANATOM 12X8

Facility

$2,041.20

Service Code	HCPCS C1781
Hospital Charge Code	8568970
Hospital Revenue Code	278
Min. Negotiated Rate	$183.71
Max. Negotiated Rate	$1,020.60
Rate for Payer: Aetna Commercial	$612.36
Rate for Payer: Amerigroup CHIP/Medicaid	$183.71
Rate for Payer: BCBS of TX Blue Advantage	$612.36
Rate for Payer: BCBS of TX Blue Essentials	$734.83
Rate for Payer: BCBS of TX PPO	$816.48
Rate for Payer: Cash Price	$1,796.26
Rate for Payer: Multiplan Auto	$1,020.60
Rate for Payer: Multiplan Commercial	$1,020.60
Rate for Payer: Multiplan Workers Comp	$1,020.60
Rate for Payer: Scott and White EPO/PPO	$1,020.60
Rate for Payer: Superior Health Plan EPO	$277.60

MESH PROGRIP PARIETEX RT ANATOM 12X8

Facility

$2,041.20

Service Code	HCPCS C1781
Hospital Charge Code	8568970
Hospital Revenue Code	278
Min. Negotiated Rate	$510.30
Max. Negotiated Rate	$1,020.60
Rate for Payer: Aetna Commercial	$612.36
Rate for Payer: Cash Price	$1,796.26
Rate for Payer: Cigna Commercial	$510.30
Rate for Payer: Multiplan Auto	$1,020.60
Rate for Payer: Multiplan Commercial	$1,020.60
Rate for Payer: Multiplan Workers Comp	$1,020.60
Rate for Payer: Scott and White EPO/PPO	$1,020.60

MESH SURGIPRO PLUG AND PATCH LARGE

Facility

$1,121.33

Service Code	HCPCS C1781
Hospital Charge Code	8568971
Hospital Revenue Code	278
Min. Negotiated Rate	$100.92
Max. Negotiated Rate	$560.66
Rate for Payer: Aetna Commercial	$336.40
Rate for Payer: Amerigroup CHIP/Medicaid	$100.92
Rate for Payer: BCBS of TX Blue Advantage	$336.40
Rate for Payer: BCBS of TX Blue Essentials	$403.68
Rate for Payer: BCBS of TX PPO	$448.53
Rate for Payer: Cash Price	$986.77
Rate for Payer: Multiplan Auto	$560.66
Rate for Payer: Multiplan Commercial	$560.66
Rate for Payer: Multiplan Workers Comp	$560.66
Rate for Payer: Scott and White EPO/PPO	$560.66
Rate for Payer: Superior Health Plan EPO	$152.50

MESH SURGIPRO PLUG AND PATCH LARGE

Facility

$1,121.33

Service Code	HCPCS C1781
Hospital Charge Code	8568971
Hospital Revenue Code	278
Min. Negotiated Rate	$280.33
Max. Negotiated Rate	$560.66
Rate for Payer: Aetna Commercial	$336.40
Rate for Payer: Cash Price	$986.77
Rate for Payer: Cigna Commercial	$280.33
Rate for Payer: Multiplan Auto	$560.66
Rate for Payer: Multiplan Commercial	$560.66
Rate for Payer: Multiplan Workers Comp	$560.66
Rate for Payer: Scott and White EPO/PPO	$560.66

MESH SYMBOTEX COMP

Facility

$4,748.19

Service Code	HCPCS C1781
Hospital Charge Code	8514470
Hospital Revenue Code	278
Min. Negotiated Rate	$427.34
Max. Negotiated Rate	$2,374.10
Rate for Payer: Aetna Commercial	$1,424.46
Rate for Payer: Amerigroup CHIP/Medicaid	$427.34
Rate for Payer: BCBS of TX Blue Advantage	$1,424.46
Rate for Payer: BCBS of TX Blue Essentials	$1,709.35
Rate for Payer: BCBS of TX PPO	$1,899.28
Rate for Payer: Cash Price	$4,178.41
Rate for Payer: Multiplan Auto	$2,374.10
Rate for Payer: Multiplan Commercial	$2,374.10
Rate for Payer: Multiplan Workers Comp	$2,374.10
Rate for Payer: Scott and White EPO/PPO	$2,374.10
Rate for Payer: Superior Health Plan EPO	$645.75

MESH SYMBOTEX COMP

Facility

$4,748.19

Service Code	HCPCS C1781
Hospital Charge Code	8514470
Hospital Revenue Code	278
Min. Negotiated Rate	$1,187.05
Max. Negotiated Rate	$2,374.10
Rate for Payer: Aetna Commercial	$1,424.46
Rate for Payer: Cash Price	$4,178.41
Rate for Payer: Cigna Commercial	$1,187.05
Rate for Payer: Multiplan Auto	$2,374.10
Rate for Payer: Multiplan Commercial	$2,374.10
Rate for Payer: Multiplan Workers Comp	$2,374.10
Rate for Payer: Scott and White EPO/PPO	$2,374.10

MESH SYMBOTEX COMP 12

Facility

$3,421.45

Service Code	HCPCS C1781
Hospital Charge Code	8514472
Hospital Revenue Code	278
Min. Negotiated Rate	$307.93
Max. Negotiated Rate	$1,710.72
Rate for Payer: Aetna Commercial	$1,026.44
Rate for Payer: Amerigroup CHIP/Medicaid	$307.93
Rate for Payer: BCBS of TX Blue Advantage	$1,026.44
Rate for Payer: BCBS of TX Blue Essentials	$1,231.72
Rate for Payer: BCBS of TX PPO	$1,368.58
Rate for Payer: Cash Price	$3,010.88
Rate for Payer: Multiplan Auto	$1,710.72
Rate for Payer: Multiplan Commercial	$1,710.72
Rate for Payer: Multiplan Workers Comp	$1,710.72
Rate for Payer: Scott and White EPO/PPO	$1,710.72
Rate for Payer: Superior Health Plan EPO	$465.32

MESH SYMBOTEX COMP 12

Facility

$3,421.45

Service Code	HCPCS C1781
Hospital Charge Code	8514472
Hospital Revenue Code	278
Min. Negotiated Rate	$855.36
Max. Negotiated Rate	$1,710.72
Rate for Payer: Aetna Commercial	$1,026.44
Rate for Payer: Cash Price	$3,010.88
Rate for Payer: Cigna Commercial	$855.36
Rate for Payer: Multiplan Auto	$1,710.72
Rate for Payer: Multiplan Commercial	$1,710.72
Rate for Payer: Multiplan Workers Comp	$1,710.72
Rate for Payer: Scott and White EPO/PPO	$1,710.72

MESH SYMBOTEX COMP 9

Facility

$2,374.03

Service Code	HCPCS C1781
Hospital Charge Code	8514471
Hospital Revenue Code	278
Min. Negotiated Rate	$213.66
Max. Negotiated Rate	$1,187.02
Rate for Payer: Aetna Commercial	$712.21
Rate for Payer: Amerigroup CHIP/Medicaid	$213.66
Rate for Payer: BCBS of TX Blue Advantage	$712.21
Rate for Payer: BCBS of TX Blue Essentials	$854.65
Rate for Payer: BCBS of TX PPO	$949.61
Rate for Payer: Cash Price	$2,089.15
Rate for Payer: Multiplan Auto	$1,187.02
Rate for Payer: Multiplan Commercial	$1,187.02
Rate for Payer: Multiplan Workers Comp	$1,187.02
Rate for Payer: Scott and White EPO/PPO	$1,187.02
Rate for Payer: Superior Health Plan EPO	$322.87

MESH SYMBOTEX COMP 9

Facility

$2,374.03

Service Code	HCPCS C1781
Hospital Charge Code	8514471
Hospital Revenue Code	278
Min. Negotiated Rate	$593.51
Max. Negotiated Rate	$1,187.02
Rate for Payer: Aetna Commercial	$712.21
Rate for Payer: Cash Price	$2,089.15
Rate for Payer: Cigna Commercial	$593.51
Rate for Payer: Multiplan Auto	$1,187.02
Rate for Payer: Multiplan Commercial	$1,187.02
Rate for Payer: Multiplan Workers Comp	$1,187.02
Rate for Payer: Scott and White EPO/PPO	$1,187.02

MESH VENTRALEX ST MED CIRCLE

Facility

$4,858.43

Service Code	HCPCS C1781
Hospital Charge Code	8538530
Hospital Revenue Code	278
Min. Negotiated Rate	$437.26
Max. Negotiated Rate	$2,429.22
Rate for Payer: Aetna Commercial	$1,457.53
Rate for Payer: Amerigroup CHIP/Medicaid	$437.26
Rate for Payer: BCBS of TX Blue Advantage	$1,457.53
Rate for Payer: BCBS of TX Blue Essentials	$1,749.03
Rate for Payer: BCBS of TX PPO	$1,943.37
Rate for Payer: Cash Price	$4,275.42
Rate for Payer: Multiplan Auto	$2,429.22
Rate for Payer: Multiplan Commercial	$2,429.22
Rate for Payer: Multiplan Workers Comp	$2,429.22
Rate for Payer: Scott and White EPO/PPO	$2,429.22
Rate for Payer: Superior Health Plan EPO	$660.75

MESH VENTRALEX ST MED CIRCLE

Facility

$4,858.43

Service Code	HCPCS C1781
Hospital Charge Code	8538530
Hospital Revenue Code	278
Min. Negotiated Rate	$1,214.61
Max. Negotiated Rate	$2,429.22
Rate for Payer: Aetna Commercial	$1,457.53
Rate for Payer: Cash Price	$4,275.42
Rate for Payer: Cigna Commercial	$1,214.61
Rate for Payer: Multiplan Auto	$2,429.22
Rate for Payer: Multiplan Commercial	$2,429.22
Rate for Payer: Multiplan Workers Comp	$2,429.22
Rate for Payer: Scott and White EPO/PPO	$2,429.22

Metanephrines, Frac., Pl. Free SO

Facility

$285.00

Service Code	CPT 83835
Hospital Charge Code	1702117
Hospital Revenue Code	301
Rate for Payer: Cash Price	$250.80

Metanephrines, Frac., Pl. Free SO

Facility

$285.00

Service Code	CPT 83835
Hospital Charge Code	1702117
Hospital Revenue Code	301
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$185.25
Rate for Payer: Aetna Commercial	$17.78
Rate for Payer: Aetna Medicare	$25.41
Rate for Payer: Amerigroup CHIP/Medicaid	$6.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.94
Rate for Payer: Amerigroup Medicare	$16.94
Rate for Payer: BCBS of TX Blue Advantage	$27.95
Rate for Payer: BCBS of TX Blue Essentials	$33.54
Rate for Payer: BCBS of TX Medicare	$16.94
Rate for Payer: BCBS of TX PPO	$37.44
Rate for Payer: Cash Price	$250.80
Rate for Payer: Cash Price	$250.80
Rate for Payer: Cigna Medicaid	$16.94
Rate for Payer: Cigna Medicare	$16.94
Rate for Payer: Employer Direct Commercial	$16.94
Rate for Payer: Humana Medicare/TRICARE	$16.94
Rate for Payer: Molina CHIP/Medicaid	$16.94
Rate for Payer: Molina Dual Medicare/Medicaid	$16.94
Rate for Payer: Molina Medicare	$16.94
Rate for Payer: Multiplan Auto	$185.25
Rate for Payer: Multiplan Commercial	$185.25
Rate for Payer: Multiplan Workers Comp	$185.25
Rate for Payer: Parkland Medicaid	$16.94
Rate for Payer: Scott and White EPO/PPO	$21.18
Rate for Payer: Scott and White Medicare	$16.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.94
Rate for Payer: Superior Health Plan EPO	$16.94
Rate for Payer: Superior Health Plan Medicare	$16.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.94
Rate for Payer: Universal American Medicare	$16.94
Rate for Payer: Wellcare Medicare	$16.94
Rate for Payer: Wellmed Medicare	$16.94

Metanephrines, Frac, Qn, 24-Hr SO

Facility

$285.00

Service Code	CPT 83835
Hospital Charge Code	1702117
Hospital Revenue Code	301
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$185.25
Rate for Payer: Aetna Commercial	$17.78
Rate for Payer: Aetna Medicare	$25.41
Rate for Payer: Amerigroup CHIP/Medicaid	$6.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.94
Rate for Payer: Amerigroup Medicare	$16.94
Rate for Payer: BCBS of TX Blue Advantage	$27.95
Rate for Payer: BCBS of TX Blue Essentials	$33.54
Rate for Payer: BCBS of TX Medicare	$16.94
Rate for Payer: BCBS of TX PPO	$37.44
Rate for Payer: Cash Price	$250.80
Rate for Payer: Cash Price	$250.80
Rate for Payer: Cigna Medicaid	$16.94
Rate for Payer: Cigna Medicare	$16.94
Rate for Payer: Employer Direct Commercial	$16.94
Rate for Payer: Humana Medicare/TRICARE	$16.94
Rate for Payer: Molina CHIP/Medicaid	$16.94
Rate for Payer: Molina Dual Medicare/Medicaid	$16.94
Rate for Payer: Molina Medicare	$16.94
Rate for Payer: Multiplan Auto	$185.25
Rate for Payer: Multiplan Commercial	$185.25
Rate for Payer: Multiplan Workers Comp	$185.25
Rate for Payer: Parkland Medicaid	$16.94
Rate for Payer: Scott and White EPO/PPO	$21.18
Rate for Payer: Scott and White Medicare	$16.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.94
Rate for Payer: Superior Health Plan EPO	$16.94
Rate for Payer: Superior Health Plan Medicare	$16.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.94
Rate for Payer: Universal American Medicare	$16.94
Rate for Payer: Wellcare Medicare	$16.94
Rate for Payer: Wellmed Medicare	$16.94

Know your out-of-pocket cost for care.

All Charges