White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$92.16
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: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
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: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

meropenem 500 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 IV Inj

Facility

$128.00

Service Code	HCPCS J2185
Hospital Charge Code	77686306
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 IV Inj

Facility

$128.00

Service Code	HCPCS J2185
Hospital Charge Code	77686306
Hospital Revenue Code	636
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$92.16
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: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
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: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

meropenem 500 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	$92.16
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: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
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: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

MESH GORTEX DUAL 8X12 -- DHF

Facility

$5,613.00

Service Code	HCPCS C1781
Hospital Charge Code	81420622
Hospital Revenue Code	272
Min. Negotiated Rate	$505.17
Max. Negotiated Rate	$4,041.36
Rate for Payer: Amerigroup CHIP/Medicaid	$505.17
Rate for Payer: BCBS of TX Blue Advantage	$1,683.90
Rate for Payer: BCBS of TX Blue Essentials	$2,020.68
Rate for Payer: BCBS of TX PPO	$2,245.20
Rate for Payer: Cash Price	$3,816.84
Rate for Payer: Cigna Medicaid	$4,041.36
Rate for Payer: Molina CHIP/Medicaid	$4,041.36
Rate for Payer: Multiplan Auto	$3,648.45
Rate for Payer: Multiplan Commercial	$3,648.45
Rate for Payer: Multiplan Workers Comp	$3,648.45
Rate for Payer: Parkland Medicaid	$4,041.36
Rate for Payer: Scott and White EPO/PPO	$2,806.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,041.36
Rate for Payer: Superior Health Plan EPO	$763.37

MESH GORTEX DUAL 8X12 -- DHF

Facility

$5,613.00

Service Code	HCPCS C1781
Hospital Charge Code	81420622
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,816.84

MESH HERNIA COMPOSITE -- DHF

Facility

$6,514.00

Service Code	HCPCS C1781
Hospital Charge Code	40240681
Hospital Revenue Code	272
Rate for Payer: Cash Price	$4,429.52

MESH HERNIA COMPOSITE -- DHF

Facility

$6,514.00

Service Code	HCPCS C1781
Hospital Charge Code	40240681
Hospital Revenue Code	272
Min. Negotiated Rate	$586.26
Max. Negotiated Rate	$4,690.08
Rate for Payer: Amerigroup CHIP/Medicaid	$586.26
Rate for Payer: BCBS of TX Blue Advantage	$1,954.20
Rate for Payer: BCBS of TX Blue Essentials	$2,345.04
Rate for Payer: BCBS of TX PPO	$2,605.60
Rate for Payer: Cash Price	$4,429.52
Rate for Payer: Cigna Medicaid	$4,690.08
Rate for Payer: Molina CHIP/Medicaid	$4,690.08
Rate for Payer: Multiplan Auto	$4,234.10
Rate for Payer: Multiplan Commercial	$4,234.10
Rate for Payer: Multiplan Workers Comp	$4,234.10
Rate for Payer: Parkland Medicaid	$4,690.08
Rate for Payer: Scott and White EPO/PPO	$3,257.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,690.08
Rate for Payer: Superior Health Plan EPO	$885.90

MESH HERNIA FLAT POLYPROPYLENE L 6 IN X W 6 IN

Facility

$1,566.00

Service Code	HCPCS C1781
Hospital Charge Code	118970
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,064.88

MESH HERNIA FLAT POLYPROPYLENE L 6 IN X W 6 IN

Facility

$1,566.00

Service Code	HCPCS C1781
Hospital Charge Code	118970
Hospital Revenue Code	272
Min. Negotiated Rate	$140.94
Max. Negotiated Rate	$1,127.52
Rate for Payer: Amerigroup CHIP/Medicaid	$140.94
Rate for Payer: BCBS of TX Blue Advantage	$469.80
Rate for Payer: BCBS of TX Blue Essentials	$563.76
Rate for Payer: BCBS of TX PPO	$626.40
Rate for Payer: Cash Price	$1,064.88
Rate for Payer: Cigna Medicaid	$1,127.52
Rate for Payer: Molina CHIP/Medicaid	$1,127.52
Rate for Payer: Multiplan Auto	$1,017.90
Rate for Payer: Multiplan Commercial	$1,017.90
Rate for Payer: Multiplan Workers Comp	$1,017.90
Rate for Payer: Parkland Medicaid	$1,127.52
Rate for Payer: Scott and White EPO/PPO	$783.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,127.52
Rate for Payer: Superior Health Plan EPO	$212.98

MESH, HERNIA LIGHTWEIGHT PARTIALLY ABSRB 10CM -- DHF

Facility

$3,257.00

Service Code	HCPCS C1781
Hospital Charge Code	82401993
Hospital Revenue Code	272
Min. Negotiated Rate	$293.13
Max. Negotiated Rate	$2,345.04
Rate for Payer: Amerigroup CHIP/Medicaid	$293.13
Rate for Payer: BCBS of TX Blue Advantage	$977.10
Rate for Payer: BCBS of TX Blue Essentials	$1,172.52
Rate for Payer: BCBS of TX PPO	$1,302.80
Rate for Payer: Cash Price	$2,214.76
Rate for Payer: Cigna Medicaid	$2,345.04
Rate for Payer: Molina CHIP/Medicaid	$2,345.04
Rate for Payer: Multiplan Auto	$2,117.05
Rate for Payer: Multiplan Commercial	$2,117.05
Rate for Payer: Multiplan Workers Comp	$2,117.05
Rate for Payer: Parkland Medicaid	$2,345.04
Rate for Payer: Scott and White EPO/PPO	$1,628.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,345.04
Rate for Payer: Superior Health Plan EPO	$442.95

MESH, HERNIA LIGHTWEIGHT PARTIALLY ABSRB 10CM -- DHF

Facility

$3,257.00

Service Code	HCPCS C1781
Hospital Charge Code	82401993
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,214.76

Mesh hernia proceed 20x25 cm pvdh1

Facility

$8,752.00

Service Code	HCPCS C1781
Hospital Charge Code	8602525
Hospital Revenue Code	272
Rate for Payer: Cash Price	$5,951.36

Mesh hernia proceed 20x25 cm pvdh1

Facility

$8,752.00

Service Code	HCPCS C1781
Hospital Charge Code	8602525
Hospital Revenue Code	272
Min. Negotiated Rate	$787.68
Max. Negotiated Rate	$6,301.44
Rate for Payer: Amerigroup CHIP/Medicaid	$787.68
Rate for Payer: BCBS of TX Blue Advantage	$2,625.60
Rate for Payer: BCBS of TX Blue Essentials	$3,150.72
Rate for Payer: BCBS of TX PPO	$3,500.80
Rate for Payer: Cash Price	$5,951.36
Rate for Payer: Cigna Medicaid	$6,301.44
Rate for Payer: Molina CHIP/Medicaid	$6,301.44
Rate for Payer: Multiplan Auto	$5,688.80
Rate for Payer: Multiplan Commercial	$5,688.80
Rate for Payer: Multiplan Workers Comp	$5,688.80
Rate for Payer: Parkland Medicaid	$6,301.44
Rate for Payer: Scott and White EPO/PPO	$4,376.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,301.44
Rate for Payer: Superior Health Plan EPO	$1,190.27

MESH HERNIA ULTRAPRO UHSL

Facility

$1,681.00

Service Code	HCPCS C1781
Hospital Charge Code	118929
Hospital Revenue Code	272
Min. Negotiated Rate	$151.29
Max. Negotiated Rate	$1,210.32
Rate for Payer: Amerigroup CHIP/Medicaid	$151.29
Rate for Payer: BCBS of TX Blue Advantage	$504.30
Rate for Payer: BCBS of TX Blue Essentials	$605.16
Rate for Payer: BCBS of TX PPO	$672.40
Rate for Payer: Cash Price	$1,143.08
Rate for Payer: Cigna Medicaid	$1,210.32
Rate for Payer: Molina CHIP/Medicaid	$1,210.32
Rate for Payer: Multiplan Auto	$1,092.65
Rate for Payer: Multiplan Commercial	$1,092.65
Rate for Payer: Multiplan Workers Comp	$1,092.65
Rate for Payer: Parkland Medicaid	$1,210.32
Rate for Payer: Scott and White EPO/PPO	$840.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,210.32
Rate for Payer: Superior Health Plan EPO	$228.62

MESH HERNIA ULTRAPRO UHSL

Facility

$1,681.00

Service Code	HCPCS C1781
Hospital Charge Code	118929
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,143.08

Mesh (implantable)

Facility

$5,630.00

Service Code	HCPCS C1781
Hospital Charge Code	990933
Hospital Revenue Code	272
Min. Negotiated Rate	$506.70
Max. Negotiated Rate	$4,053.60
Rate for Payer: Amerigroup CHIP/Medicaid	$506.70
Rate for Payer: BCBS of TX Blue Advantage	$1,689.00
Rate for Payer: BCBS of TX Blue Essentials	$2,026.80
Rate for Payer: BCBS of TX PPO	$2,252.00
Rate for Payer: Cash Price	$3,828.40
Rate for Payer: Cigna Medicaid	$4,053.60
Rate for Payer: Molina CHIP/Medicaid	$4,053.60
Rate for Payer: Multiplan Auto	$3,659.50
Rate for Payer: Multiplan Commercial	$3,659.50
Rate for Payer: Multiplan Workers Comp	$3,659.50
Rate for Payer: Parkland Medicaid	$4,053.60
Rate for Payer: Scott and White EPO/PPO	$2,815.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,053.60
Rate for Payer: Superior Health Plan EPO	$765.68

Mesh (implantable)

Facility

$5,630.00

Service Code	HCPCS C1781
Hospital Charge Code	990933
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,828.40

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

Facility

$3,490.00

Service Code	HCPCS C1781
Hospital Charge Code	40240954
Hospital Revenue Code	272
Min. Negotiated Rate	$314.10
Max. Negotiated Rate	$2,512.80
Rate for Payer: Amerigroup CHIP/Medicaid	$314.10
Rate for Payer: BCBS of TX Blue Advantage	$1,047.00
Rate for Payer: BCBS of TX Blue Essentials	$1,256.40
Rate for Payer: BCBS of TX PPO	$1,396.00
Rate for Payer: Cash Price	$2,373.20
Rate for Payer: Cigna Medicaid	$2,512.80
Rate for Payer: Molina CHIP/Medicaid	$2,512.80
Rate for Payer: Multiplan Auto	$2,268.50
Rate for Payer: Multiplan Commercial	$2,268.50
Rate for Payer: Multiplan Workers Comp	$2,268.50
Rate for Payer: Parkland Medicaid	$2,512.80
Rate for Payer: Scott and White EPO/PPO	$1,745.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,512.80
Rate for Payer: Superior Health Plan EPO	$474.64

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

Facility

$3,490.00

Service Code	HCPCS C1781
Hospital Charge Code	40240954
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,373.20

MESH PHASIZ SEPRA 4X4

Facility

$11,235.00

Service Code	HCPCS C1781
Hospital Charge Code	8528468
Hospital Revenue Code	272
Min. Negotiated Rate	$1,011.15
Max. Negotiated Rate	$8,089.20
Rate for Payer: Amerigroup CHIP/Medicaid	$1,011.15
Rate for Payer: BCBS of TX Blue Advantage	$3,370.50
Rate for Payer: BCBS of TX Blue Essentials	$4,044.60
Rate for Payer: BCBS of TX PPO	$4,494.00
Rate for Payer: Cash Price	$7,639.80
Rate for Payer: Cigna Medicaid	$8,089.20
Rate for Payer: Molina CHIP/Medicaid	$8,089.20
Rate for Payer: Multiplan Auto	$7,302.75
Rate for Payer: Multiplan Commercial	$7,302.75
Rate for Payer: Multiplan Workers Comp	$7,302.75
Rate for Payer: Parkland Medicaid	$8,089.20
Rate for Payer: Scott and White EPO/PPO	$5,617.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,089.20
Rate for Payer: Superior Health Plan EPO	$1,527.96

MESH PHASIZ SEPRA 4X4

Facility

$11,235.00

Service Code	HCPCS C1781
Hospital Charge Code	8528468
Hospital Revenue Code	272
Rate for Payer: Cash Price	$7,639.80

MESH PLUG

Facility

$14.46

Service Code	HCPCS A4649
Hospital Charge Code	992357
Hospital Revenue Code	272
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$10.41
Rate for Payer: Amerigroup CHIP/Medicaid	$1.30
Rate for Payer: BCBS of TX Blue Advantage	$4.34
Rate for Payer: BCBS of TX Blue Essentials	$5.21
Rate for Payer: BCBS of TX PPO	$5.78
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cigna Medicaid	$10.41
Rate for Payer: Molina CHIP/Medicaid	$10.41
Rate for Payer: Multiplan Auto	$9.40
Rate for Payer: Multiplan Commercial	$9.40
Rate for Payer: Multiplan Workers Comp	$9.40
Rate for Payer: Parkland Medicaid	$10.41
Rate for Payer: Scott and White EPO/PPO	$7.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.41
Rate for Payer: Superior Health Plan EPO	$1.97

MESH PLUG

Facility

$14.46

Service Code	HCPCS A4649
Hospital Charge Code	992357
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.83

Know your out-of-pocket cost for care.

All Charges