White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MESH, POLYPROPYLENE KNITTED PERFIX PLUG LARGE -- DHF

Facility

$2,116.00

Service Code	HCPCS C1781
Hospital Charge Code	40241994
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,438.88

MESH, POLYPROPYLENE KNITTED PERFIX PLUG LARGE -- DHF

Facility

$2,116.00

Service Code	HCPCS C1781
Hospital Charge Code	40241994
Hospital Revenue Code	272
Min. Negotiated Rate	$190.44
Max. Negotiated Rate	$1,523.52
Rate for Payer: Amerigroup CHIP/Medicaid	$190.44
Rate for Payer: BCBS of TX Blue Advantage	$634.80
Rate for Payer: BCBS of TX Blue Essentials	$761.76
Rate for Payer: BCBS of TX PPO	$846.40
Rate for Payer: Cash Price	$1,438.88
Rate for Payer: Cigna Medicaid	$1,523.52
Rate for Payer: Molina CHIP/Medicaid	$1,523.52
Rate for Payer: Multiplan Auto	$1,375.40
Rate for Payer: Multiplan Commercial	$1,375.40
Rate for Payer: Multiplan Workers Comp	$1,375.40
Rate for Payer: Parkland Medicaid	$1,523.52
Rate for Payer: Scott and White EPO/PPO	$1,058.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,523.52
Rate for Payer: Superior Health Plan EPO	$287.78

MESH, POLYPROPYLENE KNITTED PERFIX PLUG MEDIUM -- DHF

Facility

$1,658.00

Service Code	HCPCS C1781
Hospital Charge Code	81420853
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,127.44

MESH, POLYPROPYLENE KNITTED PERFIX PLUG MEDIUM -- DHF

Facility

$1,658.00

Service Code	HCPCS C1781
Hospital Charge Code	81420853
Hospital Revenue Code	272
Min. Negotiated Rate	$149.22
Max. Negotiated Rate	$1,193.76
Rate for Payer: Amerigroup CHIP/Medicaid	$149.22
Rate for Payer: BCBS of TX Blue Advantage	$497.40
Rate for Payer: BCBS of TX Blue Essentials	$596.88
Rate for Payer: BCBS of TX PPO	$663.20
Rate for Payer: Cash Price	$1,127.44
Rate for Payer: Cigna Medicaid	$1,193.76
Rate for Payer: Molina CHIP/Medicaid	$1,193.76
Rate for Payer: Multiplan Auto	$1,077.70
Rate for Payer: Multiplan Commercial	$1,077.70
Rate for Payer: Multiplan Workers Comp	$1,077.70
Rate for Payer: Parkland Medicaid	$1,193.76
Rate for Payer: Scott and White EPO/PPO	$829.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,193.76
Rate for Payer: Superior Health Plan EPO	$225.49

MESH, PROCEED, 6X8, OVAL, NO RETURN

Facility

$4,747.17

Service Code	HCPCS C1781
Hospital Charge Code	992394
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,228.08

MESH, PROCEED, 6X8, OVAL, NO RETURN

Facility

$4,747.17

Service Code	HCPCS C1781
Hospital Charge Code	992394
Hospital Revenue Code	272
Min. Negotiated Rate	$427.25
Max. Negotiated Rate	$3,417.96
Rate for Payer: Amerigroup CHIP/Medicaid	$427.25
Rate for Payer: BCBS of TX Blue Advantage	$1,424.15
Rate for Payer: BCBS of TX Blue Essentials	$1,708.98
Rate for Payer: BCBS of TX PPO	$1,898.87
Rate for Payer: Cash Price	$3,228.08
Rate for Payer: Cigna Medicaid	$3,417.96
Rate for Payer: Molina CHIP/Medicaid	$3,417.96
Rate for Payer: Multiplan Auto	$3,085.66
Rate for Payer: Multiplan Commercial	$3,085.66
Rate for Payer: Multiplan Workers Comp	$3,085.66
Rate for Payer: Parkland Medicaid	$3,417.96
Rate for Payer: Scott and White EPO/PPO	$2,373.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,417.96
Rate for Payer: Superior Health Plan EPO	$645.62

mesh proceed ventral patch pvpm

Facility

$2,853.00

Service Code	HCPCS C1781
Hospital Charge Code	8618508
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,940.04

mesh proceed ventral patch pvpm

Facility

$2,853.00

Service Code	HCPCS C1781
Hospital Charge Code	8618508
Hospital Revenue Code	272
Min. Negotiated Rate	$256.77
Max. Negotiated Rate	$2,054.16
Rate for Payer: Amerigroup CHIP/Medicaid	$256.77
Rate for Payer: BCBS of TX Blue Advantage	$855.90
Rate for Payer: BCBS of TX Blue Essentials	$1,027.08
Rate for Payer: BCBS of TX PPO	$1,141.20
Rate for Payer: Cash Price	$1,940.04
Rate for Payer: Cigna Medicaid	$2,054.16
Rate for Payer: Molina CHIP/Medicaid	$2,054.16
Rate for Payer: Multiplan Auto	$1,854.45
Rate for Payer: Multiplan Commercial	$1,854.45
Rate for Payer: Multiplan Workers Comp	$1,854.45
Rate for Payer: Parkland Medicaid	$2,054.16
Rate for Payer: Scott and White EPO/PPO	$1,426.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,054.16
Rate for Payer: Superior Health Plan EPO	$388.01

MESH PROGRIP PARIETEX RT ANATOM 12X8

Facility

$2,041.00

Service Code	HCPCS C1781
Hospital Charge Code	8568970
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,387.88

MESH PROGRIP PARIETEX RT ANATOM 12X8

Facility

$2,041.00

Service Code	HCPCS C1781
Hospital Charge Code	8568970
Hospital Revenue Code	272
Min. Negotiated Rate	$183.69
Max. Negotiated Rate	$1,469.52
Rate for Payer: Amerigroup CHIP/Medicaid	$183.69
Rate for Payer: BCBS of TX Blue Advantage	$612.30
Rate for Payer: BCBS of TX Blue Essentials	$734.76
Rate for Payer: BCBS of TX PPO	$816.40
Rate for Payer: Cash Price	$1,387.88
Rate for Payer: Cigna Medicaid	$1,469.52
Rate for Payer: Molina CHIP/Medicaid	$1,469.52
Rate for Payer: Multiplan Auto	$1,326.65
Rate for Payer: Multiplan Commercial	$1,326.65
Rate for Payer: Multiplan Workers Comp	$1,326.65
Rate for Payer: Parkland Medicaid	$1,469.52
Rate for Payer: Scott and White EPO/PPO	$1,020.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,469.52
Rate for Payer: Superior Health Plan EPO	$277.58

MESH SURGIPRO PLUG AND PATCH LARGE

Facility

$1,121.00

Service Code	HCPCS C1781
Hospital Charge Code	8568971
Hospital Revenue Code	272
Rate for Payer: Cash Price	$762.28

MESH SURGIPRO PLUG AND PATCH LARGE

Facility

$1,121.00

Service Code	HCPCS C1781
Hospital Charge Code	8568971
Hospital Revenue Code	272
Min. Negotiated Rate	$100.89
Max. Negotiated Rate	$807.12
Rate for Payer: Amerigroup CHIP/Medicaid	$100.89
Rate for Payer: BCBS of TX Blue Advantage	$336.30
Rate for Payer: BCBS of TX Blue Essentials	$403.56
Rate for Payer: BCBS of TX PPO	$448.40
Rate for Payer: Cash Price	$762.28
Rate for Payer: Cigna Medicaid	$807.12
Rate for Payer: Molina CHIP/Medicaid	$807.12
Rate for Payer: Multiplan Auto	$728.65
Rate for Payer: Multiplan Commercial	$728.65
Rate for Payer: Multiplan Workers Comp	$728.65
Rate for Payer: Parkland Medicaid	$807.12
Rate for Payer: Scott and White EPO/PPO	$560.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$807.12
Rate for Payer: Superior Health Plan EPO	$152.46

MESH SYMBOTEX COMP

Facility

$4,748.00

Service Code	HCPCS C1781
Hospital Charge Code	8514470
Hospital Revenue Code	272
Min. Negotiated Rate	$427.32
Max. Negotiated Rate	$3,418.56
Rate for Payer: Amerigroup CHIP/Medicaid	$427.32
Rate for Payer: BCBS of TX Blue Advantage	$1,424.40
Rate for Payer: BCBS of TX Blue Essentials	$1,709.28
Rate for Payer: BCBS of TX PPO	$1,899.20
Rate for Payer: Cash Price	$3,228.64
Rate for Payer: Cigna Medicaid	$3,418.56
Rate for Payer: Molina CHIP/Medicaid	$3,418.56
Rate for Payer: Multiplan Auto	$3,086.20
Rate for Payer: Multiplan Commercial	$3,086.20
Rate for Payer: Multiplan Workers Comp	$3,086.20
Rate for Payer: Parkland Medicaid	$3,418.56
Rate for Payer: Scott and White EPO/PPO	$2,374.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,418.56
Rate for Payer: Superior Health Plan EPO	$645.73

MESH SYMBOTEX COMP

Facility

$4,748.00

Service Code	HCPCS C1781
Hospital Charge Code	8514470
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,228.64

MESH SYMBOTEX COMP 12

Facility

$3,421.00

Service Code	HCPCS C1781
Hospital Charge Code	8514472
Hospital Revenue Code	272
Min. Negotiated Rate	$307.89
Max. Negotiated Rate	$2,463.12
Rate for Payer: Amerigroup CHIP/Medicaid	$307.89
Rate for Payer: BCBS of TX Blue Advantage	$1,026.30
Rate for Payer: BCBS of TX Blue Essentials	$1,231.56
Rate for Payer: BCBS of TX PPO	$1,368.40
Rate for Payer: Cash Price	$2,326.28
Rate for Payer: Cigna Medicaid	$2,463.12
Rate for Payer: Molina CHIP/Medicaid	$2,463.12
Rate for Payer: Multiplan Auto	$2,223.65
Rate for Payer: Multiplan Commercial	$2,223.65
Rate for Payer: Multiplan Workers Comp	$2,223.65
Rate for Payer: Parkland Medicaid	$2,463.12
Rate for Payer: Scott and White EPO/PPO	$1,710.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,463.12
Rate for Payer: Superior Health Plan EPO	$465.26

MESH SYMBOTEX COMP 12

Facility

$3,421.00

Service Code	HCPCS C1781
Hospital Charge Code	8514472
Hospital Revenue Code	272
Rate for Payer: Cash Price	$2,326.28

MESH SYMBOTEX COMP 9

Facility

$2,374.00

Service Code	HCPCS C1781
Hospital Charge Code	8514471
Hospital Revenue Code	272
Min. Negotiated Rate	$213.66
Max. Negotiated Rate	$1,709.28
Rate for Payer: Amerigroup CHIP/Medicaid	$213.66
Rate for Payer: BCBS of TX Blue Advantage	$712.20
Rate for Payer: BCBS of TX Blue Essentials	$854.64
Rate for Payer: BCBS of TX PPO	$949.60
Rate for Payer: Cash Price	$1,614.32
Rate for Payer: Cigna Medicaid	$1,709.28
Rate for Payer: Molina CHIP/Medicaid	$1,709.28
Rate for Payer: Multiplan Auto	$1,543.10
Rate for Payer: Multiplan Commercial	$1,543.10
Rate for Payer: Multiplan Workers Comp	$1,543.10
Rate for Payer: Parkland Medicaid	$1,709.28
Rate for Payer: Scott and White EPO/PPO	$1,187.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,709.28
Rate for Payer: Superior Health Plan EPO	$322.86

MESH SYMBOTEX COMP 9

Facility

$2,374.00

Service Code	HCPCS C1781
Hospital Charge Code	8514471
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,614.32

MESH SYMBOTEX COMPOSITE 9 CM

Facility

$1,804.92

Service Code	HCPCS C1781
Hospital Charge Code	992883
Hospital Revenue Code	272
Min. Negotiated Rate	$162.44
Max. Negotiated Rate	$1,299.54
Rate for Payer: Amerigroup CHIP/Medicaid	$162.44
Rate for Payer: BCBS of TX Blue Advantage	$541.48
Rate for Payer: BCBS of TX Blue Essentials	$649.77
Rate for Payer: BCBS of TX PPO	$721.97
Rate for Payer: Cash Price	$1,227.35
Rate for Payer: Cigna Medicaid	$1,299.54
Rate for Payer: Molina CHIP/Medicaid	$1,299.54
Rate for Payer: Multiplan Auto	$1,173.20
Rate for Payer: Multiplan Commercial	$1,173.20
Rate for Payer: Multiplan Workers Comp	$1,173.20
Rate for Payer: Parkland Medicaid	$1,299.54
Rate for Payer: Scott and White EPO/PPO	$902.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,299.54
Rate for Payer: Superior Health Plan EPO	$245.47

MESH SYMBOTEX COMPOSITE 9 CM

Facility

$1,804.92

Service Code	HCPCS C1781
Hospital Charge Code	992883
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,227.35

MESH SYMBOTEX COMPOSITE 9 CM

Facility

$1,804.92

Service Code	HCPCS C1781
Hospital Charge Code	81420804
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,227.35

MESH SYMBOTEX COMPOSITE 9 CM

Facility

$1,804.92

Service Code	HCPCS C1781
Hospital Charge Code	81420804
Hospital Revenue Code	272
Min. Negotiated Rate	$162.44
Max. Negotiated Rate	$1,299.54
Rate for Payer: Amerigroup CHIP/Medicaid	$162.44
Rate for Payer: BCBS of TX Blue Advantage	$541.48
Rate for Payer: BCBS of TX Blue Essentials	$649.77
Rate for Payer: BCBS of TX PPO	$721.97
Rate for Payer: Cash Price	$1,227.35
Rate for Payer: Cigna Medicaid	$1,299.54
Rate for Payer: Molina CHIP/Medicaid	$1,299.54
Rate for Payer: Multiplan Auto	$1,173.20
Rate for Payer: Multiplan Commercial	$1,173.20
Rate for Payer: Multiplan Workers Comp	$1,173.20
Rate for Payer: Parkland Medicaid	$1,299.54
Rate for Payer: Scott and White EPO/PPO	$902.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,299.54
Rate for Payer: Superior Health Plan EPO	$245.47

MESH VENTRALEX ST MED CIRCLE

Facility

$4,858.00

Service Code	HCPCS C1781
Hospital Charge Code	8538530
Hospital Revenue Code	272
Min. Negotiated Rate	$437.22
Max. Negotiated Rate	$3,497.76
Rate for Payer: Amerigroup CHIP/Medicaid	$437.22
Rate for Payer: BCBS of TX Blue Advantage	$1,457.40
Rate for Payer: BCBS of TX Blue Essentials	$1,748.88
Rate for Payer: BCBS of TX PPO	$1,943.20
Rate for Payer: Cash Price	$3,303.44
Rate for Payer: Cigna Medicaid	$3,497.76
Rate for Payer: Molina CHIP/Medicaid	$3,497.76
Rate for Payer: Multiplan Auto	$3,157.70
Rate for Payer: Multiplan Commercial	$3,157.70
Rate for Payer: Multiplan Workers Comp	$3,157.70
Rate for Payer: Parkland Medicaid	$3,497.76
Rate for Payer: Scott and White EPO/PPO	$2,429.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,497.76
Rate for Payer: Superior Health Plan EPO	$660.69

MESH VENTRALEX ST MED CIRCLE

Facility

$4,858.00

Service Code	HCPCS C1781
Hospital Charge Code	8538530
Hospital Revenue Code	272
Rate for Payer: Cash Price	$3,303.44

Metanephrines, Frac., Pl. Free SO

Facility

$285.00

Service Code	HCPCS 83835
Hospital Charge Code	1702117
Hospital Revenue Code	301
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$205.20
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	$85.50
Rate for Payer: BCBS of TX Blue Essentials	$102.60
Rate for Payer: BCBS of TX Medicare	$16.94
Rate for Payer: BCBS of TX PPO	$114.00
Rate for Payer: Cash Price	$193.80
Rate for Payer: Cash Price	$193.80
Rate for Payer: Cigna Medicaid	$205.20
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	$205.20
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	$205.20
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	$205.20
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