White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HEMOSTATIC SPONGE SURGIFORM

Facility

$82.85

Hospital Charge Code	8510470
Hospital Revenue Code	272
Rate for Payer: Cash Price	$72.91

HEMOSTATIC SPONGE SURGIFORM

Facility

$82.85

Hospital Charge Code	8510470
Hospital Revenue Code	272
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$53.85
Rate for Payer: Aetna Commercial	$45.57
Rate for Payer: Amerigroup CHIP/Medicaid	$7.46
Rate for Payer: BCBS of TX Blue Advantage	$24.86
Rate for Payer: BCBS of TX Blue Essentials	$29.83
Rate for Payer: BCBS of TX PPO	$33.14
Rate for Payer: Cash Price	$72.91
Rate for Payer: Multiplan Auto	$53.85
Rate for Payer: Multiplan Commercial	$53.85
Rate for Payer: Multiplan Workers Comp	$53.85
Rate for Payer: Scott and White EPO/PPO	$41.42
Rate for Payer: Superior Health Plan EPO	$11.27

Hep A Ab, IgM SO

Facility

$210.00

Service Code	CPT 86709
Hospital Charge Code	1600865
Hospital Revenue Code	300
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$136.50
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: Aetna Medicare	$16.89
Rate for Payer: Amerigroup CHIP/Medicaid	$4.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.26
Rate for Payer: Amerigroup Medicare	$11.26
Rate for Payer: BCBS of TX Blue Advantage	$18.58
Rate for Payer: BCBS of TX Blue Essentials	$22.29
Rate for Payer: BCBS of TX Medicare	$11.26
Rate for Payer: BCBS of TX PPO	$24.88
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cigna Medicaid	$11.26
Rate for Payer: Cigna Medicare	$11.26
Rate for Payer: Employer Direct Commercial	$11.26
Rate for Payer: Humana Medicare/TRICARE	$11.26
Rate for Payer: Molina CHIP/Medicaid	$11.26
Rate for Payer: Molina Dual Medicare/Medicaid	$11.26
Rate for Payer: Molina Medicare	$11.26
Rate for Payer: Multiplan Auto	$136.50
Rate for Payer: Multiplan Commercial	$136.50
Rate for Payer: Multiplan Workers Comp	$136.50
Rate for Payer: Parkland Medicaid	$11.26
Rate for Payer: Scott and White EPO/PPO	$14.08
Rate for Payer: Scott and White Medicare	$11.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.26
Rate for Payer: Superior Health Plan EPO	$11.26
Rate for Payer: Superior Health Plan Medicare	$11.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.26
Rate for Payer: Universal American Medicare	$11.26
Rate for Payer: Wellcare Medicare	$11.26
Rate for Payer: Wellmed Medicare	$11.26

Hep A Ab, Total SO

Facility

$383.00

Service Code	CPT 86708
Hospital Charge Code	1603125
Hospital Revenue Code	302
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$248.95
Rate for Payer: Aetna Commercial	$13.00
Rate for Payer: Aetna Medicare	$18.58
Rate for Payer: Amerigroup CHIP/Medicaid	$4.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.39
Rate for Payer: Amerigroup Medicare	$12.39
Rate for Payer: BCBS of TX Blue Advantage	$20.44
Rate for Payer: BCBS of TX Blue Essentials	$24.53
Rate for Payer: BCBS of TX Medicare	$12.39
Rate for Payer: BCBS of TX PPO	$27.38
Rate for Payer: Cash Price	$337.04
Rate for Payer: Cash Price	$337.04
Rate for Payer: Cigna Medicaid	$12.39
Rate for Payer: Cigna Medicare	$12.39
Rate for Payer: Employer Direct Commercial	$12.39
Rate for Payer: Humana Medicare/TRICARE	$12.39
Rate for Payer: Molina CHIP/Medicaid	$12.39
Rate for Payer: Molina Dual Medicare/Medicaid	$12.39
Rate for Payer: Molina Medicare	$12.39
Rate for Payer: Multiplan Auto	$248.95
Rate for Payer: Multiplan Commercial	$248.95
Rate for Payer: Multiplan Workers Comp	$248.95
Rate for Payer: Parkland Medicaid	$12.39
Rate for Payer: Scott and White EPO/PPO	$15.49
Rate for Payer: Scott and White Medicare	$12.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.39
Rate for Payer: Superior Health Plan EPO	$12.39
Rate for Payer: Superior Health Plan Medicare	$12.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.39
Rate for Payer: Universal American Medicare	$12.39
Rate for Payer: Wellcare Medicare	$12.39
Rate for Payer: Wellmed Medicare	$12.39

Hep A Ab, Total SO

Facility

$383.00

Service Code	CPT 86708
Hospital Charge Code	1603125
Hospital Revenue Code	302
Rate for Payer: Cash Price	$337.04

heparin 10,000 units/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77603003
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
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

heparin 10,000 units/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77603003
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

heparin 1000 units/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77603276
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
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

heparin 1000 units/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77603276
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

heparin 100 units/D5W IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77603166
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

heparin 100 units/D5W IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77603166
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
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

heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	3221
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

heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	3221
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
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

heparin 2 units/mL-NaCl 0.9% IV Soln 500 mL

Facility

$128.17

Service Code	HCPCS J1642
Hospital Charge Code	77603651
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.04
Rate for Payer: BCBS of TX Blue Essentials	$0.05
Rate for Payer: BCBS of TX PPO	$0.06
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

heparin 2 units/mL-NaCl 0.9% IV Soln 500 mL

Facility

$128.17

Service Code	HCPCS J1642
Hospital Charge Code	77603651
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

heparin 5000 units/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77604364
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

heparin 5000 units/mL Inj Soln 1 mL

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77604364
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.20
Rate for Payer: BCBS of TX Blue Essentials	$0.24
Rate for Payer: BCBS of TX PPO	$0.27
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

Heparin Anti-Xa SO

Facility

$284.00

Service Code	CPT 85520
Hospital Charge Code	1739622
Hospital Revenue Code	300
Rate for Payer: Cash Price	$249.92

Heparin Anti-Xa SO

Facility

$284.00

Service Code	CPT 85520
Hospital Charge Code	1739622
Hospital Revenue Code	300
Min. Negotiated Rate	$5.11
Max. Negotiated Rate	$184.60
Rate for Payer: Aetna Commercial	$13.74
Rate for Payer: Aetna Medicare	$19.64
Rate for Payer: Amerigroup CHIP/Medicaid	$5.11
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.09
Rate for Payer: Amerigroup Medicare	$13.09
Rate for Payer: BCBS of TX Blue Advantage	$21.60
Rate for Payer: BCBS of TX Blue Essentials	$25.92
Rate for Payer: BCBS of TX Medicare	$13.09
Rate for Payer: BCBS of TX PPO	$28.93
Rate for Payer: Cash Price	$249.92
Rate for Payer: Cash Price	$249.92
Rate for Payer: Cigna Medicaid	$13.09
Rate for Payer: Cigna Medicare	$13.09
Rate for Payer: Employer Direct Commercial	$13.09
Rate for Payer: Humana Medicare/TRICARE	$13.09
Rate for Payer: Molina CHIP/Medicaid	$13.09
Rate for Payer: Molina Dual Medicare/Medicaid	$13.09
Rate for Payer: Molina Medicare	$13.09
Rate for Payer: Multiplan Auto	$184.60
Rate for Payer: Multiplan Commercial	$184.60
Rate for Payer: Multiplan Workers Comp	$184.60
Rate for Payer: Parkland Medicaid	$13.09
Rate for Payer: Scott and White EPO/PPO	$16.36
Rate for Payer: Scott and White Medicare	$13.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.09
Rate for Payer: Superior Health Plan EPO	$13.09
Rate for Payer: Superior Health Plan Medicare	$13.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.09
Rate for Payer: Universal American Medicare	$13.09
Rate for Payer: Wellcare Medicare	$13.09
Rate for Payer: Wellmed Medicare	$13.09

heparin flush 100 units/mL IV Soln 3 mL

Facility

$128.17

Service Code	HCPCS J1642
Hospital Charge Code	77605281
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.04
Rate for Payer: BCBS of TX Blue Essentials	$0.05
Rate for Payer: BCBS of TX PPO	$0.06
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

heparin flush 100 units/mL IV Soln 3 mL

Facility

$128.17

Service Code	HCPCS J1642
Hospital Charge Code	77605281
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

Heparin Induced Platelet SO

Facility

$527.00

Service Code	CPT 86022
Hospital Charge Code	1701010
Hospital Revenue Code	302
Min. Negotiated Rate	$7.16
Max. Negotiated Rate	$342.55
Rate for Payer: Aetna Commercial	$19.28
Rate for Payer: Aetna Medicare	$27.56
Rate for Payer: Amerigroup CHIP/Medicaid	$7.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18.37
Rate for Payer: Amerigroup Medicare	$18.37
Rate for Payer: BCBS of TX Blue Advantage	$30.31
Rate for Payer: BCBS of TX Blue Essentials	$36.37
Rate for Payer: BCBS of TX Medicare	$18.37
Rate for Payer: BCBS of TX PPO	$40.60
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Medicaid	$18.37
Rate for Payer: Cigna Medicare	$18.37
Rate for Payer: Employer Direct Commercial	$18.37
Rate for Payer: Humana Medicare/TRICARE	$18.37
Rate for Payer: Molina CHIP/Medicaid	$18.37
Rate for Payer: Molina Dual Medicare/Medicaid	$18.37
Rate for Payer: Molina Medicare	$18.37
Rate for Payer: Multiplan Auto	$342.55
Rate for Payer: Multiplan Commercial	$342.55
Rate for Payer: Multiplan Workers Comp	$342.55
Rate for Payer: Parkland Medicaid	$18.37
Rate for Payer: Scott and White EPO/PPO	$22.96
Rate for Payer: Scott and White Medicare	$18.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18.37
Rate for Payer: Superior Health Plan EPO	$18.37
Rate for Payer: Superior Health Plan Medicare	$18.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$18.37
Rate for Payer: Universal American Medicare	$18.37
Rate for Payer: Wellcare Medicare	$18.37
Rate for Payer: Wellmed Medicare	$18.37

Hepatic Function Panel

Facility

$606.00

Service Code	CPT 80076
Hospital Charge Code	1603174
Hospital Revenue Code	301
Rate for Payer: Cash Price	$533.28

Hepatic Function Panel

Facility

$606.00

Service Code	CPT 80076
Hospital Charge Code	1603174
Hospital Revenue Code	301
Min. Negotiated Rate	$3.19
Max. Negotiated Rate	$393.90
Rate for Payer: Aetna Commercial	$8.58
Rate for Payer: Aetna Medicare	$12.26
Rate for Payer: Amerigroup CHIP/Medicaid	$3.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.17
Rate for Payer: Amerigroup Medicare	$8.17
Rate for Payer: BCBS of TX Blue Advantage	$13.48
Rate for Payer: BCBS of TX Blue Essentials	$16.18
Rate for Payer: BCBS of TX Medicare	$8.17
Rate for Payer: BCBS of TX PPO	$18.06
Rate for Payer: Cash Price	$533.28
Rate for Payer: Cash Price	$533.28
Rate for Payer: Cigna Medicaid	$8.17
Rate for Payer: Cigna Medicare	$8.17
Rate for Payer: Employer Direct Commercial	$8.17
Rate for Payer: Humana Medicare/TRICARE	$8.17
Rate for Payer: Molina CHIP/Medicaid	$8.17
Rate for Payer: Molina Dual Medicare/Medicaid	$8.17
Rate for Payer: Molina Medicare	$8.17
Rate for Payer: Multiplan Auto	$393.90
Rate for Payer: Multiplan Commercial	$393.90
Rate for Payer: Multiplan Workers Comp	$393.90
Rate for Payer: Parkland Medicaid	$8.17
Rate for Payer: Scott and White EPO/PPO	$10.21
Rate for Payer: Scott and White Medicare	$8.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.17
Rate for Payer: Superior Health Plan EPO	$8.17
Rate for Payer: Superior Health Plan Medicare	$8.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.17
Rate for Payer: Universal American Medicare	$8.17
Rate for Payer: Wellcare Medicare	$8.17
Rate for Payer: Wellmed Medicare	$8.17

Hepatitis A Antibody IgM

Facility

$210.00

Service Code	CPT 86709
Hospital Charge Code	1600865
Hospital Revenue Code	300
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$136.50
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: Aetna Medicare	$16.89
Rate for Payer: Amerigroup CHIP/Medicaid	$4.39
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.26
Rate for Payer: Amerigroup Medicare	$11.26
Rate for Payer: BCBS of TX Blue Advantage	$18.58
Rate for Payer: BCBS of TX Blue Essentials	$22.29
Rate for Payer: BCBS of TX Medicare	$11.26
Rate for Payer: BCBS of TX PPO	$24.88
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cigna Medicaid	$11.26
Rate for Payer: Cigna Medicare	$11.26
Rate for Payer: Employer Direct Commercial	$11.26
Rate for Payer: Humana Medicare/TRICARE	$11.26
Rate for Payer: Molina CHIP/Medicaid	$11.26
Rate for Payer: Molina Dual Medicare/Medicaid	$11.26
Rate for Payer: Molina Medicare	$11.26
Rate for Payer: Multiplan Auto	$136.50
Rate for Payer: Multiplan Commercial	$136.50
Rate for Payer: Multiplan Workers Comp	$136.50
Rate for Payer: Parkland Medicaid	$11.26
Rate for Payer: Scott and White EPO/PPO	$14.08
Rate for Payer: Scott and White Medicare	$11.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.26
Rate for Payer: Superior Health Plan EPO	$11.26
Rate for Payer: Superior Health Plan Medicare	$11.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.26
Rate for Payer: Universal American Medicare	$11.26
Rate for Payer: Wellcare Medicare	$11.26
Rate for Payer: Wellmed Medicare	$11.26

Know your out-of-pocket cost for care.

All Charges