White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION

Facility

$5,255.00

Service Code	APR-DRG 8103
Min. Negotiated Rate	$4,954.60
Max. Negotiated Rate	$5,255.00
Rate for Payer: Amerigroup CHIP/Medicaid	$4,954.60
Rate for Payer: Cigna Medicaid	$4,954.60
Rate for Payer: Molina CHIP/Medicaid	$4,954.60
Rate for Payer: Parkland Medicaid	$4,954.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,255.00

HEMOSTAT, ABSORBABLE 4' X 4 STERILE -- DHF

Facility

$530.59

Hospital Charge Code	81845000
Hospital Revenue Code	270
Rate for Payer: Cash Price	$360.80

HEMOSTAT, ABSORBABLE 4' X 4 STERILE -- DHF

Facility

$530.59

Hospital Charge Code	81845000
Hospital Revenue Code	270
Min. Negotiated Rate	$47.75
Max. Negotiated Rate	$382.02
Rate for Payer: Amerigroup CHIP/Medicaid	$47.75
Rate for Payer: BCBS of TX Blue Advantage	$159.18
Rate for Payer: BCBS of TX Blue Essentials	$191.01
Rate for Payer: BCBS of TX PPO	$212.24
Rate for Payer: Cash Price	$360.80
Rate for Payer: Cigna Medicaid	$382.02
Rate for Payer: Molina CHIP/Medicaid	$382.02
Rate for Payer: Multiplan Auto	$344.88
Rate for Payer: Multiplan Commercial	$344.88
Rate for Payer: Multiplan Workers Comp	$344.88
Rate for Payer: Parkland Medicaid	$382.02
Rate for Payer: Scott and White EPO/PPO	$265.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$382.02
Rate for Payer: Superior Health Plan EPO	$72.16

HEMOSTAT, ABSORBABLE SURG NON-WOVEN MATERIAL 1'X2 -- DHF

Facility

$209.72

Hospital Charge Code	80324296
Hospital Revenue Code	272
Rate for Payer: Cash Price	$142.61

HEMOSTAT, ABSORBABLE SURG NON-WOVEN MATERIAL 1'X2 -- DHF

Facility

$209.72

Hospital Charge Code	80324296
Hospital Revenue Code	272
Min. Negotiated Rate	$18.87
Max. Negotiated Rate	$151.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.87
Rate for Payer: BCBS of TX Blue Advantage	$62.92
Rate for Payer: BCBS of TX Blue Essentials	$75.50
Rate for Payer: BCBS of TX PPO	$83.89
Rate for Payer: Cash Price	$142.61
Rate for Payer: Cigna Medicaid	$151.00
Rate for Payer: Molina CHIP/Medicaid	$151.00
Rate for Payer: Multiplan Auto	$136.32
Rate for Payer: Multiplan Commercial	$136.32
Rate for Payer: Multiplan Workers Comp	$136.32
Rate for Payer: Parkland Medicaid	$151.00
Rate for Payer: Scott and White EPO/PPO	$104.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.00
Rate for Payer: Superior Health Plan EPO	$28.52

HEMOSTAT, ABSORBBLE, SURGICEL STRL, 4X8

Facility

$429.18

Service Code	NDC 63713001952
Hospital Charge Code	992308
Hospital Revenue Code	272
Rate for Payer: Cash Price	$291.84

HEMOSTAT, ABSORBBLE, SURGICEL STRL, 4X8

Facility

$429.18

Service Code	NDC 63713001952
Hospital Charge Code	992308
Hospital Revenue Code	272
Min. Negotiated Rate	$38.63
Max. Negotiated Rate	$309.01
Rate for Payer: Amerigroup CHIP/Medicaid	$38.63
Rate for Payer: BCBS of TX Blue Advantage	$128.75
Rate for Payer: BCBS of TX Blue Essentials	$154.50
Rate for Payer: BCBS of TX PPO	$171.67
Rate for Payer: Cash Price	$291.84
Rate for Payer: Cigna Medicaid	$309.01
Rate for Payer: Molina CHIP/Medicaid	$309.01
Rate for Payer: Multiplan Auto	$278.97
Rate for Payer: Multiplan Commercial	$278.97
Rate for Payer: Multiplan Workers Comp	$278.97
Rate for Payer: Parkland Medicaid	$309.01
Rate for Payer: Scott and White EPO/PPO	$214.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$309.01
Rate for Payer: Superior Health Plan EPO	$58.37

HEMOSTAT, ABSORB, SURGICEL FIBERILLAR, 1X2

Facility

$332.89

Hospital Charge Code	992307
Hospital Revenue Code	272
Rate for Payer: Cash Price	$226.37

HEMOSTAT, ABSORB, SURGICEL FIBERILLAR, 1X2

Facility

$332.89

Hospital Charge Code	992307
Hospital Revenue Code	272
Min. Negotiated Rate	$29.96
Max. Negotiated Rate	$239.68
Rate for Payer: Amerigroup CHIP/Medicaid	$29.96
Rate for Payer: BCBS of TX Blue Advantage	$99.87
Rate for Payer: BCBS of TX Blue Essentials	$119.84
Rate for Payer: BCBS of TX PPO	$133.16
Rate for Payer: Cash Price	$226.37
Rate for Payer: Cigna Medicaid	$239.68
Rate for Payer: Molina CHIP/Medicaid	$239.68
Rate for Payer: Multiplan Auto	$216.38
Rate for Payer: Multiplan Commercial	$216.38
Rate for Payer: Multiplan Workers Comp	$216.38
Rate for Payer: Parkland Medicaid	$239.68
Rate for Payer: Scott and White EPO/PPO	$166.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$239.68
Rate for Payer: Superior Health Plan EPO	$45.27

HEMOSTAT, ABSRBALE, SURGICEL STRL, 2X3

Facility

$238.40

Hospital Charge Code	992309
Hospital Revenue Code	272
Min. Negotiated Rate	$21.46
Max. Negotiated Rate	$171.65
Rate for Payer: Amerigroup CHIP/Medicaid	$21.46
Rate for Payer: BCBS of TX Blue Advantage	$71.52
Rate for Payer: BCBS of TX Blue Essentials	$85.82
Rate for Payer: BCBS of TX PPO	$95.36
Rate for Payer: Cash Price	$162.11
Rate for Payer: Cigna Medicaid	$171.65
Rate for Payer: Molina CHIP/Medicaid	$171.65
Rate for Payer: Multiplan Auto	$154.96
Rate for Payer: Multiplan Commercial	$154.96
Rate for Payer: Multiplan Workers Comp	$154.96
Rate for Payer: Parkland Medicaid	$171.65
Rate for Payer: Scott and White EPO/PPO	$119.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$171.65
Rate for Payer: Superior Health Plan EPO	$32.42

HEMOSTAT, ABSRBALE, SURGICEL STRL, 2X3

Facility

$238.40

Hospital Charge Code	992309
Hospital Revenue Code	272
Rate for Payer: Cash Price	$162.11

HEMOSTATIC SPONGE SURGIFORM

Facility

$82.85

Hospital Charge Code	8510470
Hospital Revenue Code	272
Rate for Payer: Cash Price	$56.34

HEMOSTATIC SPONGE SURGIFORM

Facility

$82.85

Hospital Charge Code	8510470
Hospital Revenue Code	272
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$59.65
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	$56.34
Rate for Payer: Cigna Medicaid	$59.65
Rate for Payer: Molina CHIP/Medicaid	$59.65
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: Parkland Medicaid	$59.65
Rate for Payer: Scott and White EPO/PPO	$41.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59.65
Rate for Payer: Superior Health Plan EPO	$11.27

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	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

Facility

$128.00

Service Code	HCPCS J1644
Hospital Charge Code	77603222
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
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	$87.04
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	$0.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

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

$128.00

Service Code	HCPCS J1644
Hospital Charge Code	77603222
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

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

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77603221
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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	$0.20
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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	77603221
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 0.9% IV Soln 250 mL Premix

Facility

$128.17

Service Code	HCPCS J1644
Hospital Charge Code	77603166
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

heparin 25,000 units/NaCl 0.9% IV Soln 250 mL Premix

Facility

$128.00

Service Code	HCPCS J1644
Hospital Charge Code	7660322
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

Know your out-of-pocket cost for care.

All Charges