White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

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	$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	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

heparin 25,000 units/NaCl 09% IV Soln 250 mL Premix

Facility

$128.00

Service Code	HCPCS J1644
Hospital Charge Code	776322
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

heparin 25,000 units/NaCl 09% IV Soln 250 mL Premix

Facility

$128.00

Service Code	HCPCS J1644
Hospital Charge Code	776322
Hospital Revenue Code	636
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	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

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 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	$92.28
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: 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 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	$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 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 Anti-Xa SO

Facility

$284.00

Service Code	HCPCS 85520
Hospital Charge Code	1739622
Hospital Revenue Code	300
Min. Negotiated Rate	$5.11
Max. Negotiated Rate	$204.48
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	$85.20
Rate for Payer: BCBS of TX Blue Essentials	$102.24
Rate for Payer: BCBS of TX Medicare	$13.09
Rate for Payer: BCBS of TX PPO	$113.60
Rate for Payer: Cash Price	$193.12
Rate for Payer: Cash Price	$193.12
Rate for Payer: Cigna Medicaid	$204.48
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	$204.48
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	$204.48
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	$204.48
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 Anti-Xa SO

Facility

$284.00

Service Code	HCPCS 85520
Hospital Charge Code	1739622
Hospital Revenue Code	300
Rate for Payer: Cash Price	$193.12

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	$92.28
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: 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 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

HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS

Facility

$4,597.18

Service Code	APR-DRG 2793
Min. Negotiated Rate	$4,334.38
Max. Negotiated Rate	$4,597.18
Rate for Payer: Amerigroup CHIP/Medicaid	$4,334.38
Rate for Payer: Cigna Medicaid	$4,334.38
Rate for Payer: Molina CHIP/Medicaid	$4,334.38
Rate for Payer: Parkland Medicaid	$4,334.38
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,597.18

HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS

Facility

$13,406.43

Service Code	APR-DRG 2794
Min. Negotiated Rate	$12,640.05
Max. Negotiated Rate	$13,406.43
Rate for Payer: Amerigroup CHIP/Medicaid	$12,640.05
Rate for Payer: Cigna Medicaid	$12,640.05
Rate for Payer: Molina CHIP/Medicaid	$12,640.05
Rate for Payer: Parkland Medicaid	$12,640.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,406.43

HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS

Facility

$2,248.05

Service Code	APR-DRG 2791
Min. Negotiated Rate	$2,119.54
Max. Negotiated Rate	$2,248.05
Rate for Payer: Amerigroup CHIP/Medicaid	$2,119.54
Rate for Payer: Cigna Medicaid	$2,119.54
Rate for Payer: Molina CHIP/Medicaid	$2,119.54
Rate for Payer: Parkland Medicaid	$2,119.54
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,248.05

HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS

Facility

$3,368.67

Service Code	APR-DRG 2792
Min. Negotiated Rate	$3,176.10
Max. Negotiated Rate	$3,368.67
Rate for Payer: Amerigroup CHIP/Medicaid	$3,176.10
Rate for Payer: Cigna Medicaid	$3,176.10
Rate for Payer: Molina CHIP/Medicaid	$3,176.10
Rate for Payer: Parkland Medicaid	$3,176.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,368.67

Hepatic Function Panel

Facility

$606.00

Service Code	HCPCS 80076
Hospital Charge Code	1603174
Hospital Revenue Code	301
Rate for Payer: Cash Price	$412.08

Hepatic Function Panel

Facility

$606.00

Service Code	HCPCS 80076
Hospital Charge Code	1603174
Hospital Revenue Code	301
Min. Negotiated Rate	$3.19
Max. Negotiated Rate	$436.32
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	$181.80
Rate for Payer: BCBS of TX Blue Essentials	$218.16
Rate for Payer: BCBS of TX Medicare	$8.17
Rate for Payer: BCBS of TX PPO	$242.40
Rate for Payer: Cash Price	$412.08
Rate for Payer: Cash Price	$412.08
Rate for Payer: Cigna Medicaid	$436.32
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	$436.32
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	$436.32
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	$436.32
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	HCPCS 86709
Hospital Charge Code	1600865
Hospital Revenue Code	300
Rate for Payer: Cash Price	$142.80

Hepatitis A Antibody IgM

Facility

$210.00

Service Code	HCPCS 86709
Hospital Charge Code	1600865
Hospital Revenue Code	300
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$151.20
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	$63.00
Rate for Payer: BCBS of TX Blue Essentials	$75.60
Rate for Payer: BCBS of TX Medicare	$11.26
Rate for Payer: BCBS of TX PPO	$84.00
Rate for Payer: Cash Price	$142.80
Rate for Payer: Cash Price	$142.80
Rate for Payer: Cigna Medicaid	$151.20
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	$151.20
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	$151.20
Rate for Payer: Scott and White EPO/PPO	$14.07
Rate for Payer: Scott and White Medicare	$11.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.20
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

Hepatitis B Core Antibody IgM

Facility

$326.00

Service Code	HCPCS 86705
Hospital Charge Code	1600873
Hospital Revenue Code	302
Rate for Payer: Cash Price	$221.68

Hepatitis B Core Antibody IgM

Facility

$326.00

Service Code	HCPCS 86705
Hospital Charge Code	1600873
Hospital Revenue Code	302
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$234.72
Rate for Payer: Amerigroup CHIP/Medicaid	$4.59
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11.77
Rate for Payer: Amerigroup Medicare	$11.77
Rate for Payer: BCBS of TX Blue Advantage	$97.80
Rate for Payer: BCBS of TX Blue Essentials	$117.36
Rate for Payer: BCBS of TX Medicare	$11.77
Rate for Payer: BCBS of TX PPO	$130.40
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cash Price	$221.68
Rate for Payer: Cigna Medicaid	$234.72
Rate for Payer: Cigna Medicare	$11.77
Rate for Payer: Employer Direct Commercial	$11.77
Rate for Payer: Humana Medicare/TRICARE	$11.77
Rate for Payer: Molina CHIP/Medicaid	$234.72
Rate for Payer: Molina Dual Medicare/Medicaid	$11.77
Rate for Payer: Molina Medicare	$11.77
Rate for Payer: Multiplan Auto	$211.90
Rate for Payer: Multiplan Commercial	$211.90
Rate for Payer: Multiplan Workers Comp	$211.90
Rate for Payer: Parkland Medicaid	$234.72
Rate for Payer: Scott and White EPO/PPO	$14.71
Rate for Payer: Scott and White Medicare	$11.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$234.72
Rate for Payer: Superior Health Plan EPO	$11.77
Rate for Payer: Superior Health Plan Medicare	$11.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$11.77
Rate for Payer: Universal American Medicare	$11.77
Rate for Payer: Wellcare Medicare	$11.77
Rate for Payer: Wellmed Medicare	$11.77

Hepatitis B Surf Ab Quant SO

Facility

$117.00

Service Code	HCPCS 86317
Hospital Charge Code	1703156
Hospital Revenue Code	302
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$84.24
Rate for Payer: Amerigroup CHIP/Medicaid	$5.85
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.99
Rate for Payer: Amerigroup Medicare	$14.99
Rate for Payer: BCBS of TX Blue Advantage	$35.10
Rate for Payer: BCBS of TX Blue Essentials	$42.12
Rate for Payer: BCBS of TX Medicare	$14.99
Rate for Payer: BCBS of TX PPO	$46.80
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cash Price	$79.56
Rate for Payer: Cigna Medicaid	$84.24
Rate for Payer: Cigna Medicare	$14.99
Rate for Payer: Employer Direct Commercial	$14.99
Rate for Payer: Humana Medicare/TRICARE	$14.99
Rate for Payer: Molina CHIP/Medicaid	$84.24
Rate for Payer: Molina Dual Medicare/Medicaid	$14.99
Rate for Payer: Molina Medicare	$14.99
Rate for Payer: Multiplan Auto	$76.05
Rate for Payer: Multiplan Commercial	$76.05
Rate for Payer: Multiplan Workers Comp	$76.05
Rate for Payer: Parkland Medicaid	$84.24
Rate for Payer: Scott and White EPO/PPO	$18.74
Rate for Payer: Scott and White Medicare	$14.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$84.24
Rate for Payer: Superior Health Plan EPO	$14.99
Rate for Payer: Superior Health Plan Medicare	$14.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.99
Rate for Payer: Universal American Medicare	$14.99
Rate for Payer: Wellcare Medicare	$14.99
Rate for Payer: Wellmed Medicare	$14.99

Hepatitis B Surf Ab Quant SO

Facility

$117.00

Service Code	HCPCS 86317
Hospital Charge Code	1703156
Hospital Revenue Code	302
Rate for Payer: Cash Price	$79.56

Hepatitis B Surface Antibody

Facility

$294.00

Service Code	HCPCS 86706
Hospital Charge Code	1603117
Hospital Revenue Code	302
Rate for Payer: Cash Price	$199.92

Know your out-of-pocket cost for care.

All Charges