White Rock Medical Center

All Charges

Charge

Type

Setting

Price

sodium chloride 0.65% Nasal Spray 45 mL

Facility

$9.35

Service Code	HCPCS J3490
Hospital Charge Code	77816570
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$6.08
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.80
Rate for Payer: BCBS of TX Blue Essentials	$3.37
Rate for Payer: BCBS of TX PPO	$3.74
Rate for Payer: Cash Price	$6.36
Rate for Payer: Multiplan Auto	$6.08
Rate for Payer: Multiplan Commercial	$6.08
Rate for Payer: Multiplan Workers Comp	$6.08
Rate for Payer: Scott and White EPO/PPO	$4.68
Rate for Payer: Superior Health Plan EPO	$1.27

sodium chloride 0.65% Nasal Spray 45 mL

Facility

$9.35

Service Code	HCPCS J3490
Hospital Charge Code	77816570
Hospital Revenue Code	250
Rate for Payer: Cash Price	$6.36

sodium chloride 0.9% Irrigation Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77817548
Hospital Revenue Code	258
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
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

sodium chloride 0.9% Irrigation Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77817548
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

sodium chloride 0.9% Irrigation Soln 3000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77817821
Hospital Revenue Code	258
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
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

sodium chloride 0.9% Irrigation Soln 3000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77817821
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

sodium chloride 0.9% Irrigation Soln 500 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77817931
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

sodium chloride 0.9% Irrigation Soln 500 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77817931
Hospital Revenue Code	258
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
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

Sodium Chloride 0.9% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339981
Hospital Revenue Code	258
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.80
Rate for Payer: BCBS of TX Blue Essentials	$12.96
Rate for Payer: BCBS of TX PPO	$14.38
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

Sodium Chloride 0.9% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339981
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Sodium Chloride 0.9% IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339761
Hospital Revenue Code	258
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.80
Rate for Payer: BCBS of TX Blue Essentials	$12.96
Rate for Payer: BCBS of TX PPO	$14.38
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

Sodium Chloride 0.9% IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339761
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Sodium Chloride 0.9% IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339871
Hospital Revenue Code	258
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.80
Rate for Payer: BCBS of TX Blue Essentials	$12.96
Rate for Payer: BCBS of TX PPO	$14.38
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

Sodium Chloride 0.9% IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339871
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Sodium Chloride 0.9% IV Soln 25 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339651
Hospital Revenue Code	258
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.80
Rate for Payer: BCBS of TX Blue Essentials	$12.96
Rate for Payer: BCBS of TX PPO	$14.38
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

Sodium Chloride 0.9% IV Soln 25 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339651
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Sodium Chloride 0.9% IV Soln 500 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339926
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

Sodium Chloride 0.9% IV Soln 500 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339926
Hospital Revenue Code	636
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.80
Rate for Payer: BCBS of TX Blue Essentials	$12.96
Rate for Payer: BCBS of TX PPO	$14.38
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

Sodium Chloride 0.9% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339706
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

Sodium Chloride 0.9% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339706
Hospital Revenue Code	636
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.80
Rate for Payer: BCBS of TX Blue Essentials	$12.96
Rate for Payer: BCBS of TX PPO	$14.38
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

Sodium Chloride 0.9% with KCl 20 mEq/L IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77336694
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
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

Sodium Chloride 0.9% with KCl 20 mEq/L IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77336694
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

sodium chloride 1000 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77818200
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

sodium chloride 1000 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77818200
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.20
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan EPO	$1.09

sodium ferric gluconate complex 12.5 mg/mL IV Soln 5 mL

Facility

$128.19

Service Code	HCPCS J2916
Hospital Charge Code	77820216
Hospital Revenue Code	636
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$83.32
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$2.32
Rate for Payer: BCBS of TX Blue Essentials	$2.78
Rate for Payer: BCBS of TX PPO	$3.09
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cash Price	$87.17
Rate for Payer: Multiplan Auto	$83.32
Rate for Payer: Multiplan Commercial	$83.32
Rate for Payer: Multiplan Workers Comp	$83.32
Rate for Payer: Scott and White EPO/PPO	$64.10
Rate for Payer: Superior Health Plan EPO	$17.43

Know your out-of-pocket cost for care.

All Charges