White Rock Medical Center

All Charges

Charge

Type

Setting

Price

sodium chloride 0.9% Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS A4216
Hospital Charge Code	77817000
Hospital Revenue Code	272
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.64
Rate for Payer: BCBS of TX Blue Essentials	$0.77
Rate for Payer: BCBS of TX PPO	$0.85
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	$0.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

sodium chloride 0.9% Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS A4216
Hospital Charge Code	77817385
Hospital Revenue Code	272
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.64
Rate for Payer: BCBS of TX Blue Essentials	$0.77
Rate for Payer: BCBS of TX PPO	$0.85
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	$0.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

sodium chloride 0.9% Inj Soln 5 mL

Facility

$128.17

Service Code	HCPCS A4216
Hospital Charge Code	77817385
Hospital Revenue Code	272
Rate for Payer: Cash Price	$87.16

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	$92.28
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: 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

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	$92.28
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: 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

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	$92.28
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: 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

Sodium Chloride 0.9% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7030
Hospital Charge Code	77339981
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Sodium Chloride 0.9% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7030
Hospital Charge Code	77339981
Hospital Revenue Code	258
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$21.61
Rate for Payer: BCBS of TX Blue Essentials	$25.93
Rate for Payer: BCBS of TX PPO	$28.76
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	$3.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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 100 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339761
Hospital Revenue Code	258
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$92.28
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: 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	$1.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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 250 mL

Facility

$128.17

Service Code	HCPCS J7040
Hospital Charge Code	77339871
Hospital Revenue Code	258
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$92.28
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: 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	$1.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$92.28
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: 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	$1.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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	$10.80
Max. Negotiated Rate	$92.28
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: 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

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 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	$92.28
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: 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

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	$92.28
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: 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

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
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
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: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
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: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

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

Know your out-of-pocket cost for care.

All Charges