White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SOAP HAND FOAMING SPECTRUM 1000ML

Facility

$56.26

Hospital Charge Code	993274
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.26

sodium bicarbonate 650 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815310
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sodium bicarbonate 650 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815310
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

sodium bicarbonate 8.4% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77815473
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 bicarbonate 8.4% IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77815473
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

sodium biphosphate-sodium phosphate 7 g-19 g Enema 133 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815785
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sodium biphosphate-sodium phosphate 7 g-19 g Enema 133 mL

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77815785
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

Sodium Chloride 0.45% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77339500
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 0.45% IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77339500
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

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	$6.73
Rate for Payer: Amerigroup CHIP/Medicaid	$0.84
Rate for Payer: BCBS of TX Blue Advantage	$2.81
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: Cigna Medicaid	$6.73
Rate for Payer: Molina CHIP/Medicaid	$6.73
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: Parkland Medicaid	$6.73
Rate for Payer: Scott and White EPO/PPO	$4.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.73
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% 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	$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% Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS A4216
Hospital Charge Code	77817000
Hospital Revenue Code	272
Rate for Payer: Cash Price	$87.16

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% 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	$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
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	$11.54
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	$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 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	$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

Know your out-of-pocket cost for care.

All Charges