White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Sodium chloride 3% inhalation solution

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77818809
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 3% inhalation solution

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77818809
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

Sodium Chloride 3% IV Soln 500 mL

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	77340087
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
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

Sodium Chloride 3% IV Soln 500 mL

Facility

$128.00

Service Code	HCPCS j3490
Hospital Charge Code	77340087
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

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	$92.30
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: Cigna Medicaid	$92.30
Rate for Payer: Molina CHIP/Medicaid	$92.30
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: Parkland Medicaid	$92.30
Rate for Payer: Scott and White EPO/PPO	$64.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.30
Rate for Payer: Superior Health Plan EPO	$17.43

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	$32.05
Max. Negotiated Rate	$64.09
Rate for Payer: Cash Price	$87.17
Rate for Payer: Cigna Commercial	$32.05
Rate for Payer: Scott and White EPO/PPO	$64.09

sodium hypochlorite 0.25% Topical Soln 473 mL

Facility

$39.50

Service Code	HCPCS J3490
Hospital Charge Code	77822015
Hospital Revenue Code	250
Rate for Payer: Cash Price	$26.86

sodium hypochlorite 0.25% Topical Soln 473 mL

Facility

$39.50

Service Code	HCPCS J3490
Hospital Charge Code	77822015
Hospital Revenue Code	250
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$28.44
Rate for Payer: Amerigroup CHIP/Medicaid	$3.56
Rate for Payer: BCBS of TX Blue Advantage	$11.85
Rate for Payer: BCBS of TX Blue Essentials	$14.22
Rate for Payer: BCBS of TX PPO	$15.80
Rate for Payer: Cash Price	$26.86
Rate for Payer: Cigna Medicaid	$28.44
Rate for Payer: Molina CHIP/Medicaid	$28.44
Rate for Payer: Multiplan Auto	$25.68
Rate for Payer: Multiplan Commercial	$25.68
Rate for Payer: Multiplan Workers Comp	$25.68
Rate for Payer: Parkland Medicaid	$28.44
Rate for Payer: Scott and White EPO/PPO	$19.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.44
Rate for Payer: Superior Health Plan EPO	$5.37

sodium hypochlorite 0.5% Topical Soln 473 mL

Facility

$39.50

Service Code	HCPCS J3490
Hospital Charge Code	77822068.5
Hospital Revenue Code	250
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$28.44
Rate for Payer: Amerigroup CHIP/Medicaid	$3.56
Rate for Payer: BCBS of TX Blue Advantage	$11.85
Rate for Payer: BCBS of TX Blue Essentials	$14.22
Rate for Payer: BCBS of TX PPO	$15.80
Rate for Payer: Cash Price	$26.86
Rate for Payer: Cigna Medicaid	$28.44
Rate for Payer: Molina CHIP/Medicaid	$28.44
Rate for Payer: Multiplan Auto	$25.68
Rate for Payer: Multiplan Commercial	$25.68
Rate for Payer: Multiplan Workers Comp	$25.68
Rate for Payer: Parkland Medicaid	$28.44
Rate for Payer: Scott and White EPO/PPO	$19.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.44
Rate for Payer: Superior Health Plan EPO	$5.37

sodium hypochlorite 0.5% Topical Soln 473 mL

Facility

$39.50

Service Code	HCPCS J3490
Hospital Charge Code	77822068
Hospital Revenue Code	250
Rate for Payer: Cash Price	$26.86

sodium hypochlorite 0.5% Topical Soln 473 mL

Facility

$39.50

Service Code	HCPCS J3490
Hospital Charge Code	77822068.5
Hospital Revenue Code	250
Rate for Payer: Cash Price	$26.86

sodium hypochlorite 0.5% Topical Soln 473 mL

Facility

$39.50

Service Code	HCPCS J3490
Hospital Charge Code	77822068
Hospital Revenue Code	250
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$28.44
Rate for Payer: Amerigroup CHIP/Medicaid	$3.56
Rate for Payer: BCBS of TX Blue Advantage	$11.85
Rate for Payer: BCBS of TX Blue Essentials	$14.22
Rate for Payer: BCBS of TX PPO	$15.80
Rate for Payer: Cash Price	$26.86
Rate for Payer: Cigna Medicaid	$28.44
Rate for Payer: Molina CHIP/Medicaid	$28.44
Rate for Payer: Multiplan Auto	$25.68
Rate for Payer: Multiplan Commercial	$25.68
Rate for Payer: Multiplan Workers Comp	$25.68
Rate for Payer: Parkland Medicaid	$28.44
Rate for Payer: Scott and White EPO/PPO	$19.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.44
Rate for Payer: Superior Health Plan EPO	$5.37

Sodium Level

Facility

$172.00

Service Code	HCPCS 84295
Hospital Charge Code	1602234
Hospital Revenue Code	301
Rate for Payer: Cash Price	$116.96

Sodium Level

Facility

$172.00

Service Code	HCPCS 84295
Hospital Charge Code	1602234
Hospital Revenue Code	301
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$123.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.81
Rate for Payer: Amerigroup Medicare	$4.81
Rate for Payer: BCBS of TX Blue Advantage	$51.60
Rate for Payer: BCBS of TX Blue Essentials	$61.92
Rate for Payer: BCBS of TX Medicare	$4.81
Rate for Payer: BCBS of TX PPO	$68.80
Rate for Payer: Cash Price	$116.96
Rate for Payer: Cash Price	$116.96
Rate for Payer: Cigna Medicaid	$123.84
Rate for Payer: Cigna Medicare	$4.81
Rate for Payer: Employer Direct Commercial	$4.81
Rate for Payer: Humana Medicare/TRICARE	$4.81
Rate for Payer: Molina CHIP/Medicaid	$123.84
Rate for Payer: Molina Dual Medicare/Medicaid	$4.81
Rate for Payer: Molina Medicare	$4.81
Rate for Payer: Multiplan Auto	$111.80
Rate for Payer: Multiplan Commercial	$111.80
Rate for Payer: Multiplan Workers Comp	$111.80
Rate for Payer: Parkland Medicaid	$123.84
Rate for Payer: Scott and White EPO/PPO	$6.01
Rate for Payer: Scott and White Medicare	$4.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$123.84
Rate for Payer: Superior Health Plan EPO	$4.81
Rate for Payer: Superior Health Plan Medicare	$4.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.81
Rate for Payer: Universal American Medicare	$4.81
Rate for Payer: Wellcare Medicare	$4.81
Rate for Payer: Wellmed Medicare	$4.81

Sodium Level 24 Hour Urine

Facility

$162.00

Service Code	HCPCS 84300
Hospital Charge Code	1601111
Hospital Revenue Code	301
Rate for Payer: Cash Price	$110.16

Sodium Level 24 Hour Urine

Facility

$162.00

Service Code	HCPCS 84300
Hospital Charge Code	1601111
Hospital Revenue Code	301
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$116.64
Rate for Payer: Amerigroup CHIP/Medicaid	$1.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.06
Rate for Payer: Amerigroup Medicare	$5.06
Rate for Payer: BCBS of TX Blue Advantage	$48.60
Rate for Payer: BCBS of TX Blue Essentials	$58.32
Rate for Payer: BCBS of TX Medicare	$5.06
Rate for Payer: BCBS of TX PPO	$64.80
Rate for Payer: Cash Price	$110.16
Rate for Payer: Cash Price	$110.16
Rate for Payer: Cigna Medicaid	$116.64
Rate for Payer: Cigna Medicare	$5.06
Rate for Payer: Employer Direct Commercial	$5.06
Rate for Payer: Humana Medicare/TRICARE	$5.06
Rate for Payer: Molina CHIP/Medicaid	$116.64
Rate for Payer: Molina Dual Medicare/Medicaid	$5.06
Rate for Payer: Molina Medicare	$5.06
Rate for Payer: Multiplan Auto	$105.30
Rate for Payer: Multiplan Commercial	$105.30
Rate for Payer: Multiplan Workers Comp	$105.30
Rate for Payer: Parkland Medicaid	$116.64
Rate for Payer: Scott and White EPO/PPO	$6.33
Rate for Payer: Scott and White Medicare	$5.06
Rate for Payer: Superior Health Plan CHIP/Medicaid	$116.64
Rate for Payer: Superior Health Plan EPO	$5.06
Rate for Payer: Superior Health Plan Medicare	$5.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.06
Rate for Payer: Universal American Medicare	$5.06
Rate for Payer: Wellcare Medicare	$5.06
Rate for Payer: Wellmed Medicare	$5.06

sodium polystyrene sulfonate 15 g/60 mL Oral Susp 60 mL

Facility

$51.60

Service Code	HCPCS J3490
Hospital Charge Code	77823134
Hospital Revenue Code	250
Min. Negotiated Rate	$4.64
Max. Negotiated Rate	$37.15
Rate for Payer: Amerigroup CHIP/Medicaid	$4.64
Rate for Payer: BCBS of TX Blue Advantage	$15.48
Rate for Payer: BCBS of TX Blue Essentials	$18.58
Rate for Payer: BCBS of TX PPO	$20.64
Rate for Payer: Cash Price	$35.09
Rate for Payer: Cigna Medicaid	$37.15
Rate for Payer: Molina CHIP/Medicaid	$37.15
Rate for Payer: Multiplan Auto	$33.54
Rate for Payer: Multiplan Commercial	$33.54
Rate for Payer: Multiplan Workers Comp	$33.54
Rate for Payer: Parkland Medicaid	$37.15
Rate for Payer: Scott and White EPO/PPO	$25.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.15
Rate for Payer: Superior Health Plan EPO	$7.02

sodium polystyrene sulfonate 15 g/60 mL Oral Susp 60 mL

Facility

$51.60

Service Code	HCPCS J3490
Hospital Charge Code	77823134
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.09

sodium zirconium cyclosilicate ORAL POWD PACK 10 G

Facility

$58.92

Service Code	HCPCS J3490
Hospital Charge Code	78364593
Hospital Revenue Code	250
Min. Negotiated Rate	$5.30
Max. Negotiated Rate	$42.42
Rate for Payer: Amerigroup CHIP/Medicaid	$5.30
Rate for Payer: BCBS of TX Blue Advantage	$17.68
Rate for Payer: BCBS of TX Blue Essentials	$21.21
Rate for Payer: BCBS of TX PPO	$23.57
Rate for Payer: Cash Price	$40.07
Rate for Payer: Cigna Medicaid	$42.42
Rate for Payer: Molina CHIP/Medicaid	$42.42
Rate for Payer: Multiplan Auto	$38.30
Rate for Payer: Multiplan Commercial	$38.30
Rate for Payer: Multiplan Workers Comp	$38.30
Rate for Payer: Parkland Medicaid	$42.42
Rate for Payer: Scott and White EPO/PPO	$29.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$42.42
Rate for Payer: Superior Health Plan EPO	$8.01

sodium zirconium cyclosilicate ORAL POWD PACK 10 G

Facility

$58.92

Service Code	HCPCS J3490
Hospital Charge Code	78364593
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.07

SOFIA INFLUENZA A & B TEST KIT CLIA WALVED 25/BX

Facility

$727.76

Hospital Charge Code	993712
Hospital Revenue Code	270
Rate for Payer: Cash Price	$494.88

SOFIA INFLUENZA A & B TEST KIT CLIA WALVED 25/BX

Facility

$727.76

Hospital Charge Code	993712
Hospital Revenue Code	270
Min. Negotiated Rate	$65.50
Max. Negotiated Rate	$523.99
Rate for Payer: Amerigroup CHIP/Medicaid	$65.50
Rate for Payer: BCBS of TX Blue Advantage	$218.33
Rate for Payer: BCBS of TX Blue Essentials	$261.99
Rate for Payer: BCBS of TX PPO	$291.10
Rate for Payer: Cash Price	$494.88
Rate for Payer: Cigna Medicaid	$523.99
Rate for Payer: Molina CHIP/Medicaid	$523.99
Rate for Payer: Multiplan Auto	$473.04
Rate for Payer: Multiplan Commercial	$473.04
Rate for Payer: Multiplan Workers Comp	$473.04
Rate for Payer: Parkland Medicaid	$523.99
Rate for Payer: Scott and White EPO/PPO	$363.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$523.99
Rate for Payer: Superior Health Plan EPO	$98.98

SOFT TISSUE PROCEDURES W CC

Facility

$33,398.20

Service Code	MSDRG 501
Min. Negotiated Rate	$14,511.64
Max. Negotiated Rate	$33,398.20
Rate for Payer: BCBS of TX Blue Advantage	$14,511.64
Rate for Payer: BCBS of TX Blue Essentials	$17,412.28
Rate for Payer: BCBS of TX PPO	$19,347.73

SOFT TISSUE PROCEDURES WITH CC

Facility

$33,398.20

Service Code	MSDRG 501
Min. Negotiated Rate	$14,511.64
Max. Negotiated Rate	$33,398.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,571.94
Rate for Payer: Amerigroup Medicare	$17,571.94
Rate for Payer: BCBS of TX Medicare	$17,571.94
Rate for Payer: Cigna Commercial	$22,515.53
Rate for Payer: Cigna Medicare	$17,571.94
Rate for Payer: Employer Direct Commercial	$17,571.94
Rate for Payer: Humana Medicare/TRICARE	$17,571.94
Rate for Payer: Molina Dual Medicare/Medicaid	$17,571.94
Rate for Payer: Molina Medicare	$17,571.94
Rate for Payer: Multiplan Auto	$33,398.20
Rate for Payer: Multiplan Commercial	$33,398.20
Rate for Payer: Multiplan Workers Comp	$33,398.20
Rate for Payer: Scott and White EPO/PPO	$15,380.75
Rate for Payer: Scott and White Medicare	$17,571.94
Rate for Payer: Superior Health Plan EPO	$17,571.94
Rate for Payer: Superior Health Plan Medicare	$17,571.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,571.94
Rate for Payer: Universal American Medicare	$17,571.94
Rate for Payer: Wellcare Medicare	$17,571.94
Rate for Payer: Wellmed Medicare	$17,571.94

SOFT TISSUE PROCEDURES WITH MCC

Facility

$60,885.50

Service Code	MSDRG 500
Min. Negotiated Rate	$26,384.80
Max. Negotiated Rate	$60,885.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$27,954.98
Rate for Payer: Amerigroup Medicare	$27,954.98
Rate for Payer: BCBS of TX Medicare	$27,954.98
Rate for Payer: Cigna Commercial	$40,762.62
Rate for Payer: Cigna Medicare	$27,954.98
Rate for Payer: Employer Direct Commercial	$27,954.98
Rate for Payer: Humana Medicare/TRICARE	$27,954.98
Rate for Payer: Molina Dual Medicare/Medicaid	$27,954.98
Rate for Payer: Molina Medicare	$27,954.98
Rate for Payer: Multiplan Auto	$60,885.50
Rate for Payer: Multiplan Commercial	$60,885.50
Rate for Payer: Multiplan Workers Comp	$60,885.50
Rate for Payer: Scott and White EPO/PPO	$28,039.38
Rate for Payer: Scott and White Medicare	$27,954.98
Rate for Payer: Superior Health Plan EPO	$27,954.98
Rate for Payer: Superior Health Plan Medicare	$27,954.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$27,954.98
Rate for Payer: Universal American Medicare	$27,954.98
Rate for Payer: Wellcare Medicare	$27,954.98
Rate for Payer: Wellmed Medicare	$27,954.98

Know your out-of-pocket cost for care.

All Charges