White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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	$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 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	$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 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% 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% 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 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 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

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
Rate for Payer: Cash Price	$87.04

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 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 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 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
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
Rate for Payer: Cash Price	$26.86

Sodium Level

Facility

$172.00

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

Know your out-of-pocket cost for care.

All Charges