White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Sodium Level

Facility

$172.00

Service Code	HCPCS 84295 QW
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
Rate for Payer: Cash Price	$40.07

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

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

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

SOFT TISSUE PROCEDURES W CC

Facility

$33,213.90

Service Code	MSDRG 501
Min. Negotiated Rate	$14,511.64
Max. Negotiated Rate	$33,213.90
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

$33,213.90

Service Code	MSDRG 501
Min. Negotiated Rate	$14,511.64
Max. Negotiated Rate	$33,213.90
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	$33,213.90
Rate for Payer: Multiplan Commercial	$33,213.90
Rate for Payer: Multiplan Workers Comp	$33,213.90
Rate for Payer: Scott and White EPO/PPO	$15,295.88
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

$60,131.20

Service Code	MSDRG 500
Min. Negotiated Rate	$26,384.80
Max. Negotiated Rate	$60,131.20
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	$60,131.20
Rate for Payer: Multiplan Commercial	$60,131.20
Rate for Payer: Multiplan Workers Comp	$60,131.20
Rate for Payer: Scott and White EPO/PPO	$27,692.00
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

SOFT TISSUE PROCEDURES WITHOUT CC/MCC

Facility

$25,572.10

Service Code	MSDRG 502
Min. Negotiated Rate	$11,103.46
Max. Negotiated Rate	$25,572.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,624.22
Rate for Payer: Amerigroup Medicare	$14,624.22
Rate for Payer: BCBS of TX Medicare	$14,624.22
Rate for Payer: Cigna Commercial	$17,335.19
Rate for Payer: Cigna Medicare	$14,624.22
Rate for Payer: Employer Direct Commercial	$14,624.22
Rate for Payer: Humana Medicare/TRICARE	$14,624.22
Rate for Payer: Molina Dual Medicare/Medicaid	$14,624.22
Rate for Payer: Molina Medicare	$14,624.22
Rate for Payer: Multiplan Auto	$25,572.10
Rate for Payer: Multiplan Commercial	$25,572.10
Rate for Payer: Multiplan Workers Comp	$25,572.10
Rate for Payer: Scott and White EPO/PPO	$11,776.62
Rate for Payer: Scott and White Medicare	$14,624.22
Rate for Payer: Superior Health Plan EPO	$14,624.22
Rate for Payer: Superior Health Plan Medicare	$14,624.22
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,624.22
Rate for Payer: Universal American Medicare	$14,624.22
Rate for Payer: Wellcare Medicare	$14,624.22
Rate for Payer: Wellmed Medicare	$14,624.22

SOFT TISSUE PROCEDURES W MCC

Facility

$60,131.20

Service Code	MSDRG 500
Min. Negotiated Rate	$26,384.80
Max. Negotiated Rate	$60,131.20
Rate for Payer: BCBS of TX Blue Advantage	$26,384.80
Rate for Payer: BCBS of TX Blue Essentials	$31,658.69
Rate for Payer: BCBS of TX PPO	$35,177.69

SOFT TISSUE PROCEDURES W/O CC/MCC

Facility

$25,572.10

Service Code	MSDRG 502
Min. Negotiated Rate	$11,103.46
Max. Negotiated Rate	$25,572.10
Rate for Payer: BCBS of TX Blue Advantage	$11,103.46
Rate for Payer: BCBS of TX Blue Essentials	$13,322.86
Rate for Payer: BCBS of TX PPO	$14,803.75

SOLENT PROXI CATHETER US

Facility

$227.00

Service Code	HCPCS C1757
Hospital Charge Code	992519
Hospital Revenue Code	272
Rate for Payer: Cash Price	$154.36

SOLENT PROXI CATHETER US

Facility

$227.00

Service Code	HCPCS C1757
Hospital Charge Code	992519
Hospital Revenue Code	272
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$163.44
Rate for Payer: Amerigroup CHIP/Medicaid	$20.43
Rate for Payer: BCBS of TX Blue Advantage	$68.10
Rate for Payer: BCBS of TX Blue Essentials	$81.72
Rate for Payer: BCBS of TX PPO	$90.80
Rate for Payer: Cash Price	$154.36
Rate for Payer: Cigna Medicaid	$163.44
Rate for Payer: Molina CHIP/Medicaid	$163.44
Rate for Payer: Multiplan Auto	$147.55
Rate for Payer: Multiplan Commercial	$147.55
Rate for Payer: Multiplan Workers Comp	$147.55
Rate for Payer: Parkland Medicaid	$163.44
Rate for Payer: Scott and White EPO/PPO	$113.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$163.44
Rate for Payer: Superior Health Plan EPO	$30.87

SOL, SOD CHL, 0.9 PERC, 1000ML, INJ, BAG

Facility

$8.71

Hospital Charge Code	993001
Hospital Revenue Code	270
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$6.27
Rate for Payer: Amerigroup CHIP/Medicaid	$0.78
Rate for Payer: BCBS of TX Blue Advantage	$2.61
Rate for Payer: BCBS of TX Blue Essentials	$3.14
Rate for Payer: BCBS of TX PPO	$3.48
Rate for Payer: Cash Price	$5.92
Rate for Payer: Cigna Medicaid	$6.27
Rate for Payer: Molina CHIP/Medicaid	$6.27
Rate for Payer: Multiplan Auto	$5.66
Rate for Payer: Multiplan Commercial	$5.66
Rate for Payer: Multiplan Workers Comp	$5.66
Rate for Payer: Parkland Medicaid	$6.27
Rate for Payer: Scott and White EPO/PPO	$4.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.27
Rate for Payer: Superior Health Plan EPO	$1.18

SOL, SOD CHL, 0.9 PERC, 1000ML, INJ, BAG

Facility

$8.71

Hospital Charge Code	993001
Hospital Revenue Code	270
Rate for Payer: Cash Price	$5.92

SOLU, NACL, 0.9% IRRG, BTL, 1000ML

Facility

$13.13

Hospital Charge Code	992947
Hospital Revenue Code	270
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$9.45
Rate for Payer: Amerigroup CHIP/Medicaid	$1.18
Rate for Payer: BCBS of TX Blue Advantage	$3.94
Rate for Payer: BCBS of TX Blue Essentials	$4.73
Rate for Payer: BCBS of TX PPO	$5.25
Rate for Payer: Cash Price	$8.93
Rate for Payer: Cigna Medicaid	$9.45
Rate for Payer: Molina CHIP/Medicaid	$9.45
Rate for Payer: Multiplan Auto	$8.53
Rate for Payer: Multiplan Commercial	$8.53
Rate for Payer: Multiplan Workers Comp	$8.53
Rate for Payer: Parkland Medicaid	$9.45
Rate for Payer: Scott and White EPO/PPO	$6.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.45
Rate for Payer: Superior Health Plan EPO	$1.79

SOLU, NACL, 0.9% IRRG, BTL, 1000ML

Facility

$13.13

Hospital Charge Code	992947
Hospital Revenue Code	270
Rate for Payer: Cash Price	$8.93

SOLU, SOD CHL, 9 PCNT, 250ML, INJ, USP, B

Facility

$9.25

Hospital Charge Code	992905
Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$6.66
Rate for Payer: Amerigroup CHIP/Medicaid	$0.83
Rate for Payer: BCBS of TX Blue Advantage	$2.77
Rate for Payer: BCBS of TX Blue Essentials	$3.33
Rate for Payer: BCBS of TX PPO	$3.70
Rate for Payer: Cash Price	$6.29
Rate for Payer: Cigna Medicaid	$6.66
Rate for Payer: Molina CHIP/Medicaid	$6.66
Rate for Payer: Multiplan Auto	$6.01
Rate for Payer: Multiplan Commercial	$6.01
Rate for Payer: Multiplan Workers Comp	$6.01
Rate for Payer: Parkland Medicaid	$6.66
Rate for Payer: Scott and White EPO/PPO	$4.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.66
Rate for Payer: Superior Health Plan EPO	$1.26

SOLU, SOD CHL, 9 PCNT, 250ML, INJ, USP, B

Facility

$9.25

Hospital Charge Code	992905
Hospital Revenue Code	270
Rate for Payer: Cash Price	$6.29

SOLUTION INHALATION STERILE WATER USP 1000ML BAG

Facility

$21.75

Hospital Charge Code	992745
Hospital Revenue Code	270
Rate for Payer: Cash Price	$14.79

SOLUTION INHALATION STERILE WATER USP 1000ML BAG

Facility

$21.75

Hospital Charge Code	992745
Hospital Revenue Code	270
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$15.66
Rate for Payer: Amerigroup CHIP/Medicaid	$1.96
Rate for Payer: BCBS of TX Blue Advantage	$6.53
Rate for Payer: BCBS of TX Blue Essentials	$7.83
Rate for Payer: BCBS of TX PPO	$8.70
Rate for Payer: Cash Price	$14.79
Rate for Payer: Cigna Medicaid	$15.66
Rate for Payer: Molina CHIP/Medicaid	$15.66
Rate for Payer: Multiplan Auto	$14.14
Rate for Payer: Multiplan Commercial	$14.14
Rate for Payer: Multiplan Workers Comp	$14.14
Rate for Payer: Parkland Medicaid	$15.66
Rate for Payer: Scott and White EPO/PPO	$10.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$15.66
Rate for Payer: Superior Health Plan EPO	$2.96

Know your out-of-pocket cost for care.

All Charges