White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Porphobilinogen, Qn, Random Ur SO

Facility

$112.00

Service Code	CPT 84110
Hospital Charge Code	1704873
Hospital Revenue Code	301
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$72.80
Rate for Payer: Aetna Commercial	$8.86
Rate for Payer: Aetna Medicare	$12.66
Rate for Payer: Amerigroup CHIP/Medicaid	$3.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.44
Rate for Payer: Amerigroup Medicare	$8.44
Rate for Payer: BCBS of TX Blue Advantage	$13.93
Rate for Payer: BCBS of TX Blue Essentials	$16.71
Rate for Payer: BCBS of TX Medicare	$8.44
Rate for Payer: BCBS of TX PPO	$18.65
Rate for Payer: Cash Price	$98.56
Rate for Payer: Cash Price	$98.56
Rate for Payer: Cigna Medicaid	$8.44
Rate for Payer: Cigna Medicare	$8.44
Rate for Payer: Employer Direct Commercial	$8.44
Rate for Payer: Humana Medicare/TRICARE	$8.44
Rate for Payer: Molina CHIP/Medicaid	$8.44
Rate for Payer: Molina Dual Medicare/Medicaid	$8.44
Rate for Payer: Molina Medicare	$8.44
Rate for Payer: Multiplan Auto	$72.80
Rate for Payer: Multiplan Commercial	$72.80
Rate for Payer: Multiplan Workers Comp	$72.80
Rate for Payer: Parkland Medicaid	$8.44
Rate for Payer: Scott and White EPO/PPO	$10.55
Rate for Payer: Scott and White Medicare	$8.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8.44
Rate for Payer: Superior Health Plan EPO	$8.44
Rate for Payer: Superior Health Plan Medicare	$8.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.44
Rate for Payer: Universal American Medicare	$8.44
Rate for Payer: Wellcare Medicare	$8.44
Rate for Payer: Wellmed Medicare	$8.44

Porphyrins, Qn, Random U SO

Facility

$168.00

Service Code	CPT 84120
Hospital Charge Code	1740109
Hospital Revenue Code	301
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$109.20
Rate for Payer: Aetna Commercial	$15.45
Rate for Payer: Aetna Medicare	$22.07
Rate for Payer: Amerigroup CHIP/Medicaid	$5.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14.71
Rate for Payer: Amerigroup Medicare	$14.71
Rate for Payer: BCBS of TX Blue Advantage	$24.27
Rate for Payer: BCBS of TX Blue Essentials	$29.13
Rate for Payer: BCBS of TX Medicare	$14.71
Rate for Payer: BCBS of TX PPO	$32.51
Rate for Payer: Cash Price	$147.84
Rate for Payer: Cash Price	$147.84
Rate for Payer: Cigna Medicaid	$14.71
Rate for Payer: Cigna Medicare	$14.71
Rate for Payer: Employer Direct Commercial	$14.71
Rate for Payer: Humana Medicare/TRICARE	$14.71
Rate for Payer: Molina CHIP/Medicaid	$14.71
Rate for Payer: Molina Dual Medicare/Medicaid	$14.71
Rate for Payer: Molina Medicare	$14.71
Rate for Payer: Multiplan Auto	$109.20
Rate for Payer: Multiplan Commercial	$109.20
Rate for Payer: Multiplan Workers Comp	$109.20
Rate for Payer: Parkland Medicaid	$14.71
Rate for Payer: Scott and White EPO/PPO	$18.39
Rate for Payer: Scott and White Medicare	$14.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14.71
Rate for Payer: Superior Health Plan EPO	$14.71
Rate for Payer: Superior Health Plan Medicare	$14.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$14.71
Rate for Payer: Universal American Medicare	$14.71
Rate for Payer: Wellcare Medicare	$14.71
Rate for Payer: Wellmed Medicare	$14.71

Porphyrins, Qn, Random U SO

Facility

$168.00

Service Code	CPT 84120
Hospital Charge Code	1740109
Hospital Revenue Code	301
Rate for Payer: Cash Price	$147.84

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

Facility

$23,999.10

Service Code	MSDRG 862
Min. Negotiated Rate	$15,609.86
Max. Negotiated Rate	$23,999.10
Rate for Payer: Aetna Commercial	$20,722.50
Rate for Payer: Aetna Medicare	$23,999.10
Rate for Payer: BCBS of TX Blue Advantage	$15,609.86
Rate for Payer: BCBS of TX Blue Essentials	$18,860.04
Rate for Payer: BCBS of TX PPO	$20,956.41
Rate for Payer: Cigna Commercial	$23,724.96

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

Facility

$15,045.14

Service Code	MSDRG 863
Min. Negotiated Rate	$8,516.58
Max. Negotiated Rate	$15,045.14
Rate for Payer: Aetna Commercial	$11,311.88
Rate for Payer: Aetna Medicare	$15,045.14
Rate for Payer: BCBS of TX Blue Advantage	$8,516.58
Rate for Payer: BCBS of TX Blue Essentials	$10,162.15
Rate for Payer: BCBS of TX PPO	$11,291.72
Rate for Payer: Cigna Commercial	$12,950.84

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC

Facility

$27,507.82

Service Code	MSDRG 857
Min. Negotiated Rate	$17,875.96
Max. Negotiated Rate	$27,507.82
Rate for Payer: Aetna Commercial	$24,026.62
Rate for Payer: Aetna Medicare	$27,142.89
Rate for Payer: BCBS of TX Blue Advantage	$17,875.96
Rate for Payer: BCBS of TX Blue Essentials	$21,223.09
Rate for Payer: BCBS of TX PPO	$23,582.12
Rate for Payer: Cigna Commercial	$27,507.82

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC

Facility

$57,037.79

Service Code	MSDRG 856
Min. Negotiated Rate	$39,925.50
Max. Negotiated Rate	$57,037.79
Rate for Payer: Aetna Commercial	$49,819.50
Rate for Payer: Aetna Medicare	$51,684.18
Rate for Payer: BCBS of TX Blue Advantage	$39,925.50
Rate for Payer: BCBS of TX Blue Essentials	$46,314.77
Rate for Payer: BCBS of TX PPO	$51,462.85
Rate for Payer: Cigna Commercial	$57,037.79

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$18,019.80

Service Code	MSDRG 858
Min. Negotiated Rate	$12,508.70
Max. Negotiated Rate	$18,019.80
Rate for Payer: Aetna Commercial	$14,438.25
Rate for Payer: Aetna Medicare	$18,019.80
Rate for Payer: BCBS of TX Blue Advantage	$12,508.70
Rate for Payer: BCBS of TX Blue Essentials	$14,241.25
Rate for Payer: BCBS of TX PPO	$15,824.23
Rate for Payer: Cigna Commercial	$16,530.19

POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES

Facility

$20,808.19

Service Code	MSDRG 769
Min. Negotiated Rate	$15,044.07
Max. Negotiated Rate	$20,808.19
Rate for Payer: Aetna Commercial	$17,368.88
Rate for Payer: Aetna Medicare	$20,808.19
Rate for Payer: BCBS of TX Blue Advantage	$17,695.36
Rate for Payer: BCBS of TX Blue Essentials	$15,044.07
Rate for Payer: BCBS of TX PPO	$16,716.28
Rate for Payer: Cigna Commercial	$19,885.43

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES

Facility

$11,953.78

Service Code	MSDRG 776
Min. Negotiated Rate	$6,085.36
Max. Negotiated Rate	$11,953.78
Rate for Payer: Aetna Commercial	$8,062.88
Rate for Payer: Aetna Medicare	$11,953.78
Rate for Payer: BCBS of TX Blue Advantage	$6,085.36
Rate for Payer: BCBS of TX Blue Essentials	$6,800.22
Rate for Payer: BCBS of TX PPO	$7,556.09
Rate for Payer: Cigna Commercial	$9,231.10

Postpartum High Risk Care 12 Hour

Facility

$1,955.00

Hospital Charge Code	300665
Hospital Revenue Code	720
Rate for Payer: Cash Price	$1,720.40

Postpartum High Risk Care 12 Hour

Facility

$1,955.00

Hospital Charge Code	300665
Hospital Revenue Code	720
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$1,270.75
Rate for Payer: Aetna Commercial	$1,075.25
Rate for Payer: Amerigroup CHIP/Medicaid	$175.95
Rate for Payer: BCBS of TX Blue Advantage	$586.50
Rate for Payer: BCBS of TX Blue Essentials	$703.80
Rate for Payer: BCBS of TX PPO	$782.00
Rate for Payer: Cash Price	$1,720.40
Rate for Payer: Multiplan Auto	$1,270.75
Rate for Payer: Multiplan Commercial	$1,270.75
Rate for Payer: Multiplan Workers Comp	$1,270.75
Rate for Payer: Scott and White EPO/PPO	$977.50
Rate for Payer: Superior Health Plan EPO	$265.88

.Post TR ABO/Rh

Facility

$152.00

Service Code	CPT 86900
Hospital Charge Code	2400406
Hospital Revenue Code	302
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$264.63
Rate for Payer: Aetna Commercial	$3.13
Rate for Payer: Aetna Medicare	$175.23
Rate for Payer: Amerigroup CHIP/Medicaid	$1.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.99
Rate for Payer: Amerigroup Medicare	$2.99
Rate for Payer: BCBS of TX Blue Advantage	$179.90
Rate for Payer: BCBS of TX Blue Essentials	$215.88
Rate for Payer: BCBS of TX Medicare	$2.99
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Commercial	$264.63
Rate for Payer: Cigna Medicaid	$2.99
Rate for Payer: Cigna Medicare	$2.99
Rate for Payer: Employer Direct Commercial	$2.99
Rate for Payer: Humana Medicare/TRICARE	$2.99
Rate for Payer: Molina CHIP/Medicaid	$2.99
Rate for Payer: Molina Dual Medicare/Medicaid	$2.99
Rate for Payer: Molina Medicare	$2.99
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$2.99
Rate for Payer: Scott and White EPO/PPO	$3.74
Rate for Payer: Scott and White Medicare	$2.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.99
Rate for Payer: Superior Health Plan EPO	$2.99
Rate for Payer: Superior Health Plan Medicare	$2.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.99
Rate for Payer: Universal American Medicare	$2.99
Rate for Payer: Wellcare Medicare	$2.99
Rate for Payer: Wellmed Medicare	$2.99

.Post TR ABO/Rh Echo

Facility

$152.00

Service Code	CPT 86900
Hospital Charge Code	2400406
Hospital Revenue Code	302
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$264.63
Rate for Payer: Aetna Commercial	$3.13
Rate for Payer: Aetna Medicare	$175.23
Rate for Payer: Amerigroup CHIP/Medicaid	$1.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.99
Rate for Payer: Amerigroup Medicare	$2.99
Rate for Payer: BCBS of TX Blue Advantage	$179.90
Rate for Payer: BCBS of TX Blue Essentials	$215.88
Rate for Payer: BCBS of TX Medicare	$2.99
Rate for Payer: BCBS of TX PPO	$240.96
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cigna Commercial	$264.63
Rate for Payer: Cigna Medicaid	$2.99
Rate for Payer: Cigna Medicare	$2.99
Rate for Payer: Employer Direct Commercial	$2.99
Rate for Payer: Humana Medicare/TRICARE	$2.99
Rate for Payer: Molina CHIP/Medicaid	$2.99
Rate for Payer: Molina Dual Medicare/Medicaid	$2.99
Rate for Payer: Molina Medicare	$2.99
Rate for Payer: Multiplan Auto	$98.80
Rate for Payer: Multiplan Commercial	$98.80
Rate for Payer: Multiplan Workers Comp	$98.80
Rate for Payer: Parkland Medicaid	$2.99
Rate for Payer: Scott and White EPO/PPO	$3.74
Rate for Payer: Scott and White Medicare	$2.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.99
Rate for Payer: Superior Health Plan EPO	$2.99
Rate for Payer: Superior Health Plan Medicare	$2.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.99
Rate for Payer: Universal American Medicare	$2.99
Rate for Payer: Wellcare Medicare	$2.99
Rate for Payer: Wellmed Medicare	$2.99

.Post TR Antibody Screen

Facility

$253.00

Service Code	CPT 86850
Hospital Charge Code	2403137
Hospital Revenue Code	302
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$164.45
Rate for Payer: Aetna Commercial	$10.26
Rate for Payer: Aetna Medicare	$74.34
Rate for Payer: Amerigroup CHIP/Medicaid	$3.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.77
Rate for Payer: Amerigroup Medicare	$9.77
Rate for Payer: BCBS of TX Blue Advantage	$81.63
Rate for Payer: BCBS of TX Blue Essentials	$97.95
Rate for Payer: BCBS of TX Medicare	$9.77
Rate for Payer: BCBS of TX PPO	$109.33
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cigna Commercial	$112.25
Rate for Payer: Cigna Medicare	$9.77
Rate for Payer: Employer Direct Commercial	$9.77
Rate for Payer: Humana Medicare/TRICARE	$9.77
Rate for Payer: Molina Dual Medicare/Medicaid	$9.77
Rate for Payer: Molina Medicare	$9.77
Rate for Payer: Multiplan Auto	$164.45
Rate for Payer: Multiplan Commercial	$164.45
Rate for Payer: Multiplan Workers Comp	$164.45
Rate for Payer: Scott and White EPO/PPO	$12.21
Rate for Payer: Scott and White Medicare	$9.77
Rate for Payer: Superior Health Plan EPO	$9.77
Rate for Payer: Superior Health Plan Medicare	$9.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.77
Rate for Payer: Universal American Medicare	$9.77
Rate for Payer: Wellcare Medicare	$9.77
Rate for Payer: Wellmed Medicare	$9.77

.Post TR Antibody Screen Echo

Facility

$253.00

Service Code	CPT 86850
Hospital Charge Code	2403137
Hospital Revenue Code	302
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$164.45
Rate for Payer: Aetna Commercial	$10.26
Rate for Payer: Aetna Medicare	$74.34
Rate for Payer: Amerigroup CHIP/Medicaid	$3.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.77
Rate for Payer: Amerigroup Medicare	$9.77
Rate for Payer: BCBS of TX Blue Advantage	$81.63
Rate for Payer: BCBS of TX Blue Essentials	$97.95
Rate for Payer: BCBS of TX Medicare	$9.77
Rate for Payer: BCBS of TX PPO	$109.33
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cigna Commercial	$112.25
Rate for Payer: Cigna Medicare	$9.77
Rate for Payer: Employer Direct Commercial	$9.77
Rate for Payer: Humana Medicare/TRICARE	$9.77
Rate for Payer: Molina Dual Medicare/Medicaid	$9.77
Rate for Payer: Molina Medicare	$9.77
Rate for Payer: Multiplan Auto	$164.45
Rate for Payer: Multiplan Commercial	$164.45
Rate for Payer: Multiplan Workers Comp	$164.45
Rate for Payer: Scott and White EPO/PPO	$12.21
Rate for Payer: Scott and White Medicare	$9.77
Rate for Payer: Superior Health Plan EPO	$9.77
Rate for Payer: Superior Health Plan Medicare	$9.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.77
Rate for Payer: Universal American Medicare	$9.77
Rate for Payer: Wellcare Medicare	$9.77
Rate for Payer: Wellmed Medicare	$9.77

.Post TR Antibody Screen Gel

Facility

$253.00

Service Code	CPT 86850
Hospital Charge Code	2403137
Hospital Revenue Code	302
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$164.45
Rate for Payer: Aetna Commercial	$10.26
Rate for Payer: Aetna Medicare	$74.34
Rate for Payer: Amerigroup CHIP/Medicaid	$3.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.77
Rate for Payer: Amerigroup Medicare	$9.77
Rate for Payer: BCBS of TX Blue Advantage	$81.63
Rate for Payer: BCBS of TX Blue Essentials	$97.95
Rate for Payer: BCBS of TX Medicare	$9.77
Rate for Payer: BCBS of TX PPO	$109.33
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cash Price	$222.64
Rate for Payer: Cigna Commercial	$112.25
Rate for Payer: Cigna Medicare	$9.77
Rate for Payer: Employer Direct Commercial	$9.77
Rate for Payer: Humana Medicare/TRICARE	$9.77
Rate for Payer: Molina Dual Medicare/Medicaid	$9.77
Rate for Payer: Molina Medicare	$9.77
Rate for Payer: Multiplan Auto	$164.45
Rate for Payer: Multiplan Commercial	$164.45
Rate for Payer: Multiplan Workers Comp	$164.45
Rate for Payer: Scott and White EPO/PPO	$12.21
Rate for Payer: Scott and White Medicare	$9.77
Rate for Payer: Superior Health Plan EPO	$9.77
Rate for Payer: Superior Health Plan Medicare	$9.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.77
Rate for Payer: Universal American Medicare	$9.77
Rate for Payer: Wellcare Medicare	$9.77
Rate for Payer: Wellmed Medicare	$9.77

.Post TR Crossmatch

Facility

$297.00

Service Code	CPT 86922
Hospital Charge Code	2400158
Hospital Revenue Code	300
Min. Negotiated Rate	$26.73
Max. Negotiated Rate	$353.86
Rate for Payer: Aetna Commercial	$40.63
Rate for Payer: Aetna Medicare	$234.31
Rate for Payer: Amerigroup CHIP/Medicaid	$26.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$156.21
Rate for Payer: Amerigroup Medicare	$156.21
Rate for Payer: BCBS of TX Blue Advantage	$236.78
Rate for Payer: BCBS of TX Blue Essentials	$284.13
Rate for Payer: BCBS of TX Medicare	$156.21
Rate for Payer: BCBS of TX PPO	$317.13
Rate for Payer: Cash Price	$261.36
Rate for Payer: Cash Price	$261.36
Rate for Payer: Cash Price	$261.36
Rate for Payer: Cigna Commercial	$353.86
Rate for Payer: Cigna Medicare	$156.21
Rate for Payer: Employer Direct Commercial	$156.21
Rate for Payer: Humana Medicare/TRICARE	$156.21
Rate for Payer: Molina Dual Medicare/Medicaid	$156.21
Rate for Payer: Molina Medicare	$156.21
Rate for Payer: Multiplan Auto	$193.05
Rate for Payer: Multiplan Commercial	$193.05
Rate for Payer: Multiplan Workers Comp	$193.05
Rate for Payer: Scott and White EPO/PPO	$234.31
Rate for Payer: Scott and White Medicare	$156.21
Rate for Payer: Superior Health Plan EPO	$156.21
Rate for Payer: Superior Health Plan Medicare	$156.21
Rate for Payer: Universal American Dual Medicare/Medicaid	$156.21
Rate for Payer: Universal American Medicare	$156.21
Rate for Payer: Wellcare Medicare	$156.21
Rate for Payer: Wellmed Medicare	$156.21

.Post TR DAT C3

Facility

$142.00

Service Code	CPT 86880
Hospital Charge Code	2403103
Hospital Revenue Code	302
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.39
Rate for Payer: Amerigroup Medicare	$5.39
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX Medicare	$5.39
Rate for Payer: BCBS of TX PPO	$73.88
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicaid	$5.39
Rate for Payer: Cigna Medicare	$5.39
Rate for Payer: Employer Direct Commercial	$5.39
Rate for Payer: Humana Medicare/TRICARE	$5.39
Rate for Payer: Molina CHIP/Medicaid	$5.39
Rate for Payer: Molina Dual Medicare/Medicaid	$5.39
Rate for Payer: Molina Medicare	$5.39
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$5.39
Rate for Payer: Scott and White EPO/PPO	$6.74
Rate for Payer: Scott and White Medicare	$5.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.39
Rate for Payer: Superior Health Plan EPO	$5.39
Rate for Payer: Superior Health Plan Medicare	$5.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.39
Rate for Payer: Universal American Medicare	$5.39
Rate for Payer: Wellcare Medicare	$5.39
Rate for Payer: Wellmed Medicare	$5.39

.Post TR DAT IgG

Facility

$142.00

Service Code	CPT 86880
Hospital Charge Code	2403103
Hospital Revenue Code	302
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.39
Rate for Payer: Amerigroup Medicare	$5.39
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX Medicare	$5.39
Rate for Payer: BCBS of TX PPO	$73.88
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicaid	$5.39
Rate for Payer: Cigna Medicare	$5.39
Rate for Payer: Employer Direct Commercial	$5.39
Rate for Payer: Humana Medicare/TRICARE	$5.39
Rate for Payer: Molina CHIP/Medicaid	$5.39
Rate for Payer: Molina Dual Medicare/Medicaid	$5.39
Rate for Payer: Molina Medicare	$5.39
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$5.39
Rate for Payer: Scott and White EPO/PPO	$6.74
Rate for Payer: Scott and White Medicare	$5.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.39
Rate for Payer: Superior Health Plan EPO	$5.39
Rate for Payer: Superior Health Plan Medicare	$5.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.39
Rate for Payer: Universal American Medicare	$5.39
Rate for Payer: Wellcare Medicare	$5.39
Rate for Payer: Wellmed Medicare	$5.39

.Post TR DAT Poly

Facility

$142.00

Service Code	CPT 86880
Hospital Charge Code	2403103
Hospital Revenue Code	302
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$126.71
Rate for Payer: Aetna Commercial	$5.65
Rate for Payer: Aetna Medicare	$83.91
Rate for Payer: Amerigroup CHIP/Medicaid	$2.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.39
Rate for Payer: Amerigroup Medicare	$5.39
Rate for Payer: BCBS of TX Blue Advantage	$55.16
Rate for Payer: BCBS of TX Blue Essentials	$66.19
Rate for Payer: BCBS of TX Medicare	$5.39
Rate for Payer: BCBS of TX PPO	$73.88
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$126.71
Rate for Payer: Cigna Medicaid	$5.39
Rate for Payer: Cigna Medicare	$5.39
Rate for Payer: Employer Direct Commercial	$5.39
Rate for Payer: Humana Medicare/TRICARE	$5.39
Rate for Payer: Molina CHIP/Medicaid	$5.39
Rate for Payer: Molina Dual Medicare/Medicaid	$5.39
Rate for Payer: Molina Medicare	$5.39
Rate for Payer: Multiplan Auto	$92.30
Rate for Payer: Multiplan Commercial	$92.30
Rate for Payer: Multiplan Workers Comp	$92.30
Rate for Payer: Parkland Medicaid	$5.39
Rate for Payer: Scott and White EPO/PPO	$6.74
Rate for Payer: Scott and White Medicare	$5.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.39
Rate for Payer: Superior Health Plan EPO	$5.39
Rate for Payer: Superior Health Plan Medicare	$5.39
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.39
Rate for Payer: Universal American Medicare	$5.39
Rate for Payer: Wellcare Medicare	$5.39
Rate for Payer: Wellmed Medicare	$5.39

potassium chloride 10 mEq/100 mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77767570
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.10
Rate for Payer: BCBS of TX Blue Essentials	$0.12
Rate for Payer: BCBS of TX PPO	$0.14
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
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: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

potassium chloride 10 mEq/100 mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77767570
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

potassium chloride 10 mEq ER Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77767519
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

potassium chloride 10 mEq ER Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77767519
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$4.97
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: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan EPO	$1.04

Know your out-of-pocket cost for care.

All Charges