White Rock Medical Center

All Charges

Charge

Type

Setting

Price

potassium chloride 20 mEq/100 mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77768244
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 20 mEq/100 mL IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77768244
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 20 mEq/15 mL Liquid 473 mL

Facility

$14.50

Service Code	HCPCS J3490
Hospital Charge Code	78877163
Hospital Revenue Code	250
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$9.42
Rate for Payer: Amerigroup CHIP/Medicaid	$1.30
Rate for Payer: BCBS of TX Blue Advantage	$4.35
Rate for Payer: BCBS of TX Blue Essentials	$5.22
Rate for Payer: BCBS of TX PPO	$5.80
Rate for Payer: Cash Price	$9.86
Rate for Payer: Multiplan Auto	$9.42
Rate for Payer: Multiplan Commercial	$9.42
Rate for Payer: Multiplan Workers Comp	$9.42
Rate for Payer: Scott and White EPO/PPO	$7.25
Rate for Payer: Superior Health Plan EPO	$1.97

potassium chloride 20 mEq/15 mL Liquid 473 mL

Facility

$14.50

Service Code	HCPCS J3490
Hospital Charge Code	78877163
Hospital Revenue Code	250
Rate for Payer: Cash Price	$9.86

potassium chloride 20 mEq ER Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77768142
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	$2.30
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	$3.82
Rate for Payer: Superior Health Plan EPO	$1.04

potassium chloride 20 mEq ER Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77768142
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

potassium chloride 2 mEq/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77767788
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

potassium chloride 2 mEq/mL IV Soln 10 mL

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77767788
Hospital Revenue Code	250
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 2 mEq/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77767906
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 2 mEq/mL IV Soln 20 mL

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77767906
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, Fecal SO

Facility

$123.00

Service Code	CPT 84999
Hospital Charge Code	1700301
Hospital Revenue Code	301
Min. Negotiated Rate	$11.07
Max. Negotiated Rate	$79.95
Rate for Payer: Aetna Commercial	$67.65
Rate for Payer: Amerigroup CHIP/Medicaid	$11.07
Rate for Payer: Cash Price	$108.24
Rate for Payer: Multiplan Auto	$79.95
Rate for Payer: Multiplan Commercial	$79.95
Rate for Payer: Multiplan Workers Comp	$79.95
Rate for Payer: Scott and White EPO/PPO	$61.50
Rate for Payer: Superior Health Plan EPO	$16.73

Potassium, Fecal SO

Facility

$123.00

Service Code	CPT 84999
Hospital Charge Code	1700301
Hospital Revenue Code	301
Rate for Payer: Cash Price	$108.24

Potassium Level

Facility

$187.00

Service Code	CPT 84132
Hospital Charge Code	1602192
Hospital Revenue Code	301
Rate for Payer: Cash Price	$164.56

Potassium Level

Facility

$187.00

Service Code	CPT 84132
Hospital Charge Code	1602192
Hospital Revenue Code	301
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$121.55
Rate for Payer: Aetna Commercial	$5.00
Rate for Payer: Aetna Medicare	$7.14
Rate for Payer: Amerigroup CHIP/Medicaid	$1.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.76
Rate for Payer: Amerigroup Medicare	$4.76
Rate for Payer: BCBS of TX Blue Advantage	$7.85
Rate for Payer: BCBS of TX Blue Essentials	$9.42
Rate for Payer: BCBS of TX Medicare	$4.76
Rate for Payer: BCBS of TX PPO	$10.52
Rate for Payer: Cash Price	$164.56
Rate for Payer: Cash Price	$164.56
Rate for Payer: Cigna Medicaid	$4.76
Rate for Payer: Cigna Medicare	$4.76
Rate for Payer: Employer Direct Commercial	$4.76
Rate for Payer: Humana Medicare/TRICARE	$4.76
Rate for Payer: Molina CHIP/Medicaid	$4.76
Rate for Payer: Molina Dual Medicare/Medicaid	$4.76
Rate for Payer: Molina Medicare	$4.76
Rate for Payer: Multiplan Auto	$121.55
Rate for Payer: Multiplan Commercial	$121.55
Rate for Payer: Multiplan Workers Comp	$121.55
Rate for Payer: Parkland Medicaid	$4.76
Rate for Payer: Scott and White EPO/PPO	$5.95
Rate for Payer: Scott and White Medicare	$4.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.76
Rate for Payer: Superior Health Plan EPO	$4.76
Rate for Payer: Superior Health Plan Medicare	$4.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.76
Rate for Payer: Universal American Medicare	$4.76
Rate for Payer: Wellcare Medicare	$4.76
Rate for Payer: Wellmed Medicare	$4.76

Potassium Level 24 Hour Urine

Facility

$217.00

Service Code	CPT 84133
Hospital Charge Code	1601145
Hospital Revenue Code	301
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$141.05
Rate for Payer: Aetna Commercial	$4.97
Rate for Payer: Aetna Medicare	$7.10
Rate for Payer: Amerigroup CHIP/Medicaid	$1.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.73
Rate for Payer: Amerigroup Medicare	$4.73
Rate for Payer: BCBS of TX Blue Advantage	$7.80
Rate for Payer: BCBS of TX Blue Essentials	$9.37
Rate for Payer: BCBS of TX Medicare	$4.73
Rate for Payer: BCBS of TX PPO	$10.45
Rate for Payer: Cash Price	$190.96
Rate for Payer: Cash Price	$190.96
Rate for Payer: Cigna Medicaid	$4.73
Rate for Payer: Cigna Medicare	$4.73
Rate for Payer: Employer Direct Commercial	$4.73
Rate for Payer: Humana Medicare/TRICARE	$4.73
Rate for Payer: Molina CHIP/Medicaid	$4.73
Rate for Payer: Molina Dual Medicare/Medicaid	$4.73
Rate for Payer: Molina Medicare	$4.73
Rate for Payer: Multiplan Auto	$141.05
Rate for Payer: Multiplan Commercial	$141.05
Rate for Payer: Multiplan Workers Comp	$141.05
Rate for Payer: Parkland Medicaid	$4.73
Rate for Payer: Scott and White EPO/PPO	$5.91
Rate for Payer: Scott and White Medicare	$4.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.73
Rate for Payer: Superior Health Plan EPO	$4.73
Rate for Payer: Superior Health Plan Medicare	$4.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.73
Rate for Payer: Universal American Medicare	$4.73
Rate for Payer: Wellcare Medicare	$4.73
Rate for Payer: Wellmed Medicare	$4.73

Potassium Level Urine

Facility

$217.00

Service Code	CPT 84133
Hospital Charge Code	1601145
Hospital Revenue Code	301
Rate for Payer: Cash Price	$190.96

Potassium Level Urine

Facility

$217.00

Service Code	CPT 84133
Hospital Charge Code	1601145
Hospital Revenue Code	301
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$141.05
Rate for Payer: Aetna Commercial	$4.97
Rate for Payer: Aetna Medicare	$7.10
Rate for Payer: Amerigroup CHIP/Medicaid	$1.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.73
Rate for Payer: Amerigroup Medicare	$4.73
Rate for Payer: BCBS of TX Blue Advantage	$7.80
Rate for Payer: BCBS of TX Blue Essentials	$9.37
Rate for Payer: BCBS of TX Medicare	$4.73
Rate for Payer: BCBS of TX PPO	$10.45
Rate for Payer: Cash Price	$190.96
Rate for Payer: Cash Price	$190.96
Rate for Payer: Cigna Medicaid	$4.73
Rate for Payer: Cigna Medicare	$4.73
Rate for Payer: Employer Direct Commercial	$4.73
Rate for Payer: Humana Medicare/TRICARE	$4.73
Rate for Payer: Molina CHIP/Medicaid	$4.73
Rate for Payer: Molina Dual Medicare/Medicaid	$4.73
Rate for Payer: Molina Medicare	$4.73
Rate for Payer: Multiplan Auto	$141.05
Rate for Payer: Multiplan Commercial	$141.05
Rate for Payer: Multiplan Workers Comp	$141.05
Rate for Payer: Parkland Medicaid	$4.73
Rate for Payer: Scott and White EPO/PPO	$5.91
Rate for Payer: Scott and White Medicare	$4.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.73
Rate for Payer: Superior Health Plan EPO	$4.73
Rate for Payer: Superior Health Plan Medicare	$4.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.73
Rate for Payer: Universal American Medicare	$4.73
Rate for Payer: Wellcare Medicare	$4.73
Rate for Payer: Wellmed Medicare	$4.73

potassium phosphate 3 mmol/mL IV Soln 15 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77769934
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
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: 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 phosphate 3 mmol/mL IV Soln 15 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77769934
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

POUCH, ENDO RETRIEVAL 80 X 137 SPEC BAG -- DHF

Facility

$363.94

Hospital Charge Code	81744203
Hospital Revenue Code	272
Min. Negotiated Rate	$32.75
Max. Negotiated Rate	$236.56
Rate for Payer: Aetna Commercial	$200.17
Rate for Payer: Amerigroup CHIP/Medicaid	$32.75
Rate for Payer: BCBS of TX Blue Advantage	$109.18
Rate for Payer: BCBS of TX Blue Essentials	$131.02
Rate for Payer: BCBS of TX PPO	$145.58
Rate for Payer: Cash Price	$320.27
Rate for Payer: Multiplan Auto	$236.56
Rate for Payer: Multiplan Commercial	$236.56
Rate for Payer: Multiplan Workers Comp	$236.56
Rate for Payer: Scott and White EPO/PPO	$181.97
Rate for Payer: Superior Health Plan EPO	$49.50

POUCH ONE PIECE HI-OUTPUT

Facility

$17.25

Hospital Charge Code	145058
Hospital Revenue Code	270
Rate for Payer: Cash Price	$15.18

POUCH ONE PIECE HI-OUTPUT

Facility

$17.25

Hospital Charge Code	145058
Hospital Revenue Code	270
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$11.21
Rate for Payer: Aetna Commercial	$9.49
Rate for Payer: Amerigroup CHIP/Medicaid	$1.55
Rate for Payer: BCBS of TX Blue Advantage	$5.18
Rate for Payer: BCBS of TX Blue Essentials	$6.21
Rate for Payer: BCBS of TX PPO	$6.90
Rate for Payer: Cash Price	$15.18
Rate for Payer: Multiplan Auto	$11.21
Rate for Payer: Multiplan Commercial	$11.21
Rate for Payer: Multiplan Workers Comp	$11.21
Rate for Payer: Scott and White EPO/PPO	$8.62
Rate for Payer: Superior Health Plan EPO	$2.35

POWERPORT CLEAR VUE 8FR

Facility

$2,922.29

Service Code	HCPCS C1788
Hospital Charge Code	8568495
Hospital Revenue Code	278
Min. Negotiated Rate	$730.57
Max. Negotiated Rate	$1,461.14
Rate for Payer: Aetna Commercial	$876.69
Rate for Payer: Cash Price	$2,571.62
Rate for Payer: Cigna Commercial	$730.57
Rate for Payer: Multiplan Auto	$1,461.14
Rate for Payer: Multiplan Commercial	$1,461.14
Rate for Payer: Multiplan Workers Comp	$1,461.14
Rate for Payer: Scott and White EPO/PPO	$1,461.14

POWERPORT CLEAR VUE 8FR

Facility

$2,922.29

Service Code	HCPCS C1788
Hospital Charge Code	8568495
Hospital Revenue Code	278
Min. Negotiated Rate	$263.01
Max. Negotiated Rate	$1,461.14
Rate for Payer: Aetna Commercial	$876.69
Rate for Payer: Amerigroup CHIP/Medicaid	$263.01
Rate for Payer: BCBS of TX Blue Advantage	$876.69
Rate for Payer: BCBS of TX Blue Essentials	$1,052.02
Rate for Payer: BCBS of TX PPO	$1,168.92
Rate for Payer: Cash Price	$2,571.62
Rate for Payer: Multiplan Auto	$1,461.14
Rate for Payer: Multiplan Commercial	$1,461.14
Rate for Payer: Multiplan Workers Comp	$1,461.14
Rate for Payer: Scott and White EPO/PPO	$1,461.14
Rate for Payer: Superior Health Plan EPO	$397.43

pravastatin 40 mg Tab

Facility

$20.85

Service Code	HCPCS A9270
Hospital Charge Code	77773906
Hospital Revenue Code	636
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$13.55
Rate for Payer: Aetna Commercial	$11.47
Rate for Payer: Amerigroup CHIP/Medicaid	$1.88
Rate for Payer: BCBS of TX Blue Advantage	$6.26
Rate for Payer: BCBS of TX Blue Essentials	$7.51
Rate for Payer: BCBS of TX PPO	$8.34
Rate for Payer: Cash Price	$14.18
Rate for Payer: Multiplan Auto	$13.55
Rate for Payer: Multiplan Commercial	$13.55
Rate for Payer: Multiplan Workers Comp	$13.55
Rate for Payer: Scott and White EPO/PPO	$10.42
Rate for Payer: Superior Health Plan EPO	$2.84

Know your out-of-pocket cost for care.

All Charges