White Rock Medical Center

All Charges

Charge

Type

Setting

Price

POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE

Facility

$18,385.70

Service Code	APR-DRG 5484
Min. Negotiated Rate	$17,334.68
Max. Negotiated Rate	$18,385.70
Rate for Payer: Amerigroup CHIP/Medicaid	$17,334.68
Rate for Payer: Cigna Medicaid	$17,334.68
Rate for Payer: Molina CHIP/Medicaid	$17,334.68
Rate for Payer: Parkland Medicaid	$17,334.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$18,385.70

POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE

Facility

$7,079.08

Service Code	APR-DRG 5483
Min. Negotiated Rate	$6,674.41
Max. Negotiated Rate	$7,079.08
Rate for Payer: Amerigroup CHIP/Medicaid	$6,674.41
Rate for Payer: Cigna Medicaid	$6,674.41
Rate for Payer: Molina CHIP/Medicaid	$6,674.41
Rate for Payer: Parkland Medicaid	$6,674.41
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,079.08

POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE

Facility

$4,904.97

Service Code	APR-DRG 5482
Min. Negotiated Rate	$4,624.57
Max. Negotiated Rate	$4,904.97
Rate for Payer: Amerigroup CHIP/Medicaid	$4,624.57
Rate for Payer: Cigna Medicaid	$4,624.57
Rate for Payer: Molina CHIP/Medicaid	$4,624.57
Rate for Payer: Parkland Medicaid	$4,624.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,904.97

POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE

Facility

$2,614.67

Service Code	APR-DRG 5481
Min. Negotiated Rate	$2,465.21
Max. Negotiated Rate	$2,614.67
Rate for Payer: Amerigroup CHIP/Medicaid	$2,465.21
Rate for Payer: Cigna Medicaid	$2,465.21
Rate for Payer: Molina CHIP/Medicaid	$2,465.21
Rate for Payer: Parkland Medicaid	$2,465.21
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,614.67

Postpartum High Risk Care 12 Hour

Facility

$1,955.00

Hospital Charge Code	300665
Hospital Revenue Code	720
Rate for Payer: Cash Price	$1,329.40

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	$1,407.60
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	$1,329.40
Rate for Payer: Cigna Medicaid	$1,407.60
Rate for Payer: Molina CHIP/Medicaid	$1,407.60
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: Parkland Medicaid	$1,407.60
Rate for Payer: Scott and White EPO/PPO	$977.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,407.60
Rate for Payer: Superior Health Plan EPO	$265.88

POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE

Facility

$12,439.30

Service Code	MSDRG 776
Min. Negotiated Rate	$5,667.40
Max. Negotiated Rate	$12,439.30
Rate for Payer: BCBS of TX Blue Advantage	$5,667.40
Rate for Payer: BCBS of TX Blue Essentials	$6,800.22
Rate for Payer: BCBS of TX PPO	$7,556.09

POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE

Facility

$32,106.20

Service Code	MSDRG 769
Min. Negotiated Rate	$12,537.94
Max. Negotiated Rate	$32,106.20
Rate for Payer: BCBS of TX Blue Advantage	$12,537.94
Rate for Payer: BCBS of TX Blue Essentials	$15,044.07
Rate for Payer: BCBS of TX PPO	$16,716.28

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	$92.28
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: 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

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
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

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 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	77767906
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$92.28
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: 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

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	$92.28
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: 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

potassium chloride 20 mEq/100 mL IV Soln 100 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 chloride 20 mEq/15 mL Liquid 15 mL

Facility

$35.30

Service Code	HCPCS J3490
Hospital Charge Code	78874387
Hospital Revenue Code	250
Rate for Payer: Cash Price	$24.00

potassium chloride 20 mEq/15 mL Liquid 15 mL

Facility

$35.30

Service Code	HCPCS J3490
Hospital Charge Code	78874387
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$25.42
Rate for Payer: Amerigroup CHIP/Medicaid	$3.18
Rate for Payer: BCBS of TX Blue Advantage	$10.59
Rate for Payer: BCBS of TX Blue Essentials	$12.71
Rate for Payer: BCBS of TX PPO	$14.12
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna Medicaid	$25.42
Rate for Payer: Molina CHIP/Medicaid	$25.42
Rate for Payer: Multiplan Auto	$22.95
Rate for Payer: Multiplan Commercial	$22.95
Rate for Payer: Multiplan Workers Comp	$22.95
Rate for Payer: Parkland Medicaid	$25.42
Rate for Payer: Scott and White EPO/PPO	$17.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25.42
Rate for Payer: Superior Health Plan EPO	$4.80

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	$10.44
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: Cigna Medicaid	$10.44
Rate for Payer: Molina CHIP/Medicaid	$10.44
Rate for Payer: Multiplan Auto	$9.43
Rate for Payer: Multiplan Commercial	$9.43
Rate for Payer: Multiplan Workers Comp	$9.43
Rate for Payer: Parkland Medicaid	$10.44
Rate for Payer: Scott and White EPO/PPO	$7.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.44
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	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
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: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
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: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
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	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.83
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Commercial	$1.91
Rate for Payer: Scott and White EPO/PPO	$3.83

potassium chloride 2 mEq/mL IV Soln 20 mL

Facility

$128.17

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

Facility

$128.17

Service Code	HCPCS J3480
Hospital Charge Code	77767788
Hospital Revenue Code	636
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$92.28
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: 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

Potassium Level

Facility

$187.00

Service Code	HCPCS 84132 QW
Hospital Charge Code	1602192
Hospital Revenue Code	301
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$134.64
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	$56.10
Rate for Payer: BCBS of TX Blue Essentials	$67.32
Rate for Payer: BCBS of TX Medicare	$4.76
Rate for Payer: BCBS of TX PPO	$74.80
Rate for Payer: Cash Price	$127.16
Rate for Payer: Cash Price	$127.16
Rate for Payer: Cigna Medicaid	$134.64
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	$134.64
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	$134.64
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	$134.64
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

Know your out-of-pocket cost for care.

All Charges