White Rock Medical Center

All Charges

Charge

Type

Setting

Price

famotidine 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78433747
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting

Facility

$10,000.00

Service Code	CPT 26121
Hospital Charge Code	36026121
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, w

Facility

$10,000.00

Service Code	CPT 26123
Hospital Charge Code	36026123
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Fasciectomy, plantar fascia; partial (separate procedure)

Facility

$10,000.00

Service Code	CPT 28060
Hospital Charge Code	36028060
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Fasciotomy, foot and/or toe

Facility

$10,000.00

Service Code	CPT 28008
Hospital Charge Code	36028008
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Fasciotomy, hip or thigh, any type

Facility

$10,000.00

Service Code	CPT 27025
Hospital Charge Code	36027025
Hospital Revenue Code	360
Min. Negotiated Rate	$1,587.08
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$7,210.00
Rate for Payer: BCBS of TX Blue Advantage	$1,587.08
Rate for Payer: BCBS of TX Blue Essentials	$1,900.70
Rate for Payer: BCBS of TX PPO	$2,394.88
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00

Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial

Facility

$10,000.00

Service Code	CPT 26045
Hospital Charge Code	36026045
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$4,635.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

FDP, Plasma SO

Facility

$190.00

Service Code	CPT 85362
Hospital Charge Code	1600642
Hospital Revenue Code	305
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$123.50
Rate for Payer: Aetna Commercial	$7.23
Rate for Payer: Aetna Medicare	$10.34
Rate for Payer: Amerigroup CHIP/Medicaid	$2.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6.89
Rate for Payer: Amerigroup Medicare	$6.89
Rate for Payer: BCBS of TX Blue Advantage	$11.37
Rate for Payer: BCBS of TX Blue Essentials	$13.64
Rate for Payer: BCBS of TX Medicare	$6.89
Rate for Payer: BCBS of TX PPO	$15.23
Rate for Payer: Cash Price	$167.20
Rate for Payer: Cash Price	$167.20
Rate for Payer: Cigna Medicaid	$6.89
Rate for Payer: Cigna Medicare	$6.89
Rate for Payer: Employer Direct Commercial	$6.89
Rate for Payer: Humana Medicare/TRICARE	$6.89
Rate for Payer: Molina CHIP/Medicaid	$6.89
Rate for Payer: Molina Dual Medicare/Medicaid	$6.89
Rate for Payer: Molina Medicare	$6.89
Rate for Payer: Multiplan Auto	$123.50
Rate for Payer: Multiplan Commercial	$123.50
Rate for Payer: Multiplan Workers Comp	$123.50
Rate for Payer: Parkland Medicaid	$6.89
Rate for Payer: Scott and White EPO/PPO	$8.61
Rate for Payer: Scott and White Medicare	$6.89
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6.89
Rate for Payer: Superior Health Plan EPO	$6.89
Rate for Payer: Superior Health Plan Medicare	$6.89
Rate for Payer: Universal American Dual Medicare/Medicaid	$6.89
Rate for Payer: Universal American Medicare	$6.89
Rate for Payer: Wellcare Medicare	$6.89
Rate for Payer: Wellmed Medicare	$6.89

FDP, Plasma SO

Facility

$190.00

Service Code	CPT 85362
Hospital Charge Code	1600642
Hospital Revenue Code	305
Rate for Payer: Cash Price	$167.20

fecal collector w/clamp

Facility

$16.21

Hospital Charge Code	131924
Hospital Revenue Code	270
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$10.54
Rate for Payer: Aetna Commercial	$8.92
Rate for Payer: Amerigroup CHIP/Medicaid	$1.46
Rate for Payer: BCBS of TX Blue Advantage	$4.86
Rate for Payer: BCBS of TX Blue Essentials	$5.84
Rate for Payer: BCBS of TX PPO	$6.48
Rate for Payer: Cash Price	$14.26
Rate for Payer: Multiplan Auto	$10.54
Rate for Payer: Multiplan Commercial	$10.54
Rate for Payer: Multiplan Workers Comp	$10.54
Rate for Payer: Scott and White EPO/PPO	$8.10
Rate for Payer: Superior Health Plan EPO	$2.20

fecal collector w/clamp

Facility

$16.21

Hospital Charge Code	131924
Hospital Revenue Code	270
Rate for Payer: Cash Price	$14.26

Fecal Fat, Qualitative SO

Facility

$59.00

Service Code	CPT 82705
Hospital Charge Code	1630029
Hospital Revenue Code	301
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$38.35
Rate for Payer: Aetna Commercial	$5.36
Rate for Payer: Aetna Medicare	$7.65
Rate for Payer: Amerigroup CHIP/Medicaid	$1.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.10
Rate for Payer: Amerigroup Medicare	$5.10
Rate for Payer: BCBS of TX Blue Advantage	$8.42
Rate for Payer: BCBS of TX Blue Essentials	$10.10
Rate for Payer: BCBS of TX Medicare	$5.10
Rate for Payer: BCBS of TX PPO	$11.27
Rate for Payer: Cash Price	$51.92
Rate for Payer: Cash Price	$51.92
Rate for Payer: Cigna Medicaid	$5.10
Rate for Payer: Cigna Medicare	$5.10
Rate for Payer: Employer Direct Commercial	$5.10
Rate for Payer: Humana Medicare/TRICARE	$5.10
Rate for Payer: Molina CHIP/Medicaid	$5.10
Rate for Payer: Molina Dual Medicare/Medicaid	$5.10
Rate for Payer: Molina Medicare	$5.10
Rate for Payer: Multiplan Auto	$38.35
Rate for Payer: Multiplan Commercial	$38.35
Rate for Payer: Multiplan Workers Comp	$38.35
Rate for Payer: Parkland Medicaid	$5.10
Rate for Payer: Scott and White EPO/PPO	$6.38
Rate for Payer: Scott and White Medicare	$5.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.10
Rate for Payer: Superior Health Plan EPO	$5.10
Rate for Payer: Superior Health Plan Medicare	$5.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.10
Rate for Payer: Universal American Medicare	$5.10
Rate for Payer: Wellcare Medicare	$5.10
Rate for Payer: Wellmed Medicare	$5.10

Fecal Fat, Qualitative SO

Facility

$59.00

Service Code	CPT 82705
Hospital Charge Code	1630029
Hospital Revenue Code	301
Rate for Payer: Cash Price	$51.92

Fecal WBC

Facility

$171.00

Service Code	CPT 89055
Hospital Charge Code	1611888
Hospital Revenue Code	300
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$111.15
Rate for Payer: Aetna Commercial	$4.48
Rate for Payer: Aetna Medicare	$6.40
Rate for Payer: Amerigroup CHIP/Medicaid	$1.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.27
Rate for Payer: Amerigroup Medicare	$4.27
Rate for Payer: BCBS of TX Blue Advantage	$7.05
Rate for Payer: BCBS of TX Blue Essentials	$8.45
Rate for Payer: BCBS of TX Medicare	$4.27
Rate for Payer: BCBS of TX PPO	$9.44
Rate for Payer: Cash Price	$150.48
Rate for Payer: Cash Price	$150.48
Rate for Payer: Cigna Medicaid	$4.27
Rate for Payer: Cigna Medicare	$4.27
Rate for Payer: Employer Direct Commercial	$4.27
Rate for Payer: Humana Medicare/TRICARE	$4.27
Rate for Payer: Molina CHIP/Medicaid	$4.27
Rate for Payer: Molina Dual Medicare/Medicaid	$4.27
Rate for Payer: Molina Medicare	$4.27
Rate for Payer: Multiplan Auto	$111.15
Rate for Payer: Multiplan Commercial	$111.15
Rate for Payer: Multiplan Workers Comp	$111.15
Rate for Payer: Parkland Medicaid	$4.27
Rate for Payer: Scott and White EPO/PPO	$5.34
Rate for Payer: Scott and White Medicare	$4.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4.27
Rate for Payer: Superior Health Plan EPO	$4.27
Rate for Payer: Superior Health Plan Medicare	$4.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.27
Rate for Payer: Universal American Medicare	$4.27
Rate for Payer: Wellcare Medicare	$4.27
Rate for Payer: Wellmed Medicare	$4.27

Fecal WBC

Facility

$171.00

Service Code	CPT 89055
Hospital Charge Code	1611888
Hospital Revenue Code	300
Rate for Payer: Cash Price	$150.48

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$26,693.10

Service Code	MSDRG 748
Min. Negotiated Rate	$10,268.40
Max. Negotiated Rate	$26,693.10
Rate for Payer: Aetna Commercial	$15,805.12
Rate for Payer: Aetna Medicare	$19,320.34
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,880.23
Rate for Payer: Amerigroup Medicare	$12,880.23
Rate for Payer: BCBS of TX Blue Advantage	$10,268.40
Rate for Payer: BCBS of TX Blue Essentials	$13,352.79
Rate for Payer: BCBS of TX Medicare	$12,880.23
Rate for Payer: BCBS of TX PPO	$14,837.00
Rate for Payer: Cigna Commercial	$18,095.11
Rate for Payer: Cigna Medicare	$12,880.23
Rate for Payer: Employer Direct Commercial	$12,880.23
Rate for Payer: Humana Medicare/TRICARE	$12,880.23
Rate for Payer: Molina Dual Medicare/Medicaid	$12,880.23
Rate for Payer: Molina Medicare	$12,880.23
Rate for Payer: Multiplan Auto	$26,693.10
Rate for Payer: Multiplan Commercial	$26,693.10
Rate for Payer: Multiplan Workers Comp	$26,693.10
Rate for Payer: Scott and White EPO/PPO	$12,292.88
Rate for Payer: Scott and White Medicare	$12,880.23
Rate for Payer: Superior Health Plan EPO	$12,880.23
Rate for Payer: Superior Health Plan Medicare	$12,880.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,880.23
Rate for Payer: Universal American Medicare	$12,880.23
Rate for Payer: Wellcare Medicare	$12,880.23
Rate for Payer: Wellmed Medicare	$12,880.23

FEM COMP ARCH -- DHF

Facility

$530.57

Hospital Charge Code	80846017
Hospital Revenue Code	272
Min. Negotiated Rate	$47.75
Max. Negotiated Rate	$344.87
Rate for Payer: Aetna Commercial	$291.81
Rate for Payer: Amerigroup CHIP/Medicaid	$47.75
Rate for Payer: BCBS of TX Blue Advantage	$159.17
Rate for Payer: BCBS of TX Blue Essentials	$191.01
Rate for Payer: BCBS of TX PPO	$212.23
Rate for Payer: Cash Price	$466.90
Rate for Payer: Multiplan Auto	$344.87
Rate for Payer: Multiplan Commercial	$344.87
Rate for Payer: Multiplan Workers Comp	$344.87
Rate for Payer: Scott and White EPO/PPO	$265.28
Rate for Payer: Superior Health Plan EPO	$72.16

FEM COMP ARCH -- DHF

Facility

$530.57

Hospital Charge Code	80846017
Hospital Revenue Code	272
Rate for Payer: Cash Price	$466.90

fenofibrate 48 mg Tab

Facility

$21.80

Service Code	HCPCS J3490
Hospital Charge Code	77563789
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$14.17
Rate for Payer: Amerigroup CHIP/Medicaid	$1.96
Rate for Payer: BCBS of TX Blue Advantage	$6.54
Rate for Payer: BCBS of TX Blue Essentials	$7.85
Rate for Payer: BCBS of TX PPO	$8.72
Rate for Payer: Cash Price	$14.82
Rate for Payer: Multiplan Auto	$14.17
Rate for Payer: Multiplan Commercial	$14.17
Rate for Payer: Multiplan Workers Comp	$14.17
Rate for Payer: Scott and White EPO/PPO	$10.90
Rate for Payer: Superior Health Plan EPO	$2.96

fenofibrate 48 mg Tab

Facility

$21.80

Service Code	HCPCS J3490
Hospital Charge Code	77563789
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.82

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	8348677
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.57
Rate for Payer: BCBS of TX Blue Essentials	$0.68
Rate for Payer: BCBS of TX PPO	$0.75
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

fentaNYL 10 mcg/mL-NS PCA; 100 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	8348677
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

fentaNYL 25 mcg/hr TD Film, ER

Facility

$55.35

Service Code	HCPCS J3490
Hospital Charge Code	77566382
Hospital Revenue Code	250
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$35.98
Rate for Payer: Amerigroup CHIP/Medicaid	$4.98
Rate for Payer: BCBS of TX Blue Advantage	$16.60
Rate for Payer: BCBS of TX Blue Essentials	$19.93
Rate for Payer: BCBS of TX PPO	$22.14
Rate for Payer: Cash Price	$37.64
Rate for Payer: Multiplan Auto	$35.98
Rate for Payer: Multiplan Commercial	$35.98
Rate for Payer: Multiplan Workers Comp	$35.98
Rate for Payer: Scott and White EPO/PPO	$27.68
Rate for Payer: Superior Health Plan EPO	$7.53

fentaNYL 25 mcg/hr TD Film, ER

Facility

$55.35

Service Code	HCPCS J3490
Hospital Charge Code	77566382
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.64

fentaNYL 50 mcg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3010
Hospital Charge Code	77567548
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

Know your out-of-pocket cost for care.

All Charges