White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Factor XII Activity SO

Facility

$306.00

Service Code	HCPCS 85280
Hospital Charge Code	1706373
Hospital Revenue Code	305
Rate for Payer: Cash Price	$208.08

Factor XII Activity SO

Facility

$306.00

Service Code	HCPCS 85280
Hospital Charge Code	1706373
Hospital Revenue Code	305
Min. Negotiated Rate	$7.55
Max. Negotiated Rate	$220.32
Rate for Payer: Amerigroup CHIP/Medicaid	$7.55
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$19.35
Rate for Payer: Amerigroup Medicare	$19.35
Rate for Payer: BCBS of TX Blue Advantage	$91.80
Rate for Payer: BCBS of TX Blue Essentials	$110.16
Rate for Payer: BCBS of TX Medicare	$19.35
Rate for Payer: BCBS of TX PPO	$122.40
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cigna Medicaid	$220.32
Rate for Payer: Cigna Medicare	$19.35
Rate for Payer: Employer Direct Commercial	$19.35
Rate for Payer: Humana Medicare/TRICARE	$19.35
Rate for Payer: Molina CHIP/Medicaid	$220.32
Rate for Payer: Molina Dual Medicare/Medicaid	$19.35
Rate for Payer: Molina Medicare	$19.35
Rate for Payer: Multiplan Auto	$198.90
Rate for Payer: Multiplan Commercial	$198.90
Rate for Payer: Multiplan Workers Comp	$198.90
Rate for Payer: Parkland Medicaid	$220.32
Rate for Payer: Scott and White EPO/PPO	$24.19
Rate for Payer: Scott and White Medicare	$19.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$220.32
Rate for Payer: Superior Health Plan EPO	$19.35
Rate for Payer: Superior Health Plan Medicare	$19.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$19.35
Rate for Payer: Universal American Medicare	$19.35
Rate for Payer: Wellcare Medicare	$19.35
Rate for Payer: Wellmed Medicare	$19.35

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77561660
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	7445530
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.16

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77561660
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

famotidine 10 mg/mL IV Soln 2 mL

Facility

$128.17

Service Code	HCPCS j3490
Hospital Charge Code	7445530
Hospital Revenue Code	250
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: 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

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

famotidine 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	78433747
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

FAN CIRCULATION 2 SPEED CLIP-ON 6

Facility

$90.39

Hospital Charge Code	993799
Hospital Revenue Code	270
Rate for Payer: Cash Price	$61.47

FAN CIRCULATION 2 SPEED CLIP-ON 6

Facility

$90.39

Hospital Charge Code	993799
Hospital Revenue Code	270
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$65.08
Rate for Payer: Amerigroup CHIP/Medicaid	$8.14
Rate for Payer: BCBS of TX Blue Advantage	$27.12
Rate for Payer: BCBS of TX Blue Essentials	$32.54
Rate for Payer: BCBS of TX PPO	$36.16
Rate for Payer: Cash Price	$61.47
Rate for Payer: Cigna Medicaid	$65.08
Rate for Payer: Molina CHIP/Medicaid	$65.08
Rate for Payer: Multiplan Auto	$58.75
Rate for Payer: Multiplan Commercial	$58.75
Rate for Payer: Multiplan Workers Comp	$58.75
Rate for Payer: Parkland Medicaid	$65.08
Rate for Payer: Scott and White EPO/PPO	$45.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65.08
Rate for Payer: Superior Health Plan EPO	$12.29

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

Facility

$7,783.60

Service Code	HCPCS 26121
Hospital Charge Code	9900319
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$5,604.19
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$5,604.19
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$5,604.19
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,604.19
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

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	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

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

Facility

$7,783.60

Service Code	HCPCS 26121
Hospital Charge Code	9900319
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,292.85

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	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

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

Facility

$16,200.00

Service Code	HCPCS 26123
Hospital Charge Code	9900320
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,016.00

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

Facility

$16,200.00

Service Code	HCPCS 26123
Hospital Charge Code	9900320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$11,664.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$11,016.00
Rate for Payer: Cash Price	$11,016.00
Rate for Payer: Cash Price	$11,016.00
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$11,664.00
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$11,664.00
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$11,664.00
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,664.00
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Fasciectomy, plantar fascia; partial (separate procedure)

Facility

$9,906.40

Service Code	HCPCS 28060
Hospital Charge Code	9900466
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cash Price	$6,736.35
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$7,132.61
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$7,132.61
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$7,132.61
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,132.61
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

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	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Fasciectomy, plantar fascia; partial (separate procedure)

Facility

$9,906.40

Service Code	HCPCS 28060
Hospital Charge Code	9900466
Hospital Revenue Code	360
Rate for Payer: Cash Price	$6,736.35

Fasciotomy, foot and/or toe

Facility

$10,000.00

Service Code	CPT 28008
Hospital Charge Code	36028008
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Fasciotomy, foot and/or toe

Facility

$8,491.20

Service Code	HCPCS 28008
Hospital Charge Code	9900457
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,774.02

Fasciotomy, foot and/or toe

Facility

$8,491.20

Service Code	HCPCS 28008
Hospital Charge Code	9900457
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$5,774.02
Rate for Payer: Cash Price	$5,774.02
Rate for Payer: Cash Price	$5,774.02
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$6,113.66
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$6,113.66
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$6,113.66
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,113.66
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

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	$1,147.14
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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 Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$2,394.88
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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: Scott and White EPO/PPO	$1,147.14
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Fasciotomy, hip or thigh, any type

Facility

$26,458.52

Service Code	HCPCS 27025
Hospital Charge Code	9900379
Hospital Revenue Code	360
Rate for Payer: Cash Price	$17,991.79

Fasciotomy, hip or thigh, any type

Facility

$26,458.52

Service Code	HCPCS 27025
Hospital Charge Code	9900379
Hospital Revenue Code	360
Min. Negotiated Rate	$1,587.08
Max. Negotiated Rate	$19,050.13
Rate for Payer: Amerigroup CHIP/Medicaid	$2,381.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
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 Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$2,394.88
Rate for Payer: Cash Price	$17,991.79
Rate for Payer: Cash Price	$17,991.79
Rate for Payer: Cash Price	$17,991.79
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$19,050.13
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$19,050.13
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$19,050.13
Rate for Payer: Scott and White EPO/PPO	$13,229.26
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,050.13
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

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