White Rock Medical Center

All Charges

Charge

Type

Setting

Price

FULL RING DIA 155 mm - ALUMINIUM

Facility

$9,143.56

Service Code	HCPCS C1713
Hospital Charge Code	993427
Hospital Revenue Code	278
Min. Negotiated Rate	$2,285.89
Max. Negotiated Rate	$4,571.78
Rate for Payer: Cash Price	$6,217.62
Rate for Payer: Cigna Commercial	$2,285.89
Rate for Payer: Multiplan Auto	$4,571.78
Rate for Payer: Multiplan Commercial	$4,571.78
Rate for Payer: Multiplan Workers Comp	$4,571.78
Rate for Payer: Scott and White EPO/PPO	$4,571.78

FULL RING DIA 155 mm - ALUMINIUM

Facility

$9,143.56

Service Code	HCPCS C1713
Hospital Charge Code	993427
Hospital Revenue Code	278
Min. Negotiated Rate	$822.92
Max. Negotiated Rate	$6,583.36
Rate for Payer: Amerigroup CHIP/Medicaid	$822.92
Rate for Payer: BCBS of TX Blue Advantage	$2,743.07
Rate for Payer: BCBS of TX Blue Essentials	$3,291.68
Rate for Payer: BCBS of TX PPO	$3,657.42
Rate for Payer: Cash Price	$6,217.62
Rate for Payer: Cigna Medicaid	$6,583.36
Rate for Payer: Molina CHIP/Medicaid	$6,583.36
Rate for Payer: Multiplan Auto	$4,571.78
Rate for Payer: Multiplan Commercial	$4,571.78
Rate for Payer: Multiplan Workers Comp	$4,571.78
Rate for Payer: Parkland Medicaid	$6,583.36
Rate for Payer: Scott and White EPO/PPO	$4,571.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,583.36
Rate for Payer: Superior Health Plan EPO	$1,243.52

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$80,256.00

Service Code	MSDRG 793
Min. Negotiated Rate	$33,100.54
Max. Negotiated Rate	$80,256.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35,319.19
Rate for Payer: Amerigroup Medicare	$35,319.19
Rate for Payer: BCBS of TX Medicare	$35,319.19
Rate for Payer: Cigna Commercial	$53,704.45
Rate for Payer: Cigna Medicare	$35,319.19
Rate for Payer: Employer Direct Commercial	$35,319.19
Rate for Payer: Humana Medicare/TRICARE	$35,319.19
Rate for Payer: Molina Dual Medicare/Medicaid	$35,319.19
Rate for Payer: Molina Medicare	$35,319.19
Rate for Payer: Multiplan Auto	$80,256.00
Rate for Payer: Multiplan Commercial	$80,256.00
Rate for Payer: Multiplan Workers Comp	$80,256.00
Rate for Payer: Scott and White EPO/PPO	$36,960.00
Rate for Payer: Scott and White Medicare	$35,319.19
Rate for Payer: Superior Health Plan EPO	$35,319.19
Rate for Payer: Superior Health Plan Medicare	$35,319.19
Rate for Payer: Universal American Dual Medicare/Medicaid	$35,319.19
Rate for Payer: Universal American Medicare	$35,319.19
Rate for Payer: Wellcare Medicare	$35,319.19
Rate for Payer: Wellmed Medicare	$35,319.19

FULL TERM NEONATE W MAJOR PROBLEMS

Facility

$80,256.00

Service Code	MSDRG 793
Min. Negotiated Rate	$33,100.54
Max. Negotiated Rate	$80,256.00
Rate for Payer: BCBS of TX Blue Advantage	$33,100.54
Rate for Payer: BCBS of TX Blue Essentials	$39,716.80
Rate for Payer: BCBS of TX PPO	$44,131.49

FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY

Facility

$35,644.00

Service Code	MSDRG 934
Min. Negotiated Rate	$15,768.10
Max. Negotiated Rate	$35,644.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,961.62
Rate for Payer: Amerigroup Medicare	$20,961.62
Rate for Payer: BCBS of TX Medicare	$20,961.62
Rate for Payer: Cigna Commercial	$28,472.53
Rate for Payer: Cigna Medicare	$20,961.62
Rate for Payer: Employer Direct Commercial	$20,961.62
Rate for Payer: Humana Medicare/TRICARE	$20,961.62
Rate for Payer: Molina Dual Medicare/Medicaid	$20,961.62
Rate for Payer: Molina Medicare	$20,961.62
Rate for Payer: Multiplan Auto	$35,644.00
Rate for Payer: Multiplan Commercial	$35,644.00
Rate for Payer: Multiplan Workers Comp	$35,644.00
Rate for Payer: Scott and White EPO/PPO	$16,415.00
Rate for Payer: Scott and White Medicare	$20,961.62
Rate for Payer: Superior Health Plan EPO	$20,961.62
Rate for Payer: Superior Health Plan Medicare	$20,961.62
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,961.62
Rate for Payer: Universal American Medicare	$20,961.62
Rate for Payer: Wellcare Medicare	$20,961.62
Rate for Payer: Wellmed Medicare	$20,961.62

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC

Facility

$117,634.70

Service Code	MSDRG 928
Min. Negotiated Rate	$50,530.16
Max. Negotiated Rate	$117,634.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$57,328.99
Rate for Payer: Amerigroup Medicare	$57,328.99
Rate for Payer: BCBS of TX Medicare	$57,328.99
Rate for Payer: Cigna Commercial	$92,384.38
Rate for Payer: Cigna Medicare	$57,328.99
Rate for Payer: Employer Direct Commercial	$57,328.99
Rate for Payer: Humana Medicare/TRICARE	$57,328.99
Rate for Payer: Molina Dual Medicare/Medicaid	$57,328.99
Rate for Payer: Molina Medicare	$57,328.99
Rate for Payer: Multiplan Auto	$117,634.70
Rate for Payer: Multiplan Commercial	$117,634.70
Rate for Payer: Multiplan Workers Comp	$117,634.70
Rate for Payer: Scott and White EPO/PPO	$54,173.88
Rate for Payer: Scott and White Medicare	$57,328.99
Rate for Payer: Superior Health Plan EPO	$57,328.99
Rate for Payer: Superior Health Plan Medicare	$57,328.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$57,328.99
Rate for Payer: Universal American Medicare	$57,328.99
Rate for Payer: Wellcare Medicare	$57,328.99
Rate for Payer: Wellmed Medicare	$57,328.99

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC

Facility

$55,837.20

Service Code	MSDRG 929
Min. Negotiated Rate	$25,560.92
Max. Negotiated Rate	$55,837.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,365.40
Rate for Payer: Amerigroup Medicare	$28,365.40
Rate for Payer: BCBS of TX Medicare	$28,365.40
Rate for Payer: Cigna Commercial	$41,483.90
Rate for Payer: Cigna Medicare	$28,365.40
Rate for Payer: Employer Direct Commercial	$28,365.40
Rate for Payer: Humana Medicare/TRICARE	$28,365.40
Rate for Payer: Molina Dual Medicare/Medicaid	$28,365.40
Rate for Payer: Molina Medicare	$28,365.40
Rate for Payer: Multiplan Auto	$55,837.20
Rate for Payer: Multiplan Commercial	$55,837.20
Rate for Payer: Multiplan Workers Comp	$55,837.20
Rate for Payer: Scott and White EPO/PPO	$25,714.50
Rate for Payer: Scott and White Medicare	$28,365.40
Rate for Payer: Superior Health Plan EPO	$28,365.40
Rate for Payer: Superior Health Plan Medicare	$28,365.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,365.40
Rate for Payer: Universal American Medicare	$28,365.40
Rate for Payer: Wellcare Medicare	$28,365.40
Rate for Payer: Wellmed Medicare	$28,365.40

FULL THICKNESS BURN W/O SKIN GRAFT OR INHAL INJ

Facility

$35,644.00

Service Code	MSDRG 934
Min. Negotiated Rate	$15,768.10
Max. Negotiated Rate	$35,644.00
Rate for Payer: BCBS of TX Blue Advantage	$15,768.10
Rate for Payer: BCBS of TX Blue Essentials	$18,919.89
Rate for Payer: BCBS of TX PPO	$21,022.91

FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC/MCC

Facility

$117,634.70

Service Code	MSDRG 928
Min. Negotiated Rate	$50,530.16
Max. Negotiated Rate	$117,634.70
Rate for Payer: BCBS of TX Blue Advantage	$50,530.16
Rate for Payer: BCBS of TX Blue Essentials	$60,630.32
Rate for Payer: BCBS of TX PPO	$67,369.63

FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W/O CC/MCC

Facility

$55,837.20

Service Code	MSDRG 929
Min. Negotiated Rate	$25,560.92
Max. Negotiated Rate	$55,837.20
Rate for Payer: BCBS of TX Blue Advantage	$25,560.92
Rate for Payer: BCBS of TX Blue Essentials	$30,670.13
Rate for Payer: BCBS of TX PPO	$34,079.25

Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth,

Facility

$10,000.00

Service Code	CPT 15240
Hospital Charge Code	36015240
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth,

Facility

$4,717.24

Service Code	HCPCS 15240
Hospital Charge Code	9900125
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,207.72

Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth,

Facility

$4,717.24

Service Code	HCPCS 15240
Hospital Charge Code	9900125
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,207.72
Rate for Payer: Cash Price	$3,207.72
Rate for Payer: Cash Price	$3,207.72
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,396.41
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,396.41
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,396.41
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,396.41
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq

Facility

$5,177.58

Service Code	HCPCS 15220
Hospital Charge Code	9900124
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,520.75

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq

Facility

$5,177.58

Service Code	HCPCS 15220
Hospital Charge Code	9900124
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$3,520.75
Rate for Payer: Cash Price	$3,520.75
Rate for Payer: Cash Price	$3,520.75
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$3,727.86
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$3,727.86
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,727.86
Rate for Payer: Scott and White EPO/PPO	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,727.86
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq

Facility

$10,000.00

Service Code	CPT 15220
Hospital Charge Code	36015220
Hospital Revenue Code	360
Min. Negotiated Rate	$709.01
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$709.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
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	$3,085.41
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

Fungal Antibodies, DID SO

Facility

$148.00

Service Code	HCPCS 86612
Hospital Charge Code	1705839
Hospital Revenue Code	302
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$106.56
Rate for Payer: Amerigroup CHIP/Medicaid	$5.03
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12.90
Rate for Payer: Amerigroup Medicare	$12.90
Rate for Payer: BCBS of TX Blue Advantage	$44.40
Rate for Payer: BCBS of TX Blue Essentials	$53.28
Rate for Payer: BCBS of TX Medicare	$12.90
Rate for Payer: BCBS of TX PPO	$59.20
Rate for Payer: Cash Price	$100.64
Rate for Payer: Cash Price	$100.64
Rate for Payer: Cigna Medicaid	$106.56
Rate for Payer: Cigna Medicare	$12.90
Rate for Payer: Employer Direct Commercial	$12.90
Rate for Payer: Humana Medicare/TRICARE	$12.90
Rate for Payer: Molina CHIP/Medicaid	$106.56
Rate for Payer: Molina Dual Medicare/Medicaid	$12.90
Rate for Payer: Molina Medicare	$12.90
Rate for Payer: Multiplan Auto	$96.20
Rate for Payer: Multiplan Commercial	$96.20
Rate for Payer: Multiplan Workers Comp	$96.20
Rate for Payer: Parkland Medicaid	$106.56
Rate for Payer: Scott and White EPO/PPO	$16.12
Rate for Payer: Scott and White Medicare	$12.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$106.56
Rate for Payer: Superior Health Plan EPO	$12.90
Rate for Payer: Superior Health Plan Medicare	$12.90
Rate for Payer: Universal American Dual Medicare/Medicaid	$12.90
Rate for Payer: Universal American Medicare	$12.90
Rate for Payer: Wellcare Medicare	$12.90
Rate for Payer: Wellmed Medicare	$12.90

Fungal Antibodies, DID SO

Facility

$148.00

Service Code	HCPCS 86612
Hospital Charge Code	1705839
Hospital Revenue Code	302
Rate for Payer: Cash Price	$100.64

Fungus (Mycology) Culture SO

Facility

$154.00

Service Code	HCPCS 87101
Hospital Charge Code	1604362
Hospital Revenue Code	306
Rate for Payer: Cash Price	$104.72

Fungus (Mycology) Culture SO

Facility

$154.00

Service Code	HCPCS 87101
Hospital Charge Code	1604362
Hospital Revenue Code	306
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$110.88
Rate for Payer: Amerigroup CHIP/Medicaid	$3.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7.71
Rate for Payer: Amerigroup Medicare	$7.71
Rate for Payer: BCBS of TX Blue Advantage	$46.20
Rate for Payer: BCBS of TX Blue Essentials	$55.44
Rate for Payer: BCBS of TX Medicare	$7.71
Rate for Payer: BCBS of TX PPO	$61.60
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cash Price	$104.72
Rate for Payer: Cigna Medicaid	$110.88
Rate for Payer: Cigna Medicare	$7.71
Rate for Payer: Employer Direct Commercial	$7.71
Rate for Payer: Humana Medicare/TRICARE	$7.71
Rate for Payer: Molina CHIP/Medicaid	$110.88
Rate for Payer: Molina Dual Medicare/Medicaid	$7.71
Rate for Payer: Molina Medicare	$7.71
Rate for Payer: Multiplan Auto	$100.10
Rate for Payer: Multiplan Commercial	$100.10
Rate for Payer: Multiplan Workers Comp	$100.10
Rate for Payer: Parkland Medicaid	$110.88
Rate for Payer: Scott and White EPO/PPO	$9.64
Rate for Payer: Scott and White Medicare	$7.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$110.88
Rate for Payer: Superior Health Plan EPO	$7.71
Rate for Payer: Superior Health Plan Medicare	$7.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$7.71
Rate for Payer: Universal American Medicare	$7.71
Rate for Payer: Wellcare Medicare	$7.71
Rate for Payer: Wellmed Medicare	$7.71

furosemide 10 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J1941
Hospital Charge Code	77585191
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$395.03
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$296.79
Rate for Payer: BCBS of TX Blue Essentials	$356.14
Rate for Payer: BCBS of TX PPO	$395.03
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

furosemide 10 mg/mL Inj Soln 2 mL

Facility

$128.17

Service Code	HCPCS J1941
Hospital Charge Code	77585191
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

furosemide 10 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1941
Hospital Charge Code	77585248
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

furosemide 10 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1941
Hospital Charge Code	77585132
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$395.03
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$296.79
Rate for Payer: BCBS of TX Blue Essentials	$356.14
Rate for Payer: BCBS of TX PPO	$395.03
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

furosemide 10 mg/mL Inj Soln 4 mL

Facility

$128.17

Service Code	HCPCS J1941
Hospital Charge Code	77585248
Hospital Revenue Code	636
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$395.03
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$296.79
Rate for Payer: BCBS of TX Blue Essentials	$356.14
Rate for Payer: BCBS of TX PPO	$395.03
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

Know your out-of-pocket cost for care.

All Charges