White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$136,281.30

Service Code	MSDRG 928
Min. Negotiated Rate	$50,530.16
Max. Negotiated Rate	$136,281.30
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	$136,281.30
Rate for Payer: Multiplan Commercial	$136,281.30
Rate for Payer: Multiplan Workers Comp	$136,281.30
Rate for Payer: Scott and White EPO/PPO	$62,761.12
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

$61,195.20

Service Code	MSDRG 929
Min. Negotiated Rate	$25,560.92
Max. Negotiated Rate	$61,195.20
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	$61,195.20
Rate for Payer: Multiplan Commercial	$61,195.20
Rate for Payer: Multiplan Workers Comp	$61,195.20
Rate for Payer: Scott and White EPO/PPO	$28,182.00
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

$42,001.40

Service Code	MSDRG 934
Min. Negotiated Rate	$15,768.10
Max. Negotiated Rate	$42,001.40
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

$136,281.30

Service Code	MSDRG 928
Min. Negotiated Rate	$50,530.16
Max. Negotiated Rate	$136,281.30
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

$61,195.20

Service Code	MSDRG 929
Min. Negotiated Rate	$25,560.92
Max. Negotiated Rate	$61,195.20
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

$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	$3,834.46
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, 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

$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	$3,834.46
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, 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

$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	$3,834.46
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, 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	$3,834.46
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

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

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

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	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

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	$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 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585407
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

furosemide 20 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585407
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

furosemide 40 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585462
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

furosemide 40 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77585462
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges