White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Open treatment of tibial frac..

Facility

$37,589.70

Service Code	HCPCS 27535
Hospital Charge Code	9900414
Hospital Revenue Code	360
Rate for Payer: Cash Price	$25,561.00

Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial an

Facility

$15,408.22

Service Code	CPT 27823
Hospital Charge Code	36027823
Hospital Revenue Code	360
Min. Negotiated Rate	$3,190.98
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,190.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial an

Facility

$40,897.98

Service Code	HCPCS 27823
Hospital Charge Code	9900448
Hospital Revenue Code	360
Min. Negotiated Rate	$3,190.98
Max. Negotiated Rate	$29,446.55
Rate for Payer: Amerigroup CHIP/Medicaid	$3,190.98
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$27,810.63
Rate for Payer: Cash Price	$27,810.63
Rate for Payer: Cash Price	$27,810.63
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$29,446.55
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$29,446.55
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$29,446.55
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,446.55
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial an

Facility

$15,408.22

Service Code	CPT 27822
Hospital Charge Code	36027822
Hospital Revenue Code	360
Min. Negotiated Rate	$3,224.61
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,224.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial an

Facility

$40,897.98

Service Code	HCPCS 27823
Hospital Charge Code	9900448
Hospital Revenue Code	360
Rate for Payer: Cash Price	$27,810.63

Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial an

Facility

$18,794.85

Service Code	HCPCS 27822
Hospital Charge Code	9900447
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,780.50

Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial an

Facility

$18,794.85

Service Code	HCPCS 27822
Hospital Charge Code	9900447
Hospital Revenue Code	360
Min. Negotiated Rate	$3,224.61
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,224.61
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$13,532.29
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$13,532.29
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,532.29
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,532.29
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes int

Facility

$38,382.30

Service Code	HCPCS 24685
Hospital Charge Code	9900262
Hospital Revenue Code	360
Rate for Payer: Cash Price	$26,099.96

Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes int

Facility

$38,382.30

Service Code	HCPCS 24685
Hospital Charge Code	9900262
Hospital Revenue Code	360
Min. Negotiated Rate	$3,173.46
Max. Negotiated Rate	$27,635.26
Rate for Payer: Amerigroup CHIP/Medicaid	$3,173.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$26,099.96
Rate for Payer: Cash Price	$26,099.96
Rate for Payer: Cash Price	$26,099.96
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$27,635.26
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$27,635.26
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$27,635.26
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,635.26
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes int

Facility

$15,408.22

Service Code	CPT 24685
Hospital Charge Code	36024685
Hospital Revenue Code	360
Min. Negotiated Rate	$3,173.46
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,173.46
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of ulnar shaft fracture

Facility

$18,794.85

Service Code	HCPCS 25545
Hospital Charge Code	9900299
Hospital Revenue Code	360
Min. Negotiated Rate	$3,160.14
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,160.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$13,532.29
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$13,532.29
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,532.29
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,532.29
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of ulnar shaft fracture

Facility

$18,794.85

Service Code	HCPCS 25545
Hospital Charge Code	9900299
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,780.50

Open treatment of ulnar shaft fracture

Facility

$15,408.22

Service Code	CPT 25545
Hospital Charge Code	36025545
Hospital Revenue Code	360
Min. Negotiated Rate	$3,160.14
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,160.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of ulnar styloid fracture

Facility

$15,408.22

Service Code	CPT 25652
Hospital Charge Code	36025652
Hospital Revenue Code	360
Min. Negotiated Rate	$3,121.14
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,121.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Open treatment of ulnar styloid fracture

Facility

$13,080.00

Service Code	HCPCS 25652
Hospital Charge Code	9900308
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,894.40

Open treatment of ulnar styloid fracture

Facility

$13,080.00

Service Code	HCPCS 25652
Hospital Charge Code	9900308
Hospital Revenue Code	360
Min. Negotiated Rate	$3,121.14
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$3,121.14
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$8,894.40
Rate for Payer: Cash Price	$8,894.40
Rate for Payer: Cash Price	$8,894.40
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$9,417.60
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$9,417.60
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$9,417.60
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,417.60
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Ophth irrigation, extraocular Ophth Soln 120 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77737205
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

Ophth irrigation, extraocular Ophth Soln 120 mL

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77737205
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

OPIOID ABUSE AND DEPENDENCE

Facility

$1,158.72

Service Code	APR-DRG 7731
Min. Negotiated Rate	$1,092.49
Max. Negotiated Rate	$1,158.72
Rate for Payer: Amerigroup CHIP/Medicaid	$1,092.49
Rate for Payer: Cigna Medicaid	$1,092.49
Rate for Payer: Molina CHIP/Medicaid	$1,092.49
Rate for Payer: Parkland Medicaid	$1,092.49
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,158.72

OPIOID ABUSE AND DEPENDENCE

Facility

$9,197.75

Service Code	APR-DRG 7734
Min. Negotiated Rate	$8,671.96
Max. Negotiated Rate	$9,197.75
Rate for Payer: Amerigroup CHIP/Medicaid	$8,671.96
Rate for Payer: Cigna Medicaid	$8,671.96
Rate for Payer: Molina CHIP/Medicaid	$8,671.96
Rate for Payer: Parkland Medicaid	$8,671.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,197.75

OPIOID ABUSE AND DEPENDENCE

Facility

$3,050.70

Service Code	APR-DRG 7733
Min. Negotiated Rate	$2,876.31
Max. Negotiated Rate	$3,050.70
Rate for Payer: Amerigroup CHIP/Medicaid	$2,876.31
Rate for Payer: Cigna Medicaid	$2,876.31
Rate for Payer: Molina CHIP/Medicaid	$2,876.31
Rate for Payer: Parkland Medicaid	$2,876.31
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,050.70

OPIOID ABUSE AND DEPENDENCE

Facility

$1,882.17

Service Code	APR-DRG 7732
Min. Negotiated Rate	$1,774.58
Max. Negotiated Rate	$1,882.17
Rate for Payer: Amerigroup CHIP/Medicaid	$1,774.58
Rate for Payer: Cigna Medicaid	$1,774.58
Rate for Payer: Molina CHIP/Medicaid	$1,774.58
Rate for Payer: Parkland Medicaid	$1,774.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,882.17

Opioids and Opiate analogs; 3 or 4

Facility

$145.00

Service Code	HCPCS 80363
Hospital Charge Code	994047
Hospital Revenue Code	301
Rate for Payer: Cash Price	$98.60

Opioids and Opiate analogs; 3 or 4

Facility

$145.00

Service Code	HCPCS 80363
Hospital Charge Code	994047
Hospital Revenue Code	301
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$104.40
Rate for Payer: Amerigroup CHIP/Medicaid	$8.28
Rate for Payer: BCBS of TX Blue Advantage	$43.50
Rate for Payer: BCBS of TX Blue Essentials	$52.20
Rate for Payer: BCBS of TX PPO	$58.00
Rate for Payer: Cash Price	$98.60
Rate for Payer: Cash Price	$98.60
Rate for Payer: Cigna Medicaid	$104.40
Rate for Payer: Molina CHIP/Medicaid	$104.40
Rate for Payer: Multiplan Auto	$94.25
Rate for Payer: Multiplan Commercial	$94.25
Rate for Payer: Multiplan Workers Comp	$94.25
Rate for Payer: Parkland Medicaid	$104.40
Rate for Payer: Scott and White EPO/PPO	$72.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$104.40
Rate for Payer: Superior Health Plan EPO	$19.72

OPMI Microscope drape, sterile, 48' x 118'

Facility

$197.14

Hospital Charge Code	993733
Hospital Revenue Code	272
Min. Negotiated Rate	$17.74
Max. Negotiated Rate	$141.94
Rate for Payer: Amerigroup CHIP/Medicaid	$17.74
Rate for Payer: BCBS of TX Blue Advantage	$59.14
Rate for Payer: BCBS of TX Blue Essentials	$70.97
Rate for Payer: BCBS of TX PPO	$78.86
Rate for Payer: Cash Price	$134.06
Rate for Payer: Cigna Medicaid	$141.94
Rate for Payer: Molina CHIP/Medicaid	$141.94
Rate for Payer: Multiplan Auto	$128.14
Rate for Payer: Multiplan Commercial	$128.14
Rate for Payer: Multiplan Workers Comp	$128.14
Rate for Payer: Parkland Medicaid	$141.94
Rate for Payer: Scott and White EPO/PPO	$98.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$141.94
Rate for Payer: Superior Health Plan EPO	$26.81

Know your out-of-pocket cost for care.

All Charges