White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Submucous resection inferior turbinate, partial or complete, any method

Facility

$6,840.98

Service Code	HCPCS 30140
Hospital Charge Code	9900595
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cash Price	$4,651.87
Rate for Payer: Cash Price	$4,651.87
Rate for Payer: Cash Price	$4,651.87
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicaid	$4,925.51
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina CHIP/Medicaid	$4,925.51
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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	$4,925.51
Rate for Payer: Scott and White EPO/PPO	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,925.51
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Submucous resection inferior turbinate, partial or complete, any method

Facility

$10,000.00

Service Code	CPT 30140
Hospital Charge Code	36030140
Hospital Revenue Code	360
Min. Negotiated Rate	$886.62
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$886.62
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Amerigroup Medicare	$3,330.57
Rate for Payer: BCBS of TX Blue Advantage	$4,374.21
Rate for Payer: BCBS of TX Blue Essentials	$5,238.58
Rate for Payer: BCBS of TX Medicare	$3,330.57
Rate for Payer: BCBS of TX PPO	$6,600.61
Rate for Payer: Cigna Commercial	$7,040.22
Rate for Payer: Cigna Medicare	$3,330.57
Rate for Payer: Employer Direct Commercial	$3,330.57
Rate for Payer: Humana Medicare/TRICARE	$3,330.57
Rate for Payer: Molina Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Molina Medicare	$3,330.57
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	$5,447.31
Rate for Payer: Scott and White Medicare	$3,330.57
Rate for Payer: Superior Health Plan EPO	$3,330.57
Rate for Payer: Superior Health Plan Medicare	$3,330.57
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,330.57
Rate for Payer: Universal American Medicare	$3,330.57
Rate for Payer: Wellcare Medicare	$3,330.57
Rate for Payer: Wellmed Medicare	$3,330.57

Submucous resection inferior turbinate, partial or complete, any method

Facility

$6,840.98

Service Code	HCPCS 30140
Hospital Charge Code	9900595
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,651.87

succinylcholine 20 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0330
Hospital Charge Code	77828712
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

succinylcholine 20 mg/mL Inj Soln 10 mL

Facility

$128.17

Service Code	HCPCS J0330
Hospital Charge Code	77828712
Hospital Revenue Code	636
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$1.93
Rate for Payer: BCBS of TX Blue Essentials	$2.31
Rate for Payer: BCBS of TX PPO	$2.57
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

sucralfate 1 g/10 mL Oral Susp 10 mL

Facility

$51.94

Service Code	HCPCS J3490
Hospital Charge Code	77828881
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.32

sucralfate 1 g/10 mL Oral Susp 10 mL

Facility

$51.94

Service Code	HCPCS J3490
Hospital Charge Code	77828881
Hospital Revenue Code	250
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$37.40
Rate for Payer: Amerigroup CHIP/Medicaid	$4.67
Rate for Payer: BCBS of TX Blue Advantage	$15.58
Rate for Payer: BCBS of TX Blue Essentials	$18.70
Rate for Payer: BCBS of TX PPO	$20.78
Rate for Payer: Cash Price	$35.32
Rate for Payer: Cigna Medicaid	$37.40
Rate for Payer: Molina CHIP/Medicaid	$37.40
Rate for Payer: Multiplan Auto	$33.76
Rate for Payer: Multiplan Commercial	$33.76
Rate for Payer: Multiplan Workers Comp	$33.76
Rate for Payer: Parkland Medicaid	$37.40
Rate for Payer: Scott and White EPO/PPO	$25.97
Rate for Payer: Superior Health Plan CHIP/Medicaid	$37.40
Rate for Payer: Superior Health Plan EPO	$7.06

sucralfate 1 g Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77828828
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

sucralfate 1 g Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77828828
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

Suction assisted lipectomy head and neck

Facility

$8,162.25

Service Code	HCPCS 15876
Hospital Charge Code	9900147
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,550.33

Suction assisted lipectomy head and neck

Facility

$10,000.00

Service Code	CPT 15876
Hospital Charge Code	36015876
Hospital Revenue Code	360
Min. Negotiated Rate	$3,559.87
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Suction assisted lipectomy head and neck

Facility

$8,162.25

Service Code	HCPCS 15876
Hospital Charge Code	9900147
Hospital Revenue Code	360
Min. Negotiated Rate	$734.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$734.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$5,550.33
Rate for Payer: Cash Price	$5,550.33
Rate for Payer: Cash Price	$5,550.33
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicaid	$5,876.82
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina CHIP/Medicaid	$5,876.82
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$5,876.82
Rate for Payer: Scott and White EPO/PPO	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,876.82
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Suction assisted lipectomy lower extremity

Facility

$1,243.40

Service Code	HCPCS 15879
Hospital Charge Code	9900150
Hospital Revenue Code	360
Rate for Payer: Cash Price	$845.51

Suction assisted lipectomy lower extremity

Facility

$10,000.00

Service Code	CPT 15879
Hospital Charge Code	36015879
Hospital Revenue Code	360
Min. Negotiated Rate	$3,559.87
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Suction assisted lipectomy lower extremity

Facility

$1,243.40

Service Code	HCPCS 15879
Hospital Charge Code	9900150
Hospital Revenue Code	360
Min. Negotiated Rate	$111.91
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$111.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$845.51
Rate for Payer: Cash Price	$845.51
Rate for Payer: Cash Price	$845.51
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicaid	$895.25
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina CHIP/Medicaid	$895.25
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$895.25
Rate for Payer: Scott and White EPO/PPO	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$895.25
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Suction assisted lipectomy trunk

Facility

$10,000.00

Service Code	CPT 15877
Hospital Charge Code	36015877
Hospital Revenue Code	360
Min. Negotiated Rate	$3,559.87
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Suction assisted lipectomy trunk

Facility

$12,243.40

Service Code	HCPCS 15877
Hospital Charge Code	9900148
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,325.51

Suction assisted lipectomy trunk

Facility

$12,243.40

Service Code	HCPCS 15877
Hospital Charge Code	9900148
Hospital Revenue Code	360
Min. Negotiated Rate	$1,101.91
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,101.91
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Amerigroup Medicare	$3,559.87
Rate for Payer: BCBS of TX Blue Advantage	$4,972.07
Rate for Payer: BCBS of TX Blue Essentials	$5,954.58
Rate for Payer: BCBS of TX Medicare	$3,559.87
Rate for Payer: BCBS of TX PPO	$7,502.77
Rate for Payer: Cash Price	$8,325.51
Rate for Payer: Cash Price	$8,325.51
Rate for Payer: Cash Price	$8,325.51
Rate for Payer: Cigna Commercial	$7,524.93
Rate for Payer: Cigna Medicaid	$8,815.25
Rate for Payer: Cigna Medicare	$3,559.87
Rate for Payer: Employer Direct Commercial	$3,559.87
Rate for Payer: Humana Medicare/TRICARE	$3,559.87
Rate for Payer: Molina CHIP/Medicaid	$8,815.25
Rate for Payer: Molina Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Molina Medicare	$3,559.87
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	$8,815.25
Rate for Payer: Scott and White EPO/PPO	$6,069.94
Rate for Payer: Scott and White Medicare	$3,559.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,815.25
Rate for Payer: Superior Health Plan EPO	$3,559.87
Rate for Payer: Superior Health Plan Medicare	$3,559.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,559.87
Rate for Payer: Universal American Medicare	$3,559.87
Rate for Payer: Wellcare Medicare	$3,559.87
Rate for Payer: Wellmed Medicare	$3,559.87

Suction assisted lipectomy upper extremity

Facility

$12,243.00

Service Code	HCPCS 15878
Hospital Charge Code	9900149
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,325.24

Suction assisted lipectomy upper extremity

Facility

$10,000.00

Service Code	CPT 15878
Hospital Charge Code	36015878
Hospital Revenue Code	360
Min. Negotiated Rate	$2,072.68
Max. Negotiated Rate	$10,000.00
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

Suction assisted lipectomy upper extremity

Facility

$12,243.00

Service Code	HCPCS 15878
Hospital Charge Code	9900149
Hospital Revenue Code	360
Min. Negotiated Rate	$1,101.87
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,101.87
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	$8,325.24
Rate for Payer: Cash Price	$8,325.24
Rate for Payer: Cash Price	$8,325.24
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$8,814.96
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	$8,814.96
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	$8,814.96
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	$8,814.96
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

sugammadex 100mg/2ml

Facility

$280.90

Service Code	HCPCS J3490
Hospital Charge Code	78353651
Hospital Revenue Code	250
Rate for Payer: Cash Price	$191.01

sugammadex 100mg/2ml

Facility

$280.90

Service Code	HCPCS J3490
Hospital Charge Code	78353651
Hospital Revenue Code	250
Min. Negotiated Rate	$25.28
Max. Negotiated Rate	$202.25
Rate for Payer: Amerigroup CHIP/Medicaid	$25.28
Rate for Payer: BCBS of TX Blue Advantage	$84.27
Rate for Payer: BCBS of TX Blue Essentials	$101.12
Rate for Payer: BCBS of TX PPO	$112.36
Rate for Payer: Cash Price	$191.01
Rate for Payer: Cigna Medicaid	$202.25
Rate for Payer: Molina CHIP/Medicaid	$202.25
Rate for Payer: Multiplan Auto	$182.59
Rate for Payer: Multiplan Commercial	$182.59
Rate for Payer: Multiplan Workers Comp	$182.59
Rate for Payer: Parkland Medicaid	$202.25
Rate for Payer: Scott and White EPO/PPO	$140.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$202.25
Rate for Payer: Superior Health Plan EPO	$38.20

sulfamethoxazole-trimethoprim 400 mg-80 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833565
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

sulfamethoxazole-trimethoprim 400 mg-80 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77833565
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

Know your out-of-pocket cost for care.

All Charges