White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHED Dislocation Repair Site Elbow w/ Anesthesia BCE

Facility

$4,398.68

Service Code	HCPCS 24605
Hospital Charge Code	8910611
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,991.10

CHED Dislocation Repair Site Elbow w/o Anesthesia BCE

Facility

$1,398.90

Service Code	HCPCS 24600
Hospital Charge Code	8914581
Hospital Revenue Code	450
Min. Negotiated Rate	$125.90
Max. Negotiated Rate	$1,007.21
Rate for Payer: Amerigroup CHIP/Medicaid	$125.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$951.25
Rate for Payer: Cash Price	$951.25
Rate for Payer: Cash Price	$951.25
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$1,007.21
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$1,007.21
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$909.28
Rate for Payer: Multiplan Commercial	$909.28
Rate for Payer: Multiplan Workers Comp	$909.28
Rate for Payer: Parkland Medicaid	$1,007.21
Rate for Payer: Scott and White EPO/PPO	$435.25
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,007.21
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED Dislocation Repair Site Elbow w/o Anesthesia BCE

Facility

$1,398.90

Service Code	HCPCS 24600
Hospital Charge Code	8914581
Hospital Revenue Code	450
Rate for Payer: Cash Price	$951.25

CHED Dislocation Repair Site Finger w/o Anesthesia BCE

Facility

$395.94

Service Code	HCPCS 26770
Hospital Charge Code	8914582
Hospital Revenue Code	450
Min. Negotiated Rate	$35.63
Max. Negotiated Rate	$543.41
Rate for Payer: Amerigroup CHIP/Medicaid	$35.63
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$269.24
Rate for Payer: Cash Price	$269.24
Rate for Payer: Cash Price	$269.24
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$285.08
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$285.08
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$257.36
Rate for Payer: Multiplan Commercial	$257.36
Rate for Payer: Multiplan Workers Comp	$257.36
Rate for Payer: Parkland Medicaid	$285.08
Rate for Payer: Scott and White EPO/PPO	$337.25
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$285.08
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED Dislocation Repair Site Finger w/o Anesthesia BCE

Facility

$395.94

Service Code	HCPCS 26770
Hospital Charge Code	8914582
Hospital Revenue Code	450
Rate for Payer: Cash Price	$269.24

CHED Dislocation Repair Site Hand BCE

Facility

$811.25

Service Code	HCPCS 26670
Hospital Charge Code	8912588
Hospital Revenue Code	450
Rate for Payer: Cash Price	$551.65

CHED Dislocation Repair Site Hand BCE

Facility

$811.25

Service Code	HCPCS 26670
Hospital Charge Code	8912588
Hospital Revenue Code	450
Min. Negotiated Rate	$73.01
Max. Negotiated Rate	$584.10
Rate for Payer: Amerigroup CHIP/Medicaid	$73.01
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$181.96
Rate for Payer: BCBS of TX Blue Essentials	$217.92
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$274.58
Rate for Payer: Cash Price	$551.65
Rate for Payer: Cash Price	$551.65
Rate for Payer: Cash Price	$551.65
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$584.10
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$584.10
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$527.31
Rate for Payer: Multiplan Commercial	$527.31
Rate for Payer: Multiplan Workers Comp	$527.31
Rate for Payer: Parkland Medicaid	$584.10
Rate for Payer: Scott and White EPO/PPO	$400.45
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$584.10
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED Dislocation Repair Site Hip Post Arthroplasty BCE

Facility

$1,329.63

Service Code	HCPCS 27265
Hospital Charge Code	8914583
Hospital Revenue Code	450
Min. Negotiated Rate	$119.67
Max. Negotiated Rate	$957.33
Rate for Payer: Amerigroup CHIP/Medicaid	$119.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$904.15
Rate for Payer: Cash Price	$904.15
Rate for Payer: Cash Price	$904.15
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$957.33
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$957.33
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$864.26
Rate for Payer: Multiplan Commercial	$864.26
Rate for Payer: Multiplan Workers Comp	$864.26
Rate for Payer: Parkland Medicaid	$957.33
Rate for Payer: Scott and White EPO/PPO	$526.65
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$957.33
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED Dislocation Repair Site Hip Post Arthroplasty BCE

Facility

$1,329.63

Service Code	HCPCS 27265
Hospital Charge Code	8914583
Hospital Revenue Code	450
Rate for Payer: Cash Price	$904.15

CHED Dislocation Repair Site Jaw BCE

Facility

$1,027.40

Service Code	HCPCS 21480
Hospital Charge Code	8912589
Hospital Revenue Code	450
Min. Negotiated Rate	$37.79
Max. Negotiated Rate	$739.73
Rate for Payer: Amerigroup CHIP/Medicaid	$92.47
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$698.63
Rate for Payer: Cash Price	$698.63
Rate for Payer: Cash Price	$698.63
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$739.73
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$739.73
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$667.81
Rate for Payer: Multiplan Commercial	$667.81
Rate for Payer: Multiplan Workers Comp	$667.81
Rate for Payer: Parkland Medicaid	$739.73
Rate for Payer: Scott and White EPO/PPO	$37.79
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$739.73
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED Dislocation Repair Site Jaw BCE

Facility

$1,027.40

Service Code	HCPCS 21480
Hospital Charge Code	8912589
Hospital Revenue Code	450
Rate for Payer: Cash Price	$698.63

CHED Dislocation Repair Site Kneecap w/o Anesthesia BCE

Facility

$550.22

Service Code	HCPCS 27560
Hospital Charge Code	8912590
Hospital Revenue Code	450
Min. Negotiated Rate	$49.52
Max. Negotiated Rate	$543.41
Rate for Payer: Amerigroup CHIP/Medicaid	$49.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$374.15
Rate for Payer: Cash Price	$374.15
Rate for Payer: Cash Price	$374.15
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$396.16
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$396.16
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$357.64
Rate for Payer: Multiplan Commercial	$357.64
Rate for Payer: Multiplan Workers Comp	$357.64
Rate for Payer: Parkland Medicaid	$396.16
Rate for Payer: Scott and White EPO/PPO	$434.84
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$396.16
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED Dislocation Repair Site Kneecap w/o Anesthesia BCE

Facility

$550.22

Service Code	HCPCS 27560
Hospital Charge Code	8912590
Hospital Revenue Code	450
Rate for Payer: Cash Price	$374.15

CHED Dislocation Repair Site Knee w/ Anesthesia BCE

Facility

$5,236.25

Service Code	HCPCS 27552
Hospital Charge Code	8914584
Hospital Revenue Code	450
Min. Negotiated Rate	$471.26
Max. Negotiated Rate	$3,770.10
Rate for Payer: Amerigroup CHIP/Medicaid	$471.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$3,560.65
Rate for Payer: Cash Price	$3,560.65
Rate for Payer: Cash Price	$3,560.65
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$3,770.10
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$3,770.10
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
Rate for Payer: Multiplan Auto	$3,403.56
Rate for Payer: Multiplan Commercial	$3,403.56
Rate for Payer: Multiplan Workers Comp	$3,403.56
Rate for Payer: Parkland Medicaid	$3,770.10
Rate for Payer: Scott and White EPO/PPO	$792.48
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,770.10
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

CHED Dislocation Repair Site Knee w/ Anesthesia BCE

Facility

$5,236.25

Service Code	HCPCS 27552
Hospital Charge Code	8914584
Hospital Revenue Code	450
Rate for Payer: Cash Price	$3,560.65

CHED Dislocation Repair Site Knuckle BCE

Facility

$983.81

Service Code	HCPCS 26700
Hospital Charge Code	8914585
Hospital Revenue Code	450
Rate for Payer: Cash Price	$668.99

CHED Dislocation Repair Site Knuckle BCE

Facility

$983.81

Service Code	HCPCS 26700
Hospital Charge Code	8914585
Hospital Revenue Code	450
Min. Negotiated Rate	$88.54
Max. Negotiated Rate	$708.34
Rate for Payer: Amerigroup CHIP/Medicaid	$88.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$181.96
Rate for Payer: BCBS of TX Blue Essentials	$217.92
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$274.58
Rate for Payer: Cash Price	$668.99
Rate for Payer: Cash Price	$668.99
Rate for Payer: Cash Price	$668.99
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$708.34
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$708.34
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$639.48
Rate for Payer: Multiplan Commercial	$639.48
Rate for Payer: Multiplan Workers Comp	$639.48
Rate for Payer: Parkland Medicaid	$708.34
Rate for Payer: Scott and White EPO/PPO	$400.51
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$708.34
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED DISLOCATION REPAIR SITE NURSEMAID ELBOW W/MAINIPLATION BCE

Facility

$1,554.75

Service Code	HCPCS 24640
Hospital Charge Code	8398504
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,057.23

CHED DISLOCATION REPAIR SITE NURSEMAID ELBOW W/MAINIPLATION BCE

Facility

$1,554.75

Service Code	HCPCS 24640
Hospital Charge Code	8398504
Hospital Revenue Code	450
Min. Negotiated Rate	$93.42
Max. Negotiated Rate	$1,119.42
Rate for Payer: Amerigroup CHIP/Medicaid	$139.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$93.42
Rate for Payer: BCBS of TX Blue Essentials	$111.88
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$140.97
Rate for Payer: Cash Price	$1,057.23
Rate for Payer: Cash Price	$1,057.23
Rate for Payer: Cash Price	$1,057.23
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$1,119.42
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$1,119.42
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$1,010.59
Rate for Payer: Multiplan Commercial	$1,010.59
Rate for Payer: Multiplan Workers Comp	$1,010.59
Rate for Payer: Parkland Medicaid	$1,119.42
Rate for Payer: Scott and White EPO/PPO	$99.47
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,119.42
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED Dislocation Repair Site Shoulder w/ Anesthesia BCE

Facility

$3,086.72

Service Code	HCPCS 23655
Hospital Charge Code	8914586
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,098.97

CHED Dislocation Repair Site Shoulder w/ Anesthesia BCE

Facility

$3,086.72

Service Code	HCPCS 23655
Hospital Charge Code	5202505
Hospital Revenue Code	450
Min. Negotiated Rate	$277.80
Max. Negotiated Rate	$3,415.58
Rate for Payer: Amerigroup CHIP/Medicaid	$277.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$2,098.97
Rate for Payer: Cash Price	$2,098.97
Rate for Payer: Cash Price	$2,098.97
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$2,222.44
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$2,222.44
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
Rate for Payer: Multiplan Auto	$2,006.37
Rate for Payer: Multiplan Commercial	$2,006.37
Rate for Payer: Multiplan Workers Comp	$2,006.37
Rate for Payer: Parkland Medicaid	$2,222.44
Rate for Payer: Scott and White EPO/PPO	$514.95
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,222.44
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

CHED Dislocation Repair Site Shoulder w/ Anesthesia BCE

Facility

$3,086.72

Service Code	HCPCS 23655
Hospital Charge Code	8914586
Hospital Revenue Code	450
Min. Negotiated Rate	$277.80
Max. Negotiated Rate	$3,415.58
Rate for Payer: Amerigroup CHIP/Medicaid	$277.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Amerigroup Medicare	$1,615.32
Rate for Payer: BCBS of TX Blue Advantage	$2,263.50
Rate for Payer: BCBS of TX Blue Essentials	$2,710.78
Rate for Payer: BCBS of TX Medicare	$1,615.32
Rate for Payer: BCBS of TX PPO	$3,415.58
Rate for Payer: Cash Price	$2,098.97
Rate for Payer: Cash Price	$2,098.97
Rate for Payer: Cash Price	$2,098.97
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$2,222.44
Rate for Payer: Cigna Medicare	$1,615.32
Rate for Payer: Employer Direct Commercial	$1,615.32
Rate for Payer: Humana Medicare/TRICARE	$1,615.32
Rate for Payer: Molina CHIP/Medicaid	$2,222.44
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
Rate for Payer: Multiplan Auto	$2,006.37
Rate for Payer: Multiplan Commercial	$2,006.37
Rate for Payer: Multiplan Workers Comp	$2,006.37
Rate for Payer: Parkland Medicaid	$2,222.44
Rate for Payer: Scott and White EPO/PPO	$514.95
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,222.44
Rate for Payer: Superior Health Plan EPO	$1,615.32
Rate for Payer: Superior Health Plan Medicare	$1,615.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Universal American Medicare	$1,615.32
Rate for Payer: Wellcare Medicare	$1,615.32
Rate for Payer: Wellmed Medicare	$1,615.32

CHED Dislocation Repair Site Shoulder w/ Anesthesia BCE

Facility

$3,086.72

Service Code	HCPCS 23655
Hospital Charge Code	5202505
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,098.97

CHED Dislocation Repair Site Shoulder w/o Anesthesia BCE

Facility

$1,758.83

Service Code	HCPCS 23650
Hospital Charge Code	8912591
Hospital Revenue Code	450
Min. Negotiated Rate	$158.29
Max. Negotiated Rate	$1,266.36
Rate for Payer: Amerigroup CHIP/Medicaid	$158.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$247.79
Rate for Payer: Amerigroup Medicare	$247.79
Rate for Payer: BCBS of TX Blue Advantage	$360.12
Rate for Payer: BCBS of TX Blue Essentials	$431.28
Rate for Payer: BCBS of TX Medicare	$247.79
Rate for Payer: BCBS of TX PPO	$543.41
Rate for Payer: Cash Price	$1,196.00
Rate for Payer: Cash Price	$1,196.00
Rate for Payer: Cash Price	$1,196.00
Rate for Payer: Cigna Commercial	$523.79
Rate for Payer: Cigna Medicaid	$1,266.36
Rate for Payer: Cigna Medicare	$247.79
Rate for Payer: Employer Direct Commercial	$247.79
Rate for Payer: Humana Medicare/TRICARE	$247.79
Rate for Payer: Molina CHIP/Medicaid	$1,266.36
Rate for Payer: Molina Dual Medicare/Medicaid	$247.79
Rate for Payer: Molina Medicare	$247.79
Rate for Payer: Multiplan Auto	$1,143.24
Rate for Payer: Multiplan Commercial	$1,143.24
Rate for Payer: Multiplan Workers Comp	$1,143.24
Rate for Payer: Parkland Medicaid	$1,266.36
Rate for Payer: Scott and White EPO/PPO	$384.12
Rate for Payer: Scott and White Medicare	$247.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,266.36
Rate for Payer: Superior Health Plan EPO	$247.79
Rate for Payer: Superior Health Plan Medicare	$247.79
Rate for Payer: Universal American Dual Medicare/Medicaid	$247.79
Rate for Payer: Universal American Medicare	$247.79
Rate for Payer: Wellcare Medicare	$247.79
Rate for Payer: Wellmed Medicare	$247.79

CHED Dislocation Repair Site Shoulder w/o Anesthesia BCE

Facility

$1,758.83

Service Code	HCPCS 23650
Hospital Charge Code	8912591
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,196.00

Know your out-of-pocket cost for care.

All Charges