White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MALIGNANT BREAST DISORDERS WITH MCC

Facility

$31,996.00

Service Code	MSDRG 597
Min. Negotiated Rate	$14,735.00
Max. Negotiated Rate	$31,996.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,978.30
Rate for Payer: Amerigroup Medicare	$16,978.30
Rate for Payer: BCBS of TX Medicare	$16,978.30
Rate for Payer: Cigna Commercial	$21,472.25
Rate for Payer: Cigna Medicare	$16,978.30
Rate for Payer: Employer Direct Commercial	$16,978.30
Rate for Payer: Humana Medicare/TRICARE	$16,978.30
Rate for Payer: Molina Dual Medicare/Medicaid	$16,978.30
Rate for Payer: Molina Medicare	$16,978.30
Rate for Payer: Multiplan Auto	$31,996.00
Rate for Payer: Multiplan Commercial	$31,996.00
Rate for Payer: Multiplan Workers Comp	$31,996.00
Rate for Payer: Scott and White EPO/PPO	$14,735.00
Rate for Payer: Scott and White Medicare	$16,978.30
Rate for Payer: Superior Health Plan EPO	$16,978.30
Rate for Payer: Superior Health Plan Medicare	$16,978.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,978.30
Rate for Payer: Universal American Medicare	$16,978.30
Rate for Payer: Wellcare Medicare	$16,978.30
Rate for Payer: Wellmed Medicare	$16,978.30

MALIGNANT BREAST DISORDERS WITHOUT CC/MCC

Facility

$14,204.40

Service Code	MSDRG 599
Min. Negotiated Rate	$6,161.04
Max. Negotiated Rate	$14,204.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,399.03
Rate for Payer: Amerigroup Medicare	$10,399.03
Rate for Payer: BCBS of TX Medicare	$10,399.03
Rate for Payer: Cigna Commercial	$9,443.62
Rate for Payer: Cigna Medicare	$10,399.03
Rate for Payer: Employer Direct Commercial	$10,399.03
Rate for Payer: Humana Medicare/TRICARE	$10,399.03
Rate for Payer: Molina Dual Medicare/Medicaid	$10,399.03
Rate for Payer: Molina Medicare	$10,399.03
Rate for Payer: Multiplan Auto	$14,204.40
Rate for Payer: Multiplan Commercial	$14,204.40
Rate for Payer: Multiplan Workers Comp	$14,204.40
Rate for Payer: Scott and White EPO/PPO	$6,541.50
Rate for Payer: Scott and White Medicare	$10,399.03
Rate for Payer: Superior Health Plan EPO	$10,399.03
Rate for Payer: Superior Health Plan Medicare	$10,399.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,399.03
Rate for Payer: Universal American Medicare	$10,399.03
Rate for Payer: Wellcare Medicare	$10,399.03
Rate for Payer: Wellmed Medicare	$10,399.03

MALIGNANT BREAST DISORDERS W MCC

Facility

$31,996.00

Service Code	MSDRG 597
Min. Negotiated Rate	$14,735.00
Max. Negotiated Rate	$31,996.00
Rate for Payer: BCBS of TX Blue Advantage	$14,792.00
Rate for Payer: BCBS of TX Blue Essentials	$17,748.68
Rate for Payer: BCBS of TX PPO	$19,721.52

MALIGNANT BREAST DISORDERS W/O CC/MCC

Facility

$14,204.40

Service Code	MSDRG 599
Min. Negotiated Rate	$6,161.04
Max. Negotiated Rate	$14,204.40
Rate for Payer: BCBS of TX Blue Advantage	$6,161.04
Rate for Payer: BCBS of TX Blue Essentials	$7,392.53
Rate for Payer: BCBS of TX PPO	$8,214.24

MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS

Facility

$5,231.99

Service Code	APR-DRG 4212
Min. Negotiated Rate	$4,932.90
Max. Negotiated Rate	$5,231.99
Rate for Payer: Amerigroup CHIP/Medicaid	$4,932.90
Rate for Payer: Cigna Medicaid	$4,932.90
Rate for Payer: Molina CHIP/Medicaid	$4,932.90
Rate for Payer: Parkland Medicaid	$4,932.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,231.99

MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS

Facility

$19,075.96

Service Code	APR-DRG 4214
Min. Negotiated Rate	$17,985.48
Max. Negotiated Rate	$19,075.96
Rate for Payer: Amerigroup CHIP/Medicaid	$17,985.48
Rate for Payer: Cigna Medicaid	$17,985.48
Rate for Payer: Molina CHIP/Medicaid	$17,985.48
Rate for Payer: Parkland Medicaid	$17,985.48
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,075.96

MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS

Facility

$7,573.58

Service Code	APR-DRG 4213
Min. Negotiated Rate	$7,140.63
Max. Negotiated Rate	$7,573.58
Rate for Payer: Amerigroup CHIP/Medicaid	$7,140.63
Rate for Payer: Cigna Medicaid	$7,140.63
Rate for Payer: Molina CHIP/Medicaid	$7,140.63
Rate for Payer: Parkland Medicaid	$7,140.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,573.58

MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS

Facility

$2,939.81

Service Code	APR-DRG 4211
Min. Negotiated Rate	$2,771.76
Max. Negotiated Rate	$2,939.81
Rate for Payer: Amerigroup CHIP/Medicaid	$2,771.76
Rate for Payer: Cigna Medicaid	$2,771.76
Rate for Payer: Molina CHIP/Medicaid	$2,771.76
Rate for Payer: Parkland Medicaid	$2,771.76
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,939.81

Mammaplasty, augmentation with prosthetic implant

Facility

$26,417.22

Service Code	HCPCS 19325
Hospital Charge Code	9900157
Hospital Revenue Code	360
Rate for Payer: Cash Price	$17,963.71

Mammaplasty, augmentation with prosthetic implant

Facility

$26,417.22

Service Code	HCPCS 19325
Hospital Charge Code	9900157
Hospital Revenue Code	360
Min. Negotiated Rate	$2,281.73
Max. Negotiated Rate	$20,501.61
Rate for Payer: Amerigroup CHIP/Medicaid	$2,281.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Amerigroup Medicare	$8,210.63
Rate for Payer: BCBS of TX Blue Advantage	$13,586.39
Rate for Payer: BCBS of TX Blue Essentials	$16,271.12
Rate for Payer: BCBS of TX Medicare	$8,210.63
Rate for Payer: BCBS of TX PPO	$20,501.61
Rate for Payer: Cash Price	$17,963.71
Rate for Payer: Cash Price	$17,963.71
Rate for Payer: Cash Price	$17,963.71
Rate for Payer: Cigna Commercial	$17,355.80
Rate for Payer: Cigna Medicaid	$19,020.40
Rate for Payer: Cigna Medicare	$8,210.63
Rate for Payer: Employer Direct Commercial	$8,210.63
Rate for Payer: Humana Medicare/TRICARE	$8,210.63
Rate for Payer: Molina CHIP/Medicaid	$19,020.40
Rate for Payer: Molina Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Molina Medicare	$8,210.63
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	$19,020.40
Rate for Payer: Scott and White EPO/PPO	$15,949.03
Rate for Payer: Scott and White Medicare	$8,210.63
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,020.40
Rate for Payer: Superior Health Plan EPO	$8,210.63
Rate for Payer: Superior Health Plan Medicare	$8,210.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Universal American Medicare	$8,210.63
Rate for Payer: Wellcare Medicare	$8,210.63
Rate for Payer: Wellmed Medicare	$8,210.63

Mammaplasty, augmentation with prosthetic implant

Facility

$20,501.61

Service Code	CPT 19325
Hospital Charge Code	36019325
Hospital Revenue Code	360
Min. Negotiated Rate	$2,281.73
Max. Negotiated Rate	$20,501.61
Rate for Payer: Amerigroup CHIP/Medicaid	$2,281.73
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Amerigroup Medicare	$8,210.63
Rate for Payer: BCBS of TX Blue Advantage	$13,586.39
Rate for Payer: BCBS of TX Blue Essentials	$16,271.12
Rate for Payer: BCBS of TX Medicare	$8,210.63
Rate for Payer: BCBS of TX PPO	$20,501.61
Rate for Payer: Cigna Commercial	$17,355.80
Rate for Payer: Cigna Medicare	$8,210.63
Rate for Payer: Employer Direct Commercial	$8,210.63
Rate for Payer: Humana Medicare/TRICARE	$8,210.63
Rate for Payer: Molina Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Molina Medicare	$8,210.63
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	$15,949.03
Rate for Payer: Scott and White Medicare	$8,210.63
Rate for Payer: Superior Health Plan EPO	$8,210.63
Rate for Payer: Superior Health Plan Medicare	$8,210.63
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,210.63
Rate for Payer: Universal American Medicare	$8,210.63
Rate for Payer: Wellcare Medicare	$8,210.63
Rate for Payer: Wellmed Medicare	$8,210.63

Manifold Kit

Facility

$155.00

Hospital Charge Code	993888
Hospital Revenue Code	272
Rate for Payer: Cash Price	$105.40

Manifold Kit

Facility

$155.00

Hospital Charge Code	993888
Hospital Revenue Code	272
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$111.60
Rate for Payer: Amerigroup CHIP/Medicaid	$13.95
Rate for Payer: BCBS of TX Blue Advantage	$46.50
Rate for Payer: BCBS of TX Blue Essentials	$55.80
Rate for Payer: BCBS of TX PPO	$62.00
Rate for Payer: Cash Price	$105.40
Rate for Payer: Cigna Medicaid	$111.60
Rate for Payer: Molina CHIP/Medicaid	$111.60
Rate for Payer: Multiplan Auto	$100.75
Rate for Payer: Multiplan Commercial	$100.75
Rate for Payer: Multiplan Workers Comp	$100.75
Rate for Payer: Parkland Medicaid	$111.60
Rate for Payer: Scott and White EPO/PPO	$77.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$111.60
Rate for Payer: Superior Health Plan EPO	$21.08

MANIFOLD, STANDARD 4-PORT FOR NEPTUNE II ROVER -- DHF

Facility

$91.70

Hospital Charge Code	80325541
Hospital Revenue Code	272
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$66.02
Rate for Payer: Amerigroup CHIP/Medicaid	$8.25
Rate for Payer: BCBS of TX Blue Advantage	$27.51
Rate for Payer: BCBS of TX Blue Essentials	$33.01
Rate for Payer: BCBS of TX PPO	$36.68
Rate for Payer: Cash Price	$62.36
Rate for Payer: Cigna Medicaid	$66.02
Rate for Payer: Molina CHIP/Medicaid	$66.02
Rate for Payer: Multiplan Auto	$59.60
Rate for Payer: Multiplan Commercial	$59.60
Rate for Payer: Multiplan Workers Comp	$59.60
Rate for Payer: Parkland Medicaid	$66.02
Rate for Payer: Scott and White EPO/PPO	$45.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$66.02
Rate for Payer: Superior Health Plan EPO	$12.47

MANIFOLD, STANDARD 4-PORT FOR NEPTUNE II ROVER -- DHF

Facility

$91.70

Hospital Charge Code	80325541
Hospital Revenue Code	272
Rate for Payer: Cash Price	$62.36

Manipulation, elbow, under anesthesia

Facility

$10,000.00

Service Code	CPT 24300
Hospital Charge Code	36024300
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
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: Cigna Commercial	$3,414.49
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 Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
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

Manipulation, elbow, under anesthesia

Facility

$4,873.23

Service Code	HCPCS 24300
Hospital Charge Code	9900245
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
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	$3,313.80
Rate for Payer: Cash Price	$3,313.80
Rate for Payer: Cash Price	$3,313.80
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$3,508.73
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	$3,508.73
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$3,508.73
Rate for Payer: Scott and White EPO/PPO	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,508.73
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

Manipulation, elbow, under anesthesia

Facility

$4,873.23

Service Code	HCPCS 24300
Hospital Charge Code	9900245
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,313.80

Manipulation of knee joint under general anesthesia (includes application of traction or other fixat

Facility

$10,000.00

Service Code	CPT 27570
Hospital Charge Code	36027570
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
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: Cigna Commercial	$3,414.49
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 Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
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

Manipulation of knee joint under general anesthesia (includes application of traction or other fixat

Facility

$4,873.23

Service Code	HCPCS 27570
Hospital Charge Code	9900415
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
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	$3,313.80
Rate for Payer: Cash Price	$3,313.80
Rate for Payer: Cash Price	$3,313.80
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$3,508.73
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	$3,508.73
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$3,508.73
Rate for Payer: Scott and White EPO/PPO	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,508.73
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

Manipulation of knee joint under general anesthesia (includes application of traction or other fixat

Facility

$4,873.23

Service Code	HCPCS 27570
Hospital Charge Code	9900415
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,313.80

Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocat

Facility

$8,354.10

Service Code	HCPCS 23700
Hospital Charge Code	9900234
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
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	$5,680.79
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cash Price	$5,680.79
Rate for Payer: Cigna Commercial	$3,414.49
Rate for Payer: Cigna Medicaid	$6,014.95
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	$6,014.95
Rate for Payer: Molina Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$6,014.95
Rate for Payer: Scott and White EPO/PPO	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,014.95
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

Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocat

Facility

$10,000.00

Service Code	CPT 23700
Hospital Charge Code	36023700
Hospital Revenue Code	360
Min. Negotiated Rate	$593.04
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$593.04
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: Cigna Commercial	$3,414.49
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 Dual Medicare/Medicaid	$1,615.32
Rate for Payer: Molina Medicare	$1,615.32
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	$2,719.24
Rate for Payer: Scott and White Medicare	$1,615.32
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

Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocat

Facility

$8,354.10

Service Code	HCPCS 23700
Hospital Charge Code	9900234
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,680.79

Manipulation, wrist, under anesthesia

Facility

$3,828.96

Service Code	HCPCS 25259
Hospital Charge Code	9900281
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,603.69

Know your out-of-pocket cost for care.

All Charges