White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Repair, flexor tendon, leg secondary, with or without graft, each tendon

Facility

$37,589.70

Service Code	HCPCS 27659
Hospital Charge Code	9900432
Hospital Revenue Code	360
Rate for Payer: Cash Price	$25,561.00

Repair Hand Joint

Facility

$10,000.00

Service Code	CPT 26540
Hospital Charge Code	36026540
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Repair Hand Joint

Facility

$22,256.00

Service Code	HCPCS 26540
Hospital Charge Code	9900354
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$16,024.32
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$15,134.08
Rate for Payer: Cash Price	$15,134.08
Rate for Payer: Cash Price	$15,134.08
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$16,024.32
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$16,024.32
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$16,024.32
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,024.32
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Repair Hand Joint

Facility

$22,256.00

Service Code	HCPCS 26540
Hospital Charge Code	9900354
Hospital Revenue Code	360
Rate for Payer: Cash Price	$15,134.08

Repair initial incisional or ventral hernia incarcerated or strangulated

Facility

$8,754.38

Service Code	HCPCS 49561
Hospital Charge Code	9900716
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,952.98

Repair initial incisional or ventral hernia incarcerated or strangulated

Facility

$10,000.00

Service Code	CPT 49561
Hospital Charge Code	36049561
Hospital Revenue Code	360
Min. Negotiated Rate	$5,192.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX PPO	$7,835.54
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

Repair initial incisional or ventral hernia incarcerated or strangulated

Facility

$8,754.38

Service Code	HCPCS 49561
Hospital Charge Code	9900716
Hospital Revenue Code	360
Min. Negotiated Rate	$787.89
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$787.89
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$5,952.98
Rate for Payer: Cash Price	$5,952.98
Rate for Payer: Cash Price	$5,952.98
Rate for Payer: Cigna Medicaid	$6,303.15
Rate for Payer: Molina CHIP/Medicaid	$6,303.15
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	$6,303.15
Rate for Payer: Scott and White EPO/PPO	$4,377.19
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,303.15
Rate for Payer: Superior Health Plan EPO	$1,190.60

Repair initial incisional or ventral hernia reducible

Facility

$14,325.35

Service Code	HCPCS 49560
Hospital Charge Code	9900715
Hospital Revenue Code	360
Min. Negotiated Rate	$1,289.28
Max. Negotiated Rate	$10,314.25
Rate for Payer: Amerigroup CHIP/Medicaid	$1,289.28
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$9,741.24
Rate for Payer: Cash Price	$9,741.24
Rate for Payer: Cash Price	$9,741.24
Rate for Payer: Cigna Medicaid	$10,314.25
Rate for Payer: Molina CHIP/Medicaid	$10,314.25
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	$10,314.25
Rate for Payer: Scott and White EPO/PPO	$7,162.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,314.25
Rate for Payer: Superior Health Plan EPO	$1,948.25

Repair initial incisional or ventral hernia reducible

Facility

$14,325.35

Service Code	HCPCS 49560
Hospital Charge Code	9900715
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,741.24

Repair initial incisional or ventral hernia reducible

Facility

$10,000.00

Service Code	CPT 49560
Hospital Charge Code	36049560
Hospital Revenue Code	360
Min. Negotiated Rate	$5,192.60
Max. Negotiated Rate	$10,000.00
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX PPO	$7,835.54
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

Repair initial inguinal hernia, age 5 years or older incarcerated or strangulated

Facility

$19,100.46

Service Code	HCPCS 49507
Hospital Charge Code	9900713
Hospital Revenue Code	360
Rate for Payer: Cash Price	$12,988.31

Repair initial inguinal hernia, age 5 years or older incarcerated or strangulated

Facility

$10,000.00

Service Code	CPT 49507
Hospital Charge Code	36049507
Hospital Revenue Code	360
Min. Negotiated Rate	$1,151.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,151.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$5,853.44
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

Repair initial inguinal hernia, age 5 years or older incarcerated or strangulated

Facility

$19,100.46

Service Code	HCPCS 49507
Hospital Charge Code	9900713
Hospital Revenue Code	360
Min. Negotiated Rate	$1,151.54
Max. Negotiated Rate	$13,752.33
Rate for Payer: Amerigroup CHIP/Medicaid	$1,151.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$12,988.31
Rate for Payer: Cash Price	$12,988.31
Rate for Payer: Cash Price	$12,988.31
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicaid	$13,752.33
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina CHIP/Medicaid	$13,752.33
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$13,752.33
Rate for Payer: Scott and White EPO/PPO	$5,853.44
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,752.33
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

Repair initial inguinal hernia, age 5 years or older; reducible

Facility

$37,220.43

Service Code	HCPCS 49505
Hospital Charge Code	9900712
Hospital Revenue Code	360
Rate for Payer: Cash Price	$25,309.89

Repair initial inguinal hernia, age 5 years or older; reducible

Facility

$10,000.00

Service Code	CPT 49505
Hospital Charge Code	36049505
Hospital Revenue Code	360
Min. Negotiated Rate	$1,151.54
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,151.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$5,853.44
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

Repair initial inguinal hernia, age 5 years or older; reducible

Facility

$37,220.43

Service Code	HCPCS 49505
Hospital Charge Code	9900712
Hospital Revenue Code	360
Min. Negotiated Rate	$1,151.54
Max. Negotiated Rate	$26,798.71
Rate for Payer: Amerigroup CHIP/Medicaid	$1,151.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Amerigroup Medicare	$3,596.72
Rate for Payer: BCBS of TX Blue Advantage	$5,192.60
Rate for Payer: BCBS of TX Blue Essentials	$6,218.68
Rate for Payer: BCBS of TX Medicare	$3,596.72
Rate for Payer: BCBS of TX PPO	$7,835.54
Rate for Payer: Cash Price	$25,309.89
Rate for Payer: Cash Price	$25,309.89
Rate for Payer: Cash Price	$25,309.89
Rate for Payer: Cigna Commercial	$7,602.81
Rate for Payer: Cigna Medicaid	$26,798.71
Rate for Payer: Cigna Medicare	$3,596.72
Rate for Payer: Employer Direct Commercial	$3,596.72
Rate for Payer: Humana Medicare/TRICARE	$3,596.72
Rate for Payer: Molina CHIP/Medicaid	$26,798.71
Rate for Payer: Molina Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Molina Medicare	$3,596.72
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	$26,798.71
Rate for Payer: Scott and White EPO/PPO	$5,853.44
Rate for Payer: Scott and White Medicare	$3,596.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26,798.71
Rate for Payer: Superior Health Plan EPO	$3,596.72
Rate for Payer: Superior Health Plan Medicare	$3,596.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,596.72
Rate for Payer: Universal American Medicare	$3,596.72
Rate for Payer: Wellcare Medicare	$3,596.72
Rate for Payer: Wellmed Medicare	$3,596.72

Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5

Facility

$1,307.92

Service Code	HCPCS 12052
Hospital Charge Code	9900107
Hospital Revenue Code	360
Rate for Payer: Cash Price	$889.39

Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5

Facility

$1,307.92

Service Code	HCPCS 12052
Hospital Charge Code	5202555
Hospital Revenue Code	360
Min. Negotiated Rate	$143.08
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$143.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$269.62
Rate for Payer: BCBS of TX Blue Essentials	$322.90
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cash Price	$889.39
Rate for Payer: Cash Price	$889.39
Rate for Payer: Cash Price	$889.39
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$941.70
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$941.70
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$941.70
Rate for Payer: Scott and White EPO/PPO	$674.64
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.70
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5

Facility

$1,307.92

Service Code	HCPCS 12052
Hospital Charge Code	9900107
Hospital Revenue Code	360
Min. Negotiated Rate	$143.08
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$143.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$269.62
Rate for Payer: BCBS of TX Blue Essentials	$322.90
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cash Price	$889.39
Rate for Payer: Cash Price	$889.39
Rate for Payer: Cash Price	$889.39
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$941.70
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$941.70
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$941.70
Rate for Payer: Scott and White EPO/PPO	$674.64
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.70
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5

Facility

$1,307.92

Service Code	HCPCS 12052
Hospital Charge Code	5202555
Hospital Revenue Code	360
Rate for Payer: Cash Price	$889.39

Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5

Facility

$10,000.00

Service Code	CPT 12052
Hospital Charge Code	36012052
Hospital Revenue Code	360
Min. Negotiated Rate	$143.08
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$143.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$269.62
Rate for Payer: BCBS of TX Blue Essentials	$322.90
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$406.85
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
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	$674.64
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

Repair lateral collateral ligament, elbow, with local tissue

Facility

$12,736.80

Service Code	HCPCS 24343
Hospital Charge Code	9900249
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,661.02

Repair lateral collateral ligament, elbow, with local tissue

Facility

$12,736.80

Service Code	HCPCS 24343
Hospital Charge Code	9900249
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,661.02
Rate for Payer: Cash Price	$8,661.02
Rate for Payer: Cash Price	$8,661.02
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$9,170.50
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$9,170.50
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$9,170.50
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,170.50
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Repair lateral collateral ligament, elbow, with local tissue

Facility

$10,000.00

Service Code	CPT 24343
Hospital Charge Code	36024343
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
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	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Repair lip, full thickness; over one-half vertical height, or complex

Facility

$5,526.16

Service Code	HCPCS 40654
Hospital Charge Code	9900640
Hospital Revenue Code	360
Min. Negotiated Rate	$420.64
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$420.64
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Amerigroup Medicare	$1,558.65
Rate for Payer: BCBS of TX Blue Advantage	$2,253.40
Rate for Payer: BCBS of TX Blue Essentials	$2,698.68
Rate for Payer: BCBS of TX Medicare	$1,558.65
Rate for Payer: BCBS of TX PPO	$3,400.34
Rate for Payer: Cash Price	$3,757.79
Rate for Payer: Cash Price	$3,757.79
Rate for Payer: Cash Price	$3,757.79
Rate for Payer: Cigna Commercial	$3,294.71
Rate for Payer: Cigna Medicaid	$3,978.84
Rate for Payer: Cigna Medicare	$1,558.65
Rate for Payer: Employer Direct Commercial	$1,558.65
Rate for Payer: Humana Medicare/TRICARE	$1,558.65
Rate for Payer: Molina CHIP/Medicaid	$3,978.84
Rate for Payer: Molina Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Molina Medicare	$1,558.65
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	$3,978.84
Rate for Payer: Scott and White EPO/PPO	$2,580.23
Rate for Payer: Scott and White Medicare	$1,558.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,978.84
Rate for Payer: Superior Health Plan EPO	$1,558.65
Rate for Payer: Superior Health Plan Medicare	$1,558.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$1,558.65
Rate for Payer: Universal American Medicare	$1,558.65
Rate for Payer: Wellcare Medicare	$1,558.65
Rate for Payer: Wellmed Medicare	$1,558.65

Know your out-of-pocket cost for care.

All Charges