White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHED Injections/Nerve Block Thrombolytic Administration BCE

Facility

$2,917.00

Service Code	HCPCS 37195
Hospital Charge Code	8912631
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,983.56

CHED Injections/Nerve Block Thrombolytic Administration BCE

Facility

$2,917.00

Service Code	HCPCS 37195
Hospital Charge Code	8912631
Hospital Revenue Code	450
Min. Negotiated Rate	$262.53
Max. Negotiated Rate	$2,100.24
Rate for Payer: Amerigroup CHIP/Medicaid	$262.53
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$331.81
Rate for Payer: Amerigroup Medicare	$331.81
Rate for Payer: BCBS of TX Blue Advantage	$517.03
Rate for Payer: BCBS of TX Blue Essentials	$619.20
Rate for Payer: BCBS of TX Medicare	$331.81
Rate for Payer: BCBS of TX PPO	$780.19
Rate for Payer: Cash Price	$1,983.56
Rate for Payer: Cash Price	$1,983.56
Rate for Payer: Cash Price	$1,983.56
Rate for Payer: Cigna Commercial	$701.38
Rate for Payer: Cigna Medicaid	$2,100.24
Rate for Payer: Cigna Medicare	$331.81
Rate for Payer: Employer Direct Commercial	$331.81
Rate for Payer: Humana Medicare/TRICARE	$331.81
Rate for Payer: Molina CHIP/Medicaid	$2,100.24
Rate for Payer: Molina Dual Medicare/Medicaid	$331.81
Rate for Payer: Molina Medicare	$331.81
Rate for Payer: Multiplan Auto	$1,896.05
Rate for Payer: Multiplan Commercial	$1,896.05
Rate for Payer: Multiplan Workers Comp	$1,896.05
Rate for Payer: Parkland Medicaid	$2,100.24
Rate for Payer: Scott and White EPO/PPO	$1,458.50
Rate for Payer: Scott and White Medicare	$331.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,100.24
Rate for Payer: Superior Health Plan EPO	$331.81
Rate for Payer: Superior Health Plan Medicare	$331.81
Rate for Payer: Universal American Dual Medicare/Medicaid	$331.81
Rate for Payer: Universal American Medicare	$331.81
Rate for Payer: Wellcare Medicare	$331.81
Rate for Payer: Wellmed Medicare	$331.81

CHED INJ W/FLUOR EVAL CV DEVICE BCE

Facility

$1,195.08

Service Code	HCPCS 36598
Hospital Charge Code	9075008
Hospital Revenue Code	450
Rate for Payer: Cash Price	$812.65

CHED INJ W/FLUOR EVAL CV DEVICE BCE

Facility

$1,195.08

Service Code	HCPCS 36598
Hospital Charge Code	9075008
Hospital Revenue Code	450
Min. Negotiated Rate	$42.61
Max. Negotiated Rate	$860.46
Rate for Payer: Amerigroup CHIP/Medicaid	$107.56
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$213.67
Rate for Payer: Amerigroup Medicare	$213.67
Rate for Payer: BCBS of TX Blue Advantage	$155.04
Rate for Payer: BCBS of TX Blue Essentials	$185.68
Rate for Payer: BCBS of TX Medicare	$213.67
Rate for Payer: BCBS of TX PPO	$233.96
Rate for Payer: Cash Price	$812.65
Rate for Payer: Cash Price	$812.65
Rate for Payer: Cash Price	$812.65
Rate for Payer: Cigna Commercial	$451.67
Rate for Payer: Cigna Medicaid	$860.46
Rate for Payer: Cigna Medicare	$213.67
Rate for Payer: Employer Direct Commercial	$213.67
Rate for Payer: Humana Medicare/TRICARE	$213.67
Rate for Payer: Molina CHIP/Medicaid	$860.46
Rate for Payer: Molina Dual Medicare/Medicaid	$213.67
Rate for Payer: Molina Medicare	$213.67
Rate for Payer: Multiplan Auto	$776.80
Rate for Payer: Multiplan Commercial	$776.80
Rate for Payer: Multiplan Workers Comp	$776.80
Rate for Payer: Parkland Medicaid	$860.46
Rate for Payer: Scott and White EPO/PPO	$42.61
Rate for Payer: Scott and White Medicare	$213.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$860.46
Rate for Payer: Superior Health Plan EPO	$213.67
Rate for Payer: Superior Health Plan Medicare	$213.67
Rate for Payer: Universal American Dual Medicare/Medicaid	$213.67
Rate for Payer: Universal American Medicare	$213.67
Rate for Payer: Wellcare Medicare	$213.67
Rate for Payer: Wellmed Medicare	$213.67

CHED INSJ TEMP NDWELLG BLD CATH SMPL BCE

Facility

$564.00

Service Code	HCPCS 51702
Hospital Charge Code	8398502
Hospital Revenue Code	450
Min. Negotiated Rate	$30.68
Max. Negotiated Rate	$406.08
Rate for Payer: Amerigroup CHIP/Medicaid	$50.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$383.52
Rate for Payer: Cash Price	$383.52
Rate for Payer: Cash Price	$383.52
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$406.08
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$406.08
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$366.60
Rate for Payer: Multiplan Commercial	$366.60
Rate for Payer: Multiplan Workers Comp	$366.60
Rate for Payer: Parkland Medicaid	$406.08
Rate for Payer: Scott and White EPO/PPO	$30.68
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$406.08
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

CHED INSJ TEMP NDWELLG BLD CATH SMPL BCE

Facility

$564.00

Service Code	HCPCS 51702
Hospital Charge Code	8398502
Hospital Revenue Code	450
Rate for Payer: Cash Price	$383.52

CHED INSJ TEMP NDWELLG BLD CATH SMPL BCE

Facility

$564.00

Service Code	HCPCS 51702
Hospital Charge Code	8912625
Hospital Revenue Code	450
Min. Negotiated Rate	$30.68
Max. Negotiated Rate	$406.08
Rate for Payer: Amerigroup CHIP/Medicaid	$50.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$133.65
Rate for Payer: Amerigroup Medicare	$133.65
Rate for Payer: BCBS of TX Blue Advantage	$182.08
Rate for Payer: BCBS of TX Blue Essentials	$218.06
Rate for Payer: BCBS of TX Medicare	$133.65
Rate for Payer: BCBS of TX PPO	$274.76
Rate for Payer: Cash Price	$383.52
Rate for Payer: Cash Price	$383.52
Rate for Payer: Cash Price	$383.52
Rate for Payer: Cigna Commercial	$282.53
Rate for Payer: Cigna Medicaid	$406.08
Rate for Payer: Cigna Medicare	$133.65
Rate for Payer: Employer Direct Commercial	$133.65
Rate for Payer: Humana Medicare/TRICARE	$133.65
Rate for Payer: Molina CHIP/Medicaid	$406.08
Rate for Payer: Molina Dual Medicare/Medicaid	$133.65
Rate for Payer: Molina Medicare	$133.65
Rate for Payer: Multiplan Auto	$366.60
Rate for Payer: Multiplan Commercial	$366.60
Rate for Payer: Multiplan Workers Comp	$366.60
Rate for Payer: Parkland Medicaid	$406.08
Rate for Payer: Scott and White EPO/PPO	$30.68
Rate for Payer: Scott and White Medicare	$133.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$406.08
Rate for Payer: Superior Health Plan EPO	$133.65
Rate for Payer: Superior Health Plan Medicare	$133.65
Rate for Payer: Universal American Dual Medicare/Medicaid	$133.65
Rate for Payer: Universal American Medicare	$133.65
Rate for Payer: Wellcare Medicare	$133.65
Rate for Payer: Wellmed Medicare	$133.65

CHED INSJ TEMP NDWELLG BLD CATH SMPL BCE

Facility

$564.00

Service Code	HCPCS 51702
Hospital Charge Code	8912625
Hospital Revenue Code	450
Rate for Payer: Cash Price	$383.52

CHED INTMD RPR FACE/MM 7.6-12.5CM BCE

Facility

$1,763.83

Service Code	HCPCS 12054
Hospital Charge Code	8914607
Hospital Revenue Code	450
Min. Negotiated Rate	$158.74
Max. Negotiated Rate	$1,269.96
Rate for Payer: Amerigroup CHIP/Medicaid	$158.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$533.58
Rate for Payer: BCBS of TX Blue Essentials	$639.02
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$805.17
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,269.96
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	$1,269.96
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,146.49
Rate for Payer: Multiplan Commercial	$1,146.49
Rate for Payer: Multiplan Workers Comp	$1,146.49
Rate for Payer: Parkland Medicaid	$1,269.96
Rate for Payer: Scott and White EPO/PPO	$269.43
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,269.96
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

CHED INTMD RPR FACE/MM 7.6-12.5CM BCE

Facility

$1,763.83

Service Code	HCPCS 12054
Hospital Charge Code	8914607
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,199.40

CHED INTMD RPR N-HF/GENIT7.6-12.5 BCE

Facility

$3,943.00

Service Code	HCPCS 12044
Hospital Charge Code	8926660
Hospital Revenue Code	450
Min. Negotiated Rate	$262.74
Max. Negotiated Rate	$2,838.96
Rate for Payer: Amerigroup CHIP/Medicaid	$354.87
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$2,681.24
Rate for Payer: Cash Price	$2,681.24
Rate for Payer: Cash Price	$2,681.24
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$2,838.96
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$2,838.96
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
Rate for Payer: Multiplan Auto	$2,562.95
Rate for Payer: Multiplan Commercial	$2,562.95
Rate for Payer: Multiplan Workers Comp	$2,562.95
Rate for Payer: Parkland Medicaid	$2,838.96
Rate for Payer: Scott and White EPO/PPO	$262.74
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,838.96
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

CHED INTMD RPR N-HF/GENIT7.6-12.5 BCE

Facility

$3,943.00

Service Code	HCPCS 12044
Hospital Charge Code	8926660
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,681.24

CHED IRRIGATION CORPORA CAVERNOSA PRIAPISM BCE

Facility

$887.00

Service Code	HCPCS 54220
Hospital Charge Code	8912626
Hospital Revenue Code	450
Min. Negotiated Rate	$79.83
Max. Negotiated Rate	$638.64
Rate for Payer: Amerigroup CHIP/Medicaid	$79.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$250.99
Rate for Payer: Amerigroup Medicare	$250.99
Rate for Payer: BCBS of TX Blue Advantage	$392.28
Rate for Payer: BCBS of TX Blue Essentials	$469.80
Rate for Payer: BCBS of TX Medicare	$250.99
Rate for Payer: BCBS of TX PPO	$591.95
Rate for Payer: Cash Price	$603.16
Rate for Payer: Cash Price	$603.16
Rate for Payer: Cash Price	$603.16
Rate for Payer: Cigna Commercial	$530.54
Rate for Payer: Cigna Medicaid	$638.64
Rate for Payer: Cigna Medicare	$250.99
Rate for Payer: Employer Direct Commercial	$250.99
Rate for Payer: Humana Medicare/TRICARE	$250.99
Rate for Payer: Molina CHIP/Medicaid	$638.64
Rate for Payer: Molina Dual Medicare/Medicaid	$250.99
Rate for Payer: Molina Medicare	$250.99
Rate for Payer: Multiplan Auto	$576.55
Rate for Payer: Multiplan Commercial	$576.55
Rate for Payer: Multiplan Workers Comp	$576.55
Rate for Payer: Parkland Medicaid	$638.64
Rate for Payer: Scott and White EPO/PPO	$163.96
Rate for Payer: Scott and White Medicare	$250.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$638.64
Rate for Payer: Superior Health Plan EPO	$250.99
Rate for Payer: Superior Health Plan Medicare	$250.99
Rate for Payer: Universal American Dual Medicare/Medicaid	$250.99
Rate for Payer: Universal American Medicare	$250.99
Rate for Payer: Wellcare Medicare	$250.99
Rate for Payer: Wellmed Medicare	$250.99

CHED IRRIGATION CORPORA CAVERNOSA PRIAPISM BCE

Facility

$887.00

Service Code	HCPCS 54220
Hospital Charge Code	8912626
Hospital Revenue Code	450
Rate for Payer: Cash Price	$603.16

CHED Laceration Complex - Eye/Ear/Nose/Lip 1.1 to 2.5 cm BCE

Facility

$1,558.00

Service Code	HCPCS 13151
Hospital Charge Code	8914610
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,059.44

CHED Laceration Complex - Eye/Ear/Nose/Lip 1.1 to 2.5 cm BCE

Facility

$1,558.00

Service Code	HCPCS 13151
Hospital Charge Code	8914610
Hospital Revenue Code	450
Min. Negotiated Rate	$140.22
Max. Negotiated Rate	$1,569.38
Rate for Payer: Amerigroup CHIP/Medicaid	$140.22
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$1,059.44
Rate for Payer: Cash Price	$1,059.44
Rate for Payer: Cash Price	$1,059.44
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,121.76
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$1,121.76
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
Rate for Payer: Multiplan Auto	$1,012.70
Rate for Payer: Multiplan Commercial	$1,012.70
Rate for Payer: Multiplan Workers Comp	$1,012.70
Rate for Payer: Parkland Medicaid	$1,121.76
Rate for Payer: Scott and White EPO/PPO	$339.11
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,121.76
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

CHED Laceration Complex - Eye/Ear/Nose/Lip Each Addl 5 cm BCE

Facility

$2,381.00

Service Code	HCPCS 13153
Hospital Charge Code	8912633
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,619.08

CHED Laceration Complex - Eye/Ear/Nose/Lip Each Addl 5 cm BCE

Facility

$2,381.00

Service Code	HCPCS 13153
Hospital Charge Code	8912633
Hospital Revenue Code	450
Min. Negotiated Rate	$165.35
Max. Negotiated Rate	$3,520.00
Rate for Payer: Amerigroup CHIP/Medicaid	$214.29
Rate for Payer: BCBS of TX Blue Advantage	$714.30
Rate for Payer: BCBS of TX Blue Essentials	$857.16
Rate for Payer: BCBS of TX PPO	$3,520.00
Rate for Payer: Cash Price	$1,619.08
Rate for Payer: Cash Price	$1,619.08
Rate for Payer: Cash Price	$1,619.08
Rate for Payer: Cigna Medicaid	$1,714.32
Rate for Payer: Molina CHIP/Medicaid	$1,714.32
Rate for Payer: Multiplan Auto	$1,547.65
Rate for Payer: Multiplan Commercial	$1,547.65
Rate for Payer: Multiplan Workers Comp	$1,547.65
Rate for Payer: Parkland Medicaid	$1,714.32
Rate for Payer: Scott and White EPO/PPO	$165.35
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,714.32
Rate for Payer: Superior Health Plan EPO	$323.82

CHED LACERATION COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/< BCE

Facility

$2,545.00

Service Code	HCPCS 13133
Hospital Charge Code	8914609
Hospital Revenue Code	450
Min. Negotiated Rate	$152.14
Max. Negotiated Rate	$3,520.00
Rate for Payer: Amerigroup CHIP/Medicaid	$229.05
Rate for Payer: BCBS of TX Blue Advantage	$763.50
Rate for Payer: BCBS of TX Blue Essentials	$916.20
Rate for Payer: BCBS of TX PPO	$3,520.00
Rate for Payer: Cash Price	$1,730.60
Rate for Payer: Cash Price	$1,730.60
Rate for Payer: Cash Price	$1,730.60
Rate for Payer: Cigna Medicaid	$1,832.40
Rate for Payer: Molina CHIP/Medicaid	$1,832.40
Rate for Payer: Multiplan Auto	$1,654.25
Rate for Payer: Multiplan Commercial	$1,654.25
Rate for Payer: Multiplan Workers Comp	$1,654.25
Rate for Payer: Parkland Medicaid	$1,832.40
Rate for Payer: Scott and White EPO/PPO	$152.14
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,832.40
Rate for Payer: Superior Health Plan EPO	$346.12

CHED LACERATION COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/< BCE

Facility

$2,545.00

Service Code	HCPCS 13133
Hospital Charge Code	8914609
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,730.60

CHED Laceration Complex - F/N/H/F/G 2.6 to 7.5 cm BCE

Facility

$1,041.00

Service Code	HCPCS 13132
Hospital Charge Code	8912634
Hospital Revenue Code	450
Rate for Payer: Cash Price	$707.88

CHED Laceration Complex - F/N/H/F/G 2.6 to 7.5 cm BCE

Facility

$1,041.00

Service Code	HCPCS 13132
Hospital Charge Code	8912634
Hospital Revenue Code	450
Min. Negotiated Rate	$93.69
Max. Negotiated Rate	$1,252.49
Rate for Payer: Amerigroup CHIP/Medicaid	$93.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$707.88
Rate for Payer: Cash Price	$707.88
Rate for Payer: Cash Price	$707.88
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$749.52
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	$749.52
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$676.65
Rate for Payer: Multiplan Commercial	$676.65
Rate for Payer: Multiplan Workers Comp	$676.65
Rate for Payer: Parkland Medicaid	$749.52
Rate for Payer: Scott and White EPO/PPO	$368.81
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$749.52
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

CHED Laceration Complex - Trunk 2.6 to 7.5 cm BCE

Facility

$2,250.00

Service Code	HCPCS 13101
Hospital Charge Code	8912635
Hospital Revenue Code	450
Min. Negotiated Rate	$202.50
Max. Negotiated Rate	$1,620.00
Rate for Payer: Amerigroup CHIP/Medicaid	$202.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$742.44
Rate for Payer: Amerigroup Medicare	$742.44
Rate for Payer: BCBS of TX Blue Advantage	$830.02
Rate for Payer: BCBS of TX Blue Essentials	$994.04
Rate for Payer: BCBS of TX Medicare	$742.44
Rate for Payer: BCBS of TX PPO	$1,252.49
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,620.00
Rate for Payer: Cigna Medicare	$742.44
Rate for Payer: Employer Direct Commercial	$742.44
Rate for Payer: Humana Medicare/TRICARE	$742.44
Rate for Payer: Molina CHIP/Medicaid	$1,620.00
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
Rate for Payer: Multiplan Auto	$1,462.50
Rate for Payer: Multiplan Commercial	$1,462.50
Rate for Payer: Multiplan Workers Comp	$1,462.50
Rate for Payer: Parkland Medicaid	$1,620.00
Rate for Payer: Scott and White EPO/PPO	$301.69
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,620.00
Rate for Payer: Superior Health Plan EPO	$742.44
Rate for Payer: Superior Health Plan Medicare	$742.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$742.44
Rate for Payer: Universal American Medicare	$742.44
Rate for Payer: Wellcare Medicare	$742.44
Rate for Payer: Wellmed Medicare	$742.44

CHED Laceration Complex - Trunk 2.6 to 7.5 cm BCE

Facility

$2,250.00

Service Code	HCPCS 13101
Hospital Charge Code	8912635
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,530.00

CHED Laceration Complex - Trunk Each Addl 5 cm BCE

Facility

$3,409.00

Service Code	HCPCS 13102
Hospital Charge Code	8912636
Hospital Revenue Code	450
Min. Negotiated Rate	$86.92
Max. Negotiated Rate	$3,520.00
Rate for Payer: Amerigroup CHIP/Medicaid	$306.81
Rate for Payer: BCBS of TX Blue Advantage	$1,022.70
Rate for Payer: BCBS of TX Blue Essentials	$1,227.24
Rate for Payer: BCBS of TX PPO	$3,520.00
Rate for Payer: Cash Price	$2,318.12
Rate for Payer: Cash Price	$2,318.12
Rate for Payer: Cash Price	$2,318.12
Rate for Payer: Cigna Medicaid	$2,454.48
Rate for Payer: Molina CHIP/Medicaid	$2,454.48
Rate for Payer: Multiplan Auto	$2,215.85
Rate for Payer: Multiplan Commercial	$2,215.85
Rate for Payer: Multiplan Workers Comp	$2,215.85
Rate for Payer: Parkland Medicaid	$2,454.48
Rate for Payer: Scott and White EPO/PPO	$86.92
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,454.48
Rate for Payer: Superior Health Plan EPO	$463.62

Know your out-of-pocket cost for care.

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