White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ED Laceration Complex - Eye/Ear/Nose/Lip -> 1.1 to 2.5 cm

Facility

$1,558.00

Service Code	HCPCS 13151
Hospital Charge Code	9250776
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,059.44

ED Laceration Complex - Eye/Ear/Nose/Lip -> 1.1 to 2.5 cm

Facility

$1,558.00

Service Code	HCPCS 13151
Hospital Charge Code	9250776
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

ED Laceration Complex - Eye/Ear/Nose/Lip -> 2.6 to 7.5 cm

Facility

$1,597.00

Service Code	HCPCS 13152
Hospital Charge Code	8912632
Hospital Revenue Code	450
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,569.38
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
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	$1,085.96
Rate for Payer: Cash Price	$1,085.96
Rate for Payer: Cash Price	$1,085.96
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,149.84
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	$1,149.84
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
Rate for Payer: Multiplan Auto	$1,038.05
Rate for Payer: Multiplan Commercial	$1,038.05
Rate for Payer: Multiplan Workers Comp	$1,038.05
Rate for Payer: Parkland Medicaid	$1,149.84
Rate for Payer: Scott and White EPO/PPO	$408.70
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.84
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

ED Laceration Complex - Eye/Ear/Nose/Lip -> 2.6 to 7.5 cm

Facility

$1,597.00

Service Code	HCPCS 13152
Hospital Charge Code	8912632
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,085.96

ED Laceration Complex - Eye/Ear/Nose/Lip -> 2.6 to 7.5 cm

Facility

$1,597.00

Service Code	HCPCS 13152
Hospital Charge Code	9250777
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,085.96

ED Laceration Complex - Eye/Ear/Nose/Lip -> 2.6 to 7.5 cm

Facility

$1,597.00

Service Code	HCPCS 13152
Hospital Charge Code	9250777
Hospital Revenue Code	450
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,569.38
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
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	$1,085.96
Rate for Payer: Cash Price	$1,085.96
Rate for Payer: Cash Price	$1,085.96
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,149.84
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	$1,149.84
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
Rate for Payer: Multiplan Auto	$1,038.05
Rate for Payer: Multiplan Commercial	$1,038.05
Rate for Payer: Multiplan Workers Comp	$1,038.05
Rate for Payer: Parkland Medicaid	$1,149.84
Rate for Payer: Scott and White EPO/PPO	$408.70
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.84
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

ED Laceration Complex - Eye/Ear/Nose/Lip -> Each Addl 5 cm

Facility

$2,381.00

Service Code	HCPCS 13153
Hospital Charge Code	5202550
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

ED Laceration Complex - Eye/Ear/Nose/Lip -> Each Addl 5 cm

Facility

$2,381.00

Service Code	HCPCS 13153
Hospital Charge Code	5202550
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,619.08

ED 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	8810574
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,730.60

ED 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	8810574
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

ED Laceration Complex - F/N/H/F/G -> 2.6 to 7.5 cm

Facility

$1,041.00

Service Code	HCPCS 13132
Hospital Charge Code	5202551
Hospital Revenue Code	450
Rate for Payer: Cash Price	$707.88

ED Laceration Complex - F/N/H/F/G -> 2.6 to 7.5 cm

Facility

$1,041.00

Service Code	HCPCS 13132
Hospital Charge Code	5202551
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

ED Laceration Complex - Trunk -> 2.6 to 7.5 cm

Facility

$2,250.00

Service Code	HCPCS 13101
Hospital Charge Code	5202552
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,530.00

ED Laceration Complex - Trunk -> 2.6 to 7.5 cm

Facility

$2,250.00

Service Code	HCPCS 13101
Hospital Charge Code	5202552
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

ED Laceration Complex - Trunk -> Each Addl 5 cm

Facility

$3,409.00

Service Code	HCPCS 13102
Hospital Charge Code	5202553
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,318.12

ED Laceration Complex - Trunk -> Each Addl 5 cm

Facility

$3,409.00

Service Code	HCPCS 13102
Hospital Charge Code	5202553
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

ED Laceration Intermediate - Face -> 20.1 to 30.0 cm

Facility

$2,839.00

Service Code	HCPCS 12056
Hospital Charge Code	5202556
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,930.52

ED Laceration Intermediate - Face -> 20.1 to 30.0 cm

Facility

$2,839.00

Service Code	HCPCS 12056
Hospital Charge Code	5202556
Hospital Revenue Code	450
Min. Negotiated Rate	$255.51
Max. Negotiated Rate	$2,044.08
Rate for Payer: Amerigroup CHIP/Medicaid	$255.51
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	$1,930.52
Rate for Payer: Cash Price	$1,930.52
Rate for Payer: Cash Price	$1,930.52
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$2,044.08
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	$2,044.08
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$1,845.35
Rate for Payer: Multiplan Commercial	$1,845.35
Rate for Payer: Multiplan Workers Comp	$1,845.35
Rate for Payer: Parkland Medicaid	$2,044.08
Rate for Payer: Scott and White EPO/PPO	$470.48
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,044.08
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

ED Laceration Intermediate - Face -> <= 2.5 cm

Facility

$1,065.00

Service Code	HCPCS 12051
Hospital Charge Code	5202554
Hospital Revenue Code	450
Min. Negotiated Rate	$95.85
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$95.85
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	$724.20
Rate for Payer: Cash Price	$724.20
Rate for Payer: Cash Price	$724.20
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$766.80
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	$766.80
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$692.25
Rate for Payer: Multiplan Commercial	$692.25
Rate for Payer: Multiplan Workers Comp	$692.25
Rate for Payer: Parkland Medicaid	$766.80
Rate for Payer: Scott and White EPO/PPO	$208.11
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$766.80
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

ED Laceration Intermediate - Face -> <= 2.5 cm

Facility

$1,065.00

Service Code	HCPCS 12051
Hospital Charge Code	5202554
Hospital Revenue Code	450
Rate for Payer: Cash Price	$724.20

ED Laceration Intermediate - Face -> > 30.0 cm

Facility

$1,050.00

Service Code	HCPCS 12057
Hospital Charge Code	5202557
Hospital Revenue Code	450
Rate for Payer: Cash Price	$714.00

ED Laceration Intermediate - Face -> > 30.0 cm

Facility

$1,050.00

Service Code	HCPCS 12057
Hospital Charge Code	5202557
Hospital Revenue Code	450
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$94.50
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	$714.00
Rate for Payer: Cash Price	$714.00
Rate for Payer: Cash Price	$714.00
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$756.00
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	$756.00
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$682.50
Rate for Payer: Multiplan Commercial	$682.50
Rate for Payer: Multiplan Workers Comp	$682.50
Rate for Payer: Parkland Medicaid	$756.00
Rate for Payer: Scott and White EPO/PPO	$513.11
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$756.00
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

ED Laceration Intermediate - Neck -> <= 2.5 cm

Facility

$688.00

Service Code	HCPCS 12041
Hospital Charge Code	5202558
Hospital Revenue Code	450
Rate for Payer: Cash Price	$467.84

ED Laceration Intermediate - Neck -> <= 2.5 cm

Facility

$688.00

Service Code	HCPCS 12041
Hospital Charge Code	5202558
Hospital Revenue Code	450
Min. Negotiated Rate	$61.92
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$61.92
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	$467.84
Rate for Payer: Cash Price	$467.84
Rate for Payer: Cash Price	$467.84
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$495.36
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	$495.36
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$447.20
Rate for Payer: Multiplan Commercial	$447.20
Rate for Payer: Multiplan Workers Comp	$447.20
Rate for Payer: Parkland Medicaid	$495.36
Rate for Payer: Scott and White EPO/PPO	$178.25
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$495.36
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

ED Laceration Intermediate - Neck -> > 30.0 cm

Facility

$6,641.00

Service Code	HCPCS 12047
Hospital Charge Code	5202559
Hospital Revenue Code	450
Rate for Payer: Cash Price	$4,515.88

Know your out-of-pocket cost for care.

All Charges