White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

ED Laceration Intermediate - Scalp -> 20.1 to 30.0 cm

Facility

$1,472.00

Service Code	HCPCS 12036
Hospital Charge Code	5202562
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,000.96

ED Laceration Intermediate - Scalp -> 20.1 to 30.0 cm

Facility

$1,472.00

Service Code	HCPCS 12036
Hospital Charge Code	5202562
Hospital Revenue Code	450
Min. Negotiated Rate	$132.48
Max. Negotiated Rate	$1,569.38
Rate for Payer: Amerigroup CHIP/Medicaid	$132.48
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	$1,000.96
Rate for Payer: Cash Price	$1,000.96
Rate for Payer: Cash Price	$1,000.96
Rate for Payer: Cigna Commercial	$1,569.38
Rate for Payer: Cigna Medicaid	$1,059.84
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	$1,059.84
Rate for Payer: Molina Dual Medicare/Medicaid	$742.44
Rate for Payer: Molina Medicare	$742.44
Rate for Payer: Multiplan Auto	$956.80
Rate for Payer: Multiplan Commercial	$956.80
Rate for Payer: Multiplan Workers Comp	$956.80
Rate for Payer: Parkland Medicaid	$1,059.84
Rate for Payer: Scott and White EPO/PPO	$345.11
Rate for Payer: Scott and White Medicare	$742.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,059.84
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 Intermediate - Scalp -> <= 2.5 cm

Facility

$710.00

Service Code	HCPCS 12031
Hospital Charge Code	5202560
Hospital Revenue Code	450
Rate for Payer: Cash Price	$482.80

ED Laceration Intermediate - Scalp -> <= 2.5 cm

Facility

$710.00

Service Code	HCPCS 12031
Hospital Charge Code	5202560
Hospital Revenue Code	450
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$63.90
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	$482.80
Rate for Payer: Cash Price	$482.80
Rate for Payer: Cash Price	$482.80
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$511.20
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	$511.20
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$461.50
Rate for Payer: Multiplan Commercial	$461.50
Rate for Payer: Multiplan Workers Comp	$461.50
Rate for Payer: Parkland Medicaid	$511.20
Rate for Payer: Scott and White EPO/PPO	$186.12
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$511.20
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 - Scalp -> 2.6 to 7.5 cm

Facility

$868.00

Service Code	HCPCS 12032
Hospital Charge Code	5202561
Hospital Revenue Code	450
Min. Negotiated Rate	$78.12
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$78.12
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	$590.24
Rate for Payer: Cash Price	$590.24
Rate for Payer: Cash Price	$590.24
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$624.96
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	$624.96
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$564.20
Rate for Payer: Multiplan Commercial	$564.20
Rate for Payer: Multiplan Workers Comp	$564.20
Rate for Payer: Parkland Medicaid	$624.96
Rate for Payer: Scott and White EPO/PPO	$233.80
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$624.96
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

ED Laceration Intermediate - Scalp -> 2.6 to 7.5 cm

Facility

$868.00

Service Code	HCPCS 12032
Hospital Charge Code	5202561
Hospital Revenue Code	450
Rate for Payer: Cash Price	$590.24

ED Laceration Intermediate - Scalp -> > 30.0 cm

Facility

$3,398.00

Service Code	HCPCS 12037
Hospital Charge Code	5202563
Hospital Revenue Code	450
Min. Negotiated Rate	$305.82
Max. Negotiated Rate	$4,381.27
Rate for Payer: Amerigroup CHIP/Medicaid	$305.82
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Amerigroup Medicare	$2,072.68
Rate for Payer: BCBS of TX Blue Advantage	$2,709.98
Rate for Payer: BCBS of TX Blue Essentials	$3,245.48
Rate for Payer: BCBS of TX Medicare	$2,072.68
Rate for Payer: BCBS of TX PPO	$4,089.30
Rate for Payer: Cash Price	$2,310.64
Rate for Payer: Cash Price	$2,310.64
Rate for Payer: Cash Price	$2,310.64
Rate for Payer: Cigna Commercial	$4,381.27
Rate for Payer: Cigna Medicaid	$2,446.56
Rate for Payer: Cigna Medicare	$2,072.68
Rate for Payer: Employer Direct Commercial	$2,072.68
Rate for Payer: Humana Medicare/TRICARE	$2,072.68
Rate for Payer: Molina CHIP/Medicaid	$2,446.56
Rate for Payer: Molina Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Molina Medicare	$2,072.68
Rate for Payer: Multiplan Auto	$2,208.70
Rate for Payer: Multiplan Commercial	$2,208.70
Rate for Payer: Multiplan Workers Comp	$2,208.70
Rate for Payer: Parkland Medicaid	$2,446.56
Rate for Payer: Scott and White EPO/PPO	$400.75
Rate for Payer: Scott and White Medicare	$2,072.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,446.56
Rate for Payer: Superior Health Plan EPO	$2,072.68
Rate for Payer: Superior Health Plan Medicare	$2,072.68
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,072.68
Rate for Payer: Universal American Medicare	$2,072.68
Rate for Payer: Wellcare Medicare	$2,072.68
Rate for Payer: Wellmed Medicare	$2,072.68

ED Laceration Intermediate - Scalp -> > 30.0 cm

Facility

$3,398.00

Service Code	HCPCS 12037
Hospital Charge Code	5202563
Hospital Revenue Code	450
Rate for Payer: Cash Price	$2,310.64

ED Laceration Simple - Face -> 12.6 to 20.0 cm

Facility

$1,143.00

Service Code	HCPCS 12016
Hospital Charge Code	8776543
Hospital Revenue Code	450
Min. Negotiated Rate	$102.87
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$102.87
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	$777.24
Rate for Payer: Cash Price	$777.24
Rate for Payer: Cash Price	$777.24
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$822.96
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	$822.96
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$742.95
Rate for Payer: Multiplan Commercial	$742.95
Rate for Payer: Multiplan Workers Comp	$742.95
Rate for Payer: Parkland Medicaid	$822.96
Rate for Payer: Scott and White EPO/PPO	$154.60
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$822.96
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

ED Laceration Simple - Face -> 12.6 to 20.0 cm

Facility

$1,143.00

Service Code	HCPCS 12016
Hospital Charge Code	8776543
Hospital Revenue Code	450
Rate for Payer: Cash Price	$777.24

ED Laceration Simple - Face -> 20.1 to 30.0 cm

Facility

$1,383.00

Service Code	HCPCS 12017
Hospital Charge Code	5202566
Hospital Revenue Code	450
Rate for Payer: Cash Price	$940.44

ED Laceration Simple - Face -> 20.1 to 30.0 cm

Facility

$1,383.00

Service Code	HCPCS 12017
Hospital Charge Code	5202566
Hospital Revenue Code	450
Min. Negotiated Rate	$124.47
Max. Negotiated Rate	$995.76
Rate for Payer: Amerigroup CHIP/Medicaid	$124.47
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	$940.44
Rate for Payer: Cash Price	$940.44
Rate for Payer: Cash Price	$940.44
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$995.76
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	$995.76
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$898.95
Rate for Payer: Multiplan Commercial	$898.95
Rate for Payer: Multiplan Workers Comp	$898.95
Rate for Payer: Parkland Medicaid	$995.76
Rate for Payer: Scott and White EPO/PPO	$186.45
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$995.76
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 Simple - Face -> <= 2.5 cm

Facility

$641.00

Service Code	HCPCS 12011
Hospital Charge Code	9240524
Hospital Revenue Code	450
Min. Negotiated Rate	$57.69
Max. Negotiated Rate	$461.52
Rate for Payer: Amerigroup CHIP/Medicaid	$57.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$435.88
Rate for Payer: Cash Price	$435.88
Rate for Payer: Cash Price	$435.88
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$461.52
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$461.52
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$416.65
Rate for Payer: Multiplan Commercial	$416.65
Rate for Payer: Multiplan Workers Comp	$416.65
Rate for Payer: Parkland Medicaid	$461.52
Rate for Payer: Scott and White EPO/PPO	$67.47
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$461.52
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

ED Laceration Simple - Face -> <= 2.5 cm

Facility

$641.00

Service Code	HCPCS 12011
Hospital Charge Code	9240524
Hospital Revenue Code	450
Rate for Payer: Cash Price	$435.88

ED Laceration Simple - Face -> 2.6 to 5.0 cm

Facility

$793.00

Service Code	HCPCS 12013
Hospital Charge Code	5202564
Hospital Revenue Code	450
Min. Negotiated Rate	$70.22
Max. Negotiated Rate	$570.96
Rate for Payer: Amerigroup CHIP/Medicaid	$71.37
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$539.24
Rate for Payer: Cash Price	$539.24
Rate for Payer: Cash Price	$539.24
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$570.96
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$570.96
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$515.45
Rate for Payer: Multiplan Commercial	$515.45
Rate for Payer: Multiplan Workers Comp	$515.45
Rate for Payer: Parkland Medicaid	$570.96
Rate for Payer: Scott and White EPO/PPO	$70.22
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$570.96
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

ED Laceration Simple - Face -> 2.6 to 5.0 cm

Facility

$793.00

Service Code	HCPCS 12013
Hospital Charge Code	5202564
Hospital Revenue Code	450
Rate for Payer: Cash Price	$539.24

ED Laceration Simple - Face -> > 30.0 cm

Facility

$1,570.00

Service Code	HCPCS 12018
Hospital Charge Code	5202567
Hospital Revenue Code	450
Min. Negotiated Rate	$141.30
Max. Negotiated Rate	$1,130.40
Rate for Payer: Amerigroup CHIP/Medicaid	$141.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$1,067.60
Rate for Payer: Cash Price	$1,067.60
Rate for Payer: Cash Price	$1,067.60
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$1,130.40
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$1,130.40
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$1,020.50
Rate for Payer: Multiplan Commercial	$1,020.50
Rate for Payer: Multiplan Workers Comp	$1,020.50
Rate for Payer: Parkland Medicaid	$1,130.40
Rate for Payer: Scott and White EPO/PPO	$210.00
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,130.40
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

ED Laceration Simple - Face -> > 30.0 cm

Facility

$1,570.00

Service Code	HCPCS 12018
Hospital Charge Code	5202567
Hospital Revenue Code	450
Rate for Payer: Cash Price	$1,067.60

ED Laceration Simple - Face -> 5.1 to 7.5 cm

Facility

$881.00

Service Code	HCPCS 12014
Hospital Charge Code	5202565
Hospital Revenue Code	450
Min. Negotiated Rate	$79.29
Max. Negotiated Rate	$634.32
Rate for Payer: Amerigroup CHIP/Medicaid	$79.29
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$599.08
Rate for Payer: Cash Price	$599.08
Rate for Payer: Cash Price	$599.08
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$634.32
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$634.32
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$572.65
Rate for Payer: Multiplan Commercial	$572.65
Rate for Payer: Multiplan Workers Comp	$572.65
Rate for Payer: Parkland Medicaid	$634.32
Rate for Payer: Scott and White EPO/PPO	$90.88
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$634.32
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

ED Laceration Simple - Face -> 5.1 to 7.5 cm

Facility

$881.00

Service Code	HCPCS 12014
Hospital Charge Code	5202565
Hospital Revenue Code	450
Rate for Payer: Cash Price	$599.08

ED Laceration Simple - Face -> 7.6 to 12.5 cm

Facility

$998.50

Service Code	HCPCS 12015
Hospital Charge Code	8776544
Hospital Revenue Code	450
Min. Negotiated Rate	$89.86
Max. Negotiated Rate	$718.92
Rate for Payer: Amerigroup CHIP/Medicaid	$89.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$201.55
Rate for Payer: Amerigroup Medicare	$201.55
Rate for Payer: BCBS of TX Blue Advantage	$291.80
Rate for Payer: BCBS of TX Blue Essentials	$349.46
Rate for Payer: BCBS of TX Medicare	$201.55
Rate for Payer: BCBS of TX PPO	$440.32
Rate for Payer: Cash Price	$678.98
Rate for Payer: Cash Price	$678.98
Rate for Payer: Cash Price	$678.98
Rate for Payer: Cigna Commercial	$426.04
Rate for Payer: Cigna Medicaid	$718.92
Rate for Payer: Cigna Medicare	$201.55
Rate for Payer: Employer Direct Commercial	$201.55
Rate for Payer: Humana Medicare/TRICARE	$201.55
Rate for Payer: Molina CHIP/Medicaid	$718.92
Rate for Payer: Molina Dual Medicare/Medicaid	$201.55
Rate for Payer: Molina Medicare	$201.55
Rate for Payer: Multiplan Auto	$649.02
Rate for Payer: Multiplan Commercial	$649.02
Rate for Payer: Multiplan Workers Comp	$649.02
Rate for Payer: Parkland Medicaid	$718.92
Rate for Payer: Scott and White EPO/PPO	$114.01
Rate for Payer: Scott and White Medicare	$201.55
Rate for Payer: Superior Health Plan CHIP/Medicaid	$718.92
Rate for Payer: Superior Health Plan EPO	$201.55
Rate for Payer: Superior Health Plan Medicare	$201.55
Rate for Payer: Universal American Dual Medicare/Medicaid	$201.55
Rate for Payer: Universal American Medicare	$201.55
Rate for Payer: Wellcare Medicare	$201.55
Rate for Payer: Wellmed Medicare	$201.55

ED Laceration Simple - Face -> 7.6 to 12.5 cm

Facility

$998.50

Service Code	HCPCS 12015
Hospital Charge Code	8776544
Hospital Revenue Code	450
Rate for Payer: Cash Price	$678.98

ED Laceration Simple - Scalp -> 12.6 to 20.0 cm

Facility

$1,134.67

Service Code	HCPCS 12005
Hospital Charge Code	8538504
Hospital Revenue Code	450
Min. Negotiated Rate	$102.12
Max. Negotiated Rate	$863.21
Rate for Payer: Amerigroup CHIP/Medicaid	$102.12
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	$771.58
Rate for Payer: Cash Price	$771.58
Rate for Payer: Cash Price	$771.58
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$816.96
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	$816.96
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$737.54
Rate for Payer: Multiplan Commercial	$737.54
Rate for Payer: Multiplan Workers Comp	$737.54
Rate for Payer: Parkland Medicaid	$816.96
Rate for Payer: Scott and White EPO/PPO	$114.84
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$816.96
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

ED Laceration Simple - Scalp -> 12.6 to 20.0 cm

Facility

$1,134.67

Service Code	HCPCS 12005
Hospital Charge Code	8538504
Hospital Revenue Code	450
Rate for Payer: Cash Price	$771.58

Know your out-of-pocket cost for care.

All Charges