White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Repair, flexor tendon, leg primary, without graft, each tendon

Facility

$7,076.00

Service Code	HCPCS 27658
Hospital Charge Code	9900431
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,811.68

Repair, flexor tendon, leg primary, without graft, each tendon

Facility

$10,000.00

Service Code	CPT 27658
Hospital Charge Code	36027658
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	$6,080.78
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, 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
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$27,064.58
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$25,561.00
Rate for Payer: Cash Price	$25,561.00
Rate for Payer: Cash Price	$25,561.00
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$27,064.58
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$27,064.58
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$27,064.58
Rate for Payer: Scott and White EPO/PPO	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27,064.58
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

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

Facility

$15,408.22

Service Code	CPT 27659
Hospital Charge Code	36027659
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
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	$13,485.17
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

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	$6,080.78
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
Rate for Payer: Cash Price	$15,134.08

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	$6,080.78
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 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
Rate for Payer: Cash Price	$5,952.98

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

$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 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 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	$6,653.93
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	$6,653.93
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
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	$6,653.93
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 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	$6,653.93
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, 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	$755.48
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

$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	$755.48
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

$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	$755.48
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

Know your out-of-pocket cost for care.

All Charges