White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Amputation, foot transmetatarsal

Facility

$7,783.60

Service Code	HCPCS 28805
Hospital Charge Code	9900533
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,292.85

AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC

Facility

$51,569.80

Service Code	MSDRG 240
Min. Negotiated Rate	$23,606.14
Max. Negotiated Rate	$51,569.80
Rate for Payer: BCBS of TX Blue Advantage	$23,606.14
Rate for Payer: BCBS of TX Blue Essentials	$28,324.62
Rate for Payer: BCBS of TX PPO	$31,473.02

AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC

Facility

$88,351.90

Service Code	MSDRG 239
Min. Negotiated Rate	$40,499.98
Max. Negotiated Rate	$88,351.90
Rate for Payer: BCBS of TX Blue Advantage	$40,499.98
Rate for Payer: BCBS of TX Blue Essentials	$48,595.27
Rate for Payer: BCBS of TX PPO	$53,996.83

AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W/O CC/MCC

Facility

$29,429.10

Service Code	MSDRG 241
Min. Negotiated Rate	$13,552.88
Max. Negotiated Rate	$29,429.10
Rate for Payer: BCBS of TX Blue Advantage	$13,725.60
Rate for Payer: BCBS of TX Blue Essentials	$16,469.12
Rate for Payer: BCBS of TX PPO	$18,299.74

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$51,569.80

Service Code	MSDRG 240
Min. Negotiated Rate	$23,606.14
Max. Negotiated Rate	$51,569.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25,651.46
Rate for Payer: Amerigroup Medicare	$25,651.46
Rate for Payer: BCBS of TX Medicare	$25,651.46
Rate for Payer: Cigna Commercial	$36,714.44
Rate for Payer: Cigna Medicare	$25,651.46
Rate for Payer: Employer Direct Commercial	$25,651.46
Rate for Payer: Humana Medicare/TRICARE	$25,651.46
Rate for Payer: Molina Dual Medicare/Medicaid	$25,651.46
Rate for Payer: Molina Medicare	$25,651.46
Rate for Payer: Multiplan Auto	$51,569.80
Rate for Payer: Multiplan Commercial	$51,569.80
Rate for Payer: Multiplan Workers Comp	$51,569.80
Rate for Payer: Scott and White EPO/PPO	$23,749.25
Rate for Payer: Scott and White Medicare	$25,651.46
Rate for Payer: Superior Health Plan EPO	$25,651.46
Rate for Payer: Superior Health Plan Medicare	$25,651.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$25,651.46
Rate for Payer: Universal American Medicare	$25,651.46
Rate for Payer: Wellcare Medicare	$25,651.46
Rate for Payer: Wellmed Medicare	$25,651.46

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$88,351.90

Service Code	MSDRG 239
Min. Negotiated Rate	$40,499.98
Max. Negotiated Rate	$88,351.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$40,831.35
Rate for Payer: Amerigroup Medicare	$40,831.35
Rate for Payer: BCBS of TX Medicare	$40,831.35
Rate for Payer: Cigna Commercial	$63,391.50
Rate for Payer: Cigna Medicare	$40,831.35
Rate for Payer: Employer Direct Commercial	$40,831.35
Rate for Payer: Humana Medicare/TRICARE	$40,831.35
Rate for Payer: Molina Dual Medicare/Medicaid	$40,831.35
Rate for Payer: Molina Medicare	$40,831.35
Rate for Payer: Multiplan Auto	$88,351.90
Rate for Payer: Multiplan Commercial	$88,351.90
Rate for Payer: Multiplan Workers Comp	$88,351.90
Rate for Payer: Scott and White EPO/PPO	$40,688.38
Rate for Payer: Scott and White Medicare	$40,831.35
Rate for Payer: Superior Health Plan EPO	$40,831.35
Rate for Payer: Superior Health Plan Medicare	$40,831.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$40,831.35
Rate for Payer: Universal American Medicare	$40,831.35
Rate for Payer: Wellcare Medicare	$40,831.35
Rate for Payer: Wellmed Medicare	$40,831.35

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$29,429.10

Service Code	MSDRG 241
Min. Negotiated Rate	$13,552.88
Max. Negotiated Rate	$29,429.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,906.38
Rate for Payer: Amerigroup Medicare	$14,906.38
Rate for Payer: BCBS of TX Medicare	$14,906.38
Rate for Payer: Cigna Commercial	$17,831.07
Rate for Payer: Cigna Medicare	$14,906.38
Rate for Payer: Employer Direct Commercial	$14,906.38
Rate for Payer: Humana Medicare/TRICARE	$14,906.38
Rate for Payer: Molina Dual Medicare/Medicaid	$14,906.38
Rate for Payer: Molina Medicare	$14,906.38
Rate for Payer: Multiplan Auto	$29,429.10
Rate for Payer: Multiplan Commercial	$29,429.10
Rate for Payer: Multiplan Workers Comp	$29,429.10
Rate for Payer: Scott and White EPO/PPO	$13,552.88
Rate for Payer: Scott and White Medicare	$14,906.38
Rate for Payer: Superior Health Plan EPO	$14,906.38
Rate for Payer: Superior Health Plan Medicare	$14,906.38
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,906.38
Rate for Payer: Universal American Medicare	$14,906.38
Rate for Payer: Wellcare Medicare	$14,906.38
Rate for Payer: Wellmed Medicare	$14,906.38

AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC

Facility

$42,202.80

Service Code	MSDRG 475
Min. Negotiated Rate	$18,479.68
Max. Negotiated Rate	$42,202.80
Rate for Payer: BCBS of TX Blue Advantage	$18,479.68
Rate for Payer: BCBS of TX Blue Essentials	$22,173.47
Rate for Payer: BCBS of TX PPO	$24,638.14

AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC

Facility

$77,841.10

Service Code	MSDRG 474
Min. Negotiated Rate	$32,637.86
Max. Negotiated Rate	$77,841.10
Rate for Payer: BCBS of TX Blue Advantage	$32,637.86
Rate for Payer: BCBS of TX Blue Essentials	$39,161.64
Rate for Payer: BCBS of TX PPO	$43,514.62

AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W/O CC/MCC

Facility

$23,322.50

Service Code	MSDRG 476
Min. Negotiated Rate	$9,896.02
Max. Negotiated Rate	$23,322.50
Rate for Payer: BCBS of TX Blue Advantage	$9,896.02
Rate for Payer: BCBS of TX Blue Essentials	$11,874.07
Rate for Payer: BCBS of TX PPO	$13,193.93

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$42,202.80

Service Code	MSDRG 475
Min. Negotiated Rate	$18,479.68
Max. Negotiated Rate	$42,202.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,438.73
Rate for Payer: Amerigroup Medicare	$21,438.73
Rate for Payer: BCBS of TX Medicare	$21,438.73
Rate for Payer: Cigna Commercial	$29,311.02
Rate for Payer: Cigna Medicare	$21,438.73
Rate for Payer: Employer Direct Commercial	$21,438.73
Rate for Payer: Humana Medicare/TRICARE	$21,438.73
Rate for Payer: Molina Dual Medicare/Medicaid	$21,438.73
Rate for Payer: Molina Medicare	$21,438.73
Rate for Payer: Multiplan Auto	$42,202.80
Rate for Payer: Multiplan Commercial	$42,202.80
Rate for Payer: Multiplan Workers Comp	$42,202.80
Rate for Payer: Scott and White EPO/PPO	$19,435.50
Rate for Payer: Scott and White Medicare	$21,438.73
Rate for Payer: Superior Health Plan EPO	$21,438.73
Rate for Payer: Superior Health Plan Medicare	$21,438.73
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,438.73
Rate for Payer: Universal American Medicare	$21,438.73
Rate for Payer: Wellcare Medicare	$21,438.73
Rate for Payer: Wellmed Medicare	$21,438.73

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$77,841.10

Service Code	MSDRG 474
Min. Negotiated Rate	$32,637.86
Max. Negotiated Rate	$77,841.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$36,222.86
Rate for Payer: Amerigroup Medicare	$36,222.86
Rate for Payer: BCBS of TX Medicare	$36,222.86
Rate for Payer: Cigna Commercial	$55,292.55
Rate for Payer: Cigna Medicare	$36,222.86
Rate for Payer: Employer Direct Commercial	$36,222.86
Rate for Payer: Humana Medicare/TRICARE	$36,222.86
Rate for Payer: Molina Dual Medicare/Medicaid	$36,222.86
Rate for Payer: Molina Medicare	$36,222.86
Rate for Payer: Multiplan Auto	$77,841.10
Rate for Payer: Multiplan Commercial	$77,841.10
Rate for Payer: Multiplan Workers Comp	$77,841.10
Rate for Payer: Scott and White EPO/PPO	$35,847.88
Rate for Payer: Scott and White Medicare	$36,222.86
Rate for Payer: Superior Health Plan EPO	$36,222.86
Rate for Payer: Superior Health Plan Medicare	$36,222.86
Rate for Payer: Universal American Dual Medicare/Medicaid	$36,222.86
Rate for Payer: Universal American Medicare	$36,222.86
Rate for Payer: Wellcare Medicare	$36,222.86
Rate for Payer: Wellmed Medicare	$36,222.86

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$23,322.50

Service Code	MSDRG 476
Min. Negotiated Rate	$9,896.02
Max. Negotiated Rate	$23,322.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,409.80
Rate for Payer: Amerigroup Medicare	$13,409.80
Rate for Payer: BCBS of TX Medicare	$13,409.80
Rate for Payer: Cigna Commercial	$15,200.98
Rate for Payer: Cigna Medicare	$13,409.80
Rate for Payer: Employer Direct Commercial	$13,409.80
Rate for Payer: Humana Medicare/TRICARE	$13,409.80
Rate for Payer: Molina Dual Medicare/Medicaid	$13,409.80
Rate for Payer: Molina Medicare	$13,409.80
Rate for Payer: Multiplan Auto	$23,322.50
Rate for Payer: Multiplan Commercial	$23,322.50
Rate for Payer: Multiplan Workers Comp	$23,322.50
Rate for Payer: Scott and White EPO/PPO	$10,740.62
Rate for Payer: Scott and White Medicare	$13,409.80
Rate for Payer: Superior Health Plan EPO	$13,409.80
Rate for Payer: Superior Health Plan Medicare	$13,409.80
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,409.80
Rate for Payer: Universal American Medicare	$13,409.80
Rate for Payer: Wellcare Medicare	$13,409.80
Rate for Payer: Wellmed Medicare	$13,409.80

Amputation, leg, through tibia and fibula

Facility

$30,840.30

Service Code	HCPCS 27880
Hospital Charge Code	990971
Hospital Revenue Code	360
Rate for Payer: Cash Price	$20,971.40

Amputation, leg, through tibia and fibula

Facility

$30,840.30

Service Code	HCPCS 27880
Hospital Charge Code	990971
Hospital Revenue Code	360
Min. Negotiated Rate	$1,582.88
Max. Negotiated Rate	$22,205.02
Rate for Payer: Amerigroup CHIP/Medicaid	$2,775.63
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	$1,582.88
Rate for Payer: BCBS of TX Blue Essentials	$1,895.66
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$2,388.53
Rate for Payer: Cash Price	$20,971.40
Rate for Payer: Cash Price	$20,971.40
Rate for Payer: Cash Price	$20,971.40
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$22,205.02
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	$22,205.02
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	$22,205.02
Rate for Payer: Scott and White EPO/PPO	$15,420.15
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,205.02
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

Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous

Facility

$17,353.68

Service Code	HCPCS 26910
Hospital Charge Code	9900375
Hospital Revenue Code	360
Rate for Payer: Cash Price	$11,800.50

Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous

Facility

$10,000.00

Service Code	CPT 26910
Hospital Charge Code	36026910
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

Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous

Facility

$17,353.68

Service Code	HCPCS 26910
Hospital Charge Code	9900375
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$12,494.65
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	$11,800.50
Rate for Payer: Cash Price	$11,800.50
Rate for Payer: Cash Price	$11,800.50
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$12,494.65
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	$12,494.65
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	$12,494.65
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	$12,494.65
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

Amputation, metatarsal, with toe, single

Facility

$10,000.00

Service Code	CPT 28810
Hospital Charge Code	36028810
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

Amputation, metatarsal, with toe, single

Facility

$8,491.20

Service Code	HCPCS 28810
Hospital Charge Code	9900534
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,774.02

Amputation, metatarsal, with toe, single

Facility

$8,491.20

Service Code	HCPCS 28810
Hospital Charge Code	9900534
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	$5,774.02
Rate for Payer: Cash Price	$5,774.02
Rate for Payer: Cash Price	$5,774.02
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$6,113.66
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	$6,113.66
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	$6,113.66
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	$6,113.66
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

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$11,467.30

Service Code	APR-DRG 3053
Min. Negotiated Rate	$10,811.77
Max. Negotiated Rate	$11,467.30
Rate for Payer: Amerigroup CHIP/Medicaid	$10,811.77
Rate for Payer: Cigna Medicaid	$10,811.77
Rate for Payer: Molina CHIP/Medicaid	$10,811.77
Rate for Payer: Parkland Medicaid	$10,811.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11,467.30

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$5,659.34

Service Code	APR-DRG 3051
Min. Negotiated Rate	$5,335.83
Max. Negotiated Rate	$5,659.34
Rate for Payer: Amerigroup CHIP/Medicaid	$5,335.83
Rate for Payer: Cigna Medicaid	$5,335.83
Rate for Payer: Molina CHIP/Medicaid	$5,335.83
Rate for Payer: Parkland Medicaid	$5,335.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,659.34

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$7,391.40

Service Code	APR-DRG 3052
Min. Negotiated Rate	$6,968.87
Max. Negotiated Rate	$7,391.40
Rate for Payer: Amerigroup CHIP/Medicaid	$6,968.87
Rate for Payer: Cigna Medicaid	$6,968.87
Rate for Payer: Molina CHIP/Medicaid	$6,968.87
Rate for Payer: Parkland Medicaid	$6,968.87
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,391.40

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$20,579.43

Service Code	APR-DRG 3054
Min. Negotiated Rate	$19,403.01
Max. Negotiated Rate	$20,579.43
Rate for Payer: Amerigroup CHIP/Medicaid	$19,403.01
Rate for Payer: Cigna Medicaid	$19,403.01
Rate for Payer: Molina CHIP/Medicaid	$19,403.01
Rate for Payer: Parkland Medicaid	$19,403.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,579.43

Know your out-of-pocket cost for care.

All Charges