White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SPINAL PROCEDURES

Facility

$7,573.96

Service Code	APR-DRG 0231
Min. Negotiated Rate	$7,140.99
Max. Negotiated Rate	$7,573.96
Rate for Payer: Amerigroup CHIP/Medicaid	$7,140.99
Rate for Payer: Cigna Medicaid	$7,140.99
Rate for Payer: Molina CHIP/Medicaid	$7,140.99
Rate for Payer: Parkland Medicaid	$7,140.99
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,573.96

SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS

Facility

$64,934.40

Service Code	MSDRG 029
Min. Negotiated Rate	$27,139.02
Max. Negotiated Rate	$64,934.40
Rate for Payer: BCBS of TX Blue Advantage	$27,139.02
Rate for Payer: BCBS of TX Blue Essentials	$32,563.67
Rate for Payer: BCBS of TX PPO	$36,183.26

SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS

Facility

$64,934.40

Service Code	MSDRG 029
Min. Negotiated Rate	$27,139.02
Max. Negotiated Rate	$64,934.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$29,763.78
Rate for Payer: Amerigroup Medicare	$29,763.78
Rate for Payer: BCBS of TX Medicare	$29,763.78
Rate for Payer: Cigna Commercial	$43,941.41
Rate for Payer: Cigna Medicare	$29,763.78
Rate for Payer: Employer Direct Commercial	$29,763.78
Rate for Payer: Humana Medicare/TRICARE	$29,763.78
Rate for Payer: Molina Dual Medicare/Medicaid	$29,763.78
Rate for Payer: Molina Medicare	$29,763.78
Rate for Payer: Multiplan Auto	$64,934.40
Rate for Payer: Multiplan Commercial	$64,934.40
Rate for Payer: Multiplan Workers Comp	$64,934.40
Rate for Payer: Scott and White EPO/PPO	$29,904.00
Rate for Payer: Scott and White Medicare	$29,763.78
Rate for Payer: Superior Health Plan EPO	$29,763.78
Rate for Payer: Superior Health Plan Medicare	$29,763.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$29,763.78
Rate for Payer: Universal American Medicare	$29,763.78
Rate for Payer: Wellcare Medicare	$29,763.78
Rate for Payer: Wellmed Medicare	$29,763.78

SPINAL PROCEDURES WITH MCC

Facility

$111,672.50

Service Code	MSDRG 028
Min. Negotiated Rate	$46,223.28
Max. Negotiated Rate	$111,672.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$48,795.08
Rate for Payer: Amerigroup Medicare	$48,795.08
Rate for Payer: BCBS of TX Medicare	$48,795.08
Rate for Payer: Cigna Commercial	$77,386.90
Rate for Payer: Cigna Medicare	$48,795.08
Rate for Payer: Employer Direct Commercial	$48,795.08
Rate for Payer: Humana Medicare/TRICARE	$48,795.08
Rate for Payer: Molina Dual Medicare/Medicaid	$48,795.08
Rate for Payer: Molina Medicare	$48,795.08
Rate for Payer: Multiplan Auto	$111,672.50
Rate for Payer: Multiplan Commercial	$111,672.50
Rate for Payer: Multiplan Workers Comp	$111,672.50
Rate for Payer: Scott and White EPO/PPO	$51,428.12
Rate for Payer: Scott and White Medicare	$48,795.08
Rate for Payer: Superior Health Plan EPO	$48,795.08
Rate for Payer: Superior Health Plan Medicare	$48,795.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$48,795.08
Rate for Payer: Universal American Medicare	$48,795.08
Rate for Payer: Wellcare Medicare	$48,795.08
Rate for Payer: Wellmed Medicare	$48,795.08

SPINAL PROCEDURES WITHOUT CC/MCC

Facility

$44,482.80

Service Code	MSDRG 030
Min. Negotiated Rate	$18,711.02
Max. Negotiated Rate	$44,482.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,848.76
Rate for Payer: Amerigroup Medicare	$20,848.76
Rate for Payer: BCBS of TX Medicare	$20,848.76
Rate for Payer: Cigna Commercial	$28,274.18
Rate for Payer: Cigna Medicare	$20,848.76
Rate for Payer: Employer Direct Commercial	$20,848.76
Rate for Payer: Humana Medicare/TRICARE	$20,848.76
Rate for Payer: Molina Dual Medicare/Medicaid	$20,848.76
Rate for Payer: Molina Medicare	$20,848.76
Rate for Payer: Multiplan Auto	$44,482.80
Rate for Payer: Multiplan Commercial	$44,482.80
Rate for Payer: Multiplan Workers Comp	$44,482.80
Rate for Payer: Scott and White EPO/PPO	$20,485.50
Rate for Payer: Scott and White Medicare	$20,848.76
Rate for Payer: Superior Health Plan EPO	$20,848.76
Rate for Payer: Superior Health Plan Medicare	$20,848.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,848.76
Rate for Payer: Universal American Medicare	$20,848.76
Rate for Payer: Wellcare Medicare	$20,848.76
Rate for Payer: Wellmed Medicare	$20,848.76

SPINAL PROCEDURES W MCC

Facility

$111,672.50

Service Code	MSDRG 028
Min. Negotiated Rate	$46,223.28
Max. Negotiated Rate	$111,672.50
Rate for Payer: BCBS of TX Blue Advantage	$46,223.28
Rate for Payer: BCBS of TX Blue Essentials	$55,462.56
Rate for Payer: BCBS of TX PPO	$61,627.46

SPINAL PROCEDURES W/O CC/MCC

Facility

$44,482.80

Service Code	MSDRG 030
Min. Negotiated Rate	$18,711.02
Max. Negotiated Rate	$44,482.80
Rate for Payer: BCBS of TX Blue Advantage	$18,711.02
Rate for Payer: BCBS of TX Blue Essentials	$22,451.05
Rate for Payer: BCBS of TX PPO	$24,946.58

Spinal puncture, lumbar, diagnostic

Facility

$2,221.07

Service Code	HCPCS 62270
Hospital Charge Code	8912630
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$1,599.17
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$1,599.17
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,599.17
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,599.17
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, lumbar, diagnostic

Facility

$2,221.07

Service Code	HCPCS 62270
Hospital Charge Code	9900741
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,510.33

Spinal puncture, lumbar, diagnostic

Facility

$2,221.07

Service Code	HCPCS 62270
Hospital Charge Code	9900741
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cash Price	$1,510.33
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$1,599.17
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$1,599.17
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,599.17
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,599.17
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, lumbar, diagnostic

Facility

$10,000.00

Service Code	CPT 62270
Hospital Charge Code	36062270
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, lumbar, diagnostic

Facility

$2,221.07

Service Code	HCPCS 62270
Hospital Charge Code	8912630
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,510.33

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$3,172.95

Service Code	HCPCS 62272
Hospital Charge Code	9900742
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,157.61

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$3,172.95

Service Code	HCPCS 62272
Hospital Charge Code	9900742
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$2,284.52
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$2,284.52
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$2,284.52
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,284.52
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$3,172.95

Service Code	HCPCS 62272
Hospital Charge Code	2161020
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,157.61

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$3,172.95

Service Code	HCPCS 62272
Hospital Charge Code	2161020
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cash Price	$2,157.61
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$2,284.52
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$2,284.52
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$2,284.52
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,284.52
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)

Facility

$10,000.00

Service Code	CPT 62272
Hospital Charge Code	36062272
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

SPINAL PUNCTURE THERAPTC

Facility

$1,519.00

Service Code	HCPCS 62272
Hospital Charge Code	4612272
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,032.92

SPINAL PUNCTURE THERAPTC

Facility

$1,519.00

Service Code	HCPCS 62272
Hospital Charge Code	4612272
Hospital Revenue Code	360
Min. Negotiated Rate	$262.86
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$262.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$709.10
Rate for Payer: Amerigroup Medicare	$709.10
Rate for Payer: BCBS of TX Blue Advantage	$1,043.83
Rate for Payer: BCBS of TX Blue Essentials	$1,250.10
Rate for Payer: BCBS of TX Medicare	$709.10
Rate for Payer: BCBS of TX PPO	$1,575.13
Rate for Payer: Cash Price	$1,032.92
Rate for Payer: Cash Price	$1,032.92
Rate for Payer: Cash Price	$1,032.92
Rate for Payer: Cigna Commercial	$1,498.91
Rate for Payer: Cigna Medicaid	$1,093.68
Rate for Payer: Cigna Medicare	$709.10
Rate for Payer: Employer Direct Commercial	$709.10
Rate for Payer: Humana Medicare/TRICARE	$709.10
Rate for Payer: Molina CHIP/Medicaid	$1,093.68
Rate for Payer: Molina Dual Medicare/Medicaid	$709.10
Rate for Payer: Molina Medicare	$709.10
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	$1,093.68
Rate for Payer: Scott and White EPO/PPO	$1,170.03
Rate for Payer: Scott and White Medicare	$709.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,093.68
Rate for Payer: Superior Health Plan EPO	$709.10
Rate for Payer: Superior Health Plan Medicare	$709.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$709.10
Rate for Payer: Universal American Medicare	$709.10
Rate for Payer: Wellcare Medicare	$709.10
Rate for Payer: Wellmed Medicare	$709.10

SPIROMETER, INCNTIV, VOLDYNE, 4000ML

Facility

$18.81

Service Code	HCPCS A9284
Hospital Charge Code	993976
Hospital Revenue Code	279
Rate for Payer: Cash Price	$12.79

SPIROMETER, INCNTIV, VOLDYNE, 4000ML

Facility

$18.81

Service Code	HCPCS A9284
Hospital Charge Code	993976
Hospital Revenue Code	279
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$13.54
Rate for Payer: Amerigroup CHIP/Medicaid	$1.69
Rate for Payer: BCBS of TX Blue Advantage	$5.64
Rate for Payer: BCBS of TX Blue Essentials	$6.77
Rate for Payer: BCBS of TX PPO	$7.52
Rate for Payer: Cash Price	$12.79
Rate for Payer: Cigna Medicaid	$13.54
Rate for Payer: Molina CHIP/Medicaid	$13.54
Rate for Payer: Multiplan Auto	$12.23
Rate for Payer: Multiplan Commercial	$12.23
Rate for Payer: Multiplan Workers Comp	$12.23
Rate for Payer: Parkland Medicaid	$13.54
Rate for Payer: Scott and White EPO/PPO	$9.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.54
Rate for Payer: Superior Health Plan EPO	$2.56

spironolactone 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77826262
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.51
Rate for Payer: Amerigroup CHIP/Medicaid	$0.69
Rate for Payer: BCBS of TX Blue Advantage	$2.29
Rate for Payer: BCBS of TX Blue Essentials	$2.75
Rate for Payer: BCBS of TX PPO	$3.06
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cigna Medicaid	$5.51
Rate for Payer: Molina CHIP/Medicaid	$5.51
Rate for Payer: Multiplan Auto	$4.97
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Multiplan Workers Comp	$4.97
Rate for Payer: Parkland Medicaid	$5.51
Rate for Payer: Scott and White EPO/PPO	$3.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.51
Rate for Payer: Superior Health Plan EPO	$1.04

spironolactone 25 mg Tab

Facility

$7.65

Service Code	HCPCS J3490
Hospital Charge Code	77826262
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.20

SPLENECTOMY

Facility

$20,845.35

Service Code	APR-DRG 6504
Min. Negotiated Rate	$19,653.73
Max. Negotiated Rate	$20,845.35
Rate for Payer: Amerigroup CHIP/Medicaid	$19,653.73
Rate for Payer: Cigna Medicaid	$19,653.73
Rate for Payer: Molina CHIP/Medicaid	$19,653.73
Rate for Payer: Parkland Medicaid	$19,653.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$20,845.35

SPLENECTOMY

Facility

$13,593.14

Service Code	APR-DRG 6503
Min. Negotiated Rate	$12,816.09
Max. Negotiated Rate	$13,593.14
Rate for Payer: Amerigroup CHIP/Medicaid	$12,816.09
Rate for Payer: Cigna Medicaid	$12,816.09
Rate for Payer: Molina CHIP/Medicaid	$12,816.09
Rate for Payer: Parkland Medicaid	$12,816.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,593.14

Know your out-of-pocket cost for care.

All Charges