DETAIL FOR SERVICES: | Surgery Procedure | Hospital Stay (4 days) | Anesthesia | Physician Services |
2020 CPT/HCPCS Primary Code | 60254 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Negotiated Private Fee | $5,487.00 | $2,088.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Prossam | $4,560.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Champva | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
First Medical | $2,600.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
First Medical Vital | $2,415.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Plan de Salud Menonita | $3,600.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Menonita Vital | $2,520.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Humana Gold Plus / Gold Choice | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Humana | $2,460.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Mapfre | $2,996.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Mcsclassicare | $3,748.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
MCS Life | $3,140.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Medicare | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
MMM | $4,580.30 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
MMM Vital | $3,769.82 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Panamerican Life | $2,752.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
PMC | $4,580.30 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Tricare | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Triple S Salud | $3,200.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Triple S Vital | $2,520.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Triple S Advantage | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Negotiated Minimum Charge | $2,415.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Negotiated Maximum Charge | $4,580.30 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
Discounted Cash Price | $4,489.60 | $1,670.40 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
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