White Rock Medical Center

All Charges

Charge

Type

Setting

Price

LUBRICANT, ULTRA CONCEN'TE PROLYSTICA, 10L

Facility

$1,404.81

Hospital Charge Code	993814
Hospital Revenue Code	270
Min. Negotiated Rate	$126.43
Max. Negotiated Rate	$1,011.46
Rate for Payer: Amerigroup CHIP/Medicaid	$126.43
Rate for Payer: BCBS of TX Blue Advantage	$421.44
Rate for Payer: BCBS of TX Blue Essentials	$505.73
Rate for Payer: BCBS of TX PPO	$561.92
Rate for Payer: Cash Price	$955.27
Rate for Payer: Cigna Medicaid	$1,011.46
Rate for Payer: Molina CHIP/Medicaid	$1,011.46
Rate for Payer: Multiplan Auto	$913.13
Rate for Payer: Multiplan Commercial	$913.13
Rate for Payer: Multiplan Workers Comp	$913.13
Rate for Payer: Parkland Medicaid	$1,011.46
Rate for Payer: Scott and White EPO/PPO	$702.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,011.46
Rate for Payer: Superior Health Plan EPO	$191.05

LUBRICANT, ULTRA CONCEN'TE PROLYSTICA, 10L

Facility

$1,404.81

Hospital Charge Code	993814
Hospital Revenue Code	270
Rate for Payer: Cash Price	$955.27

LUBRICANT VPR SLD 20ML

Facility

$18.16

Hospital Charge Code	993512
Hospital Revenue Code	270
Rate for Payer: Cash Price	$12.35

LUBRICANT VPR SLD 20ML

Facility

$18.16

Hospital Charge Code	993512
Hospital Revenue Code	270
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$13.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1.63
Rate for Payer: BCBS of TX Blue Advantage	$5.45
Rate for Payer: BCBS of TX Blue Essentials	$6.54
Rate for Payer: BCBS of TX PPO	$7.26
Rate for Payer: Cash Price	$12.35
Rate for Payer: Cigna Medicaid	$13.08
Rate for Payer: Molina CHIP/Medicaid	$13.08
Rate for Payer: Multiplan Auto	$11.80
Rate for Payer: Multiplan Commercial	$11.80
Rate for Payer: Multiplan Workers Comp	$11.80
Rate for Payer: Parkland Medicaid	$13.08
Rate for Payer: Scott and White EPO/PPO	$9.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13.08
Rate for Payer: Superior Health Plan EPO	$2.47

LUMBAR SINGLE LEVEL INJ BCE

Facility

$1,630.00

Service Code	HCPCS 64483
Hospital Charge Code	8494477
Hospital Revenue Code	361
Min. Negotiated Rate	$340.77
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$340.77
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$888.50
Rate for Payer: Amerigroup Medicare	$888.50
Rate for Payer: BCBS of TX Blue Advantage	$1,356.12
Rate for Payer: BCBS of TX Blue Essentials	$1,624.10
Rate for Payer: BCBS of TX Medicare	$888.50
Rate for Payer: BCBS of TX PPO	$2,046.37
Rate for Payer: Cash Price	$1,108.40
Rate for Payer: Cash Price	$1,108.40
Rate for Payer: Cash Price	$1,108.40
Rate for Payer: Cigna Commercial	$1,878.13
Rate for Payer: Cigna Medicaid	$1,173.60
Rate for Payer: Cigna Medicare	$888.50
Rate for Payer: Employer Direct Commercial	$888.50
Rate for Payer: Humana Medicare/TRICARE	$888.50
Rate for Payer: Molina CHIP/Medicaid	$1,173.60
Rate for Payer: Molina Dual Medicare/Medicaid	$888.50
Rate for Payer: Molina Medicare	$888.50
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	$1,173.60
Rate for Payer: Scott and White EPO/PPO	$1,643.72
Rate for Payer: Scott and White Medicare	$888.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,173.60
Rate for Payer: Superior Health Plan EPO	$888.50
Rate for Payer: Superior Health Plan Medicare	$888.50
Rate for Payer: Universal American Dual Medicare/Medicaid	$888.50
Rate for Payer: Universal American Medicare	$888.50
Rate for Payer: Wellcare Medicare	$888.50
Rate for Payer: Wellmed Medicare	$888.50

LUMBAR SINGLE LEVEL INJ BCE

Facility

$1,630.00

Service Code	HCPCS 64483
Hospital Charge Code	8494477
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,108.40

LUNG TRANSPLANT

Facility

$246,053.80

Service Code	MSDRG 007
Min. Negotiated Rate	$91,598.60
Max. Negotiated Rate	$246,053.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$99,672.44
Rate for Payer: Amerigroup Medicare	$99,672.44
Rate for Payer: BCBS of TX Blue Advantage	$91,598.60
Rate for Payer: BCBS of TX Blue Essentials	$109,907.67
Rate for Payer: BCBS of TX Medicare	$99,672.44
Rate for Payer: BCBS of TX PPO	$122,124.37
Rate for Payer: Cigna Commercial	$166,798.58
Rate for Payer: Cigna Medicare	$99,672.44
Rate for Payer: Employer Direct Commercial	$99,672.44
Rate for Payer: Molina Dual Medicare/Medicaid	$99,672.44
Rate for Payer: Molina Medicare	$99,672.44
Rate for Payer: Multiplan Auto	$246,053.80
Rate for Payer: Multiplan Commercial	$246,053.80
Rate for Payer: Multiplan Workers Comp	$246,053.80
Rate for Payer: Scott and White EPO/PPO	$113,314.25
Rate for Payer: Scott and White Medicare	$99,672.44
Rate for Payer: Superior Health Plan EPO	$99,672.44
Rate for Payer: Superior Health Plan Medicare	$99,672.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$99,672.44
Rate for Payer: Universal American Medicare	$99,672.44
Rate for Payer: Wellcare Medicare	$99,672.44
Rate for Payer: Wellmed Medicare	$99,672.44

L VENTRIC PACING LEAD ADD-ON

Facility

$14,696.00

Service Code	HCPCS 33225
Hospital Charge Code	2303311
Hospital Revenue Code	481
Rate for Payer: Cash Price	$9,993.28

L VENTRIC PACING LEAD ADD-ON

Facility

$14,696.00

Service Code	HCPCS 33225
Hospital Charge Code	2303311
Hospital Revenue Code	481
Min. Negotiated Rate	$1,322.64
Max. Negotiated Rate	$10,581.12
Rate for Payer: Amerigroup CHIP/Medicaid	$1,322.64
Rate for Payer: BCBS of TX Blue Advantage	$4,408.80
Rate for Payer: BCBS of TX Blue Essentials	$5,290.56
Rate for Payer: BCBS of TX PPO	$5,878.40
Rate for Payer: Cash Price	$9,993.28
Rate for Payer: Cigna Medicaid	$10,581.12
Rate for Payer: Molina CHIP/Medicaid	$10,581.12
Rate for Payer: Multiplan Auto	$9,552.40
Rate for Payer: Multiplan Commercial	$9,552.40
Rate for Payer: Multiplan Workers Comp	$9,552.40
Rate for Payer: Parkland Medicaid	$10,581.12
Rate for Payer: Scott and White EPO/PPO	$7,348.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,581.12
Rate for Payer: Superior Health Plan EPO	$1,998.66

LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$29,128.80

Service Code	APR-DRG 6944
Min. Negotiated Rate	$27,463.65
Max. Negotiated Rate	$29,128.80
Rate for Payer: Amerigroup CHIP/Medicaid	$27,463.65
Rate for Payer: Cigna Medicaid	$27,463.65
Rate for Payer: Molina CHIP/Medicaid	$27,463.65
Rate for Payer: Parkland Medicaid	$27,463.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$29,128.80

LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$6,511.04

Service Code	APR-DRG 6943
Min. Negotiated Rate	$6,138.83
Max. Negotiated Rate	$6,511.04
Rate for Payer: Amerigroup CHIP/Medicaid	$6,138.83
Rate for Payer: Cigna Medicaid	$6,138.83
Rate for Payer: Molina CHIP/Medicaid	$6,138.83
Rate for Payer: Parkland Medicaid	$6,138.83
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,511.04

LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$3,155.56

Service Code	APR-DRG 6941
Min. Negotiated Rate	$2,975.18
Max. Negotiated Rate	$3,155.56
Rate for Payer: Amerigroup CHIP/Medicaid	$2,975.18
Rate for Payer: Cigna Medicaid	$2,975.18
Rate for Payer: Molina CHIP/Medicaid	$2,975.18
Rate for Payer: Parkland Medicaid	$2,975.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,155.56

LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$4,293.17

Service Code	APR-DRG 6942
Min. Negotiated Rate	$4,047.75
Max. Negotiated Rate	$4,293.17
Rate for Payer: Amerigroup CHIP/Medicaid	$4,047.75
Rate for Payer: Cigna Medicaid	$4,047.75
Rate for Payer: Molina CHIP/Medicaid	$4,047.75
Rate for Payer: Parkland Medicaid	$4,047.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,293.17

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$42,533.40

Service Code	MSDRG 821
Min. Negotiated Rate	$19,587.75
Max. Negotiated Rate	$42,533.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,166.83
Rate for Payer: Amerigroup Medicare	$21,166.83
Rate for Payer: BCBS of TX Medicare	$21,166.83
Rate for Payer: Cigna Commercial	$28,833.17
Rate for Payer: Cigna Medicare	$21,166.83
Rate for Payer: Employer Direct Commercial	$21,166.83
Rate for Payer: Humana Medicare/TRICARE	$21,166.83
Rate for Payer: Molina Dual Medicare/Medicaid	$21,166.83
Rate for Payer: Molina Medicare	$21,166.83
Rate for Payer: Multiplan Auto	$42,533.40
Rate for Payer: Multiplan Commercial	$42,533.40
Rate for Payer: Multiplan Workers Comp	$42,533.40
Rate for Payer: Scott and White EPO/PPO	$19,587.75
Rate for Payer: Scott and White Medicare	$21,166.83
Rate for Payer: Superior Health Plan EPO	$21,166.83
Rate for Payer: Superior Health Plan Medicare	$21,166.83
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,166.83
Rate for Payer: Universal American Medicare	$21,166.83
Rate for Payer: Wellcare Medicare	$21,166.83
Rate for Payer: Wellmed Medicare	$21,166.83

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$111,431.20

Service Code	MSDRG 820
Min. Negotiated Rate	$46,815.82
Max. Negotiated Rate	$111,431.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$47,743.35
Rate for Payer: Amerigroup Medicare	$47,743.35
Rate for Payer: BCBS of TX Medicare	$47,743.35
Rate for Payer: Cigna Commercial	$75,538.62
Rate for Payer: Cigna Medicare	$47,743.35
Rate for Payer: Employer Direct Commercial	$47,743.35
Rate for Payer: Humana Medicare/TRICARE	$47,743.35
Rate for Payer: Molina Dual Medicare/Medicaid	$47,743.35
Rate for Payer: Molina Medicare	$47,743.35
Rate for Payer: Multiplan Auto	$111,431.20
Rate for Payer: Multiplan Commercial	$111,431.20
Rate for Payer: Multiplan Workers Comp	$111,431.20
Rate for Payer: Scott and White EPO/PPO	$51,317.00
Rate for Payer: Scott and White Medicare	$47,743.35
Rate for Payer: Superior Health Plan EPO	$47,743.35
Rate for Payer: Superior Health Plan Medicare	$47,743.35
Rate for Payer: Universal American Dual Medicare/Medicaid	$47,743.35
Rate for Payer: Universal American Medicare	$47,743.35
Rate for Payer: Wellcare Medicare	$47,743.35
Rate for Payer: Wellmed Medicare	$47,743.35

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$22,876.00

Service Code	MSDRG 822
Min. Negotiated Rate	$10,404.28
Max. Negotiated Rate	$22,876.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13,584.23
Rate for Payer: Amerigroup Medicare	$13,584.23
Rate for Payer: BCBS of TX Medicare	$13,584.23
Rate for Payer: Cigna Commercial	$15,507.52
Rate for Payer: Cigna Medicare	$13,584.23
Rate for Payer: Employer Direct Commercial	$13,584.23
Rate for Payer: Humana Medicare/TRICARE	$13,584.23
Rate for Payer: Molina Dual Medicare/Medicaid	$13,584.23
Rate for Payer: Molina Medicare	$13,584.23
Rate for Payer: Multiplan Auto	$22,876.00
Rate for Payer: Multiplan Commercial	$22,876.00
Rate for Payer: Multiplan Workers Comp	$22,876.00
Rate for Payer: Scott and White EPO/PPO	$10,535.00
Rate for Payer: Scott and White Medicare	$13,584.23
Rate for Payer: Superior Health Plan EPO	$13,584.23
Rate for Payer: Superior Health Plan Medicare	$13,584.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$13,584.23
Rate for Payer: Universal American Medicare	$13,584.23
Rate for Payer: Wellcare Medicare	$13,584.23
Rate for Payer: Wellmed Medicare	$13,584.23

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$30,996.60

Service Code	MSDRG 841
Min. Negotiated Rate	$14,059.28
Max. Negotiated Rate	$30,996.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16,716.66
Rate for Payer: Amerigroup Medicare	$16,716.66
Rate for Payer: BCBS of TX Medicare	$16,716.66
Rate for Payer: Cigna Commercial	$21,012.43
Rate for Payer: Cigna Medicare	$16,716.66
Rate for Payer: Employer Direct Commercial	$16,716.66
Rate for Payer: Humana Medicare/TRICARE	$16,716.66
Rate for Payer: Molina Dual Medicare/Medicaid	$16,716.66
Rate for Payer: Molina Medicare	$16,716.66
Rate for Payer: Multiplan Auto	$30,996.60
Rate for Payer: Multiplan Commercial	$30,996.60
Rate for Payer: Multiplan Workers Comp	$30,996.60
Rate for Payer: Scott and White EPO/PPO	$14,274.75
Rate for Payer: Scott and White Medicare	$16,716.66
Rate for Payer: Superior Health Plan EPO	$16,716.66
Rate for Payer: Superior Health Plan Medicare	$16,716.66
Rate for Payer: Universal American Dual Medicare/Medicaid	$16,716.66
Rate for Payer: Universal American Medicare	$16,716.66
Rate for Payer: Wellcare Medicare	$16,716.66
Rate for Payer: Wellmed Medicare	$16,716.66

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$61,463.10

Service Code	MSDRG 840
Min. Negotiated Rate	$28,305.38
Max. Negotiated Rate	$61,463.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$28,468.75
Rate for Payer: Amerigroup Medicare	$28,468.75
Rate for Payer: BCBS of TX Medicare	$28,468.75
Rate for Payer: Cigna Commercial	$41,665.51
Rate for Payer: Cigna Medicare	$28,468.75
Rate for Payer: Employer Direct Commercial	$28,468.75
Rate for Payer: Humana Medicare/TRICARE	$28,468.75
Rate for Payer: Molina Dual Medicare/Medicaid	$28,468.75
Rate for Payer: Molina Medicare	$28,468.75
Rate for Payer: Multiplan Auto	$61,463.10
Rate for Payer: Multiplan Commercial	$61,463.10
Rate for Payer: Multiplan Workers Comp	$61,463.10
Rate for Payer: Scott and White EPO/PPO	$28,305.38
Rate for Payer: Scott and White Medicare	$28,468.75
Rate for Payer: Superior Health Plan EPO	$28,468.75
Rate for Payer: Superior Health Plan Medicare	$28,468.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$28,468.75
Rate for Payer: Universal American Medicare	$28,468.75
Rate for Payer: Wellcare Medicare	$28,468.75
Rate for Payer: Wellmed Medicare	$28,468.75

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$43,046.40

Service Code	MSDRG 824
Min. Negotiated Rate	$18,871.84
Max. Negotiated Rate	$43,046.40
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21,364.72
Rate for Payer: Amerigroup Medicare	$21,364.72
Rate for Payer: BCBS of TX Medicare	$21,364.72
Rate for Payer: Cigna Commercial	$29,180.93
Rate for Payer: Cigna Medicare	$21,364.72
Rate for Payer: Employer Direct Commercial	$21,364.72
Rate for Payer: Humana Medicare/TRICARE	$21,364.72
Rate for Payer: Molina Dual Medicare/Medicaid	$21,364.72
Rate for Payer: Molina Medicare	$21,364.72
Rate for Payer: Multiplan Auto	$43,046.40
Rate for Payer: Multiplan Commercial	$43,046.40
Rate for Payer: Multiplan Workers Comp	$43,046.40
Rate for Payer: Scott and White EPO/PPO	$19,824.00
Rate for Payer: Scott and White Medicare	$21,364.72
Rate for Payer: Superior Health Plan EPO	$21,364.72
Rate for Payer: Superior Health Plan Medicare	$21,364.72
Rate for Payer: Universal American Dual Medicare/Medicaid	$21,364.72
Rate for Payer: Universal American Medicare	$21,364.72
Rate for Payer: Wellcare Medicare	$21,364.72
Rate for Payer: Wellmed Medicare	$21,364.72

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$87,111.20

Service Code	MSDRG 823
Min. Negotiated Rate	$38,362.20
Max. Negotiated Rate	$87,111.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38,362.20
Rate for Payer: Amerigroup Medicare	$38,362.20
Rate for Payer: BCBS of TX Medicare	$38,362.20
Rate for Payer: Cigna Commercial	$59,052.22
Rate for Payer: Cigna Medicare	$38,362.20
Rate for Payer: Employer Direct Commercial	$38,362.20
Rate for Payer: Humana Medicare/TRICARE	$38,362.20
Rate for Payer: Molina Dual Medicare/Medicaid	$38,362.20
Rate for Payer: Molina Medicare	$38,362.20
Rate for Payer: Multiplan Auto	$87,111.20
Rate for Payer: Multiplan Commercial	$87,111.20
Rate for Payer: Multiplan Workers Comp	$87,111.20
Rate for Payer: Scott and White EPO/PPO	$40,117.00
Rate for Payer: Scott and White Medicare	$38,362.20
Rate for Payer: Superior Health Plan EPO	$38,362.20
Rate for Payer: Superior Health Plan Medicare	$38,362.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$38,362.20
Rate for Payer: Universal American Medicare	$38,362.20
Rate for Payer: Wellcare Medicare	$38,362.20
Rate for Payer: Wellmed Medicare	$38,362.20

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$25,638.60

Service Code	MSDRG 825
Min. Negotiated Rate	$11,687.40
Max. Negotiated Rate	$25,638.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,649.87
Rate for Payer: Amerigroup Medicare	$14,649.87
Rate for Payer: BCBS of TX Medicare	$14,649.87
Rate for Payer: Cigna Commercial	$17,380.27
Rate for Payer: Cigna Medicare	$14,649.87
Rate for Payer: Employer Direct Commercial	$14,649.87
Rate for Payer: Humana Medicare/TRICARE	$14,649.87
Rate for Payer: Molina Dual Medicare/Medicaid	$14,649.87
Rate for Payer: Molina Medicare	$14,649.87
Rate for Payer: Multiplan Auto	$25,638.60
Rate for Payer: Multiplan Commercial	$25,638.60
Rate for Payer: Multiplan Workers Comp	$25,638.60
Rate for Payer: Scott and White EPO/PPO	$11,807.25
Rate for Payer: Scott and White Medicare	$14,649.87
Rate for Payer: Superior Health Plan EPO	$14,649.87
Rate for Payer: Superior Health Plan Medicare	$14,649.87
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,649.87
Rate for Payer: Universal American Medicare	$14,649.87
Rate for Payer: Wellcare Medicare	$14,649.87
Rate for Payer: Wellmed Medicare	$14,649.87

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$19,197.60

Service Code	MSDRG 842
Min. Negotiated Rate	$8,841.00
Max. Negotiated Rate	$19,197.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,165.34
Rate for Payer: Amerigroup Medicare	$12,165.34
Rate for Payer: BCBS of TX Medicare	$12,165.34
Rate for Payer: Cigna Commercial	$13,013.95
Rate for Payer: Cigna Medicare	$12,165.34
Rate for Payer: Employer Direct Commercial	$12,165.34
Rate for Payer: Humana Medicare/TRICARE	$12,165.34
Rate for Payer: Molina Dual Medicare/Medicaid	$12,165.34
Rate for Payer: Molina Medicare	$12,165.34
Rate for Payer: Multiplan Auto	$19,197.60
Rate for Payer: Multiplan Commercial	$19,197.60
Rate for Payer: Multiplan Workers Comp	$19,197.60
Rate for Payer: Scott and White EPO/PPO	$8,841.00
Rate for Payer: Scott and White Medicare	$12,165.34
Rate for Payer: Superior Health Plan EPO	$12,165.34
Rate for Payer: Superior Health Plan Medicare	$12,165.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,165.34
Rate for Payer: Universal American Medicare	$12,165.34
Rate for Payer: Wellcare Medicare	$12,165.34
Rate for Payer: Wellmed Medicare	$12,165.34

LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC

Facility

$42,533.40

Service Code	MSDRG 821
Min. Negotiated Rate	$19,587.75
Max. Negotiated Rate	$42,533.40
Rate for Payer: BCBS of TX Blue Advantage	$20,590.98
Rate for Payer: BCBS of TX Blue Essentials	$24,706.78
Rate for Payer: BCBS of TX PPO	$27,453.04

LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC

Facility

$111,431.20

Service Code	MSDRG 820
Min. Negotiated Rate	$46,815.82
Max. Negotiated Rate	$111,431.20
Rate for Payer: BCBS of TX Blue Advantage	$46,815.82
Rate for Payer: BCBS of TX Blue Essentials	$56,173.54
Rate for Payer: BCBS of TX PPO	$62,417.46

LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W/O CC/MCC

Facility

$22,876.00

Service Code	MSDRG 822
Min. Negotiated Rate	$10,404.28
Max. Negotiated Rate	$22,876.00
Rate for Payer: BCBS of TX Blue Advantage	$10,404.28
Rate for Payer: BCBS of TX Blue Essentials	$12,483.93
Rate for Payer: BCBS of TX PPO	$13,871.57

Know your out-of-pocket cost for care.

All Charges