White Rock Medical Center

All Charges

Charge

Type

Setting

Price

UPGRADE TO DUAL CHAMBER

Facility

$32,225.00

Service Code	HCPCS 33214
Hospital Charge Code	2302453
Hospital Revenue Code	481
Rate for Payer: Cash Price	$21,913.00

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$32,260.10

Service Code	MSDRG 256
Min. Negotiated Rate	$14,856.62
Max. Negotiated Rate	$32,260.10
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,204.03
Rate for Payer: Amerigroup Medicare	$17,204.03
Rate for Payer: BCBS of TX Medicare	$17,204.03
Rate for Payer: Cigna Commercial	$21,868.95
Rate for Payer: Cigna Medicare	$17,204.03
Rate for Payer: Employer Direct Commercial	$17,204.03
Rate for Payer: Humana Medicare/TRICARE	$17,204.03
Rate for Payer: Molina Dual Medicare/Medicaid	$17,204.03
Rate for Payer: Molina Medicare	$17,204.03
Rate for Payer: Multiplan Auto	$32,260.10
Rate for Payer: Multiplan Commercial	$32,260.10
Rate for Payer: Multiplan Workers Comp	$32,260.10
Rate for Payer: Scott and White EPO/PPO	$14,856.62
Rate for Payer: Scott and White Medicare	$17,204.03
Rate for Payer: Superior Health Plan EPO	$17,204.03
Rate for Payer: Superior Health Plan Medicare	$17,204.03
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,204.03
Rate for Payer: Universal American Medicare	$17,204.03
Rate for Payer: Wellcare Medicare	$17,204.03
Rate for Payer: Wellmed Medicare	$17,204.03

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$51,250.60

Service Code	MSDRG 255
Min. Negotiated Rate	$21,846.58
Max. Negotiated Rate	$51,250.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$24,529.40
Rate for Payer: Amerigroup Medicare	$24,529.40
Rate for Payer: BCBS of TX Medicare	$24,529.40
Rate for Payer: Cigna Commercial	$34,742.51
Rate for Payer: Cigna Medicare	$24,529.40
Rate for Payer: Employer Direct Commercial	$24,529.40
Rate for Payer: Humana Medicare/TRICARE	$24,529.40
Rate for Payer: Molina Dual Medicare/Medicaid	$24,529.40
Rate for Payer: Molina Medicare	$24,529.40
Rate for Payer: Multiplan Auto	$51,250.60
Rate for Payer: Multiplan Commercial	$51,250.60
Rate for Payer: Multiplan Workers Comp	$51,250.60
Rate for Payer: Scott and White EPO/PPO	$23,602.25
Rate for Payer: Scott and White Medicare	$24,529.40
Rate for Payer: Superior Health Plan EPO	$24,529.40
Rate for Payer: Superior Health Plan Medicare	$24,529.40
Rate for Payer: Universal American Dual Medicare/Medicaid	$24,529.40
Rate for Payer: Universal American Medicare	$24,529.40
Rate for Payer: Wellcare Medicare	$24,529.40
Rate for Payer: Wellmed Medicare	$24,529.40

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

Facility

$20,751.80

Service Code	MSDRG 257
Min. Negotiated Rate	$9,556.75
Max. Negotiated Rate	$20,751.80
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,764.84
Rate for Payer: Amerigroup Medicare	$12,764.84
Rate for Payer: BCBS of TX Medicare	$12,764.84
Rate for Payer: Cigna Commercial	$14,067.54
Rate for Payer: Cigna Medicare	$12,764.84
Rate for Payer: Employer Direct Commercial	$12,764.84
Rate for Payer: Humana Medicare/TRICARE	$12,764.84
Rate for Payer: Molina Dual Medicare/Medicaid	$12,764.84
Rate for Payer: Molina Medicare	$12,764.84
Rate for Payer: Multiplan Auto	$20,751.80
Rate for Payer: Multiplan Commercial	$20,751.80
Rate for Payer: Multiplan Workers Comp	$20,751.80
Rate for Payer: Scott and White EPO/PPO	$9,556.75
Rate for Payer: Scott and White Medicare	$12,764.84
Rate for Payer: Superior Health Plan EPO	$12,764.84
Rate for Payer: Superior Health Plan Medicare	$12,764.84
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,764.84
Rate for Payer: Universal American Medicare	$12,764.84
Rate for Payer: Wellcare Medicare	$12,764.84
Rate for Payer: Wellmed Medicare	$12,764.84

UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC

Facility

$32,260.10

Service Code	MSDRG 256
Min. Negotiated Rate	$14,856.62
Max. Negotiated Rate	$32,260.10
Rate for Payer: BCBS of TX Blue Advantage	$15,038.82
Rate for Payer: BCBS of TX Blue Essentials	$18,044.84
Rate for Payer: BCBS of TX PPO	$20,050.59

UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W MCC

Facility

$51,250.60

Service Code	MSDRG 255
Min. Negotiated Rate	$21,846.58
Max. Negotiated Rate	$51,250.60
Rate for Payer: BCBS of TX Blue Advantage	$21,846.58
Rate for Payer: BCBS of TX Blue Essentials	$26,213.36
Rate for Payer: BCBS of TX PPO	$29,127.08

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

Facility

$20,751.80

Service Code	MSDRG 257
Min. Negotiated Rate	$9,556.75
Max. Negotiated Rate	$20,751.80
Rate for Payer: BCBS of TX Blue Advantage	$9,684.46
Rate for Payer: BCBS of TX Blue Essentials	$11,620.23
Rate for Payer: BCBS of TX PPO	$12,911.86

Urea Nitrogen 24 Hour Urine

Facility

$174.00

Service Code	HCPCS 84540
Hospital Charge Code	1602622
Hospital Revenue Code	301
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$125.28
Rate for Payer: Amerigroup CHIP/Medicaid	$2.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.56
Rate for Payer: Amerigroup Medicare	$5.56
Rate for Payer: BCBS of TX Blue Advantage	$52.20
Rate for Payer: BCBS of TX Blue Essentials	$62.64
Rate for Payer: BCBS of TX Medicare	$5.56
Rate for Payer: BCBS of TX PPO	$69.60
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cigna Medicaid	$125.28
Rate for Payer: Cigna Medicare	$5.56
Rate for Payer: Employer Direct Commercial	$5.56
Rate for Payer: Humana Medicare/TRICARE	$5.56
Rate for Payer: Molina CHIP/Medicaid	$125.28
Rate for Payer: Molina Dual Medicare/Medicaid	$5.56
Rate for Payer: Molina Medicare	$5.56
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$125.28
Rate for Payer: Scott and White EPO/PPO	$6.95
Rate for Payer: Scott and White Medicare	$5.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28
Rate for Payer: Superior Health Plan EPO	$5.56
Rate for Payer: Superior Health Plan Medicare	$5.56
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.56
Rate for Payer: Universal American Medicare	$5.56
Rate for Payer: Wellcare Medicare	$5.56
Rate for Payer: Wellmed Medicare	$5.56

Urea Nitrogen 24 Hour Urine

Facility

$174.00

Service Code	HCPCS 84540
Hospital Charge Code	1602622
Hospital Revenue Code	301
Rate for Payer: Cash Price	$118.32

URETHRAL AND TRANSURETHRAL PROCEDURES

Facility

$5,073.19

Service Code	APR-DRG 4462
Min. Negotiated Rate	$4,783.18
Max. Negotiated Rate	$5,073.19
Rate for Payer: Amerigroup CHIP/Medicaid	$4,783.18
Rate for Payer: Cigna Medicaid	$4,783.18
Rate for Payer: Molina CHIP/Medicaid	$4,783.18
Rate for Payer: Parkland Medicaid	$4,783.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,073.19

URETHRAL AND TRANSURETHRAL PROCEDURES

Facility

$4,311.27

Service Code	APR-DRG 4461
Min. Negotiated Rate	$4,064.82
Max. Negotiated Rate	$4,311.27
Rate for Payer: Amerigroup CHIP/Medicaid	$4,064.82
Rate for Payer: Cigna Medicaid	$4,064.82
Rate for Payer: Molina CHIP/Medicaid	$4,064.82
Rate for Payer: Parkland Medicaid	$4,064.82
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,311.27

URETHRAL AND TRANSURETHRAL PROCEDURES

Facility

$9,223.78

Service Code	APR-DRG 4463
Min. Negotiated Rate	$8,696.50
Max. Negotiated Rate	$9,223.78
Rate for Payer: Amerigroup CHIP/Medicaid	$8,696.50
Rate for Payer: Cigna Medicaid	$8,696.50
Rate for Payer: Molina CHIP/Medicaid	$8,696.50
Rate for Payer: Parkland Medicaid	$8,696.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,223.78

URETHRAL AND TRANSURETHRAL PROCEDURES

Facility

$16,591.79

Service Code	APR-DRG 4464
Min. Negotiated Rate	$15,643.32
Max. Negotiated Rate	$16,591.79
Rate for Payer: Amerigroup CHIP/Medicaid	$15,643.32
Rate for Payer: Cigna Medicaid	$15,643.32
Rate for Payer: Molina CHIP/Medicaid	$15,643.32
Rate for Payer: Parkland Medicaid	$15,643.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16,591.79

URETHRAL PROCEDURES W CC/MCC

Facility

$34,105.00

Service Code	MSDRG 671
Min. Negotiated Rate	$14,478.10
Max. Negotiated Rate	$34,105.00
Rate for Payer: BCBS of TX Blue Advantage	$14,478.10
Rate for Payer: BCBS of TX Blue Essentials	$17,372.04
Rate for Payer: BCBS of TX PPO	$19,303.01

URETHRAL PROCEDURES WITH CC/MCC

Facility

$34,105.00

Service Code	MSDRG 671
Min. Negotiated Rate	$14,478.10
Max. Negotiated Rate	$34,105.00
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,915.69
Rate for Payer: Amerigroup Medicare	$17,915.69
Rate for Payer: BCBS of TX Medicare	$17,915.69
Rate for Payer: Cigna Commercial	$23,119.60
Rate for Payer: Cigna Medicare	$17,915.69
Rate for Payer: Employer Direct Commercial	$17,915.69
Rate for Payer: Humana Medicare/TRICARE	$17,915.69
Rate for Payer: Molina Dual Medicare/Medicaid	$17,915.69
Rate for Payer: Molina Medicare	$17,915.69
Rate for Payer: Multiplan Auto	$34,105.00
Rate for Payer: Multiplan Commercial	$34,105.00
Rate for Payer: Multiplan Workers Comp	$34,105.00
Rate for Payer: Scott and White EPO/PPO	$15,706.25
Rate for Payer: Scott and White Medicare	$17,915.69
Rate for Payer: Superior Health Plan EPO	$17,915.69
Rate for Payer: Superior Health Plan Medicare	$17,915.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,915.69
Rate for Payer: Universal American Medicare	$17,915.69
Rate for Payer: Wellcare Medicare	$17,915.69
Rate for Payer: Wellmed Medicare	$17,915.69

URETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$20,510.50

Service Code	MSDRG 672
Min. Negotiated Rate	$9,089.34
Max. Negotiated Rate	$20,510.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,671.77
Rate for Payer: Amerigroup Medicare	$12,671.77
Rate for Payer: BCBS of TX Medicare	$12,671.77
Rate for Payer: Cigna Commercial	$13,903.96
Rate for Payer: Cigna Medicare	$12,671.77
Rate for Payer: Employer Direct Commercial	$12,671.77
Rate for Payer: Humana Medicare/TRICARE	$12,671.77
Rate for Payer: Molina Dual Medicare/Medicaid	$12,671.77
Rate for Payer: Molina Medicare	$12,671.77
Rate for Payer: Multiplan Auto	$20,510.50
Rate for Payer: Multiplan Commercial	$20,510.50
Rate for Payer: Multiplan Workers Comp	$20,510.50
Rate for Payer: Scott and White EPO/PPO	$9,445.62
Rate for Payer: Scott and White Medicare	$12,671.77
Rate for Payer: Superior Health Plan EPO	$12,671.77
Rate for Payer: Superior Health Plan Medicare	$12,671.77
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,671.77
Rate for Payer: Universal American Medicare	$12,671.77
Rate for Payer: Wellcare Medicare	$12,671.77
Rate for Payer: Wellmed Medicare	$12,671.77

URETHRAL PROCEDURES W/O CC/MCC

Facility

$20,510.50

Service Code	MSDRG 672
Min. Negotiated Rate	$9,089.34
Max. Negotiated Rate	$20,510.50
Rate for Payer: BCBS of TX Blue Advantage	$9,089.34
Rate for Payer: BCBS of TX Blue Essentials	$10,906.15
Rate for Payer: BCBS of TX PPO	$12,118.42

URETHRAL STRICTURE

Facility

$20,478.20

Service Code	MSDRG 697
Min. Negotiated Rate	$8,256.00
Max. Negotiated Rate	$20,478.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,659.30
Rate for Payer: Amerigroup Medicare	$12,659.30
Rate for Payer: BCBS of TX Blue Advantage	$8,256.00
Rate for Payer: BCBS of TX Blue Essentials	$9,906.24
Rate for Payer: BCBS of TX Medicare	$12,659.30
Rate for Payer: BCBS of TX PPO	$11,007.36
Rate for Payer: Cigna Commercial	$13,882.06
Rate for Payer: Cigna Medicare	$12,659.30
Rate for Payer: Employer Direct Commercial	$12,659.30
Rate for Payer: Humana Medicare/TRICARE	$12,659.30
Rate for Payer: Molina Dual Medicare/Medicaid	$12,659.30
Rate for Payer: Molina Medicare	$12,659.30
Rate for Payer: Multiplan Auto	$20,478.20
Rate for Payer: Multiplan Commercial	$20,478.20
Rate for Payer: Multiplan Workers Comp	$20,478.20
Rate for Payer: Scott and White EPO/PPO	$9,430.75
Rate for Payer: Scott and White Medicare	$12,659.30
Rate for Payer: Superior Health Plan EPO	$12,659.30
Rate for Payer: Superior Health Plan Medicare	$12,659.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,659.30
Rate for Payer: Universal American Medicare	$12,659.30
Rate for Payer: Wellcare Medicare	$12,659.30
Rate for Payer: Wellmed Medicare	$12,659.30

Uric Acid

Facility

$205.00

Service Code	HCPCS 84550
Hospital Charge Code	1602374
Hospital Revenue Code	301
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$147.60
Rate for Payer: Amerigroup CHIP/Medicaid	$1.76
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$4.52
Rate for Payer: Amerigroup Medicare	$4.52
Rate for Payer: BCBS of TX Blue Advantage	$61.50
Rate for Payer: BCBS of TX Blue Essentials	$73.80
Rate for Payer: BCBS of TX Medicare	$4.52
Rate for Payer: BCBS of TX PPO	$82.00
Rate for Payer: Cash Price	$139.40
Rate for Payer: Cash Price	$139.40
Rate for Payer: Cigna Medicaid	$147.60
Rate for Payer: Cigna Medicare	$4.52
Rate for Payer: Employer Direct Commercial	$4.52
Rate for Payer: Humana Medicare/TRICARE	$4.52
Rate for Payer: Molina CHIP/Medicaid	$147.60
Rate for Payer: Molina Dual Medicare/Medicaid	$4.52
Rate for Payer: Molina Medicare	$4.52
Rate for Payer: Multiplan Auto	$133.25
Rate for Payer: Multiplan Commercial	$133.25
Rate for Payer: Multiplan Workers Comp	$133.25
Rate for Payer: Parkland Medicaid	$147.60
Rate for Payer: Scott and White EPO/PPO	$5.65
Rate for Payer: Scott and White Medicare	$4.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$147.60
Rate for Payer: Superior Health Plan EPO	$4.52
Rate for Payer: Superior Health Plan Medicare	$4.52
Rate for Payer: Universal American Dual Medicare/Medicaid	$4.52
Rate for Payer: Universal American Medicare	$4.52
Rate for Payer: Wellcare Medicare	$4.52
Rate for Payer: Wellmed Medicare	$4.52

Uric Acid

Facility

$205.00

Service Code	HCPCS 84550
Hospital Charge Code	1602374
Hospital Revenue Code	301
Rate for Payer: Cash Price	$139.40

URINAL, MALE, SUPREME

Facility

$2.06

Hospital Charge Code	993980
Hospital Revenue Code	271
Rate for Payer: Cash Price	$1.40

URINAL, MALE, SUPREME

Facility

$2.06

Hospital Charge Code	993980
Hospital Revenue Code	271
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$1.48
Rate for Payer: Amerigroup CHIP/Medicaid	$0.19
Rate for Payer: BCBS of TX Blue Advantage	$0.62
Rate for Payer: BCBS of TX Blue Essentials	$0.74
Rate for Payer: BCBS of TX PPO	$0.82
Rate for Payer: Cash Price	$1.40
Rate for Payer: Cigna Medicaid	$1.48
Rate for Payer: Molina CHIP/Medicaid	$1.48
Rate for Payer: Multiplan Auto	$1.34
Rate for Payer: Multiplan Commercial	$1.34
Rate for Payer: Multiplan Workers Comp	$1.34
Rate for Payer: Parkland Medicaid	$1.48
Rate for Payer: Scott and White EPO/PPO	$1.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1.48
Rate for Payer: Superior Health Plan EPO	$0.28

Urinalysis Microscopic

Facility

$188.00

Service Code	HCPCS 81001
Hospital Charge Code	1605260
Hospital Revenue Code	307
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$135.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3.17
Rate for Payer: Amerigroup Medicare	$3.17
Rate for Payer: BCBS of TX Blue Advantage	$56.40
Rate for Payer: BCBS of TX Blue Essentials	$67.68
Rate for Payer: BCBS of TX Medicare	$3.17
Rate for Payer: BCBS of TX PPO	$75.20
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cigna Medicaid	$135.36
Rate for Payer: Cigna Medicare	$3.17
Rate for Payer: Employer Direct Commercial	$3.17
Rate for Payer: Humana Medicare/TRICARE	$3.17
Rate for Payer: Molina CHIP/Medicaid	$135.36
Rate for Payer: Molina Dual Medicare/Medicaid	$3.17
Rate for Payer: Molina Medicare	$3.17
Rate for Payer: Multiplan Auto	$122.20
Rate for Payer: Multiplan Commercial	$122.20
Rate for Payer: Multiplan Workers Comp	$122.20
Rate for Payer: Parkland Medicaid	$135.36
Rate for Payer: Scott and White EPO/PPO	$3.96
Rate for Payer: Scott and White Medicare	$3.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$135.36
Rate for Payer: Superior Health Plan EPO	$3.17
Rate for Payer: Superior Health Plan Medicare	$3.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$3.17
Rate for Payer: Universal American Medicare	$3.17
Rate for Payer: Wellcare Medicare	$3.17
Rate for Payer: Wellmed Medicare	$3.17

Urinalysis Microscopic

Facility

$188.00

Service Code	HCPCS 81001
Hospital Charge Code	1605260
Hospital Revenue Code	307
Rate for Payer: Cash Price	$127.84

Urinalysis without Microscopic

Facility

$122.00

Service Code	HCPCS 81003 QW
Hospital Charge Code	48231605211
Hospital Revenue Code	307
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$87.84
Rate for Payer: Amerigroup CHIP/Medicaid	$0.88
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.25
Rate for Payer: Amerigroup Medicare	$2.25
Rate for Payer: BCBS of TX Blue Advantage	$36.60
Rate for Payer: BCBS of TX Blue Essentials	$43.92
Rate for Payer: BCBS of TX Medicare	$2.25
Rate for Payer: BCBS of TX PPO	$48.80
Rate for Payer: Cash Price	$82.96
Rate for Payer: Cash Price	$82.96
Rate for Payer: Cigna Medicaid	$87.84
Rate for Payer: Cigna Medicare	$2.25
Rate for Payer: Employer Direct Commercial	$2.25
Rate for Payer: Humana Medicare/TRICARE	$2.25
Rate for Payer: Molina CHIP/Medicaid	$87.84
Rate for Payer: Molina Dual Medicare/Medicaid	$2.25
Rate for Payer: Molina Medicare	$2.25
Rate for Payer: Multiplan Auto	$79.30
Rate for Payer: Multiplan Commercial	$79.30
Rate for Payer: Multiplan Workers Comp	$79.30
Rate for Payer: Parkland Medicaid	$87.84
Rate for Payer: Scott and White EPO/PPO	$2.81
Rate for Payer: Scott and White Medicare	$2.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$87.84
Rate for Payer: Superior Health Plan EPO	$2.25
Rate for Payer: Superior Health Plan Medicare	$2.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.25
Rate for Payer: Universal American Medicare	$2.25
Rate for Payer: Wellcare Medicare	$2.25
Rate for Payer: Wellmed Medicare	$2.25

Know your out-of-pocket cost for care.

All Charges