White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Urinalysis without Microscopic

Facility

$122.00

Service Code	HCPCS 81003 QW
Hospital Charge Code	48231605211
Hospital Revenue Code	307
Rate for Payer: Cash Price	$82.96

URINARY LEG BAG/EXT TUBE/STRAP S/M/L

Facility

$31.60

Hospital Charge Code	145059
Hospital Revenue Code	270
Rate for Payer: Cash Price	$21.49

URINARY LEG BAG/EXT TUBE/STRAP S/M/L

Facility

$31.60

Hospital Charge Code	145059
Hospital Revenue Code	270
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$22.75
Rate for Payer: Amerigroup CHIP/Medicaid	$2.84
Rate for Payer: BCBS of TX Blue Advantage	$9.48
Rate for Payer: BCBS of TX Blue Essentials	$11.38
Rate for Payer: BCBS of TX PPO	$12.64
Rate for Payer: Cash Price	$21.49
Rate for Payer: Cigna Medicaid	$22.75
Rate for Payer: Molina CHIP/Medicaid	$22.75
Rate for Payer: Multiplan Auto	$20.54
Rate for Payer: Multiplan Commercial	$20.54
Rate for Payer: Multiplan Workers Comp	$20.54
Rate for Payer: Parkland Medicaid	$22.75
Rate for Payer: Scott and White EPO/PPO	$15.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.75
Rate for Payer: Superior Health Plan EPO	$4.30

URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$2,500.39

Service Code	APR-DRG 4651
Min. Negotiated Rate	$2,357.45
Max. Negotiated Rate	$2,500.39
Rate for Payer: Amerigroup CHIP/Medicaid	$2,357.45
Rate for Payer: Cigna Medicaid	$2,357.45
Rate for Payer: Molina CHIP/Medicaid	$2,357.45
Rate for Payer: Parkland Medicaid	$2,357.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,500.39

URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$5,981.46

Service Code	APR-DRG 4653
Min. Negotiated Rate	$5,639.53
Max. Negotiated Rate	$5,981.46
Rate for Payer: Amerigroup CHIP/Medicaid	$5,639.53
Rate for Payer: Cigna Medicaid	$5,639.53
Rate for Payer: Molina CHIP/Medicaid	$5,639.53
Rate for Payer: Parkland Medicaid	$5,639.53
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,981.46

URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$10,696.70

Service Code	APR-DRG 4654
Min. Negotiated Rate	$10,085.23
Max. Negotiated Rate	$10,696.70
Rate for Payer: Amerigroup CHIP/Medicaid	$10,085.23
Rate for Payer: Cigna Medicaid	$10,085.23
Rate for Payer: Molina CHIP/Medicaid	$10,085.23
Rate for Payer: Parkland Medicaid	$10,085.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10,696.70

URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION

Facility

$3,515.78

Service Code	APR-DRG 4652
Min. Negotiated Rate	$3,314.80
Max. Negotiated Rate	$3,515.78
Rate for Payer: Amerigroup CHIP/Medicaid	$3,314.80
Rate for Payer: Cigna Medicaid	$3,314.80
Rate for Payer: Molina CHIP/Medicaid	$3,314.80
Rate for Payer: Parkland Medicaid	$3,314.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,515.78

URINARY STONES W ESW LITHOTRIPSY W CC/MCC

Facility

$18,623.08

Service Code	MSDRG 691
Min. Negotiated Rate	$13,968.12
Max. Negotiated Rate	$18,623.08
Rate for Payer: BCBS of TX Blue Advantage	$13,968.12
Rate for Payer: BCBS of TX Blue Essentials	$16,760.12
Rate for Payer: BCBS of TX PPO	$18,623.08

URINARY STONES W ESW LITHOTRIPSY W/O CC/MCC

Facility

$12,963.46

Service Code	MSDRG 692
Min. Negotiated Rate	$9,723.16
Max. Negotiated Rate	$12,963.46
Rate for Payer: BCBS of TX Blue Advantage	$9,723.16
Rate for Payer: BCBS of TX Blue Essentials	$11,666.66
Rate for Payer: BCBS of TX PPO	$12,963.46

URINARY STONES WITH MCC

Facility

$25,545.50

Service Code	MSDRG 693
Min. Negotiated Rate	$11,382.96
Max. Negotiated Rate	$25,545.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,613.94
Rate for Payer: Amerigroup Medicare	$14,613.94
Rate for Payer: BCBS of TX Medicare	$14,613.94
Rate for Payer: Cigna Commercial	$17,317.16
Rate for Payer: Cigna Medicare	$14,613.94
Rate for Payer: Employer Direct Commercial	$14,613.94
Rate for Payer: Humana Medicare/TRICARE	$14,613.94
Rate for Payer: Molina Dual Medicare/Medicaid	$14,613.94
Rate for Payer: Molina Medicare	$14,613.94
Rate for Payer: Multiplan Auto	$25,545.50
Rate for Payer: Multiplan Commercial	$25,545.50
Rate for Payer: Multiplan Workers Comp	$25,545.50
Rate for Payer: Scott and White EPO/PPO	$11,764.38
Rate for Payer: Scott and White Medicare	$14,613.94
Rate for Payer: Superior Health Plan EPO	$14,613.94
Rate for Payer: Superior Health Plan Medicare	$14,613.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,613.94
Rate for Payer: Universal American Medicare	$14,613.94
Rate for Payer: Wellcare Medicare	$14,613.94
Rate for Payer: Wellmed Medicare	$14,613.94

URINARY STONES WITHOUT MCC

Facility

$14,852.30

Service Code	MSDRG 694
Min. Negotiated Rate	$6,038.06
Max. Negotiated Rate	$14,852.30
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,489.17
Rate for Payer: Amerigroup Medicare	$10,489.17
Rate for Payer: BCBS of TX Medicare	$10,489.17
Rate for Payer: Cigna Commercial	$10,068.30
Rate for Payer: Cigna Medicare	$10,489.17
Rate for Payer: Employer Direct Commercial	$10,489.17
Rate for Payer: Humana Medicare/TRICARE	$10,489.17
Rate for Payer: Molina Dual Medicare/Medicaid	$10,489.17
Rate for Payer: Molina Medicare	$10,489.17
Rate for Payer: Multiplan Auto	$14,852.30
Rate for Payer: Multiplan Commercial	$14,852.30
Rate for Payer: Multiplan Workers Comp	$14,852.30
Rate for Payer: Scott and White EPO/PPO	$6,839.88
Rate for Payer: Scott and White Medicare	$10,489.17
Rate for Payer: Superior Health Plan EPO	$10,489.17
Rate for Payer: Superior Health Plan Medicare	$10,489.17
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,489.17
Rate for Payer: Universal American Medicare	$10,489.17
Rate for Payer: Wellcare Medicare	$10,489.17
Rate for Payer: Wellmed Medicare	$10,489.17

URINARY STONES W/O ESW LITHOTRIPSY W MCC

Facility

$25,545.50

Service Code	MSDRG 693
Min. Negotiated Rate	$11,382.96
Max. Negotiated Rate	$25,545.50
Rate for Payer: BCBS of TX Blue Advantage	$11,382.96
Rate for Payer: BCBS of TX Blue Essentials	$13,658.23
Rate for Payer: BCBS of TX PPO	$15,176.40

URINARY STONES W/O ESW LITHOTRIPSY W/O MCC

Facility

$14,852.30

Service Code	MSDRG 694
Min. Negotiated Rate	$6,038.06
Max. Negotiated Rate	$14,852.30
Rate for Payer: BCBS of TX Blue Advantage	$6,038.06
Rate for Payer: BCBS of TX Blue Essentials	$7,244.97
Rate for Payer: BCBS of TX PPO	$8,050.28

Urine Creatinine

Facility

$96.00

Service Code	HCPCS 82570 QW
Hospital Charge Code	4102573
Hospital Revenue Code	301
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$69.12
Rate for Payer: Amerigroup CHIP/Medicaid	$2.02
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$5.18
Rate for Payer: BCBS of TX Blue Advantage	$28.80
Rate for Payer: BCBS of TX Blue Essentials	$34.56
Rate for Payer: BCBS of TX Medicare	$5.18
Rate for Payer: BCBS of TX PPO	$38.40
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cigna Medicaid	$69.12
Rate for Payer: Cigna Medicare	$5.18
Rate for Payer: Employer Direct Commercial	$5.18
Rate for Payer: Humana Medicare/TRICARE	$5.18
Rate for Payer: Molina CHIP/Medicaid	$69.12
Rate for Payer: Molina Dual Medicare/Medicaid	$5.18
Rate for Payer: Molina Medicare	$5.18
Rate for Payer: Multiplan Auto	$62.40
Rate for Payer: Multiplan Commercial	$62.40
Rate for Payer: Multiplan Workers Comp	$62.40
Rate for Payer: Parkland Medicaid	$69.12
Rate for Payer: Scott and White EPO/PPO	$6.47
Rate for Payer: Scott and White Medicare	$5.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$69.12
Rate for Payer: Superior Health Plan EPO	$5.18
Rate for Payer: Superior Health Plan Medicare	$5.18
Rate for Payer: Universal American Dual Medicare/Medicaid	$5.18
Rate for Payer: Universal American Medicare	$5.18
Rate for Payer: Wellcare Medicare	$5.18
Rate for Payer: Wellmed Medicare	$5.18

Urine Creatinine

Facility

$96.00

Service Code	HCPCS 82570 QW
Hospital Charge Code	4102573
Hospital Revenue Code	301
Rate for Payer: Cash Price	$65.28

Urine Culture

Facility

$141.00

Service Code	HCPCS 87088
Hospital Charge Code	4107088
Hospital Revenue Code	306
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$101.52
Rate for Payer: Amerigroup CHIP/Medicaid	$3.16
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8.09
Rate for Payer: Amerigroup Medicare	$8.09
Rate for Payer: BCBS of TX Blue Advantage	$42.30
Rate for Payer: BCBS of TX Blue Essentials	$50.76
Rate for Payer: BCBS of TX Medicare	$8.09
Rate for Payer: BCBS of TX PPO	$56.40
Rate for Payer: Cash Price	$95.88
Rate for Payer: Cash Price	$95.88
Rate for Payer: Cigna Medicaid	$101.52
Rate for Payer: Cigna Medicare	$8.09
Rate for Payer: Employer Direct Commercial	$8.09
Rate for Payer: Humana Medicare/TRICARE	$8.09
Rate for Payer: Molina CHIP/Medicaid	$101.52
Rate for Payer: Molina Dual Medicare/Medicaid	$8.09
Rate for Payer: Molina Medicare	$8.09
Rate for Payer: Multiplan Auto	$91.65
Rate for Payer: Multiplan Commercial	$91.65
Rate for Payer: Multiplan Workers Comp	$91.65
Rate for Payer: Parkland Medicaid	$101.52
Rate for Payer: Scott and White EPO/PPO	$10.11
Rate for Payer: Scott and White Medicare	$8.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$101.52
Rate for Payer: Superior Health Plan EPO	$8.09
Rate for Payer: Superior Health Plan Medicare	$8.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$8.09
Rate for Payer: Universal American Medicare	$8.09
Rate for Payer: Wellcare Medicare	$8.09
Rate for Payer: Wellmed Medicare	$8.09

Urine Culture

Facility

$141.00

Service Code	HCPCS 87088
Hospital Charge Code	4107088
Hospital Revenue Code	306
Rate for Payer: Cash Price	$95.88

US Abdomen Complete

Facility

$1,598.00

Service Code	HCPCS 76700
Hospital Charge Code	3500212
Hospital Revenue Code	402
Min. Negotiated Rate	$104.75
Max. Negotiated Rate	$1,150.56
Rate for Payer: Amerigroup CHIP/Medicaid	$104.75
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$1,086.64
Rate for Payer: Cash Price	$1,086.64
Rate for Payer: Cash Price	$1,086.64
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$1,150.56
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$1,150.56
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$1,038.70
Rate for Payer: Multiplan Commercial	$1,038.70
Rate for Payer: Multiplan Workers Comp	$1,038.70
Rate for Payer: Parkland Medicaid	$1,150.56
Rate for Payer: Scott and White EPO/PPO	$799.00
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,150.56
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

US Abdomen Complete

Facility

$1,598.00

Service Code	HCPCS 76700
Hospital Charge Code	3500212
Hospital Revenue Code	402
Rate for Payer: Cash Price	$1,086.64

US Abdomen Limited

Facility

$1,236.00

Service Code	HCPCS 76705
Hospital Charge Code	3500055
Hospital Revenue Code	402
Min. Negotiated Rate	$87.21
Max. Negotiated Rate	$889.92
Rate for Payer: Amerigroup CHIP/Medicaid	$87.21
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$184.93
Rate for Payer: BCBS of TX Blue Essentials	$221.92
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$247.70
Rate for Payer: Cash Price	$840.48
Rate for Payer: Cash Price	$840.48
Rate for Payer: Cash Price	$840.48
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$889.92
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$889.92
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$803.40
Rate for Payer: Multiplan Commercial	$803.40
Rate for Payer: Multiplan Workers Comp	$803.40
Rate for Payer: Parkland Medicaid	$889.92
Rate for Payer: Scott and White EPO/PPO	$618.00
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$889.92
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

US Abdomen Limited

Facility

$1,236.00

Service Code	HCPCS 76705
Hospital Charge Code	3500055
Hospital Revenue Code	402
Rate for Payer: Cash Price	$840.48

US Aorta IVC Iliac Duplex Complete

Facility

$974.00

Service Code	HCPCS 93978
Hospital Charge Code	3500352
Hospital Revenue Code	921
Rate for Payer: Cash Price	$662.32

US Aorta IVC Iliac Duplex Complete

Facility

$974.00

Service Code	HCPCS 93978
Hospital Charge Code	3500352
Hospital Revenue Code	921
Min. Negotiated Rate	$87.66
Max. Negotiated Rate	$701.28
Rate for Payer: Amerigroup CHIP/Medicaid	$87.66
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
Rate for Payer: BCBS of TX Blue Advantage	$292.20
Rate for Payer: BCBS of TX Blue Essentials	$350.64
Rate for Payer: BCBS of TX Medicare	$239.69
Rate for Payer: BCBS of TX PPO	$389.60
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cash Price	$662.32
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$701.28
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$701.28
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$633.10
Rate for Payer: Multiplan Commercial	$633.10
Rate for Payer: Multiplan Workers Comp	$633.10
Rate for Payer: Parkland Medicaid	$701.28
Rate for Payer: Scott and White EPO/PPO	$487.00
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$701.28
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

US Aorta IVC Iliac Duplex Limited

Facility

$666.00

Service Code	HCPCS 93979
Hospital Charge Code	3500360
Hospital Revenue Code	921
Rate for Payer: Cash Price	$452.88

US Aorta IVC Iliac Duplex Limited

Facility

$666.00

Service Code	HCPCS 93979
Hospital Charge Code	3500360
Hospital Revenue Code	921
Min. Negotiated Rate	$59.94
Max. Negotiated Rate	$479.52
Rate for Payer: Amerigroup CHIP/Medicaid	$59.94
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$105.02
Rate for Payer: Amerigroup Medicare	$105.02
Rate for Payer: BCBS of TX Blue Advantage	$199.80
Rate for Payer: BCBS of TX Blue Essentials	$239.76
Rate for Payer: BCBS of TX Medicare	$105.02
Rate for Payer: BCBS of TX PPO	$266.40
Rate for Payer: Cash Price	$452.88
Rate for Payer: Cash Price	$452.88
Rate for Payer: Cash Price	$452.88
Rate for Payer: Cigna Commercial	$222.00
Rate for Payer: Cigna Medicaid	$479.52
Rate for Payer: Cigna Medicare	$105.02
Rate for Payer: Employer Direct Commercial	$105.02
Rate for Payer: Humana Medicare/TRICARE	$105.02
Rate for Payer: Molina CHIP/Medicaid	$479.52
Rate for Payer: Molina Dual Medicare/Medicaid	$105.02
Rate for Payer: Molina Medicare	$105.02
Rate for Payer: Multiplan Auto	$432.90
Rate for Payer: Multiplan Commercial	$432.90
Rate for Payer: Multiplan Workers Comp	$432.90
Rate for Payer: Parkland Medicaid	$479.52
Rate for Payer: Scott and White EPO/PPO	$333.00
Rate for Payer: Scott and White Medicare	$105.02
Rate for Payer: Superior Health Plan CHIP/Medicaid	$479.52
Rate for Payer: Superior Health Plan EPO	$105.02
Rate for Payer: Superior Health Plan Medicare	$105.02
Rate for Payer: Universal American Dual Medicare/Medicaid	$105.02
Rate for Payer: Universal American Medicare	$105.02
Rate for Payer: Wellcare Medicare	$105.02
Rate for Payer: Wellmed Medicare	$105.02

Know your out-of-pocket cost for care.

All Charges