CPT 74240

X-ray upper GI tract

The standard charge for X-ray upper GI tract is $981.00. However, the price you pay depends on the rate negotiated by your insurance plan and what portion your insurance plan requires you to contribute towards that amount. Enter your info below to start your estimate.

To calculate an estimate of your cost, you will need two things:

  • Your Summary of Benefits and Coverage statement from your health insurance plan. If you don't have a paper copy, this is often also available online through your health insurance company's website.
  • Your remaining deductible amount for this year for your insurance plan. Many insurance plans require you to pay a certain amount out of pocket before the insurance kicks in. This amount is called the deductible and is different for each insurance plan.

More Information

White Rock Medical Center

Cost Estimate

Choose a plan to view the insurance rate estimate.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$858.04

  • Price Negotiated by Insurer

    $122.96

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $3.03

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $11.54

  • Basic Metabolic Panel

    $3.30

  • CHED 96374- IV Injection, single/initial BCE

    $32.40

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $188.11

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $12.78

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $11.52

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $11.52

  • metoclopramide 5 mg/mL Sol

    $11.52

  • ROOM/BED: Observation

    $400.00

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $11.54

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $29.70

  • XR Abdomen KUB 1 View

    $30.40

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$680.34

  • Price Negotiated by Insurer

    $300.66

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $116.10

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $0.44

  • Basic Metabolic Panel

    $148.80

  • CHED 96374- IV Injection, single/initial BCE

    $108.00

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $384.52

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $0.28

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $0.20

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $0.03

  • metoclopramide 5 mg/mL Sol

    $2.20

  • ROOM/BED: Observation

    $2,745.00

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $21.61

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $99.00

  • XR Abdomen KUB 1 View

    $131.69

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$620.20

  • Price Negotiated by Insurer

    $360.80

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $139.32

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $0.52

  • Basic Metabolic Panel

    $178.56

  • CHED 96374- IV Injection, single/initial BCE

    $129.60

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $461.42

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $0.33

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $0.24

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $0.03

  • metoclopramide 5 mg/mL Sol

    $2.64

  • ROOM/BED: Observation

    $3,294.00

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $25.93

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $118.80

  • XR Abdomen KUB 1 View

    $158.02

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$578.29

  • Price Negotiated by Insurer

    $402.71

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $154.80

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $0.58

  • Basic Metabolic Panel

    $198.40

  • CHED 96374- IV Injection, single/initial BCE

    $144.00

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $515.02

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $0.37

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $0.27

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $0.04

  • metoclopramide 5 mg/mL Sol

    $2.93

  • ROOM/BED: Observation

    $3,660.00

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $28.76

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $132.00

  • XR Abdomen KUB 1 View

    $176.38

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$313.92

  • Price Negotiated by Insurer

    $667.08

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $263.16

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $87.16

  • Basic Metabolic Panel

    $337.28

  • CHED 96374- IV Injection, single/initial BCE

    $244.80

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $5,303.32

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $96.56

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $87.04

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $87.04

  • metoclopramide 5 mg/mL Sol

    $87.04

  • ROOM/BED: Observation

    $74.80

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $87.16

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $224.40

  • XR Abdomen KUB 1 View

    $502.52

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$608.54

  • Price Negotiated by Insurer

    $372.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • CHED 96374- IV Injection, single/initial BCE

    $451.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $506.65

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $152.89

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $99.43

  • XR Abdomen KUB 1 View

    $184.79

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$274.68

  • Price Negotiated by Insurer

    $706.32

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $278.64

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $92.28

  • Basic Metabolic Panel

    $357.12

  • CHED 96374- IV Injection, single/initial BCE

    $259.20

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $5,615.28

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $102.24

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $92.16

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $92.16

  • metoclopramide 5 mg/mL Sol

    $92.16

  • ROOM/BED: Observation

    $79.20

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $92.28

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $237.60

  • XR Abdomen KUB 1 View

    $532.08

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$274.68

  • Price Negotiated by Insurer

    $706.32

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $278.64

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $92.28

  • Basic Metabolic Panel

    $357.12

  • CHED 96374- IV Injection, single/initial BCE

    $259.20

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $5,615.28

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $102.24

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $92.16

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $92.16

  • metoclopramide 5 mg/mL Sol

    $92.16

  • ROOM/BED: Observation

    $79.20

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $92.28

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $237.60

  • XR Abdomen KUB 1 View

    $532.08

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$343.35

  • Price Negotiated by Insurer

    $637.65

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $251.55

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $83.31

  • Basic Metabolic Panel

    $322.40

  • CHED 96374- IV Injection, single/initial BCE

    $234.00

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $5,069.35

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $92.30

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $83.20

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $83.20

  • metoclopramide 5 mg/mL Sol

    $83.20

  • ROOM/BED: Observation

    $71.50

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $83.31

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $10,000.00

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $214.50

  • XR Abdomen KUB 1 View

    $480.35

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$343.35

  • Price Negotiated by Insurer

    $637.65

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $251.55

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $83.31

  • Basic Metabolic Panel

    $322.40

  • CHED 96374- IV Injection, single/initial BCE

    $234.00

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $5,069.35

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $92.30

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $83.20

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $83.20

  • metoclopramide 5 mg/mL Sol

    $83.20

  • ROOM/BED: Observation

    $71.50

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $83.31

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $10,000.00

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $214.50

  • XR Abdomen KUB 1 View

    $480.35

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$343.35

  • Price Negotiated by Insurer

    $637.65

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $251.55

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $83.31

  • Basic Metabolic Panel

    $322.40

  • CHED 96374- IV Injection, single/initial BCE

    $234.00

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $5,069.35

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $92.30

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $83.20

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $83.20

  • metoclopramide 5 mg/mL Sol

    $83.20

  • ROOM/BED: Observation

    $71.50

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $83.31

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $10,000.00

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $214.50

  • XR Abdomen KUB 1 View

    $480.35

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$274.68

  • Price Negotiated by Insurer

    $706.32

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $278.64

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $92.28

  • Basic Metabolic Panel

    $357.12

  • CHED 96374- IV Injection, single/initial BCE

    $259.20

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $5,615.28

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $102.24

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $92.16

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $92.16

  • metoclopramide 5 mg/mL Sol

    $92.16

  • ROOM/BED: Observation

    $79.20

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $92.28

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $237.60

  • XR Abdomen KUB 1 View

    $532.08

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$716.70

  • Price Negotiated by Insurer

    $264.30

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $9.71

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $64.08

  • Basic Metabolic Panel

    $10.57

  • CHED 96374- IV Injection, single/initial BCE

    $180.00

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $3,899.50

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $71.00

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $64.00

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $64.00

  • metoclopramide 5 mg/mL Sol

    $64.00

  • ROOM/BED: Observation

    $55.00

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $64.08

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $165.00

  • XR Abdomen KUB 1 View

    $131.13

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$274.68

  • Price Negotiated by Insurer

    $706.32

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $278.64

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $92.28

  • Basic Metabolic Panel

    $357.12

  • CHED 96374- IV Injection, single/initial BCE

    $259.20

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $5,615.28

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $102.24

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $92.16

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $92.16

  • metoclopramide 5 mg/mL Sol

    $92.16

  • ROOM/BED: Observation

    $79.20

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $92.28

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $237.60

  • XR Abdomen KUB 1 View

    $532.08

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • acetaminophen 10 mg/mL IV Soln 100 mL

    $17.43

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • diatrizoate meglumine-diatrizoate sodium 66%-10% Oral and Rectal Soln 120 mL

    $19.31

  • heparin 25,000 units/NaCl 0.45% IV Soln 250 mL Premix

    $17.41

  • HYDROmorphone 0.5 mg/0.5 mL Inj Soln 0.5 mL

    $17.41

  • metoclopramide 5 mg/mL Sol

    $17.41

  • ROOM/BED: Observation

    $14.96

  • Sodium Chloride 0.9% IV Soln 1000 mL

    $17.43

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $981.00

  • Insurance Discount

    -$804.80

  • Price Negotiated by Insurer

    $176.20

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 96374- IV Injection, single/initial BCE

    $213.67

  • CT Abd/Pelvis w/o IV and Oral Contrast

    $239.69

  • Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intr

    $72.33

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

  • XR Abdomen KUB 1 View

    $87.42

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.