White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77336588
Hospital Revenue Code	258
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77336588
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% with 0.45% NaCl IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77337000
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% with 0.45% NaCl IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77337000
Hospital Revenue Code	258
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% with 0.9% NaCl IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77337153
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% with 0.9% NaCl IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J3490
Hospital Charge Code	77337153
Hospital Revenue Code	258
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$83.31
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$38.45
Rate for Payer: BCBS of TX Blue Essentials	$46.14
Rate for Payer: BCBS of TX PPO	$51.27
Rate for Payer: Cash Price	$87.16
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan EPO	$17.43

DFB AMPLIA DTMB1D1

Facility

$112,319.28

Service Code	HCPCS C1882
Hospital Charge Code	144867
Hospital Revenue Code	275
Min. Negotiated Rate	$10,108.74
Max. Negotiated Rate	$56,159.64
Rate for Payer: Aetna Commercial	$33,695.78
Rate for Payer: Amerigroup CHIP/Medicaid	$10,108.74
Rate for Payer: BCBS of TX Blue Advantage	$33,695.78
Rate for Payer: BCBS of TX Blue Essentials	$40,434.94
Rate for Payer: BCBS of TX PPO	$44,927.71
Rate for Payer: Cash Price	$98,840.97
Rate for Payer: Multiplan Auto	$56,159.64
Rate for Payer: Multiplan Commercial	$56,159.64
Rate for Payer: Multiplan Workers Comp	$56,159.64
Rate for Payer: Scott and White EPO/PPO	$56,159.64
Rate for Payer: Superior Health Plan EPO	$15,275.42

DFB AMPLIA DTMB1D1

Facility

$112,319.28

Service Code	HCPCS C1882
Hospital Charge Code	144867
Hospital Revenue Code	275
Min. Negotiated Rate	$28,079.82
Max. Negotiated Rate	$56,159.64
Rate for Payer: Aetna Commercial	$33,695.78
Rate for Payer: Cash Price	$98,840.97
Rate for Payer: Cigna Commercial	$28,079.82
Rate for Payer: Multiplan Auto	$56,159.64
Rate for Payer: Multiplan Commercial	$56,159.64
Rate for Payer: Multiplan Workers Comp	$56,159.64
Rate for Payer: Scott and White EPO/PPO	$56,159.64

DFB ASSURA CD3357-40C

Facility

$120,371.02

Service Code	HCPCS C1882
Hospital Charge Code	110263
Hospital Revenue Code	275
Min. Negotiated Rate	$30,092.76
Max. Negotiated Rate	$60,185.51
Rate for Payer: Aetna Commercial	$36,111.31
Rate for Payer: Cash Price	$105,926.50
Rate for Payer: Cigna Commercial	$30,092.76
Rate for Payer: Multiplan Auto	$60,185.51
Rate for Payer: Multiplan Commercial	$60,185.51
Rate for Payer: Multiplan Workers Comp	$60,185.51
Rate for Payer: Scott and White EPO/PPO	$60,185.51

DFB ASSURA CD3357-40C

Facility

$120,371.02

Service Code	HCPCS C1882
Hospital Charge Code	110263
Hospital Revenue Code	275
Min. Negotiated Rate	$10,833.39
Max. Negotiated Rate	$60,185.51
Rate for Payer: Aetna Commercial	$36,111.31
Rate for Payer: Amerigroup CHIP/Medicaid	$10,833.39
Rate for Payer: BCBS of TX Blue Advantage	$36,111.31
Rate for Payer: BCBS of TX Blue Essentials	$43,333.57
Rate for Payer: BCBS of TX PPO	$48,148.41
Rate for Payer: Cash Price	$105,926.50
Rate for Payer: Multiplan Auto	$60,185.51
Rate for Payer: Multiplan Commercial	$60,185.51
Rate for Payer: Multiplan Workers Comp	$60,185.51
Rate for Payer: Scott and White EPO/PPO	$60,185.51
Rate for Payer: Superior Health Plan EPO	$16,370.46

DFB CLARIA MRI DTMA1D1

Facility

$114,126.51

Service Code	HCPCS C1882
Hospital Charge Code	141478
Hospital Revenue Code	275
Min. Negotiated Rate	$28,531.63
Max. Negotiated Rate	$57,063.26
Rate for Payer: Aetna Commercial	$34,237.95
Rate for Payer: Cash Price	$100,431.33
Rate for Payer: Cigna Commercial	$28,531.63
Rate for Payer: Multiplan Auto	$57,063.26
Rate for Payer: Multiplan Commercial	$57,063.26
Rate for Payer: Multiplan Workers Comp	$57,063.26
Rate for Payer: Scott and White EPO/PPO	$57,063.26

DFB CLARIA MRI DTMA1D1

Facility

$114,126.51

Service Code	HCPCS C1882
Hospital Charge Code	141478
Hospital Revenue Code	275
Min. Negotiated Rate	$10,271.39
Max. Negotiated Rate	$57,063.26
Rate for Payer: Aetna Commercial	$34,237.95
Rate for Payer: Amerigroup CHIP/Medicaid	$10,271.39
Rate for Payer: BCBS of TX Blue Advantage	$34,237.95
Rate for Payer: BCBS of TX Blue Essentials	$41,085.54
Rate for Payer: BCBS of TX PPO	$45,650.60
Rate for Payer: Cash Price	$100,431.33
Rate for Payer: Multiplan Auto	$57,063.26
Rate for Payer: Multiplan Commercial	$57,063.26
Rate for Payer: Multiplan Workers Comp	$57,063.26
Rate for Payer: Scott and White EPO/PPO	$57,063.26
Rate for Payer: Superior Health Plan EPO	$15,521.21

DFB CLARIA MRI DTMA1QQ -- DHF

Facility

$115,331.33

Service Code	HCPCS C1882
Hospital Charge Code	40084931
Hospital Revenue Code	275
Min. Negotiated Rate	$28,832.83
Max. Negotiated Rate	$57,665.66
Rate for Payer: Aetna Commercial	$34,599.40
Rate for Payer: Cash Price	$101,491.57
Rate for Payer: Cigna Commercial	$28,832.83
Rate for Payer: Multiplan Auto	$57,665.66
Rate for Payer: Multiplan Commercial	$57,665.66
Rate for Payer: Multiplan Workers Comp	$57,665.66
Rate for Payer: Scott and White EPO/PPO	$57,665.66

DFB CLARIA MRI DTMA1QQ -- DHF

Facility

$115,331.33

Service Code	HCPCS C1882
Hospital Charge Code	40084931
Hospital Revenue Code	275
Min. Negotiated Rate	$10,379.82
Max. Negotiated Rate	$57,665.66
Rate for Payer: Aetna Commercial	$34,599.40
Rate for Payer: Amerigroup CHIP/Medicaid	$10,379.82
Rate for Payer: BCBS of TX Blue Advantage	$34,599.40
Rate for Payer: BCBS of TX Blue Essentials	$41,519.28
Rate for Payer: BCBS of TX PPO	$46,132.53
Rate for Payer: Cash Price	$101,491.57
Rate for Payer: Multiplan Auto	$57,665.66
Rate for Payer: Multiplan Commercial	$57,665.66
Rate for Payer: Multiplan Workers Comp	$57,665.66
Rate for Payer: Scott and White EPO/PPO	$57,665.66
Rate for Payer: Superior Health Plan EPO	$15,685.06

DFB CLARIA MRI QUAD DTMA1Q1

Facility

$115,331.33

Service Code	HCPCS C1882
Hospital Charge Code	141460
Hospital Revenue Code	275
Min. Negotiated Rate	$10,379.82
Max. Negotiated Rate	$57,665.66
Rate for Payer: Aetna Commercial	$34,599.40
Rate for Payer: Amerigroup CHIP/Medicaid	$10,379.82
Rate for Payer: BCBS of TX Blue Advantage	$34,599.40
Rate for Payer: BCBS of TX Blue Essentials	$41,519.28
Rate for Payer: BCBS of TX PPO	$46,132.53
Rate for Payer: Cash Price	$101,491.57
Rate for Payer: Multiplan Auto	$57,665.66
Rate for Payer: Multiplan Commercial	$57,665.66
Rate for Payer: Multiplan Workers Comp	$57,665.66
Rate for Payer: Scott and White EPO/PPO	$57,665.66
Rate for Payer: Superior Health Plan EPO	$15,685.06

DFB CLARIA MRI QUAD DTMA1Q1

Facility

$115,331.33

Service Code	HCPCS C1882
Hospital Charge Code	141460
Hospital Revenue Code	275
Min. Negotiated Rate	$28,832.83
Max. Negotiated Rate	$57,665.66
Rate for Payer: Aetna Commercial	$34,599.40
Rate for Payer: Cash Price	$101,491.57
Rate for Payer: Cigna Commercial	$28,832.83
Rate for Payer: Multiplan Auto	$57,665.66
Rate for Payer: Multiplan Commercial	$57,665.66
Rate for Payer: Multiplan Workers Comp	$57,665.66
Rate for Payer: Scott and White EPO/PPO	$57,665.66

DFB DYNAGEN CRT-D G150

Facility

$99,759.04

Service Code	HCPCS C1882
Hospital Charge Code	110353
Hospital Revenue Code	275
Min. Negotiated Rate	$8,978.31
Max. Negotiated Rate	$49,879.52
Rate for Payer: Aetna Commercial	$29,927.71
Rate for Payer: Amerigroup CHIP/Medicaid	$8,978.31
Rate for Payer: BCBS of TX Blue Advantage	$29,927.71
Rate for Payer: BCBS of TX Blue Essentials	$35,913.25
Rate for Payer: BCBS of TX PPO	$39,903.62
Rate for Payer: Cash Price	$87,787.96
Rate for Payer: Multiplan Auto	$49,879.52
Rate for Payer: Multiplan Commercial	$49,879.52
Rate for Payer: Multiplan Workers Comp	$49,879.52
Rate for Payer: Scott and White EPO/PPO	$49,879.52
Rate for Payer: Superior Health Plan EPO	$13,567.23

DFB DYNAGEN CRT-D G150

Facility

$99,759.04

Service Code	HCPCS C1882
Hospital Charge Code	110353
Hospital Revenue Code	275
Min. Negotiated Rate	$24,939.76
Max. Negotiated Rate	$49,879.52
Rate for Payer: Aetna Commercial	$29,927.71
Rate for Payer: Cash Price	$87,787.96
Rate for Payer: Cigna Commercial	$24,939.76
Rate for Payer: Multiplan Auto	$49,879.52
Rate for Payer: Multiplan Commercial	$49,879.52
Rate for Payer: Multiplan Workers Comp	$49,879.52
Rate for Payer: Scott and White EPO/PPO	$49,879.52

DFB DYNAGEN EL DR D152 -- DHF

Facility

$82,301.20

Service Code	HCPCS C1721
Hospital Charge Code	40082976
Hospital Revenue Code	278
Min. Negotiated Rate	$7,407.11
Max. Negotiated Rate	$41,150.60
Rate for Payer: Aetna Commercial	$24,690.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7,407.11
Rate for Payer: BCBS of TX Blue Advantage	$24,690.36
Rate for Payer: BCBS of TX Blue Essentials	$29,628.43
Rate for Payer: BCBS of TX PPO	$32,920.48
Rate for Payer: Cash Price	$72,425.06
Rate for Payer: Multiplan Auto	$41,150.60
Rate for Payer: Multiplan Commercial	$41,150.60
Rate for Payer: Multiplan Workers Comp	$41,150.60
Rate for Payer: Scott and White EPO/PPO	$41,150.60
Rate for Payer: Superior Health Plan EPO	$11,192.96

DFB DYNAGEN EL DR D152 -- DHF

Facility

$82,301.20

Service Code	HCPCS C1721
Hospital Charge Code	40082976
Hospital Revenue Code	278
Min. Negotiated Rate	$20,575.30
Max. Negotiated Rate	$41,150.60
Rate for Payer: Aetna Commercial	$24,690.36
Rate for Payer: Cash Price	$72,425.06
Rate for Payer: Cigna Commercial	$20,575.30
Rate for Payer: Multiplan Auto	$41,150.60
Rate for Payer: Multiplan Commercial	$41,150.60
Rate for Payer: Multiplan Workers Comp	$41,150.60
Rate for Payer: Scott and White EPO/PPO	$41,150.60

DFB DYNAGEN EL DR D153 -- DHF

Facility

$82,301.20

Service Code	HCPCS C1721
Hospital Charge Code	40082919
Hospital Revenue Code	278
Min. Negotiated Rate	$20,575.30
Max. Negotiated Rate	$41,150.60
Rate for Payer: Aetna Commercial	$24,690.36
Rate for Payer: Cash Price	$72,425.06
Rate for Payer: Cigna Commercial	$20,575.30
Rate for Payer: Multiplan Auto	$41,150.60
Rate for Payer: Multiplan Commercial	$41,150.60
Rate for Payer: Multiplan Workers Comp	$41,150.60
Rate for Payer: Scott and White EPO/PPO	$41,150.60

DFB DYNAGEN EL DR D153 -- DHF

Facility

$82,301.20

Service Code	HCPCS C1721
Hospital Charge Code	40082919
Hospital Revenue Code	278
Min. Negotiated Rate	$7,407.11
Max. Negotiated Rate	$41,150.60
Rate for Payer: Aetna Commercial	$24,690.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7,407.11
Rate for Payer: BCBS of TX Blue Advantage	$24,690.36
Rate for Payer: BCBS of TX Blue Essentials	$29,628.43
Rate for Payer: BCBS of TX PPO	$32,920.48
Rate for Payer: Cash Price	$72,425.06
Rate for Payer: Multiplan Auto	$41,150.60
Rate for Payer: Multiplan Commercial	$41,150.60
Rate for Payer: Multiplan Workers Comp	$41,150.60
Rate for Payer: Scott and White EPO/PPO	$41,150.60
Rate for Payer: Superior Health Plan EPO	$11,192.96

DFB DYNAGEN EL VR D150 -- DHF

Facility

$81,054.22

Service Code	HCPCS C1722
Hospital Charge Code	40082984
Hospital Revenue Code	278
Min. Negotiated Rate	$20,263.56
Max. Negotiated Rate	$40,527.11
Rate for Payer: Aetna Commercial	$24,316.27
Rate for Payer: Cash Price	$71,327.71
Rate for Payer: Cigna Commercial	$20,263.56
Rate for Payer: Multiplan Auto	$40,527.11
Rate for Payer: Multiplan Commercial	$40,527.11
Rate for Payer: Multiplan Workers Comp	$40,527.11
Rate for Payer: Scott and White EPO/PPO	$40,527.11

DFB DYNAGEN EL VR D150 -- DHF

Facility

$81,054.22

Service Code	HCPCS C1722
Hospital Charge Code	40082984
Hospital Revenue Code	278
Min. Negotiated Rate	$7,294.88
Max. Negotiated Rate	$40,527.11
Rate for Payer: Aetna Commercial	$24,316.27
Rate for Payer: Amerigroup CHIP/Medicaid	$7,294.88
Rate for Payer: BCBS of TX Blue Advantage	$24,316.27
Rate for Payer: BCBS of TX Blue Essentials	$29,179.52
Rate for Payer: BCBS of TX PPO	$32,421.69
Rate for Payer: Cash Price	$71,327.71
Rate for Payer: Multiplan Auto	$40,527.11
Rate for Payer: Multiplan Commercial	$40,527.11
Rate for Payer: Multiplan Workers Comp	$40,527.11
Rate for Payer: Scott and White EPO/PPO	$40,527.11
Rate for Payer: Superior Health Plan EPO	$11,023.37

DFB ELLIPSE DR CD241136Q -- DHF

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	40001877
Hospital Revenue Code	278
Min. Negotiated Rate	$9,589.16
Max. Negotiated Rate	$53,273.10
Rate for Payer: Aetna Commercial	$31,963.86
Rate for Payer: Amerigroup CHIP/Medicaid	$9,589.16
Rate for Payer: BCBS of TX Blue Advantage	$31,963.86
Rate for Payer: BCBS of TX Blue Essentials	$38,356.63
Rate for Payer: BCBS of TX PPO	$42,618.48
Rate for Payer: Cash Price	$93,760.66
Rate for Payer: Multiplan Auto	$53,273.10
Rate for Payer: Multiplan Commercial	$53,273.10
Rate for Payer: Multiplan Workers Comp	$53,273.10
Rate for Payer: Scott and White EPO/PPO	$53,273.10
Rate for Payer: Superior Health Plan EPO	$14,490.28

Know your out-of-pocket cost for care.

All Charges