White Rock Medical Center

All Charges

Charge

Type

Setting

Price

DFB ELLIPSE DR CD241136Q -- DHF

Facility

$106,546.20

Service Code	HCPCS C1721
Hospital Charge Code	40001877
Hospital Revenue Code	278
Min. Negotiated Rate	$26,636.55
Max. Negotiated Rate	$53,273.10
Rate for Payer: Aetna Commercial	$31,963.86
Rate for Payer: Cash Price	$93,760.66
Rate for Payer: Cigna Commercial	$26,636.55
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

DFB EVERA MRI XT DDMB1D1 -- DHF

Facility

$78,313.25

Service Code	HCPCS C1721
Hospital Charge Code	40083370
Hospital Revenue Code	278
Min. Negotiated Rate	$19,578.31
Max. Negotiated Rate	$39,156.62
Rate for Payer: Aetna Commercial	$23,493.98
Rate for Payer: Cash Price	$68,915.66
Rate for Payer: Cigna Commercial	$19,578.31
Rate for Payer: Multiplan Auto	$39,156.62
Rate for Payer: Multiplan Commercial	$39,156.62
Rate for Payer: Multiplan Workers Comp	$39,156.62
Rate for Payer: Scott and White EPO/PPO	$39,156.62

DFB EVERA MRI XT DDMB1D1 -- DHF

Facility

$78,313.25

Service Code	HCPCS C1721
Hospital Charge Code	40083370
Hospital Revenue Code	278
Min. Negotiated Rate	$7,048.19
Max. Negotiated Rate	$39,156.62
Rate for Payer: Aetna Commercial	$23,493.98
Rate for Payer: Amerigroup CHIP/Medicaid	$7,048.19
Rate for Payer: BCBS of TX Blue Advantage	$23,493.98
Rate for Payer: BCBS of TX Blue Essentials	$28,192.77
Rate for Payer: BCBS of TX PPO	$31,325.30
Rate for Payer: Cash Price	$68,915.66
Rate for Payer: Multiplan Auto	$39,156.62
Rate for Payer: Multiplan Commercial	$39,156.62
Rate for Payer: Multiplan Workers Comp	$39,156.62
Rate for Payer: Scott and White EPO/PPO	$39,156.62
Rate for Payer: Superior Health Plan EPO	$10,650.60

DFB EVERA MRI XT DDMB1D4 -- DHF

Facility

$78,313.25

Service Code	HCPCS C1721
Hospital Charge Code	40083305
Hospital Revenue Code	278
Min. Negotiated Rate	$7,048.19
Max. Negotiated Rate	$39,156.62
Rate for Payer: Aetna Commercial	$23,493.98
Rate for Payer: Amerigroup CHIP/Medicaid	$7,048.19
Rate for Payer: BCBS of TX Blue Advantage	$23,493.98
Rate for Payer: BCBS of TX Blue Essentials	$28,192.77
Rate for Payer: BCBS of TX PPO	$31,325.30
Rate for Payer: Cash Price	$68,915.66
Rate for Payer: Multiplan Auto	$39,156.62
Rate for Payer: Multiplan Commercial	$39,156.62
Rate for Payer: Multiplan Workers Comp	$39,156.62
Rate for Payer: Scott and White EPO/PPO	$39,156.62
Rate for Payer: Superior Health Plan EPO	$10,650.60

DFB EVERA MRI XT DDMB1D4 -- DHF

Facility

$78,313.25

Service Code	HCPCS C1721
Hospital Charge Code	40083305
Hospital Revenue Code	278
Min. Negotiated Rate	$19,578.31
Max. Negotiated Rate	$39,156.62
Rate for Payer: Aetna Commercial	$23,493.98
Rate for Payer: Cash Price	$68,915.66
Rate for Payer: Cigna Commercial	$19,578.31
Rate for Payer: Multiplan Auto	$39,156.62
Rate for Payer: Multiplan Commercial	$39,156.62
Rate for Payer: Multiplan Workers Comp	$39,156.62
Rate for Payer: Scott and White EPO/PPO	$39,156.62

DFB INTICA NEO HF-T 429553

Facility

$145,075.30

Service Code	HCPCS C1722
Hospital Charge Code	145069
Hospital Revenue Code	278
Min. Negotiated Rate	$13,056.78
Max. Negotiated Rate	$72,537.65
Rate for Payer: Aetna Commercial	$43,522.59
Rate for Payer: Amerigroup CHIP/Medicaid	$13,056.78
Rate for Payer: BCBS of TX Blue Advantage	$43,522.59
Rate for Payer: BCBS of TX Blue Essentials	$52,227.11
Rate for Payer: BCBS of TX PPO	$58,030.12
Rate for Payer: Cash Price	$127,666.26
Rate for Payer: Multiplan Auto	$72,537.65
Rate for Payer: Multiplan Commercial	$72,537.65
Rate for Payer: Multiplan Workers Comp	$72,537.65
Rate for Payer: Scott and White EPO/PPO	$72,537.65
Rate for Payer: Superior Health Plan EPO	$19,730.24

DFB INTICA NEO HF-T 429553

Facility

$145,075.30

Service Code	HCPCS C1722
Hospital Charge Code	145069
Hospital Revenue Code	278
Min. Negotiated Rate	$36,268.82
Max. Negotiated Rate	$72,537.65
Rate for Payer: Aetna Commercial	$43,522.59
Rate for Payer: Cash Price	$127,666.26
Rate for Payer: Cigna Commercial	$36,268.82
Rate for Payer: Multiplan Auto	$72,537.65
Rate for Payer: Multiplan Commercial	$72,537.65
Rate for Payer: Multiplan Workers Comp	$72,537.65
Rate for Payer: Scott and White EPO/PPO	$72,537.65

dfb momemtum el icd d121

Facility

$90,433.73

Service Code	HCPCS C1721
Hospital Charge Code	139407
Hospital Revenue Code	278
Min. Negotiated Rate	$8,139.04
Max. Negotiated Rate	$45,216.86
Rate for Payer: Aetna Commercial	$27,130.12
Rate for Payer: Amerigroup CHIP/Medicaid	$8,139.04
Rate for Payer: BCBS of TX Blue Advantage	$27,130.12
Rate for Payer: BCBS of TX Blue Essentials	$32,556.14
Rate for Payer: BCBS of TX PPO	$36,173.49
Rate for Payer: Cash Price	$79,581.68
Rate for Payer: Multiplan Auto	$45,216.86
Rate for Payer: Multiplan Commercial	$45,216.86
Rate for Payer: Multiplan Workers Comp	$45,216.86
Rate for Payer: Scott and White EPO/PPO	$45,216.86
Rate for Payer: Superior Health Plan EPO	$12,298.99

dfb momemtum el icd d121

Facility

$90,433.73

Service Code	HCPCS C1721
Hospital Charge Code	139407
Hospital Revenue Code	278
Min. Negotiated Rate	$22,608.43
Max. Negotiated Rate	$45,216.86
Rate for Payer: Aetna Commercial	$27,130.12
Rate for Payer: Cash Price	$79,581.68
Rate for Payer: Cigna Commercial	$22,608.43
Rate for Payer: Multiplan Auto	$45,216.86
Rate for Payer: Multiplan Commercial	$45,216.86
Rate for Payer: Multiplan Workers Comp	$45,216.86
Rate for Payer: Scott and White EPO/PPO	$45,216.86

dfb momentum heartlogic g125

Facility

$112,879.52

Service Code	HCPCS C1882
Hospital Charge Code	8628563
Hospital Revenue Code	275
Min. Negotiated Rate	$28,219.88
Max. Negotiated Rate	$56,439.76
Rate for Payer: Aetna Commercial	$33,863.86
Rate for Payer: Cash Price	$99,333.98
Rate for Payer: Cigna Commercial	$28,219.88
Rate for Payer: Multiplan Auto	$56,439.76
Rate for Payer: Multiplan Commercial	$56,439.76
Rate for Payer: Multiplan Workers Comp	$56,439.76
Rate for Payer: Scott and White EPO/PPO	$56,439.76

dfb momentum heartlogic g125

Facility

$112,879.52

Service Code	HCPCS C1882
Hospital Charge Code	8628563
Hospital Revenue Code	275
Min. Negotiated Rate	$10,159.16
Max. Negotiated Rate	$56,439.76
Rate for Payer: Aetna Commercial	$33,863.86
Rate for Payer: Amerigroup CHIP/Medicaid	$10,159.16
Rate for Payer: BCBS of TX Blue Advantage	$33,863.86
Rate for Payer: BCBS of TX Blue Essentials	$40,636.63
Rate for Payer: BCBS of TX PPO	$45,151.81
Rate for Payer: Cash Price	$99,333.98
Rate for Payer: Multiplan Auto	$56,439.76
Rate for Payer: Multiplan Commercial	$56,439.76
Rate for Payer: Multiplan Workers Comp	$56,439.76
Rate for Payer: Scott and White EPO/PPO	$56,439.76
Rate for Payer: Superior Health Plan EPO	$15,351.61

DFB QUAD ASSUR CD336940Q -- DHF

Facility

$145,963.86

Service Code	HCPCS C1882
Hospital Charge Code	40085201
Hospital Revenue Code	275
Min. Negotiated Rate	$13,136.75
Max. Negotiated Rate	$72,981.93
Rate for Payer: Aetna Commercial	$43,789.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13,136.75
Rate for Payer: BCBS of TX Blue Advantage	$43,789.16
Rate for Payer: BCBS of TX Blue Essentials	$52,546.99
Rate for Payer: BCBS of TX PPO	$58,385.54
Rate for Payer: Cash Price	$128,448.20
Rate for Payer: Multiplan Auto	$72,981.93
Rate for Payer: Multiplan Commercial	$72,981.93
Rate for Payer: Multiplan Workers Comp	$72,981.93
Rate for Payer: Scott and White EPO/PPO	$72,981.93
Rate for Payer: Superior Health Plan EPO	$19,851.08

DFB QUAD ASSUR CD336940Q -- DHF

Facility

$145,963.86

Service Code	HCPCS C1882
Hospital Charge Code	40085201
Hospital Revenue Code	275
Min. Negotiated Rate	$36,490.96
Max. Negotiated Rate	$72,981.93
Rate for Payer: Aetna Commercial	$43,789.16
Rate for Payer: Cash Price	$128,448.20
Rate for Payer: Cigna Commercial	$36,490.96
Rate for Payer: Multiplan Auto	$72,981.93
Rate for Payer: Multiplan Commercial	$72,981.93
Rate for Payer: Multiplan Workers Comp	$72,981.93
Rate for Payer: Scott and White EPO/PPO	$72,981.93

DFB VISIA AF MRI DVFB1D4 -- DHF

Facility

$71,084.34

Service Code	HCPCS C1722
Hospital Charge Code	40084881
Hospital Revenue Code	278
Min. Negotiated Rate	$6,397.59
Max. Negotiated Rate	$35,542.17
Rate for Payer: Aetna Commercial	$21,325.30
Rate for Payer: Amerigroup CHIP/Medicaid	$6,397.59
Rate for Payer: BCBS of TX Blue Advantage	$21,325.30
Rate for Payer: BCBS of TX Blue Essentials	$25,590.36
Rate for Payer: BCBS of TX PPO	$28,433.74
Rate for Payer: Cash Price	$62,554.22
Rate for Payer: Multiplan Auto	$35,542.17
Rate for Payer: Multiplan Commercial	$35,542.17
Rate for Payer: Multiplan Workers Comp	$35,542.17
Rate for Payer: Scott and White EPO/PPO	$35,542.17
Rate for Payer: Superior Health Plan EPO	$9,667.47

DFB VISIA AF MRI DVFB1D4 -- DHF

Facility

$71,084.34

Service Code	HCPCS C1722
Hospital Charge Code	40084881
Hospital Revenue Code	278
Min. Negotiated Rate	$17,771.08
Max. Negotiated Rate	$35,542.17
Rate for Payer: Aetna Commercial	$21,325.30
Rate for Payer: Cash Price	$62,554.22
Rate for Payer: Cigna Commercial	$17,771.08
Rate for Payer: Multiplan Auto	$35,542.17
Rate for Payer: Multiplan Commercial	$35,542.17
Rate for Payer: Multiplan Workers Comp	$35,542.17
Rate for Payer: Scott and White EPO/PPO	$35,542.17

DHEA, Serum SO

Facility

$186.00

Service Code	CPT 82626
Hospital Charge Code	1701911
Hospital Revenue Code	301
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$120.90
Rate for Payer: Aetna Commercial	$26.53
Rate for Payer: Aetna Medicare	$37.90
Rate for Payer: Amerigroup CHIP/Medicaid	$9.86
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$25.27
Rate for Payer: Amerigroup Medicare	$25.27
Rate for Payer: BCBS of TX Blue Advantage	$41.70
Rate for Payer: BCBS of TX Blue Essentials	$50.03
Rate for Payer: BCBS of TX Medicare	$25.27
Rate for Payer: BCBS of TX PPO	$55.85
Rate for Payer: Cash Price	$163.68
Rate for Payer: Cash Price	$163.68
Rate for Payer: Cigna Medicaid	$25.27
Rate for Payer: Cigna Medicare	$25.27
Rate for Payer: Employer Direct Commercial	$25.27
Rate for Payer: Humana Medicare/TRICARE	$25.27
Rate for Payer: Molina CHIP/Medicaid	$25.27
Rate for Payer: Molina Dual Medicare/Medicaid	$25.27
Rate for Payer: Molina Medicare	$25.27
Rate for Payer: Multiplan Auto	$120.90
Rate for Payer: Multiplan Commercial	$120.90
Rate for Payer: Multiplan Workers Comp	$120.90
Rate for Payer: Parkland Medicaid	$25.27
Rate for Payer: Scott and White EPO/PPO	$31.59
Rate for Payer: Scott and White Medicare	$25.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25.27
Rate for Payer: Superior Health Plan EPO	$25.27
Rate for Payer: Superior Health Plan Medicare	$25.27
Rate for Payer: Universal American Dual Medicare/Medicaid	$25.27
Rate for Payer: Universal American Medicare	$25.27
Rate for Payer: Wellcare Medicare	$25.27
Rate for Payer: Wellmed Medicare	$25.27

DHEA, Serum SO

Facility

$186.00

Service Code	CPT 82626
Hospital Charge Code	1701911
Hospital Revenue Code	301
Rate for Payer: Cash Price	$163.68

DHEA-Sulfate SO

Facility

$42.00

Service Code	CPT 82627
Hospital Charge Code	1701929
Hospital Revenue Code	300
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$49.13
Rate for Payer: Aetna Commercial	$23.34
Rate for Payer: Aetna Medicare	$33.34
Rate for Payer: Amerigroup CHIP/Medicaid	$8.67
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22.23
Rate for Payer: Amerigroup Medicare	$22.23
Rate for Payer: BCBS of TX Blue Advantage	$36.68
Rate for Payer: BCBS of TX Blue Essentials	$44.02
Rate for Payer: BCBS of TX Medicare	$22.23
Rate for Payer: BCBS of TX PPO	$49.13
Rate for Payer: Cash Price	$36.96
Rate for Payer: Cash Price	$36.96
Rate for Payer: Cigna Medicaid	$22.23
Rate for Payer: Cigna Medicare	$22.23
Rate for Payer: Employer Direct Commercial	$22.23
Rate for Payer: Humana Medicare/TRICARE	$22.23
Rate for Payer: Molina CHIP/Medicaid	$22.23
Rate for Payer: Molina Dual Medicare/Medicaid	$22.23
Rate for Payer: Molina Medicare	$22.23
Rate for Payer: Multiplan Auto	$27.30
Rate for Payer: Multiplan Commercial	$27.30
Rate for Payer: Multiplan Workers Comp	$27.30
Rate for Payer: Parkland Medicaid	$22.23
Rate for Payer: Scott and White EPO/PPO	$27.79
Rate for Payer: Scott and White Medicare	$22.23
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22.23
Rate for Payer: Superior Health Plan EPO	$22.23
Rate for Payer: Superior Health Plan Medicare	$22.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$22.23
Rate for Payer: Universal American Medicare	$22.23
Rate for Payer: Wellcare Medicare	$22.23
Rate for Payer: Wellmed Medicare	$22.23

DHEA-Sulfate SO

Facility

$42.00

Service Code	CPT 82627
Hospital Charge Code	1701929
Hospital Revenue Code	300
Rate for Payer: Cash Price	$36.96

Diabetes Self Mgmnt Group per 30 Min

Facility

$109.00

Service Code	HCPCS G0109
Hospital Charge Code	8590002
Hospital Revenue Code	510
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$70.85
Rate for Payer: Aetna Commercial	$59.95
Rate for Payer: Amerigroup CHIP/Medicaid	$9.81
Rate for Payer: BCBS of TX Blue Advantage	$26.97
Rate for Payer: BCBS of TX Blue Essentials	$32.24
Rate for Payer: BCBS of TX PPO	$35.96
Rate for Payer: Cash Price	$95.92
Rate for Payer: Cash Price	$95.92
Rate for Payer: Multiplan Auto	$70.85
Rate for Payer: Multiplan Commercial	$70.85
Rate for Payer: Multiplan Workers Comp	$70.85
Rate for Payer: Scott and White EPO/PPO	$54.50

Diabetes Self Mgmnt Group per 30 Min BCE

Facility

$109.00

Service Code	HCPCS G0109
Hospital Charge Code	8590002
Hospital Revenue Code	510
Rate for Payer: Cash Price	$95.92

Diabetes Self Mgmnt Group per 30 Min BCE

Facility

$109.00

Service Code	HCPCS G0109
Hospital Charge Code	8590002
Hospital Revenue Code	510
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$70.85
Rate for Payer: Aetna Commercial	$59.95
Rate for Payer: Amerigroup CHIP/Medicaid	$9.81
Rate for Payer: BCBS of TX Blue Advantage	$26.97
Rate for Payer: BCBS of TX Blue Essentials	$32.24
Rate for Payer: BCBS of TX PPO	$35.96
Rate for Payer: Cash Price	$95.92
Rate for Payer: Cash Price	$95.92
Rate for Payer: Multiplan Auto	$70.85
Rate for Payer: Multiplan Commercial	$70.85
Rate for Payer: Multiplan Workers Comp	$70.85
Rate for Payer: Scott and White EPO/PPO	$54.50

Diabetes Self Mgmnt Individual 30 Min

Facility

$194.00

Service Code	HCPCS G0108
Hospital Charge Code	8590001
Hospital Revenue Code	510
Min. Negotiated Rate	$17.46
Max. Negotiated Rate	$130.43
Rate for Payer: Aetna Commercial	$106.70
Rate for Payer: Amerigroup CHIP/Medicaid	$17.46
Rate for Payer: BCBS of TX Blue Advantage	$97.82
Rate for Payer: BCBS of TX Blue Essentials	$116.94
Rate for Payer: BCBS of TX PPO	$130.43
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cash Price	$170.72
Rate for Payer: Multiplan Auto	$126.10
Rate for Payer: Multiplan Commercial	$126.10
Rate for Payer: Multiplan Workers Comp	$126.10
Rate for Payer: Scott and White EPO/PPO	$97.00

Diabetes Self Mgmnt Individual 30 Min BCE

Facility

$194.00

Service Code	HCPCS G0108
Hospital Charge Code	8590001
Hospital Revenue Code	510
Rate for Payer: Cash Price	$170.72

Diabetes Self Mgmnt Individual 30 Min BCE

Facility

$194.00

Service Code	HCPCS G0108
Hospital Charge Code	8590001
Hospital Revenue Code	510
Min. Negotiated Rate	$17.46
Max. Negotiated Rate	$130.43
Rate for Payer: Aetna Commercial	$106.70
Rate for Payer: Amerigroup CHIP/Medicaid	$17.46
Rate for Payer: BCBS of TX Blue Advantage	$97.82
Rate for Payer: BCBS of TX Blue Essentials	$116.94
Rate for Payer: BCBS of TX PPO	$130.43
Rate for Payer: Cash Price	$170.72
Rate for Payer: Cash Price	$170.72
Rate for Payer: Multiplan Auto	$126.10
Rate for Payer: Multiplan Commercial	$126.10
Rate for Payer: Multiplan Workers Comp	$126.10
Rate for Payer: Scott and White EPO/PPO	$97.00

Know your out-of-pocket cost for care.

All Charges