White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Dextrose 5% in Lactated Ringers IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7121
Hospital Charge Code	77337318
Hospital Revenue Code	258
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$7.18
Rate for Payer: BCBS of TX Blue Essentials	$8.61
Rate for Payer: BCBS of TX PPO	$9.55
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% in Lactated Ringers IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7121
Hospital Charge Code	77337318
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337479
Hospital Revenue Code	258
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% in Water IV Soln 1000 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337479
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337699
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 100 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337699
Hospital Revenue Code	258
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% in Water IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337589
Hospital Revenue Code	258
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

Dextrose 5% in Water IV Soln 250 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337589
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 500 mL

Facility

$128.00

Service Code	HCPCS J7060
Hospital Charge Code	77337534
Hospital Revenue Code	636
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

Dextrose 5% in Water IV Soln 500 mL

Facility

$128.00

Service Code	HCPCS J7060
Hospital Charge Code	77337534
Hospital Revenue Code	636
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Commercial	$32.00
Rate for Payer: Scott and White EPO/PPO	$64.00

Dextrose 5% in Water IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337754
Hospital Revenue Code	258
Rate for Payer: Cash Price	$87.16

Dextrose 5% in Water IV Soln 50 mL

Facility

$128.17

Service Code	HCPCS J7060
Hospital Charge Code	77337754
Hospital Revenue Code	258
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$10.99
Rate for Payer: BCBS of TX Blue Essentials	$13.19
Rate for Payer: BCBS of TX PPO	$14.63
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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
Min. Negotiated Rate	$11.54
Max. Negotiated Rate	$92.28
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: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
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: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
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

DFB DYNAGEN EL DR D153 -- DHF

Facility

$82,301.00

Service Code	HCPCS C1722
Hospital Charge Code	40082919
Hospital Revenue Code	278
Min. Negotiated Rate	$7,407.09
Max. Negotiated Rate	$59,256.72
Rate for Payer: Amerigroup CHIP/Medicaid	$7,407.09
Rate for Payer: BCBS of TX Blue Advantage	$24,690.30
Rate for Payer: BCBS of TX Blue Essentials	$29,628.36
Rate for Payer: BCBS of TX PPO	$32,920.40
Rate for Payer: Cash Price	$55,964.68
Rate for Payer: Cigna Medicaid	$59,256.72
Rate for Payer: Molina CHIP/Medicaid	$59,256.72
Rate for Payer: Multiplan Auto	$41,150.50
Rate for Payer: Multiplan Commercial	$41,150.50
Rate for Payer: Multiplan Workers Comp	$41,150.50
Rate for Payer: Parkland Medicaid	$59,256.72
Rate for Payer: Scott and White EPO/PPO	$41,150.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$59,256.72
Rate for Payer: Superior Health Plan EPO	$11,192.94

DFB DYNAGEN EL DR D153 -- DHF

Facility

$82,301.00

Service Code	HCPCS C1722
Hospital Charge Code	40082919
Hospital Revenue Code	278
Min. Negotiated Rate	$20,575.25
Max. Negotiated Rate	$41,150.50
Rate for Payer: Cash Price	$55,964.68
Rate for Payer: Cigna Commercial	$20,575.25
Rate for Payer: Multiplan Auto	$41,150.50
Rate for Payer: Multiplan Commercial	$41,150.50
Rate for Payer: Multiplan Workers Comp	$41,150.50
Rate for Payer: Scott and White EPO/PPO	$41,150.50

DFB DYNAGEN EL VR D150 -- DHF

Facility

$81,054.00

Service Code	HCPCS C1722
Hospital Charge Code	40082984
Hospital Revenue Code	278
Min. Negotiated Rate	$20,263.50
Max. Negotiated Rate	$40,527.00
Rate for Payer: Cash Price	$55,116.72
Rate for Payer: Cigna Commercial	$20,263.50
Rate for Payer: Multiplan Auto	$40,527.00
Rate for Payer: Multiplan Commercial	$40,527.00
Rate for Payer: Multiplan Workers Comp	$40,527.00
Rate for Payer: Scott and White EPO/PPO	$40,527.00

DFB DYNAGEN EL VR D150 -- DHF

Facility

$81,054.00

Service Code	HCPCS C1722
Hospital Charge Code	40082984
Hospital Revenue Code	278
Min. Negotiated Rate	$7,294.86
Max. Negotiated Rate	$58,358.88
Rate for Payer: Amerigroup CHIP/Medicaid	$7,294.86
Rate for Payer: BCBS of TX Blue Advantage	$24,316.20
Rate for Payer: BCBS of TX Blue Essentials	$29,179.44
Rate for Payer: BCBS of TX PPO	$32,421.60
Rate for Payer: Cash Price	$55,116.72
Rate for Payer: Cigna Medicaid	$58,358.88
Rate for Payer: Molina CHIP/Medicaid	$58,358.88
Rate for Payer: Multiplan Auto	$40,527.00
Rate for Payer: Multiplan Commercial	$40,527.00
Rate for Payer: Multiplan Workers Comp	$40,527.00
Rate for Payer: Parkland Medicaid	$58,358.88
Rate for Payer: Scott and White EPO/PPO	$40,527.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$58,358.88
Rate for Payer: Superior Health Plan EPO	$11,023.34

DFB ELLIPSE DR CD241136Q -- DHF

Facility

$106,546.00

Service Code	HCPCS C1722
Hospital Charge Code	40001877
Hospital Revenue Code	278
Min. Negotiated Rate	$9,589.14
Max. Negotiated Rate	$76,713.12
Rate for Payer: Amerigroup CHIP/Medicaid	$9,589.14
Rate for Payer: BCBS of TX Blue Advantage	$31,963.80
Rate for Payer: BCBS of TX Blue Essentials	$38,356.56
Rate for Payer: BCBS of TX PPO	$42,618.40
Rate for Payer: Cash Price	$72,451.28
Rate for Payer: Cigna Medicaid	$76,713.12
Rate for Payer: Molina CHIP/Medicaid	$76,713.12
Rate for Payer: Multiplan Auto	$53,273.00
Rate for Payer: Multiplan Commercial	$53,273.00
Rate for Payer: Multiplan Workers Comp	$53,273.00
Rate for Payer: Parkland Medicaid	$76,713.12
Rate for Payer: Scott and White EPO/PPO	$53,273.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$76,713.12
Rate for Payer: Superior Health Plan EPO	$14,490.26

DFB ELLIPSE DR CD241136Q -- DHF

Facility

$106,546.00

Service Code	HCPCS C1722
Hospital Charge Code	40001877
Hospital Revenue Code	278
Min. Negotiated Rate	$26,636.50
Max. Negotiated Rate	$53,273.00
Rate for Payer: Cash Price	$72,451.28
Rate for Payer: Cigna Commercial	$26,636.50
Rate for Payer: Multiplan Auto	$53,273.00
Rate for Payer: Multiplan Commercial	$53,273.00
Rate for Payer: Multiplan Workers Comp	$53,273.00
Rate for Payer: Scott and White EPO/PPO	$53,273.00

DFB EVERA MRI XT DDMB1D1 -- DHF

Facility

$78,313.00

Service Code	HCPCS C1722
Hospital Charge Code	40083370
Hospital Revenue Code	278
Min. Negotiated Rate	$7,048.17
Max. Negotiated Rate	$56,385.36
Rate for Payer: Amerigroup CHIP/Medicaid	$7,048.17
Rate for Payer: BCBS of TX Blue Advantage	$23,493.90
Rate for Payer: BCBS of TX Blue Essentials	$28,192.68
Rate for Payer: BCBS of TX PPO	$31,325.20
Rate for Payer: Cash Price	$53,252.84
Rate for Payer: Cigna Medicaid	$56,385.36
Rate for Payer: Molina CHIP/Medicaid	$56,385.36
Rate for Payer: Multiplan Auto	$39,156.50
Rate for Payer: Multiplan Commercial	$39,156.50
Rate for Payer: Multiplan Workers Comp	$39,156.50
Rate for Payer: Parkland Medicaid	$56,385.36
Rate for Payer: Scott and White EPO/PPO	$39,156.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$56,385.36
Rate for Payer: Superior Health Plan EPO	$10,650.57

Know your out-of-pocket cost for care.

All Charges