White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$19,578.25
Max. Negotiated Rate	$39,156.50
Rate for Payer: Cash Price	$53,252.84
Rate for Payer: Cigna Commercial	$19,578.25
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: Scott and White EPO/PPO	$39,156.50

DFB EVERA MRI XT DDMB1D4 -- DHF

Facility

$78,313.00

Service Code	HCPCS C1722
Hospital Charge Code	40083305
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

DFB EVERA MRI XT DDMB1D4 -- DHF

Facility

$78,313.00

Service Code	HCPCS C1722
Hospital Charge Code	40083305
Hospital Revenue Code	278
Min. Negotiated Rate	$19,578.25
Max. Negotiated Rate	$39,156.50
Rate for Payer: Cash Price	$53,252.84
Rate for Payer: Cigna Commercial	$19,578.25
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: Scott and White EPO/PPO	$39,156.50

DFB INTICA NEO HF-T 429553

Facility

$145,075.00

Service Code	HCPCS C1722
Hospital Charge Code	145069
Hospital Revenue Code	278
Min. Negotiated Rate	$13,056.75
Max. Negotiated Rate	$104,454.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13,056.75
Rate for Payer: BCBS of TX Blue Advantage	$43,522.50
Rate for Payer: BCBS of TX Blue Essentials	$52,227.00
Rate for Payer: BCBS of TX PPO	$58,030.00
Rate for Payer: Cash Price	$98,651.00
Rate for Payer: Cigna Medicaid	$104,454.00
Rate for Payer: Molina CHIP/Medicaid	$104,454.00
Rate for Payer: Multiplan Auto	$72,537.50
Rate for Payer: Multiplan Commercial	$72,537.50
Rate for Payer: Multiplan Workers Comp	$72,537.50
Rate for Payer: Parkland Medicaid	$104,454.00
Rate for Payer: Scott and White EPO/PPO	$72,537.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$104,454.00
Rate for Payer: Superior Health Plan EPO	$19,730.20

DFB INTICA NEO HF-T 429553

Facility

$145,075.00

Service Code	HCPCS C1722
Hospital Charge Code	145069
Hospital Revenue Code	278
Min. Negotiated Rate	$36,268.75
Max. Negotiated Rate	$72,537.50
Rate for Payer: Cash Price	$98,651.00
Rate for Payer: Cigna Commercial	$36,268.75
Rate for Payer: Multiplan Auto	$72,537.50
Rate for Payer: Multiplan Commercial	$72,537.50
Rate for Payer: Multiplan Workers Comp	$72,537.50
Rate for Payer: Scott and White EPO/PPO	$72,537.50

dfb momemtum el icd d121

Facility

$90,434.00

Service Code	HCPCS C1722
Hospital Charge Code	139407
Hospital Revenue Code	278
Min. Negotiated Rate	$22,608.50
Max. Negotiated Rate	$45,217.00
Rate for Payer: Cash Price	$61,495.12
Rate for Payer: Cigna Commercial	$22,608.50
Rate for Payer: Multiplan Auto	$45,217.00
Rate for Payer: Multiplan Commercial	$45,217.00
Rate for Payer: Multiplan Workers Comp	$45,217.00
Rate for Payer: Scott and White EPO/PPO	$45,217.00

dfb momemtum el icd d121

Facility

$90,434.00

Service Code	HCPCS C1722
Hospital Charge Code	139407
Hospital Revenue Code	278
Min. Negotiated Rate	$8,139.06
Max. Negotiated Rate	$65,112.48
Rate for Payer: Amerigroup CHIP/Medicaid	$8,139.06
Rate for Payer: BCBS of TX Blue Advantage	$27,130.20
Rate for Payer: BCBS of TX Blue Essentials	$32,556.24
Rate for Payer: BCBS of TX PPO	$36,173.60
Rate for Payer: Cash Price	$61,495.12
Rate for Payer: Cigna Medicaid	$65,112.48
Rate for Payer: Molina CHIP/Medicaid	$65,112.48
Rate for Payer: Multiplan Auto	$45,217.00
Rate for Payer: Multiplan Commercial	$45,217.00
Rate for Payer: Multiplan Workers Comp	$45,217.00
Rate for Payer: Parkland Medicaid	$65,112.48
Rate for Payer: Scott and White EPO/PPO	$45,217.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$65,112.48
Rate for Payer: Superior Health Plan EPO	$12,299.02

DFB QUAD ASSUR CD336940Q -- DHF

Facility

$145,963.86

Service Code	HCPCS C1768
Hospital Charge Code	40085201
Hospital Revenue Code	275
Min. Negotiated Rate	$13,136.75
Max. Negotiated Rate	$105,093.98
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	$99,255.42
Rate for Payer: Cigna Medicaid	$105,093.98
Rate for Payer: Molina CHIP/Medicaid	$105,093.98
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: Parkland Medicaid	$105,093.98
Rate for Payer: Scott and White EPO/PPO	$72,981.93
Rate for Payer: Superior Health Plan CHIP/Medicaid	$105,093.98
Rate for Payer: Superior Health Plan EPO	$19,851.08

DFB QUAD ASSUR CD336940Q -- DHF

Facility

$145,963.86

Service Code	HCPCS C1768
Hospital Charge Code	40085201
Hospital Revenue Code	275
Min. Negotiated Rate	$36,490.96
Max. Negotiated Rate	$72,981.93
Rate for Payer: Cash Price	$99,255.42
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

$71,084.00

Service Code	HCPCS C1722
Hospital Charge Code	40084881
Hospital Revenue Code	278
Min. Negotiated Rate	$6,397.56
Max. Negotiated Rate	$51,180.48
Rate for Payer: Amerigroup CHIP/Medicaid	$6,397.56
Rate for Payer: BCBS of TX Blue Advantage	$21,325.20
Rate for Payer: BCBS of TX Blue Essentials	$25,590.24
Rate for Payer: BCBS of TX PPO	$28,433.60
Rate for Payer: Cash Price	$48,337.12
Rate for Payer: Cigna Medicaid	$51,180.48
Rate for Payer: Molina CHIP/Medicaid	$51,180.48
Rate for Payer: Multiplan Auto	$35,542.00
Rate for Payer: Multiplan Commercial	$35,542.00
Rate for Payer: Multiplan Workers Comp	$35,542.00
Rate for Payer: Parkland Medicaid	$51,180.48
Rate for Payer: Scott and White EPO/PPO	$35,542.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$51,180.48
Rate for Payer: Superior Health Plan EPO	$9,667.42

DFB VISIA AF MRI DVFB1D4 -- DHF

Facility

$71,084.00

Service Code	HCPCS C1722
Hospital Charge Code	40084881
Hospital Revenue Code	278
Min. Negotiated Rate	$17,771.00
Max. Negotiated Rate	$35,542.00
Rate for Payer: Cash Price	$48,337.12
Rate for Payer: Cigna Commercial	$17,771.00
Rate for Payer: Multiplan Auto	$35,542.00
Rate for Payer: Multiplan Commercial	$35,542.00
Rate for Payer: Multiplan Workers Comp	$35,542.00
Rate for Payer: Scott and White EPO/PPO	$35,542.00

DFW BARIATRIC BEHAVIOR COUNSEL OBESITY 15MIN BCE

Facility

$150.00

Hospital Charge Code	8994975
Hospital Revenue Code	510
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$108.00
Rate for Payer: Amerigroup CHIP/Medicaid	$13.50
Rate for Payer: BCBS of TX Blue Advantage	$45.00
Rate for Payer: BCBS of TX Blue Essentials	$54.00
Rate for Payer: BCBS of TX PPO	$60.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cigna Medicaid	$108.00
Rate for Payer: Molina CHIP/Medicaid	$108.00
Rate for Payer: Multiplan Auto	$97.50
Rate for Payer: Multiplan Commercial	$97.50
Rate for Payer: Multiplan Workers Comp	$97.50
Rate for Payer: Parkland Medicaid	$108.00
Rate for Payer: Scott and White EPO/PPO	$75.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$108.00

DFW BARIATRIC BEHAVIOR COUNSEL OBESITY 15MIN BCE

Facility

$150.00

Hospital Charge Code	8994975
Hospital Revenue Code	510
Rate for Payer: Cash Price	$102.00

DFW BARIATRIC E&M-EST. PATIENT-LVL I BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	8996974
Hospital Revenue Code	510
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$81.36
Rate for Payer: Amerigroup CHIP/Medicaid	$10.17
Rate for Payer: BCBS of TX Blue Advantage	$33.90
Rate for Payer: BCBS of TX Blue Essentials	$40.68
Rate for Payer: BCBS of TX PPO	$45.20
Rate for Payer: Cash Price	$76.84
Rate for Payer: Cigna Medicaid	$81.36
Rate for Payer: Molina CHIP/Medicaid	$81.36
Rate for Payer: Multiplan Auto	$73.45
Rate for Payer: Multiplan Commercial	$73.45
Rate for Payer: Multiplan Workers Comp	$73.45
Rate for Payer: Parkland Medicaid	$81.36
Rate for Payer: Scott and White EPO/PPO	$56.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$81.36

DFW BARIATRIC E&M-EST. PATIENT-LVL I BCE

Facility

$113.00

Service Code	HCPCS 99211
Hospital Charge Code	8996974
Hospital Revenue Code	510
Rate for Payer: Cash Price	$76.84

DFW BARIATRIC E&M-EST. PATIENT-LVL II BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	8994976
Hospital Revenue Code	510
Rate for Payer: Cash Price	$118.32

DFW BARIATRIC E&M-EST. PATIENT-LVL II BCE

Facility

$174.00

Service Code	HCPCS 99212
Hospital Charge Code	8994976
Hospital Revenue Code	510
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$125.28
Rate for Payer: Amerigroup CHIP/Medicaid	$15.66
Rate for Payer: BCBS of TX Blue Advantage	$52.20
Rate for Payer: BCBS of TX Blue Essentials	$62.64
Rate for Payer: BCBS of TX PPO	$69.60
Rate for Payer: Cash Price	$118.32
Rate for Payer: Cigna Medicaid	$125.28
Rate for Payer: Molina CHIP/Medicaid	$125.28
Rate for Payer: Multiplan Auto	$113.10
Rate for Payer: Multiplan Commercial	$113.10
Rate for Payer: Multiplan Workers Comp	$113.10
Rate for Payer: Parkland Medicaid	$125.28
Rate for Payer: Scott and White EPO/PPO	$87.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$125.28

DFW BARIATRIC E&M-EST. PATIENT-LVL III BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8996975
Hospital Revenue Code	510
Min. Negotiated Rate	$18.99
Max. Negotiated Rate	$151.92
Rate for Payer: Amerigroup CHIP/Medicaid	$18.99
Rate for Payer: BCBS of TX Blue Advantage	$63.30
Rate for Payer: BCBS of TX Blue Essentials	$75.96
Rate for Payer: BCBS of TX PPO	$84.40
Rate for Payer: Cash Price	$143.48
Rate for Payer: Cigna Medicaid	$151.92
Rate for Payer: Molina CHIP/Medicaid	$151.92
Rate for Payer: Multiplan Auto	$137.15
Rate for Payer: Multiplan Commercial	$137.15
Rate for Payer: Multiplan Workers Comp	$137.15
Rate for Payer: Parkland Medicaid	$151.92
Rate for Payer: Scott and White EPO/PPO	$105.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.92

DFW BARIATRIC E&M-EST. PATIENT-LVL III BCE

Facility

$211.00

Service Code	HCPCS 99213
Hospital Charge Code	8996975
Hospital Revenue Code	510
Rate for Payer: Cash Price	$143.48

DFW BARIATRIC E&M-EST. PATIENT-LVL IV BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	8994977
Hospital Revenue Code	510
Rate for Payer: Cash Price	$265.20

DFW BARIATRIC E&M-EST. PATIENT-LVL IV BCE

Facility

$390.00

Service Code	HCPCS 99214
Hospital Charge Code	8994977
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$280.80
Rate for Payer: Amerigroup CHIP/Medicaid	$35.10
Rate for Payer: BCBS of TX Blue Advantage	$117.00
Rate for Payer: BCBS of TX Blue Essentials	$140.40
Rate for Payer: BCBS of TX PPO	$156.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cigna Medicaid	$280.80
Rate for Payer: Molina CHIP/Medicaid	$280.80
Rate for Payer: Multiplan Auto	$253.50
Rate for Payer: Multiplan Commercial	$253.50
Rate for Payer: Multiplan Workers Comp	$253.50
Rate for Payer: Parkland Medicaid	$280.80
Rate for Payer: Scott and White EPO/PPO	$195.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$280.80

DFW BARIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	8996973
Hospital Revenue Code	510
Rate for Payer: Cash Price	$184.96

DFW BARIATRIC E&M-NEW PATIENT-LVL II BCE

Facility

$272.00

Service Code	HCPCS 99202
Hospital Charge Code	8996973
Hospital Revenue Code	510
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$195.84
Rate for Payer: Amerigroup CHIP/Medicaid	$24.48
Rate for Payer: BCBS of TX Blue Advantage	$81.60
Rate for Payer: BCBS of TX Blue Essentials	$97.92
Rate for Payer: BCBS of TX PPO	$108.80
Rate for Payer: Cash Price	$184.96
Rate for Payer: Cigna Medicaid	$195.84
Rate for Payer: Molina CHIP/Medicaid	$195.84
Rate for Payer: Multiplan Auto	$176.80
Rate for Payer: Multiplan Commercial	$176.80
Rate for Payer: Multiplan Workers Comp	$176.80
Rate for Payer: Parkland Medicaid	$195.84
Rate for Payer: Scott and White EPO/PPO	$136.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$195.84

DFW BARIATRIC E&M-NEW. PATIENT-LVL III BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8994978
Hospital Revenue Code	510
Rate for Payer: Cash Price	$279.48

DFW BARIATRIC E&M-NEW. PATIENT-LVL III BCE

Facility

$411.00

Service Code	HCPCS 99203
Hospital Charge Code	8994978
Hospital Revenue Code	510
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$295.92
Rate for Payer: Amerigroup CHIP/Medicaid	$36.99
Rate for Payer: BCBS of TX Blue Advantage	$123.30
Rate for Payer: BCBS of TX Blue Essentials	$147.96
Rate for Payer: BCBS of TX PPO	$164.40
Rate for Payer: Cash Price	$279.48
Rate for Payer: Cigna Medicaid	$295.92
Rate for Payer: Molina CHIP/Medicaid	$295.92
Rate for Payer: Multiplan Auto	$267.15
Rate for Payer: Multiplan Commercial	$267.15
Rate for Payer: Multiplan Workers Comp	$267.15
Rate for Payer: Parkland Medicaid	$295.92
Rate for Payer: Scott and White EPO/PPO	$205.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$295.92

Know your out-of-pocket cost for care.

All Charges