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
Rate for Payer: Cash Price	$87.16

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 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 0.45% 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 0.9% 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	$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

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	$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 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 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	$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 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

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 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 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 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 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	$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 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 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
Rate for Payer: Cash Price	$102.00

Know your out-of-pocket cost for care.

All Charges