CPT 72158

MRI lumbar spine without & with contrast material

The standard charge for MRI lumbar spine without & with contrast material is $10,113.00. However, the price you pay depends on the rate negotiated by your insurance plan and what portion your insurance plan requires you to contribute towards that amount. Enter your info below to start your estimate.

To calculate an estimate of your cost, you will need two things:

  • Your Summary of Benefits and Coverage statement from your health insurance plan. If you don't have a paper copy, this is often also available online through your health insurance company's website.
  • Your remaining deductible amount for this year for your insurance plan. Many insurance plans require you to pay a certain amount out of pocket before the insurance kicks in. This amount is called the deductible and is different for each insurance plan.

More Information

White Rock Medical Center

Cost Estimate

Choose a plan to view the insurance rate estimate.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,783.87

  • Price Negotiated by Insurer

    $329.13

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $3.03

  • 96376- IV Injection, add same drug

    $29.70

  • Basic Metabolic Panel

    $3.30

  • CHED 99284 - Level 4 BCE

    $280.00

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $60.57

  • Comprehensive Metabolic Panel

    $4.12

  • CT Brain Stroke Protocol w/o Contrast

    $104.75

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $0.72

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $5.45

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $11.52

  • MRI Brain w/ + w/o Contrast

    $328.11

  • piperacillin-tazobactam 3.375g

    $11.52

  • sterile water Inj Soln 10 mL

    $11.54

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $29.70

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,482.95

  • Price Negotiated by Insurer

    $630.05

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $116.10

  • 96376- IV Injection, add same drug

    $99.00

  • Basic Metabolic Panel

    $148.80

  • CHED 99284 - Level 4 BCE

    $1,875.00

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $201.90

  • Comprehensive Metabolic Panel

    $198.30

  • CT Brain Stroke Protocol w/o Contrast

    $184.93

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $2.40

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $3.13

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.26

  • MRI Brain w/ + w/o Contrast

    $630.05

  • piperacillin-tazobactam 3.375g

    $3.35

  • sterile water Inj Soln 10 mL

    $0.64

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $99.00

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,356.94

  • Price Negotiated by Insurer

    $756.06

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $139.32

  • 96376- IV Injection, add same drug

    $118.80

  • Basic Metabolic Panel

    $178.56

  • CHED 99284 - Level 4 BCE

    $2,250.00

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $242.28

  • Comprehensive Metabolic Panel

    $237.96

  • CT Brain Stroke Protocol w/o Contrast

    $221.92

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $2.88

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $3.76

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.31

  • MRI Brain w/ + w/o Contrast

    $756.06

  • piperacillin-tazobactam 3.375g

    $4.02

  • sterile water Inj Soln 10 mL

    $0.77

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $118.80

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,269.11

  • Price Negotiated by Insurer

    $843.89

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $154.80

  • 96376- IV Injection, add same drug

    $132.00

  • Basic Metabolic Panel

    $198.40

  • CHED 99284 - Level 4 BCE

    $2,500.00

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $269.20

  • Comprehensive Metabolic Panel

    $264.40

  • CT Brain Stroke Protocol w/o Contrast

    $247.70

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $3.20

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $4.17

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.35

  • MRI Brain w/ + w/o Contrast

    $843.89

  • piperacillin-tazobactam 3.375g

    $4.46

  • sterile water Inj Soln 10 mL

    $0.85

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $132.00

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$3,236.16

  • Price Negotiated by Insurer

    $6,876.84

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $263.16

  • 96376- IV Injection, add same drug

    $224.40

  • Basic Metabolic Panel

    $337.28

  • CHED 99284 - Level 4 BCE

    $1,439.56

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $457.64

  • Comprehensive Metabolic Panel

    $449.48

  • CT Brain Stroke Protocol w/o Contrast

    $3,056.60

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $5.44

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $41.14

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $87.04

  • MRI Brain w/ + w/o Contrast

    $6,093.48

  • piperacillin-tazobactam 3.375g

    $87.04

  • sterile water Inj Soln 10 mL

    $87.16

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $224.40

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,372.19

  • Price Negotiated by Insurer

    $740.81

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • CHED 99284 - Level 4 BCE

    $1,557.58

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $125.27

  • CT Brain Stroke Protocol w/o Contrast

    $222.00

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $99.43

  • MRI Brain w/ + w/o Contrast

    $740.81

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $99.43

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$2,831.64

  • Price Negotiated by Insurer

    $7,281.36

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $278.64

  • 96376- IV Injection, add same drug

    $237.60

  • Basic Metabolic Panel

    $357.12

  • CHED 99284 - Level 4 BCE

    $1,524.24

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $484.56

  • Comprehensive Metabolic Panel

    $475.92

  • CT Brain Stroke Protocol w/o Contrast

    $3,236.40

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $5.76

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $43.56

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $92.16

  • MRI Brain w/ + w/o Contrast

    $6,451.92

  • piperacillin-tazobactam 3.375g

    $92.16

  • sterile water Inj Soln 10 mL

    $92.28

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $237.60

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$2,831.64

  • Price Negotiated by Insurer

    $7,281.36

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $278.64

  • 96376- IV Injection, add same drug

    $237.60

  • Basic Metabolic Panel

    $357.12

  • CHED 99284 - Level 4 BCE

    $1,524.24

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $484.56

  • Comprehensive Metabolic Panel

    $475.92

  • CT Brain Stroke Protocol w/o Contrast

    $3,236.40

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $5.76

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $43.56

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $92.16

  • MRI Brain w/ + w/o Contrast

    $6,451.92

  • piperacillin-tazobactam 3.375g

    $92.16

  • sterile water Inj Soln 10 mL

    $92.28

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $237.60

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$3,539.55

  • Price Negotiated by Insurer

    $6,573.45

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $251.55

  • 96376- IV Injection, add same drug

    $214.50

  • Basic Metabolic Panel

    $322.40

  • CHED 99284 - Level 4 BCE

    $1,376.05

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $437.45

  • Comprehensive Metabolic Panel

    $429.65

  • CT Brain Stroke Protocol w/o Contrast

    $2,921.75

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $5.20

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $39.33

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $10,000.00

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $83.20

  • MRI Brain w/ + w/o Contrast

    $5,824.65

  • piperacillin-tazobactam 3.375g

    $83.20

  • sterile water Inj Soln 10 mL

    $83.31

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $214.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$3,539.55

  • Price Negotiated by Insurer

    $6,573.45

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $251.55

  • 96376- IV Injection, add same drug

    $214.50

  • Basic Metabolic Panel

    $322.40

  • CHED 99284 - Level 4 BCE

    $1,376.05

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $437.45

  • Comprehensive Metabolic Panel

    $429.65

  • CT Brain Stroke Protocol w/o Contrast

    $2,921.75

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $5.20

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $39.33

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $10,000.00

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $83.20

  • MRI Brain w/ + w/o Contrast

    $5,824.65

  • piperacillin-tazobactam 3.375g

    $83.20

  • sterile water Inj Soln 10 mL

    $83.31

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $214.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$3,539.55

  • Price Negotiated by Insurer

    $6,573.45

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $251.55

  • 96376- IV Injection, add same drug

    $214.50

  • Basic Metabolic Panel

    $322.40

  • CHED 99284 - Level 4 BCE

    $1,376.05

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $437.45

  • Comprehensive Metabolic Panel

    $429.65

  • CT Brain Stroke Protocol w/o Contrast

    $2,921.75

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $5.20

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $39.33

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $10,000.00

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $83.20

  • MRI Brain w/ + w/o Contrast

    $5,824.65

  • piperacillin-tazobactam 3.375g

    $83.20

  • sterile water Inj Soln 10 mL

    $83.31

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $214.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$2,831.64

  • Price Negotiated by Insurer

    $7,281.36

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $278.64

  • 96376- IV Injection, add same drug

    $237.60

  • Basic Metabolic Panel

    $357.12

  • CHED 99284 - Level 4 BCE

    $1,524.24

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $484.56

  • Comprehensive Metabolic Panel

    $475.92

  • CT Brain Stroke Protocol w/o Contrast

    $3,236.40

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $5.76

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $43.56

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $92.16

  • MRI Brain w/ + w/o Contrast

    $6,451.92

  • piperacillin-tazobactam 3.375g

    $92.16

  • sterile water Inj Soln 10 mL

    $92.28

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $237.60

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$5,056.50

  • Price Negotiated by Insurer

    $5,056.50

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $9.71

  • 96376- IV Injection, add same drug

    $165.00

  • Basic Metabolic Panel

    $10.57

  • CHED 99284 - Level 4 BCE

    $2,500.00

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $336.50

  • Comprehensive Metabolic Panel

    $13.20

  • CT Brain Stroke Protocol w/o Contrast

    $2,247.50

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $4.00

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $30.25

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $64.00

  • MRI Brain w/ + w/o Contrast

    $4,480.50

  • piperacillin-tazobactam 3.375g

    $64.00

  • sterile water Inj Soln 10 mL

    $64.08

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $165.00

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$2,831.64

  • Price Negotiated by Insurer

    $7,281.36

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $278.64

  • 96376- IV Injection, add same drug

    $237.60

  • Basic Metabolic Panel

    $357.12

  • CHED 99284 - Level 4 BCE

    $1,524.24

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $484.56

  • Comprehensive Metabolic Panel

    $475.92

  • CT Brain Stroke Protocol w/o Contrast

    $3,236.40

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $5.76

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $43.56

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $92.16

  • MRI Brain w/ + w/o Contrast

    $6,451.92

  • piperacillin-tazobactam 3.375g

    $92.16

  • sterile water Inj Soln 10 mL

    $92.28

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $237.60

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • 96376- IV Injection, add same drug

    $44.88

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • ferrous gluconate 324 mg (38 mg elemental iron) Tab

    $1.09

  • gadoteridol 279.3 mg/mL Inj Soln 5 mL

    $8.23

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • piperacillin-tazobactam 3.375g

    $17.41

  • sterile water Inj Soln 10 mL

    $17.43

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.

Cost Estimate

  • Total estimated charges

    $10,113.00

  • Insurance Discount

    -$9,762.54

  • Price Negotiated by Insurer

    $350.46

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • 85025 CBC W/AUTOMATED DIFFERENTIAL

    $7.77

  • Basic Metabolic Panel

    $8.46

  • CHED 99284 - Level 4 BCE

    $419.16

  • CHED Routine ECG 12 lead/15 lead tracing only BCE

    $59.26

  • Comprehensive Metabolic Panel

    $10.56

  • CT Brain Stroke Protocol w/o Contrast

    $105.02

  • Intravenous infusion, hydration; each additional hour (List separately in addition to code for prima

    $47.04

  • ketorolac 15 mg/mL Inj Soln 1 mL

    $0.29

  • MRI Brain w/ + w/o Contrast

    $350.46

  • Therapy, Prophylactic, Diag Each Addl Seq IVP New Drug 96375

    $47.04

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to White Rock Medical Center so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact White Rock Medical Center directly at (214) 324-6100.