White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NMI I-131 IODIDE THERAPY CAP PER MCI BCE

Facility

$77.00

Service Code	HCPCS A9517
Hospital Charge Code	3406162
Hospital Revenue Code	344
Min. Negotiated Rate	$6.93
Max. Negotiated Rate	$50.05
Rate for Payer: Aetna Medicare	$32.01
Rate for Payer: Amerigroup CHIP/Medicaid	$6.93
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$21.34
Rate for Payer: Amerigroup Medicare	$21.34
Rate for Payer: BCBS of TX Blue Advantage	$23.10
Rate for Payer: BCBS of TX Blue Essentials	$27.72
Rate for Payer: BCBS of TX Medicare	$21.34
Rate for Payer: BCBS of TX PPO	$30.80
Rate for Payer: Cash Price	$67.76
Rate for Payer: Cash Price	$67.76
Rate for Payer: Cigna Medicare	$21.34
Rate for Payer: Employer Direct Commercial	$21.34
Rate for Payer: Humana Medicare/TRICARE	$21.34
Rate for Payer: Molina Dual Medicare/Medicaid	$21.34
Rate for Payer: Molina Medicare	$21.34
Rate for Payer: Multiplan Auto	$50.05
Rate for Payer: Multiplan Commercial	$50.05
Rate for Payer: Multiplan Workers Comp	$50.05
Rate for Payer: Scott and White EPO/PPO	$38.50
Rate for Payer: Scott and White Medicare	$21.34
Rate for Payer: Superior Health Plan EPO	$21.34
Rate for Payer: Superior Health Plan Medicare	$21.34
Rate for Payer: Universal American Dual Medicare/Medicaid	$21.34
Rate for Payer: Universal American Medicare	$21.34
Rate for Payer: Wellcare Medicare	$21.34
Rate for Payer: Wellmed Medicare	$21.34

NMI I-131 MIBG PER 0.5MCI

Facility

$7,017.00

Service Code	HCPCS A9508
Hospital Charge Code	5192142
Hospital Revenue Code	343
Min. Negotiated Rate	$631.53
Max. Negotiated Rate	$4,561.05
Rate for Payer: Amerigroup CHIP/Medicaid	$631.53
Rate for Payer: BCBS of TX Blue Advantage	$2,105.10
Rate for Payer: BCBS of TX Blue Essentials	$2,526.12
Rate for Payer: BCBS of TX PPO	$2,806.80
Rate for Payer: Cash Price	$6,174.96
Rate for Payer: Multiplan Auto	$4,561.05
Rate for Payer: Multiplan Commercial	$4,561.05
Rate for Payer: Multiplan Workers Comp	$4,561.05
Rate for Payer: Scott and White EPO/PPO	$3,508.50
Rate for Payer: Superior Health Plan EPO	$954.31

NMI I-131 MIBG PER 0.5MCI BCE

Facility

$7,017.00

Service Code	HCPCS A9508
Hospital Charge Code	5192142
Hospital Revenue Code	343
Rate for Payer: Cash Price	$6,174.96

NMI I-131 MIBG PER 0.5MCI BCE

Facility

$7,017.00

Service Code	HCPCS A9508
Hospital Charge Code	5192142
Hospital Revenue Code	343
Min. Negotiated Rate	$631.53
Max. Negotiated Rate	$4,561.05
Rate for Payer: Amerigroup CHIP/Medicaid	$631.53
Rate for Payer: BCBS of TX Blue Advantage	$2,105.10
Rate for Payer: BCBS of TX Blue Essentials	$2,526.12
Rate for Payer: BCBS of TX PPO	$2,806.80
Rate for Payer: Cash Price	$6,174.96
Rate for Payer: Multiplan Auto	$4,561.05
Rate for Payer: Multiplan Commercial	$4,561.05
Rate for Payer: Multiplan Workers Comp	$4,561.05
Rate for Payer: Scott and White EPO/PPO	$3,508.50
Rate for Payer: Superior Health Plan EPO	$954.31

NMI IN-111 WBC DOSE

Facility

$3,586.00

Service Code	HCPCS A9570
Hospital Charge Code	5199570
Hospital Revenue Code	343
Min. Negotiated Rate	$322.74
Max. Negotiated Rate	$2,330.90
Rate for Payer: Amerigroup CHIP/Medicaid	$322.74
Rate for Payer: BCBS of TX Blue Advantage	$1,075.80
Rate for Payer: BCBS of TX Blue Essentials	$1,290.96
Rate for Payer: BCBS of TX PPO	$1,434.40
Rate for Payer: Cash Price	$3,155.68
Rate for Payer: Multiplan Auto	$2,330.90
Rate for Payer: Multiplan Commercial	$2,330.90
Rate for Payer: Multiplan Workers Comp	$2,330.90
Rate for Payer: Scott and White EPO/PPO	$1,793.00
Rate for Payer: Superior Health Plan EPO	$487.70

NMI IN-111 WBC DOSE BCE

Facility

$3,586.00

Service Code	HCPCS A9570
Hospital Charge Code	5199570
Hospital Revenue Code	343
Rate for Payer: Cash Price	$3,155.68

NMI IN-111 WBC DOSE BCE

Facility

$3,586.00

Service Code	HCPCS A9570
Hospital Charge Code	5199570
Hospital Revenue Code	343
Min. Negotiated Rate	$322.74
Max. Negotiated Rate	$2,330.90
Rate for Payer: Amerigroup CHIP/Medicaid	$322.74
Rate for Payer: BCBS of TX Blue Advantage	$1,075.80
Rate for Payer: BCBS of TX Blue Essentials	$1,290.96
Rate for Payer: BCBS of TX PPO	$1,434.40
Rate for Payer: Cash Price	$3,155.68
Rate for Payer: Multiplan Auto	$2,330.90
Rate for Payer: Multiplan Commercial	$2,330.90
Rate for Payer: Multiplan Workers Comp	$2,330.90
Rate for Payer: Scott and White EPO/PPO	$1,793.00
Rate for Payer: Superior Health Plan EPO	$487.70

NM Intestine Imaging Meckels

Facility

$750.00

Service Code	CPT 78290
Hospital Charge Code	3400116
Hospital Revenue Code	341
Min. Negotiated Rate	$6.75
Max. Negotiated Rate	$854.47
Rate for Payer: Aetna Commercial	$322.32
Rate for Payer: Aetna Medicare	$565.80
Rate for Payer: Amerigroup CHIP/Medicaid	$307.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$377.20
Rate for Payer: Amerigroup Medicare	$377.20
Rate for Payer: BCBS of TX Blue Advantage	$510.21
Rate for Payer: BCBS of TX Blue Essentials	$612.26
Rate for Payer: BCBS of TX Medicare	$377.20
Rate for Payer: BCBS of TX PPO	$683.38
Rate for Payer: Cash Price	$660.00
Rate for Payer: Cash Price	$660.00
Rate for Payer: Cash Price	$660.00
Rate for Payer: Cigna Commercial	$854.47
Rate for Payer: Cigna Medicaid	$307.74
Rate for Payer: Cigna Medicare	$377.20
Rate for Payer: Employer Direct Commercial	$377.20
Rate for Payer: Humana Medicare/TRICARE	$377.20
Rate for Payer: Molina CHIP/Medicaid	$307.74
Rate for Payer: Molina Dual Medicare/Medicaid	$377.20
Rate for Payer: Molina Medicare	$377.20
Rate for Payer: Multiplan Auto	$487.50
Rate for Payer: Multiplan Commercial	$487.50
Rate for Payer: Multiplan Workers Comp	$487.50
Rate for Payer: Parkland Medicaid	$307.74
Rate for Payer: Scott and White EPO/PPO	$6.75
Rate for Payer: Scott and White Medicare	$377.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$307.74
Rate for Payer: Superior Health Plan EPO	$377.20
Rate for Payer: Superior Health Plan Medicare	$377.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$377.20
Rate for Payer: Universal American Medicare	$377.20
Rate for Payer: Wellcare Medicare	$377.20
Rate for Payer: Wellmed Medicare	$377.20

NM Intestine Imaging Meckels BCE

Facility

$750.00

Service Code	CPT 78290
Hospital Charge Code	3400116
Hospital Revenue Code	341
Min. Negotiated Rate	$6.75
Max. Negotiated Rate	$854.47
Rate for Payer: Aetna Commercial	$322.32
Rate for Payer: Aetna Medicare	$565.80
Rate for Payer: Amerigroup CHIP/Medicaid	$307.74
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$377.20
Rate for Payer: Amerigroup Medicare	$377.20
Rate for Payer: BCBS of TX Blue Advantage	$510.21
Rate for Payer: BCBS of TX Blue Essentials	$612.26
Rate for Payer: BCBS of TX Medicare	$377.20
Rate for Payer: BCBS of TX PPO	$683.38
Rate for Payer: Cash Price	$660.00
Rate for Payer: Cash Price	$660.00
Rate for Payer: Cash Price	$660.00
Rate for Payer: Cigna Commercial	$854.47
Rate for Payer: Cigna Medicaid	$307.74
Rate for Payer: Cigna Medicare	$377.20
Rate for Payer: Employer Direct Commercial	$377.20
Rate for Payer: Humana Medicare/TRICARE	$377.20
Rate for Payer: Molina CHIP/Medicaid	$307.74
Rate for Payer: Molina Dual Medicare/Medicaid	$377.20
Rate for Payer: Molina Medicare	$377.20
Rate for Payer: Multiplan Auto	$487.50
Rate for Payer: Multiplan Commercial	$487.50
Rate for Payer: Multiplan Workers Comp	$487.50
Rate for Payer: Parkland Medicaid	$307.74
Rate for Payer: Scott and White EPO/PPO	$6.75
Rate for Payer: Scott and White Medicare	$377.20
Rate for Payer: Superior Health Plan CHIP/Medicaid	$307.74
Rate for Payer: Superior Health Plan EPO	$377.20
Rate for Payer: Superior Health Plan Medicare	$377.20
Rate for Payer: Universal American Dual Medicare/Medicaid	$377.20
Rate for Payer: Universal American Medicare	$377.20
Rate for Payer: Wellcare Medicare	$377.20
Rate for Payer: Wellmed Medicare	$377.20

NM Intestine Imaging Meckels BCE

Facility

$750.00

Service Code	CPT 78290
Hospital Charge Code	3400116
Hospital Revenue Code	341
Rate for Payer: Cash Price	$660.00

NMI TC-99M BICISATE DOSE

Facility

$1,987.00

Service Code	HCPCS A9557
Hospital Charge Code	5194089
Hospital Revenue Code	343
Min. Negotiated Rate	$178.83
Max. Negotiated Rate	$1,291.55
Rate for Payer: Amerigroup CHIP/Medicaid	$178.83
Rate for Payer: BCBS of TX Blue Advantage	$596.10
Rate for Payer: BCBS of TX Blue Essentials	$715.32
Rate for Payer: BCBS of TX PPO	$794.80
Rate for Payer: Cash Price	$1,748.56
Rate for Payer: Multiplan Auto	$1,291.55
Rate for Payer: Multiplan Commercial	$1,291.55
Rate for Payer: Multiplan Workers Comp	$1,291.55
Rate for Payer: Scott and White EPO/PPO	$993.50
Rate for Payer: Superior Health Plan EPO	$270.23

NMI TC-99M BICISATE DOSE BCE

Facility

$1,987.00

Service Code	HCPCS A9557
Hospital Charge Code	5194089
Hospital Revenue Code	343
Rate for Payer: Cash Price	$1,748.56

NMI TC-99M BICISATE DOSE BCE

Facility

$1,987.00

Service Code	HCPCS A9557
Hospital Charge Code	5194089
Hospital Revenue Code	343
Min. Negotiated Rate	$178.83
Max. Negotiated Rate	$1,291.55
Rate for Payer: Amerigroup CHIP/Medicaid	$178.83
Rate for Payer: BCBS of TX Blue Advantage	$596.10
Rate for Payer: BCBS of TX Blue Essentials	$715.32
Rate for Payer: BCBS of TX PPO	$794.80
Rate for Payer: Cash Price	$1,748.56
Rate for Payer: Multiplan Auto	$1,291.55
Rate for Payer: Multiplan Commercial	$1,291.55
Rate for Payer: Multiplan Workers Comp	$1,291.55
Rate for Payer: Scott and White EPO/PPO	$993.50
Rate for Payer: Superior Health Plan EPO	$270.23

NMI TC-99M CERETEC WBC

Facility

$2,352.00

Service Code	HCPCS A9521
Hospital Charge Code	3410005
Hospital Revenue Code	343
Min. Negotiated Rate	$211.68
Max. Negotiated Rate	$1,528.80
Rate for Payer: Amerigroup CHIP/Medicaid	$211.68
Rate for Payer: BCBS of TX Blue Advantage	$705.60
Rate for Payer: BCBS of TX Blue Essentials	$846.72
Rate for Payer: BCBS of TX PPO	$940.80
Rate for Payer: Cash Price	$2,069.76
Rate for Payer: Multiplan Auto	$1,528.80
Rate for Payer: Multiplan Commercial	$1,528.80
Rate for Payer: Multiplan Workers Comp	$1,528.80
Rate for Payer: Scott and White EPO/PPO	$1,176.00
Rate for Payer: Superior Health Plan EPO	$319.87

NMI TC-99M CERETEC WBC BCE

Facility

$2,352.00

Service Code	HCPCS A9521
Hospital Charge Code	3410005
Hospital Revenue Code	343
Rate for Payer: Cash Price	$2,069.76

NMI TC-99M CERETEC WBC BCE

Facility

$2,352.00

Service Code	HCPCS A9521
Hospital Charge Code	3410005
Hospital Revenue Code	343
Min. Negotiated Rate	$211.68
Max. Negotiated Rate	$1,528.80
Rate for Payer: Amerigroup CHIP/Medicaid	$211.68
Rate for Payer: BCBS of TX Blue Advantage	$705.60
Rate for Payer: BCBS of TX Blue Essentials	$846.72
Rate for Payer: BCBS of TX PPO	$940.80
Rate for Payer: Cash Price	$2,069.76
Rate for Payer: Multiplan Auto	$1,528.80
Rate for Payer: Multiplan Commercial	$1,528.80
Rate for Payer: Multiplan Workers Comp	$1,528.80
Rate for Payer: Scott and White EPO/PPO	$1,176.00
Rate for Payer: Superior Health Plan EPO	$319.87

NMI TC-99M EXAMETAZIME PER DOSE

Facility

$5,817.25

Service Code	HCPCS A9569
Hospital Charge Code	3406774
Hospital Revenue Code	343
Rate for Payer: Cash Price	$5,119.18

NMI TC-99M EXAMETAZIME PER DOSE

Facility

$5,817.25

Service Code	HCPCS A9569
Hospital Charge Code	3406774
Hospital Revenue Code	343
Min. Negotiated Rate	$523.55
Max. Negotiated Rate	$3,781.21
Rate for Payer: Amerigroup CHIP/Medicaid	$523.55
Rate for Payer: BCBS of TX Blue Advantage	$1,745.18
Rate for Payer: BCBS of TX Blue Essentials	$2,094.21
Rate for Payer: BCBS of TX PPO	$2,326.90
Rate for Payer: Cash Price	$5,119.18
Rate for Payer: Multiplan Auto	$3,781.21
Rate for Payer: Multiplan Commercial	$3,781.21
Rate for Payer: Multiplan Workers Comp	$3,781.21
Rate for Payer: Scott and White EPO/PPO	$2,908.62
Rate for Payer: Superior Health Plan EPO	$791.15

NMI TC-99M MAA PER DOSE

Facility

$207.00

Service Code	HCPCS A9540
Hospital Charge Code	3403060
Hospital Revenue Code	343
Min. Negotiated Rate	$18.63
Max. Negotiated Rate	$134.55
Rate for Payer: Amerigroup CHIP/Medicaid	$18.63
Rate for Payer: BCBS of TX Blue Advantage	$62.10
Rate for Payer: BCBS of TX Blue Essentials	$74.52
Rate for Payer: BCBS of TX PPO	$82.80
Rate for Payer: Cash Price	$182.16
Rate for Payer: Multiplan Auto	$134.55
Rate for Payer: Multiplan Commercial	$134.55
Rate for Payer: Multiplan Workers Comp	$134.55
Rate for Payer: Scott and White EPO/PPO	$103.50
Rate for Payer: Superior Health Plan EPO	$28.15

NMI TC-99M MAA PER DOSE BCE

Facility

$207.00

Service Code	HCPCS A9540
Hospital Charge Code	3403060
Hospital Revenue Code	343
Min. Negotiated Rate	$18.63
Max. Negotiated Rate	$134.55
Rate for Payer: Amerigroup CHIP/Medicaid	$18.63
Rate for Payer: BCBS of TX Blue Advantage	$62.10
Rate for Payer: BCBS of TX Blue Essentials	$74.52
Rate for Payer: BCBS of TX PPO	$82.80
Rate for Payer: Cash Price	$182.16
Rate for Payer: Multiplan Auto	$134.55
Rate for Payer: Multiplan Commercial	$134.55
Rate for Payer: Multiplan Workers Comp	$134.55
Rate for Payer: Scott and White EPO/PPO	$103.50
Rate for Payer: Superior Health Plan EPO	$28.15

NMI TC-99M MAA PER DOSE BCE

Facility

$207.00

Service Code	HCPCS A9540
Hospital Charge Code	3403060
Hospital Revenue Code	343
Rate for Payer: Cash Price	$182.16

NMI TC-99M MEBROFENIN PER DOSE

Facility

$369.00

Service Code	HCPCS A9537
Hospital Charge Code	3403037
Hospital Revenue Code	343
Min. Negotiated Rate	$33.21
Max. Negotiated Rate	$239.85
Rate for Payer: Amerigroup CHIP/Medicaid	$33.21
Rate for Payer: BCBS of TX Blue Advantage	$110.70
Rate for Payer: BCBS of TX Blue Essentials	$132.84
Rate for Payer: BCBS of TX PPO	$147.60
Rate for Payer: Cash Price	$324.72
Rate for Payer: Multiplan Auto	$239.85
Rate for Payer: Multiplan Commercial	$239.85
Rate for Payer: Multiplan Workers Comp	$239.85
Rate for Payer: Scott and White EPO/PPO	$184.50
Rate for Payer: Superior Health Plan EPO	$50.18

NMI TC-99M MEBROFENIN PER DOSE BCE

Facility

$369.00

Service Code	HCPCS A9537
Hospital Charge Code	3403037
Hospital Revenue Code	343
Min. Negotiated Rate	$33.21
Max. Negotiated Rate	$239.85
Rate for Payer: Amerigroup CHIP/Medicaid	$33.21
Rate for Payer: BCBS of TX Blue Advantage	$110.70
Rate for Payer: BCBS of TX Blue Essentials	$132.84
Rate for Payer: BCBS of TX PPO	$147.60
Rate for Payer: Cash Price	$324.72
Rate for Payer: Multiplan Auto	$239.85
Rate for Payer: Multiplan Commercial	$239.85
Rate for Payer: Multiplan Workers Comp	$239.85
Rate for Payer: Scott and White EPO/PPO	$184.50
Rate for Payer: Superior Health Plan EPO	$50.18

NMI TC-99M MEBROFENIN PER DOSE BCE

Facility

$369.00

Service Code	HCPCS A9537
Hospital Charge Code	3403037
Hospital Revenue Code	343
Rate for Payer: Cash Price	$324.72

NMI TC-99M MEDRONATE PER DOSE

Facility

$210.00

Service Code	HCPCS A9503
Hospital Charge Code	3402484
Hospital Revenue Code	343
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$136.50
Rate for Payer: Amerigroup CHIP/Medicaid	$18.90
Rate for Payer: BCBS of TX Blue Advantage	$63.00
Rate for Payer: BCBS of TX Blue Essentials	$75.60
Rate for Payer: BCBS of TX PPO	$84.00
Rate for Payer: Cash Price	$184.80
Rate for Payer: Multiplan Auto	$136.50
Rate for Payer: Multiplan Commercial	$136.50
Rate for Payer: Multiplan Workers Comp	$136.50
Rate for Payer: Scott and White EPO/PPO	$105.00
Rate for Payer: Superior Health Plan EPO	$28.56

Know your out-of-pocket cost for care.

All Charges