White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NMI TC-99M MEDRONATE PER DOSE BCE

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

NMI TC-99M MEDRONATE PER DOSE BCE

Facility

$210.00

Service Code	HCPCS A9503
Hospital Charge Code	3402484
Hospital Revenue Code	343
Rate for Payer: Cash Price	$184.80

NMI TC-99M MERTIATIDE PER DOSE

Facility

$1,050.00

Service Code	HCPCS A9562
Hospital Charge Code	3406105
Hospital Revenue Code	343
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$682.50
Rate for Payer: Amerigroup CHIP/Medicaid	$94.50
Rate for Payer: BCBS of TX Blue Advantage	$315.00
Rate for Payer: BCBS of TX Blue Essentials	$378.00
Rate for Payer: BCBS of TX PPO	$420.00
Rate for Payer: Cash Price	$924.00
Rate for Payer: Multiplan Auto	$682.50
Rate for Payer: Multiplan Commercial	$682.50
Rate for Payer: Multiplan Workers Comp	$682.50
Rate for Payer: Scott and White EPO/PPO	$525.00
Rate for Payer: Superior Health Plan EPO	$142.80

NMI TC-99M MERTIATIDE PER DOSE BCE

Facility

$1,050.00

Service Code	HCPCS A9562
Hospital Charge Code	3406105
Hospital Revenue Code	343
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$682.50
Rate for Payer: Amerigroup CHIP/Medicaid	$94.50
Rate for Payer: BCBS of TX Blue Advantage	$315.00
Rate for Payer: BCBS of TX Blue Essentials	$378.00
Rate for Payer: BCBS of TX PPO	$420.00
Rate for Payer: Cash Price	$924.00
Rate for Payer: Multiplan Auto	$682.50
Rate for Payer: Multiplan Commercial	$682.50
Rate for Payer: Multiplan Workers Comp	$682.50
Rate for Payer: Scott and White EPO/PPO	$525.00
Rate for Payer: Superior Health Plan EPO	$142.80

NMI TC-99M MERTIATIDE PER DOSE BCE

Facility

$1,050.00

Service Code	HCPCS A9562
Hospital Charge Code	3406105
Hospital Revenue Code	343
Rate for Payer: Cash Price	$924.00

NMI TC-99M PENTETATE PER DOSE

Facility

$236.00

Service Code	HCPCS A9539
Hospital Charge Code	3403052
Hospital Revenue Code	343
Min. Negotiated Rate	$21.24
Max. Negotiated Rate	$153.40
Rate for Payer: Amerigroup CHIP/Medicaid	$21.24
Rate for Payer: BCBS of TX Blue Advantage	$70.80
Rate for Payer: BCBS of TX Blue Essentials	$84.96
Rate for Payer: BCBS of TX PPO	$94.40
Rate for Payer: Cash Price	$207.68
Rate for Payer: Multiplan Auto	$153.40
Rate for Payer: Multiplan Commercial	$153.40
Rate for Payer: Multiplan Workers Comp	$153.40
Rate for Payer: Scott and White EPO/PPO	$118.00
Rate for Payer: Superior Health Plan EPO	$32.10

NMI TC-99M PENTETATE PER DOSE BCE

Facility

$236.00

Service Code	HCPCS A9539
Hospital Charge Code	3403052
Hospital Revenue Code	343
Min. Negotiated Rate	$21.24
Max. Negotiated Rate	$153.40
Rate for Payer: Amerigroup CHIP/Medicaid	$21.24
Rate for Payer: BCBS of TX Blue Advantage	$70.80
Rate for Payer: BCBS of TX Blue Essentials	$84.96
Rate for Payer: BCBS of TX PPO	$94.40
Rate for Payer: Cash Price	$207.68
Rate for Payer: Multiplan Auto	$153.40
Rate for Payer: Multiplan Commercial	$153.40
Rate for Payer: Multiplan Workers Comp	$153.40
Rate for Payer: Scott and White EPO/PPO	$118.00
Rate for Payer: Superior Health Plan EPO	$32.10

NMI TC-99M PENTETATE PER DOSE BCE

Facility

$236.00

Service Code	HCPCS A9539
Hospital Charge Code	3403052
Hospital Revenue Code	343
Rate for Payer: Cash Price	$207.68

NMI TC-99M PERTECHNETATE PER MCI

Facility

$7.00

Service Code	HCPCS A9512
Hospital Charge Code	3401890
Hospital Revenue Code	343
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$4.55
Rate for Payer: Amerigroup CHIP/Medicaid	$0.63
Rate for Payer: BCBS of TX Blue Advantage	$2.10
Rate for Payer: BCBS of TX Blue Essentials	$2.52
Rate for Payer: BCBS of TX PPO	$2.80
Rate for Payer: Cash Price	$6.16
Rate for Payer: Multiplan Auto	$4.55
Rate for Payer: Multiplan Commercial	$4.55
Rate for Payer: Multiplan Workers Comp	$4.55
Rate for Payer: Scott and White EPO/PPO	$3.50
Rate for Payer: Superior Health Plan EPO	$0.95

NMI TC-99M PERTECHNETATE PER MCI BCE

Facility

$7.00

Service Code	HCPCS A9512
Hospital Charge Code	3401890
Hospital Revenue Code	343
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$4.55
Rate for Payer: Amerigroup CHIP/Medicaid	$0.63
Rate for Payer: BCBS of TX Blue Advantage	$2.10
Rate for Payer: BCBS of TX Blue Essentials	$2.52
Rate for Payer: BCBS of TX PPO	$2.80
Rate for Payer: Cash Price	$6.16
Rate for Payer: Multiplan Auto	$4.55
Rate for Payer: Multiplan Commercial	$4.55
Rate for Payer: Multiplan Workers Comp	$4.55
Rate for Payer: Scott and White EPO/PPO	$3.50
Rate for Payer: Superior Health Plan EPO	$0.95

NMI TC-99M PERTECHNETATE PER MCI BCE

Facility

$7.00

Service Code	HCPCS A9512
Hospital Charge Code	3401890
Hospital Revenue Code	343
Rate for Payer: Cash Price	$6.16

NMI TC-99M RBC PER DOSE

Facility

$478.00

Service Code	HCPCS A9560
Hospital Charge Code	3406097
Hospital Revenue Code	343
Min. Negotiated Rate	$43.02
Max. Negotiated Rate	$310.70
Rate for Payer: Amerigroup CHIP/Medicaid	$43.02
Rate for Payer: BCBS of TX Blue Advantage	$143.40
Rate for Payer: BCBS of TX Blue Essentials	$172.08
Rate for Payer: BCBS of TX PPO	$191.20
Rate for Payer: Cash Price	$420.64
Rate for Payer: Multiplan Auto	$310.70
Rate for Payer: Multiplan Commercial	$310.70
Rate for Payer: Multiplan Workers Comp	$310.70
Rate for Payer: Scott and White EPO/PPO	$239.00
Rate for Payer: Superior Health Plan EPO	$65.01

NMI TC-99M RBC PER DOSE BCE

Facility

$478.00

Service Code	HCPCS A9560
Hospital Charge Code	3406097
Hospital Revenue Code	343
Rate for Payer: Cash Price	$420.64

NMI TC-99M RBC PER DOSE BCE

Facility

$478.00

Service Code	HCPCS A9560
Hospital Charge Code	3406097
Hospital Revenue Code	343
Min. Negotiated Rate	$43.02
Max. Negotiated Rate	$310.70
Rate for Payer: Amerigroup CHIP/Medicaid	$43.02
Rate for Payer: BCBS of TX Blue Advantage	$143.40
Rate for Payer: BCBS of TX Blue Essentials	$172.08
Rate for Payer: BCBS of TX PPO	$191.20
Rate for Payer: Cash Price	$420.64
Rate for Payer: Multiplan Auto	$310.70
Rate for Payer: Multiplan Commercial	$310.70
Rate for Payer: Multiplan Workers Comp	$310.70
Rate for Payer: Scott and White EPO/PPO	$239.00
Rate for Payer: Superior Health Plan EPO	$65.01

NMI TC-99M SESTAMIBI PER DOSE

Facility

$1,428.00

Service Code	HCPCS A9500
Hospital Charge Code	3400892
Hospital Revenue Code	343
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$928.20
Rate for Payer: Amerigroup CHIP/Medicaid	$128.52
Rate for Payer: BCBS of TX Blue Advantage	$428.40
Rate for Payer: BCBS of TX Blue Essentials	$514.08
Rate for Payer: BCBS of TX PPO	$571.20
Rate for Payer: Cash Price	$1,256.64
Rate for Payer: Multiplan Auto	$928.20
Rate for Payer: Multiplan Commercial	$928.20
Rate for Payer: Multiplan Workers Comp	$928.20
Rate for Payer: Scott and White EPO/PPO	$714.00
Rate for Payer: Superior Health Plan EPO	$194.21

NMI TC-99M SESTAMIBI PER DOSE BCE

Facility

$1,428.00

Service Code	HCPCS A9500
Hospital Charge Code	3400892
Hospital Revenue Code	343
Rate for Payer: Cash Price	$1,256.64

NMI TC-99M SESTAMIBI PER DOSE BCE

Facility

$1,428.00

Service Code	HCPCS A9500
Hospital Charge Code	3400892
Hospital Revenue Code	343
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$928.20
Rate for Payer: Amerigroup CHIP/Medicaid	$128.52
Rate for Payer: BCBS of TX Blue Advantage	$428.40
Rate for Payer: BCBS of TX Blue Essentials	$514.08
Rate for Payer: BCBS of TX PPO	$571.20
Rate for Payer: Cash Price	$1,256.64
Rate for Payer: Multiplan Auto	$928.20
Rate for Payer: Multiplan Commercial	$928.20
Rate for Payer: Multiplan Workers Comp	$928.20
Rate for Payer: Scott and White EPO/PPO	$714.00
Rate for Payer: Superior Health Plan EPO	$194.21

NMI TC-99M SULFUR COLLOID PER DOSE

Facility

$136.00

Service Code	HCPCS A9541
Hospital Charge Code	3406071
Hospital Revenue Code	343
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$88.40
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$119.68
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$68.00
Rate for Payer: Superior Health Plan EPO	$18.50

NMI TC-99M SULFUR COLLOID PER DOSE BCE

Facility

$136.00

Service Code	HCPCS A9541
Hospital Charge Code	3406071
Hospital Revenue Code	343
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$88.40
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$119.68
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Scott and White EPO/PPO	$68.00
Rate for Payer: Superior Health Plan EPO	$18.50

NMI TC-99M SULFUR COLLOID PER DOSE BCE

Facility

$136.00

Service Code	HCPCS A9541
Hospital Charge Code	3406071
Hospital Revenue Code	343
Rate for Payer: Cash Price	$119.68

NMI TI-201 THALLOUS CHLORIDE PER MCI

Facility

$1,035.00

Service Code	HCPCS A9505
Hospital Charge Code	3401080
Hospital Revenue Code	343
Min. Negotiated Rate	$93.15
Max. Negotiated Rate	$672.75
Rate for Payer: Amerigroup CHIP/Medicaid	$93.15
Rate for Payer: BCBS of TX Blue Advantage	$310.50
Rate for Payer: BCBS of TX Blue Essentials	$372.60
Rate for Payer: BCBS of TX PPO	$414.00
Rate for Payer: Cash Price	$910.80
Rate for Payer: Multiplan Auto	$672.75
Rate for Payer: Multiplan Commercial	$672.75
Rate for Payer: Multiplan Workers Comp	$672.75
Rate for Payer: Scott and White EPO/PPO	$517.50
Rate for Payer: Superior Health Plan EPO	$140.76

NMI TI-201 THALLOUS CHLORIDE PER MCI BCE

Facility

$1,035.00

Service Code	HCPCS A9505
Hospital Charge Code	3401080
Hospital Revenue Code	343
Min. Negotiated Rate	$93.15
Max. Negotiated Rate	$672.75
Rate for Payer: Amerigroup CHIP/Medicaid	$93.15
Rate for Payer: BCBS of TX Blue Advantage	$310.50
Rate for Payer: BCBS of TX Blue Essentials	$372.60
Rate for Payer: BCBS of TX PPO	$414.00
Rate for Payer: Cash Price	$910.80
Rate for Payer: Multiplan Auto	$672.75
Rate for Payer: Multiplan Commercial	$672.75
Rate for Payer: Multiplan Workers Comp	$672.75
Rate for Payer: Scott and White EPO/PPO	$517.50
Rate for Payer: Superior Health Plan EPO	$140.76

NMI TI-201 THALLOUS CHLORIDE PER MCI BCE

Facility

$1,035.00

Service Code	HCPCS A9505
Hospital Charge Code	3401080
Hospital Revenue Code	343
Rate for Payer: Cash Price	$910.80

NM Kidney Imaging Multiple w/+w/o Pharm

Facility

$1,774.00

Service Code	CPT 78709
Hospital Charge Code	5208709
Hospital Revenue Code	341
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,153.10
Rate for Payer: Aetna Commercial	$327.70
Rate for Payer: Aetna Medicare	$741.48
Rate for Payer: Amerigroup CHIP/Medicaid	$345.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$494.32
Rate for Payer: Amerigroup Medicare	$494.32
Rate for Payer: BCBS of TX Blue Advantage	$514.96
Rate for Payer: BCBS of TX Blue Essentials	$617.96
Rate for Payer: BCBS of TX Medicare	$494.32
Rate for Payer: BCBS of TX PPO	$689.74
Rate for Payer: Cash Price	$1,561.12
Rate for Payer: Cash Price	$1,561.12
Rate for Payer: Cash Price	$1,561.12
Rate for Payer: Cigna Commercial	$1,119.78
Rate for Payer: Cigna Medicaid	$345.49
Rate for Payer: Cigna Medicare	$494.32
Rate for Payer: Employer Direct Commercial	$494.32
Rate for Payer: Humana Medicare/TRICARE	$494.32
Rate for Payer: Molina CHIP/Medicaid	$345.49
Rate for Payer: Molina Dual Medicare/Medicaid	$494.32
Rate for Payer: Molina Medicare	$494.32
Rate for Payer: Multiplan Auto	$1,153.10
Rate for Payer: Multiplan Commercial	$1,153.10
Rate for Payer: Multiplan Workers Comp	$1,153.10
Rate for Payer: Parkland Medicaid	$345.49
Rate for Payer: Scott and White EPO/PPO	$8.84
Rate for Payer: Scott and White Medicare	$494.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$345.49
Rate for Payer: Superior Health Plan EPO	$494.32
Rate for Payer: Superior Health Plan Medicare	$494.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$494.32
Rate for Payer: Universal American Medicare	$494.32
Rate for Payer: Wellcare Medicare	$494.32
Rate for Payer: Wellmed Medicare	$494.32

NM Kidney Imaging Multiple w/+w/o Pharm BCE

Facility

$1,774.00

Service Code	CPT 78709
Hospital Charge Code	5208709
Hospital Revenue Code	341
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$1,153.10
Rate for Payer: Aetna Commercial	$327.70
Rate for Payer: Aetna Medicare	$741.48
Rate for Payer: Amerigroup CHIP/Medicaid	$345.49
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$494.32
Rate for Payer: Amerigroup Medicare	$494.32
Rate for Payer: BCBS of TX Blue Advantage	$514.96
Rate for Payer: BCBS of TX Blue Essentials	$617.96
Rate for Payer: BCBS of TX Medicare	$494.32
Rate for Payer: BCBS of TX PPO	$689.74
Rate for Payer: Cash Price	$1,561.12
Rate for Payer: Cash Price	$1,561.12
Rate for Payer: Cash Price	$1,561.12
Rate for Payer: Cigna Commercial	$1,119.78
Rate for Payer: Cigna Medicaid	$345.49
Rate for Payer: Cigna Medicare	$494.32
Rate for Payer: Employer Direct Commercial	$494.32
Rate for Payer: Humana Medicare/TRICARE	$494.32
Rate for Payer: Molina CHIP/Medicaid	$345.49
Rate for Payer: Molina Dual Medicare/Medicaid	$494.32
Rate for Payer: Molina Medicare	$494.32
Rate for Payer: Multiplan Auto	$1,153.10
Rate for Payer: Multiplan Commercial	$1,153.10
Rate for Payer: Multiplan Workers Comp	$1,153.10
Rate for Payer: Parkland Medicaid	$345.49
Rate for Payer: Scott and White EPO/PPO	$8.84
Rate for Payer: Scott and White Medicare	$494.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$345.49
Rate for Payer: Superior Health Plan EPO	$494.32
Rate for Payer: Superior Health Plan Medicare	$494.32
Rate for Payer: Universal American Dual Medicare/Medicaid	$494.32
Rate for Payer: Universal American Medicare	$494.32
Rate for Payer: Wellcare Medicare	$494.32
Rate for Payer: Wellmed Medicare	$494.32

Know your out-of-pocket cost for care.

All Charges