White Rock Medical Center

All Charges

Charge

Type

Setting

Price

niacin 100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77723739
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

niacin 100 mg Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77723739
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

NICARDIPINE HCL 20 MG/200ML

Facility

$166.73

Service Code	HCPCS J2404
Hospital Charge Code	77724315
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$120.05
Rate for Payer: Amerigroup CHIP/Medicaid	$15.01
Rate for Payer: BCBS of TX Blue Advantage	$0.15
Rate for Payer: BCBS of TX Blue Essentials	$0.17
Rate for Payer: BCBS of TX PPO	$0.19
Rate for Payer: Cash Price	$113.38
Rate for Payer: Cash Price	$113.38
Rate for Payer: Cigna Medicaid	$120.05
Rate for Payer: Molina CHIP/Medicaid	$120.05
Rate for Payer: Multiplan Auto	$108.37
Rate for Payer: Multiplan Commercial	$108.37
Rate for Payer: Multiplan Workers Comp	$108.37
Rate for Payer: Parkland Medicaid	$120.05
Rate for Payer: Scott and White EPO/PPO	$83.36
Rate for Payer: Superior Health Plan CHIP/Medicaid	$120.05
Rate for Payer: Superior Health Plan EPO	$22.68

NICARDIPINE HCL 20 MG/200ML

Facility

$166.73

Service Code	HCPCS J2404
Hospital Charge Code	77724315
Hospital Revenue Code	636
Min. Negotiated Rate	$41.68
Max. Negotiated Rate	$83.36
Rate for Payer: Cash Price	$113.38
Rate for Payer: Cigna Commercial	$41.68
Rate for Payer: Scott and White EPO/PPO	$83.36

nicotine 14 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78424116
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

nicotine 14 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78424116
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nicotine 21 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78430226
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nicotine 21 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78430226
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

nicotine 7 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78414941
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nicotine 7 mg/24 hr TD ER Film

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	78414941
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

Nicotine and Metabolite, Quant SO

Facility

$74.00

Service Code	HCPCS 80323
Hospital Charge Code	9106973
Hospital Revenue Code	301
Min. Negotiated Rate	$7.94
Max. Negotiated Rate	$53.28
Rate for Payer: Amerigroup CHIP/Medicaid	$7.94
Rate for Payer: BCBS of TX Blue Advantage	$22.20
Rate for Payer: BCBS of TX Blue Essentials	$26.64
Rate for Payer: BCBS of TX PPO	$29.60
Rate for Payer: Cash Price	$50.32
Rate for Payer: Cash Price	$50.32
Rate for Payer: Cigna Medicaid	$53.28
Rate for Payer: Molina CHIP/Medicaid	$53.28
Rate for Payer: Multiplan Auto	$48.10
Rate for Payer: Multiplan Commercial	$48.10
Rate for Payer: Multiplan Workers Comp	$48.10
Rate for Payer: Parkland Medicaid	$53.28
Rate for Payer: Scott and White EPO/PPO	$37.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.28
Rate for Payer: Superior Health Plan EPO	$10.06

Nicotine and Metabolite, Quant SO

Facility

$74.00

Service Code	HCPCS 80323
Hospital Charge Code	7258388
Hospital Revenue Code	301
Min. Negotiated Rate	$7.94
Max. Negotiated Rate	$53.28
Rate for Payer: Amerigroup CHIP/Medicaid	$7.94
Rate for Payer: BCBS of TX Blue Advantage	$22.20
Rate for Payer: BCBS of TX Blue Essentials	$26.64
Rate for Payer: BCBS of TX PPO	$29.60
Rate for Payer: Cash Price	$50.32
Rate for Payer: Cash Price	$50.32
Rate for Payer: Cigna Medicaid	$53.28
Rate for Payer: Molina CHIP/Medicaid	$53.28
Rate for Payer: Multiplan Auto	$48.10
Rate for Payer: Multiplan Commercial	$48.10
Rate for Payer: Multiplan Workers Comp	$48.10
Rate for Payer: Parkland Medicaid	$53.28
Rate for Payer: Scott and White EPO/PPO	$37.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$53.28
Rate for Payer: Superior Health Plan EPO	$10.06

Nicotine and Metabolite, Quant SO

Facility

$74.00

Service Code	HCPCS 80323
Hospital Charge Code	9106973
Hospital Revenue Code	301
Rate for Payer: Cash Price	$50.32

Nicotine and Metabolite, Quant SO

Facility

$74.00

Service Code	HCPCS 80323
Hospital Charge Code	7258388
Hospital Revenue Code	301
Rate for Payer: Cash Price	$50.32

NIFEdipine 10 mg Cap

Facility

$14.00

Service Code	HCPCS J8499
Hospital Charge Code	77725772
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$7.00
Rate for Payer: Cash Price	$9.52
Rate for Payer: Cigna Commercial	$3.50
Rate for Payer: Scott and White EPO/PPO	$7.00

NIFEdipine 10 mg Cap

Facility

$14.00

Service Code	HCPCS J8499
Hospital Charge Code	77725772
Hospital Revenue Code	636
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$10.08
Rate for Payer: Amerigroup CHIP/Medicaid	$1.26
Rate for Payer: BCBS of TX Blue Advantage	$4.20
Rate for Payer: BCBS of TX Blue Essentials	$5.04
Rate for Payer: BCBS of TX PPO	$5.60
Rate for Payer: Cash Price	$9.52
Rate for Payer: Cigna Medicaid	$10.08
Rate for Payer: Molina CHIP/Medicaid	$10.08
Rate for Payer: Multiplan Auto	$9.10
Rate for Payer: Multiplan Commercial	$9.10
Rate for Payer: Multiplan Workers Comp	$9.10
Rate for Payer: Parkland Medicaid	$10.08
Rate for Payer: Scott and White EPO/PPO	$7.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$10.08
Rate for Payer: Superior Health Plan EPO	$1.90

NIFEdipine 30 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77725876
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

NIFEdipine 30 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77725876
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

NIFEdipine 60 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77725927
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

NIFEdipine 60 mg ER Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77725927
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nitrofurantoin macrocrystals-monohydrate 100 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77727165
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nitrofurantoin macrocrystals-monohydrate 100 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77727165
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

nitroglycerin 0.4 mg SL Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77727642
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

nitroglycerin 0.4 mg SL Tab

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77727642
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nitroglycerin 2% TD Oint 1 g

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77728168
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$2.40
Rate for Payer: BCBS of TX Blue Essentials	$2.88
Rate for Payer: BCBS of TX PPO	$3.20
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

Know your out-of-pocket cost for care.

All Charges