White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NM GI Blood Loss Initial delay

Facility

$1,075.00

Service Code	HCPCS 78278
Hospital Charge Code	3400413
Hospital Revenue Code	341
Min. Negotiated Rate	$313.08
Max. Negotiated Rate	$848.90
Rate for Payer: Amerigroup CHIP/Medicaid	$313.08
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$401.59
Rate for Payer: Amerigroup Medicare	$401.59
Rate for Payer: BCBS of TX Blue Advantage	$515.56
Rate for Payer: BCBS of TX Blue Essentials	$618.67
Rate for Payer: BCBS of TX Medicare	$401.59
Rate for Payer: BCBS of TX PPO	$690.54
Rate for Payer: Cash Price	$731.00
Rate for Payer: Cash Price	$731.00
Rate for Payer: Cash Price	$731.00
Rate for Payer: Cigna Commercial	$848.90
Rate for Payer: Cigna Medicaid	$774.00
Rate for Payer: Cigna Medicare	$401.59
Rate for Payer: Employer Direct Commercial	$401.59
Rate for Payer: Humana Medicare/TRICARE	$401.59
Rate for Payer: Molina CHIP/Medicaid	$774.00
Rate for Payer: Molina Dual Medicare/Medicaid	$401.59
Rate for Payer: Molina Medicare	$401.59
Rate for Payer: Multiplan Auto	$698.75
Rate for Payer: Multiplan Commercial	$698.75
Rate for Payer: Multiplan Workers Comp	$698.75
Rate for Payer: Parkland Medicaid	$774.00
Rate for Payer: Scott and White EPO/PPO	$393.61
Rate for Payer: Scott and White Medicare	$401.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$774.00
Rate for Payer: Superior Health Plan EPO	$401.59
Rate for Payer: Superior Health Plan Medicare	$401.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$401.59
Rate for Payer: Universal American Medicare	$401.59
Rate for Payer: Wellcare Medicare	$401.59
Rate for Payer: Wellmed Medicare	$401.59

NM GI Blood Loss Initial delay

Facility

$1,075.00

Service Code	HCPCS 78278
Hospital Charge Code	3400413
Hospital Revenue Code	341
Rate for Payer: Cash Price	$731.00

NM Hepatobiliary Imaging Injection/Scan

Facility

$2,704.00

Service Code	HCPCS 78226
Hospital Charge Code	3400008
Hospital Revenue Code	341
Min. Negotiated Rate	$290.70
Max. Negotiated Rate	$1,946.88
Rate for Payer: Amerigroup CHIP/Medicaid	$290.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$401.59
Rate for Payer: Amerigroup Medicare	$401.59
Rate for Payer: BCBS of TX Blue Advantage	$504.26
Rate for Payer: BCBS of TX Blue Essentials	$605.11
Rate for Payer: BCBS of TX Medicare	$401.59
Rate for Payer: BCBS of TX PPO	$675.40
Rate for Payer: Cash Price	$1,838.72
Rate for Payer: Cash Price	$1,838.72
Rate for Payer: Cash Price	$1,838.72
Rate for Payer: Cigna Commercial	$848.90
Rate for Payer: Cigna Medicaid	$1,946.88
Rate for Payer: Cigna Medicare	$401.59
Rate for Payer: Employer Direct Commercial	$401.59
Rate for Payer: Humana Medicare/TRICARE	$401.59
Rate for Payer: Molina CHIP/Medicaid	$1,946.88
Rate for Payer: Molina Dual Medicare/Medicaid	$401.59
Rate for Payer: Molina Medicare	$401.59
Rate for Payer: Multiplan Auto	$1,757.60
Rate for Payer: Multiplan Commercial	$1,757.60
Rate for Payer: Multiplan Workers Comp	$1,757.60
Rate for Payer: Parkland Medicaid	$1,946.88
Rate for Payer: Scott and White EPO/PPO	$366.48
Rate for Payer: Scott and White Medicare	$401.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,946.88
Rate for Payer: Superior Health Plan EPO	$401.59
Rate for Payer: Superior Health Plan Medicare	$401.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$401.59
Rate for Payer: Universal American Medicare	$401.59
Rate for Payer: Wellcare Medicare	$401.59
Rate for Payer: Wellmed Medicare	$401.59

NM Hepatobiliary Imaging Injection/Scan

Facility

$2,704.00

Service Code	HCPCS 78226
Hospital Charge Code	3400008
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,838.72

NM HIDA w/ Drug Injection/Scan

Facility

$3,439.00

Service Code	HCPCS 78227
Hospital Charge Code	3400009
Hospital Revenue Code	341
Min. Negotiated Rate	$390.26
Max. Negotiated Rate	$2,476.08
Rate for Payer: Amerigroup CHIP/Medicaid	$390.26
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$545.44
Rate for Payer: Amerigroup Medicare	$545.44
Rate for Payer: BCBS of TX Blue Advantage	$689.78
Rate for Payer: BCBS of TX Blue Essentials	$827.74
Rate for Payer: BCBS of TX Medicare	$545.44
Rate for Payer: BCBS of TX PPO	$923.89
Rate for Payer: Cash Price	$2,338.52
Rate for Payer: Cash Price	$2,338.52
Rate for Payer: Cash Price	$2,338.52
Rate for Payer: Cigna Commercial	$1,152.98
Rate for Payer: Cigna Medicaid	$2,476.08
Rate for Payer: Cigna Medicare	$545.44
Rate for Payer: Employer Direct Commercial	$545.44
Rate for Payer: Humana Medicare/TRICARE	$545.44
Rate for Payer: Molina CHIP/Medicaid	$2,476.08
Rate for Payer: Molina Dual Medicare/Medicaid	$545.44
Rate for Payer: Molina Medicare	$545.44
Rate for Payer: Multiplan Auto	$2,235.35
Rate for Payer: Multiplan Commercial	$2,235.35
Rate for Payer: Multiplan Workers Comp	$2,235.35
Rate for Payer: Parkland Medicaid	$2,476.08
Rate for Payer: Scott and White EPO/PPO	$491.69
Rate for Payer: Scott and White Medicare	$545.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,476.08
Rate for Payer: Superior Health Plan EPO	$545.44
Rate for Payer: Superior Health Plan Medicare	$545.44
Rate for Payer: Universal American Dual Medicare/Medicaid	$545.44
Rate for Payer: Universal American Medicare	$545.44
Rate for Payer: Wellcare Medicare	$545.44
Rate for Payer: Wellmed Medicare	$545.44

NM HIDA w/ Drug Injection/Scan

Facility

$3,439.00

Service Code	HCPCS 78227
Hospital Charge Code	3400009
Hospital Revenue Code	341
Rate for Payer: Cash Price	$2,338.52

NMI F-18 FDG DIAGNOSTIC PER DOSE

Facility

$1,645.00

Hospital Charge Code	3403029
Hospital Revenue Code	343
Min. Negotiated Rate	$148.05
Max. Negotiated Rate	$1,184.40
Rate for Payer: Amerigroup CHIP/Medicaid	$148.05
Rate for Payer: BCBS of TX Blue Advantage	$493.50
Rate for Payer: BCBS of TX Blue Essentials	$592.20
Rate for Payer: BCBS of TX PPO	$658.00
Rate for Payer: Cash Price	$1,118.60
Rate for Payer: Cigna Medicaid	$1,184.40
Rate for Payer: Molina CHIP/Medicaid	$1,184.40
Rate for Payer: Multiplan Auto	$1,069.25
Rate for Payer: Multiplan Commercial	$1,069.25
Rate for Payer: Multiplan Workers Comp	$1,069.25
Rate for Payer: Parkland Medicaid	$1,184.40
Rate for Payer: Scott and White EPO/PPO	$822.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,184.40
Rate for Payer: Superior Health Plan EPO	$223.72

NMI F-18 FDG DIAGNOSTIC PER DOSE

Facility

$1,645.00

Hospital Charge Code	3403029
Hospital Revenue Code	343
Rate for Payer: Cash Price	$1,118.60

NMI I-123 IODIDE/100UCI UP TO 999UCI

Facility

$1,105.00

Hospital Charge Code	3401882
Hospital Revenue Code	343
Rate for Payer: Cash Price	$751.40

NMI I-123 IODIDE/100UCI UP TO 999UCI

Facility

$1,105.00

Hospital Charge Code	3401882
Hospital Revenue Code	343
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$795.60
Rate for Payer: Amerigroup CHIP/Medicaid	$99.45
Rate for Payer: BCBS of TX Blue Advantage	$331.50
Rate for Payer: BCBS of TX Blue Essentials	$397.80
Rate for Payer: BCBS of TX PPO	$442.00
Rate for Payer: Cash Price	$751.40
Rate for Payer: Cigna Medicaid	$795.60
Rate for Payer: Molina CHIP/Medicaid	$795.60
Rate for Payer: Multiplan Auto	$718.25
Rate for Payer: Multiplan Commercial	$718.25
Rate for Payer: Multiplan Workers Comp	$718.25
Rate for Payer: Parkland Medicaid	$795.60
Rate for Payer: Scott and White EPO/PPO	$552.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$795.60
Rate for Payer: Superior Health Plan EPO	$150.28

NMI I-131 IODIDE THERAPY CAP PER MCI

Facility

$77.00

Hospital Charge Code	3406162
Hospital Revenue Code	344
Rate for Payer: Cash Price	$52.36

NMI I-131 IODIDE THERAPY CAP PER MCI

Facility

$77.00

Hospital Charge Code	3406162
Hospital Revenue Code	344
Min. Negotiated Rate	$6.93
Max. Negotiated Rate	$55.44
Rate for Payer: Amerigroup CHIP/Medicaid	$6.93
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 PPO	$30.80
Rate for Payer: Cash Price	$52.36
Rate for Payer: Cigna Medicaid	$55.44
Rate for Payer: Molina CHIP/Medicaid	$55.44
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: Parkland Medicaid	$55.44
Rate for Payer: Scott and White EPO/PPO	$38.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55.44
Rate for Payer: Superior Health Plan EPO	$10.47

NMI I-131 MIBG PER 0.5MCI

Facility

$7,017.00

Hospital Charge Code	5192142
Hospital Revenue Code	343
Min. Negotiated Rate	$631.53
Max. Negotiated Rate	$5,052.24
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	$4,771.56
Rate for Payer: Cigna Medicaid	$5,052.24
Rate for Payer: Molina CHIP/Medicaid	$5,052.24
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: Parkland Medicaid	$5,052.24
Rate for Payer: Scott and White EPO/PPO	$3,508.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,052.24
Rate for Payer: Superior Health Plan EPO	$954.31

NMI I-131 MIBG PER 0.5MCI

Facility

$7,017.00

Hospital Charge Code	5192142
Hospital Revenue Code	343
Rate for Payer: Cash Price	$4,771.56

NMI IN-111 WBC DOSE

Facility

$3,586.00

Hospital Charge Code	5199570
Hospital Revenue Code	343
Rate for Payer: Cash Price	$2,438.48

NMI IN-111 WBC DOSE

Facility

$3,586.00

Hospital Charge Code	5199570
Hospital Revenue Code	343
Min. Negotiated Rate	$322.74
Max. Negotiated Rate	$2,581.92
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	$2,438.48
Rate for Payer: Cigna Medicaid	$2,581.92
Rate for Payer: Molina CHIP/Medicaid	$2,581.92
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: Parkland Medicaid	$2,581.92
Rate for Payer: Scott and White EPO/PPO	$1,793.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,581.92
Rate for Payer: Superior Health Plan EPO	$487.70

NM Intestine Imaging Meckels

Facility

$750.00

Service Code	HCPCS 78290
Hospital Charge Code	3400116
Hospital Revenue Code	341
Rate for Payer: Cash Price	$510.00

NM Intestine Imaging Meckels

Facility

$750.00

Service Code	HCPCS 78290
Hospital Charge Code	3400116
Hospital Revenue Code	341
Min. Negotiated Rate	$295.70
Max. Negotiated Rate	$848.90
Rate for Payer: Amerigroup CHIP/Medicaid	$295.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$401.59
Rate for Payer: Amerigroup Medicare	$401.59
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	$401.59
Rate for Payer: BCBS of TX PPO	$683.38
Rate for Payer: Cash Price	$510.00
Rate for Payer: Cash Price	$510.00
Rate for Payer: Cash Price	$510.00
Rate for Payer: Cigna Commercial	$848.90
Rate for Payer: Cigna Medicaid	$540.00
Rate for Payer: Cigna Medicare	$401.59
Rate for Payer: Employer Direct Commercial	$401.59
Rate for Payer: Humana Medicare/TRICARE	$401.59
Rate for Payer: Molina CHIP/Medicaid	$540.00
Rate for Payer: Molina Dual Medicare/Medicaid	$401.59
Rate for Payer: Molina Medicare	$401.59
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	$540.00
Rate for Payer: Scott and White EPO/PPO	$371.00
Rate for Payer: Scott and White Medicare	$401.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$540.00
Rate for Payer: Superior Health Plan EPO	$401.59
Rate for Payer: Superior Health Plan Medicare	$401.59
Rate for Payer: Universal American Dual Medicare/Medicaid	$401.59
Rate for Payer: Universal American Medicare	$401.59
Rate for Payer: Wellcare Medicare	$401.59
Rate for Payer: Wellmed Medicare	$401.59

NMI TC-99M BICISATE DOSE

Facility

$1,987.00

Hospital Charge Code	5194089
Hospital Revenue Code	343
Rate for Payer: Cash Price	$1,351.16

NMI TC-99M BICISATE DOSE

Facility

$1,987.00

Hospital Charge Code	5194089
Hospital Revenue Code	343
Min. Negotiated Rate	$178.83
Max. Negotiated Rate	$1,430.64
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	$1,351.16
Rate for Payer: Cigna Medicaid	$1,430.64
Rate for Payer: Molina CHIP/Medicaid	$1,430.64
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: Parkland Medicaid	$1,430.64
Rate for Payer: Scott and White EPO/PPO	$993.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,430.64
Rate for Payer: Superior Health Plan EPO	$270.23

NMI TC-99M CERETEC WBC

Facility

$2,352.00

Hospital Charge Code	3410005
Hospital Revenue Code	343
Min. Negotiated Rate	$211.68
Max. Negotiated Rate	$1,693.44
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	$1,599.36
Rate for Payer: Cigna Medicaid	$1,693.44
Rate for Payer: Molina CHIP/Medicaid	$1,693.44
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: Parkland Medicaid	$1,693.44
Rate for Payer: Scott and White EPO/PPO	$1,176.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,693.44
Rate for Payer: Superior Health Plan EPO	$319.87

NMI TC-99M CERETEC WBC

Facility

$2,352.00

Hospital Charge Code	3410005
Hospital Revenue Code	343
Rate for Payer: Cash Price	$1,599.36

NMI TC-99M EXAMETAZIME PER DOSE

Facility

$5,817.25

Hospital Charge Code	3406774
Hospital Revenue Code	343
Min. Negotiated Rate	$523.55
Max. Negotiated Rate	$4,188.42
Rate for Payer: Amerigroup CHIP/Medicaid	$523.55
Rate for Payer: BCBS of TX Blue Advantage	$1,745.17
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	$3,955.73
Rate for Payer: Cigna Medicaid	$4,188.42
Rate for Payer: Molina CHIP/Medicaid	$4,188.42
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: Parkland Medicaid	$4,188.42
Rate for Payer: Scott and White EPO/PPO	$2,908.62
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,188.42
Rate for Payer: Superior Health Plan EPO	$791.15

NMI TC-99M EXAMETAZIME PER DOSE

Facility

$5,817.25

Hospital Charge Code	3406774
Hospital Revenue Code	343
Rate for Payer: Cash Price	$3,955.73

NMI TC-99M MAA PER DOSE

Facility

$207.00

Hospital Charge Code	3403060
Hospital Revenue Code	343
Rate for Payer: Cash Price	$140.76

Know your out-of-pocket cost for care.

All Charges