White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NMI TC-99M MAA PER DOSE

Facility

$207.00

Hospital Charge Code	3403060
Hospital Revenue Code	343
Min. Negotiated Rate	$18.63
Max. Negotiated Rate	$149.04
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	$140.76
Rate for Payer: Cigna Medicaid	$149.04
Rate for Payer: Molina CHIP/Medicaid	$149.04
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: Parkland Medicaid	$149.04
Rate for Payer: Scott and White EPO/PPO	$103.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$149.04
Rate for Payer: Superior Health Plan EPO	$28.15

NMI TC-99M MEBROFENIN PER DOSE

Facility

$369.00

Hospital Charge Code	3403037
Hospital Revenue Code	343
Rate for Payer: Cash Price	$250.92

NMI TC-99M MEBROFENIN PER DOSE

Facility

$369.00

Hospital Charge Code	3403037
Hospital Revenue Code	343
Min. Negotiated Rate	$33.21
Max. Negotiated Rate	$265.68
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	$250.92
Rate for Payer: Cigna Medicaid	$265.68
Rate for Payer: Molina CHIP/Medicaid	$265.68
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: Parkland Medicaid	$265.68
Rate for Payer: Scott and White EPO/PPO	$184.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$265.68
Rate for Payer: Superior Health Plan EPO	$50.18

NMI TC-99M MEDRONATE PER DOSE

Facility

$210.00

Hospital Charge Code	3402484
Hospital Revenue Code	343
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$151.20
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	$142.80
Rate for Payer: Cigna Medicaid	$151.20
Rate for Payer: Molina CHIP/Medicaid	$151.20
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: Parkland Medicaid	$151.20
Rate for Payer: Scott and White EPO/PPO	$105.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$151.20
Rate for Payer: Superior Health Plan EPO	$28.56

NMI TC-99M MEDRONATE PER DOSE

Facility

$210.00

Hospital Charge Code	3402484
Hospital Revenue Code	343
Rate for Payer: Cash Price	$142.80

NMI TC-99M MERTIATIDE PER DOSE

Facility

$1,050.00

Hospital Charge Code	3406105
Hospital Revenue Code	343
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$756.00
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	$714.00
Rate for Payer: Cigna Medicaid	$756.00
Rate for Payer: Molina CHIP/Medicaid	$756.00
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: Parkland Medicaid	$756.00
Rate for Payer: Scott and White EPO/PPO	$525.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$756.00
Rate for Payer: Superior Health Plan EPO	$142.80

NMI TC-99M MERTIATIDE PER DOSE

Facility

$1,050.00

Hospital Charge Code	3406105
Hospital Revenue Code	343
Rate for Payer: Cash Price	$714.00

NMI TC-99M PENTETATE PER DOSE

Facility

$236.00

Hospital Charge Code	3403052
Hospital Revenue Code	343
Min. Negotiated Rate	$21.24
Max. Negotiated Rate	$169.92
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	$160.48
Rate for Payer: Cigna Medicaid	$169.92
Rate for Payer: Molina CHIP/Medicaid	$169.92
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: Parkland Medicaid	$169.92
Rate for Payer: Scott and White EPO/PPO	$118.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$169.92
Rate for Payer: Superior Health Plan EPO	$32.10

NMI TC-99M PENTETATE PER DOSE

Facility

$236.00

Hospital Charge Code	3403052
Hospital Revenue Code	343
Rate for Payer: Cash Price	$160.48

NMI TC-99M PERTECHNETATE PER MCI

Facility

$7.00

Hospital Charge Code	3401890
Hospital Revenue Code	343
Rate for Payer: Cash Price	$4.76

NMI TC-99M PERTECHNETATE PER MCI

Facility

$7.00

Hospital Charge Code	3401890
Hospital Revenue Code	343
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$5.04
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	$4.76
Rate for Payer: Cigna Medicaid	$5.04
Rate for Payer: Molina CHIP/Medicaid	$5.04
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: Parkland Medicaid	$5.04
Rate for Payer: Scott and White EPO/PPO	$3.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.04
Rate for Payer: Superior Health Plan EPO	$0.95

NMI TC-99M RBC PER DOSE

Facility

$478.00

Hospital Charge Code	3406097
Hospital Revenue Code	343
Min. Negotiated Rate	$43.02
Max. Negotiated Rate	$344.16
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	$325.04
Rate for Payer: Cigna Medicaid	$344.16
Rate for Payer: Molina CHIP/Medicaid	$344.16
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: Parkland Medicaid	$344.16
Rate for Payer: Scott and White EPO/PPO	$239.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$344.16
Rate for Payer: Superior Health Plan EPO	$65.01

NMI TC-99M RBC PER DOSE

Facility

$478.00

Hospital Charge Code	3406097
Hospital Revenue Code	343
Rate for Payer: Cash Price	$325.04

NMI TC-99M SESTAMIBI PER DOSE

Facility

$1,428.00

Hospital Charge Code	3400892
Hospital Revenue Code	343
Rate for Payer: Cash Price	$971.04

NMI TC-99M SESTAMIBI PER DOSE

Facility

$1,428.00

Hospital Charge Code	3400892
Hospital Revenue Code	343
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$1,028.16
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	$971.04
Rate for Payer: Cigna Medicaid	$1,028.16
Rate for Payer: Molina CHIP/Medicaid	$1,028.16
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: Parkland Medicaid	$1,028.16
Rate for Payer: Scott and White EPO/PPO	$714.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,028.16
Rate for Payer: Superior Health Plan EPO	$194.21

NMI TC-99M SULFUR COLLOID PER DOSE

Facility

$136.00

Hospital Charge Code	3406071
Hospital Revenue Code	343
Rate for Payer: Cash Price	$92.48

NMI TC-99M SULFUR COLLOID PER DOSE

Facility

$136.00

Hospital Charge Code	3406071
Hospital Revenue Code	343
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$97.92
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	$92.48
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
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: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$68.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

NMI TI-201 THALLOUS CHLORIDE PER MCI

Facility

$1,035.00

Hospital Charge Code	3401080
Hospital Revenue Code	343
Rate for Payer: Cash Price	$703.80

NMI TI-201 THALLOUS CHLORIDE PER MCI

Facility

$1,035.00

Hospital Charge Code	3401080
Hospital Revenue Code	343
Min. Negotiated Rate	$93.15
Max. Negotiated Rate	$745.20
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	$703.80
Rate for Payer: Cigna Medicaid	$745.20
Rate for Payer: Molina CHIP/Medicaid	$745.20
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: Parkland Medicaid	$745.20
Rate for Payer: Scott and White EPO/PPO	$517.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$745.20
Rate for Payer: Superior Health Plan EPO	$140.76

NM Kidney Imaging Multiple w/+w/o Pharm

Facility

$1,774.00

Service Code	HCPCS 78709
Hospital Charge Code	5208709
Hospital Revenue Code	341
Min. Negotiated Rate	$332.13
Max. Negotiated Rate	$1,277.28
Rate for Payer: Amerigroup CHIP/Medicaid	$332.13
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$545.44
Rate for Payer: Amerigroup Medicare	$545.44
Rate for Payer: BCBS of TX Blue Advantage	$514.97
Rate for Payer: BCBS of TX Blue Essentials	$617.96
Rate for Payer: BCBS of TX Medicare	$545.44
Rate for Payer: BCBS of TX PPO	$689.74
Rate for Payer: Cash Price	$1,206.32
Rate for Payer: Cash Price	$1,206.32
Rate for Payer: Cash Price	$1,206.32
Rate for Payer: Cigna Commercial	$1,152.98
Rate for Payer: Cigna Medicaid	$1,277.28
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	$1,277.28
Rate for Payer: Molina Dual Medicare/Medicaid	$545.44
Rate for Payer: Molina Medicare	$545.44
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	$1,277.28
Rate for Payer: Scott and White EPO/PPO	$417.11
Rate for Payer: Scott and White Medicare	$545.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,277.28
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 Kidney Imaging Multiple w/+w/o Pharm

Facility

$1,774.00

Service Code	HCPCS 78709
Hospital Charge Code	5208709
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,206.32

NM Kidney Imaging Single w/o Pharm

Facility

$1,199.00

Service Code	HCPCS 78707
Hospital Charge Code	3400165
Hospital Revenue Code	341
Rate for Payer: Cash Price	$815.32

NM Kidney Imaging Single w/o Pharm

Facility

$1,199.00

Service Code	HCPCS 78707
Hospital Charge Code	3400165
Hospital Revenue Code	341
Min. Negotiated Rate	$212.84
Max. Negotiated Rate	$1,152.98
Rate for Payer: Amerigroup CHIP/Medicaid	$212.84
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$545.44
Rate for Payer: Amerigroup Medicare	$545.44
Rate for Payer: BCBS of TX Blue Advantage	$319.32
Rate for Payer: BCBS of TX Blue Essentials	$383.19
Rate for Payer: BCBS of TX Medicare	$545.44
Rate for Payer: BCBS of TX PPO	$427.70
Rate for Payer: Cash Price	$815.32
Rate for Payer: Cash Price	$815.32
Rate for Payer: Cash Price	$815.32
Rate for Payer: Cigna Commercial	$1,152.98
Rate for Payer: Cigna Medicaid	$863.28
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	$863.28
Rate for Payer: Molina Dual Medicare/Medicaid	$545.44
Rate for Payer: Molina Medicare	$545.44
Rate for Payer: Multiplan Auto	$779.35
Rate for Payer: Multiplan Commercial	$779.35
Rate for Payer: Multiplan Workers Comp	$779.35
Rate for Payer: Parkland Medicaid	$863.28
Rate for Payer: Scott and White EPO/PPO	$265.57
Rate for Payer: Scott and White Medicare	$545.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$863.28
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 Liver Imaging Static

Facility

$2,255.00

Service Code	HCPCS 78201
Hospital Charge Code	5218201
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,533.40

NM Liver Imaging Static

Facility

$2,255.00

Service Code	HCPCS 78201
Hospital Charge Code	5218201
Hospital Revenue Code	341
Min. Negotiated Rate	$175.43
Max. Negotiated Rate	$1,623.60
Rate for Payer: Amerigroup CHIP/Medicaid	$175.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$545.44
Rate for Payer: Amerigroup Medicare	$545.44
Rate for Payer: BCBS of TX Blue Advantage	$290.78
Rate for Payer: BCBS of TX Blue Essentials	$348.94
Rate for Payer: BCBS of TX Medicare	$545.44
Rate for Payer: BCBS of TX PPO	$389.47
Rate for Payer: Cash Price	$1,533.40
Rate for Payer: Cash Price	$1,533.40
Rate for Payer: Cash Price	$1,533.40
Rate for Payer: Cigna Commercial	$1,152.98
Rate for Payer: Cigna Medicaid	$1,623.60
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	$1,623.60
Rate for Payer: Molina Dual Medicare/Medicaid	$545.44
Rate for Payer: Molina Medicare	$545.44
Rate for Payer: Multiplan Auto	$1,465.75
Rate for Payer: Multiplan Commercial	$1,465.75
Rate for Payer: Multiplan Workers Comp	$1,465.75
Rate for Payer: Parkland Medicaid	$1,623.60
Rate for Payer: Scott and White EPO/PPO	$218.20
Rate for Payer: Scott and White Medicare	$545.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,623.60
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

Know your out-of-pocket cost for care.

All Charges