White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC

Facility

$17,170.30

Service Code	MSDRG 068
Min. Negotiated Rate	$7,728.82
Max. Negotiated Rate	$17,170.30
Rate for Payer: BCBS of TX Blue Advantage	$7,728.82
Rate for Payer: BCBS of TX Blue Essentials	$9,273.69
Rate for Payer: BCBS of TX PPO	$10,304.49

NONTRAUMATIC STUPOR AND COMA WITH MCC

Facility

$38,756.20

Service Code	MSDRG 080
Min. Negotiated Rate	$16,157.68
Max. Negotiated Rate	$38,756.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$18,025.61
Rate for Payer: Amerigroup Medicare	$18,025.61
Rate for Payer: BCBS of TX Medicare	$18,025.61
Rate for Payer: Cigna Commercial	$23,312.80
Rate for Payer: Cigna Medicare	$18,025.61
Rate for Payer: Employer Direct Commercial	$18,025.61
Rate for Payer: Humana Medicare/TRICARE	$18,025.61
Rate for Payer: Molina Dual Medicare/Medicaid	$18,025.61
Rate for Payer: Molina Medicare	$18,025.61
Rate for Payer: Multiplan Auto	$38,756.20
Rate for Payer: Multiplan Commercial	$38,756.20
Rate for Payer: Multiplan Workers Comp	$38,756.20
Rate for Payer: Scott and White EPO/PPO	$17,848.25
Rate for Payer: Scott and White Medicare	$18,025.61
Rate for Payer: Superior Health Plan EPO	$18,025.61
Rate for Payer: Superior Health Plan Medicare	$18,025.61
Rate for Payer: Universal American Dual Medicare/Medicaid	$18,025.61
Rate for Payer: Universal American Medicare	$18,025.61
Rate for Payer: Wellcare Medicare	$18,025.61
Rate for Payer: Wellmed Medicare	$18,025.61

NONTRAUMATIC STUPOR AND COMA WITHOUT MCC

Facility

$17,071.50

Service Code	MSDRG 081
Min. Negotiated Rate	$7,349.56
Max. Negotiated Rate	$17,071.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$11,323.96
Rate for Payer: Amerigroup Medicare	$11,323.96
Rate for Payer: BCBS of TX Medicare	$11,323.96
Rate for Payer: Cigna Commercial	$11,535.33
Rate for Payer: Cigna Medicare	$11,323.96
Rate for Payer: Employer Direct Commercial	$11,323.96
Rate for Payer: Humana Medicare/TRICARE	$11,323.96
Rate for Payer: Molina Dual Medicare/Medicaid	$11,323.96
Rate for Payer: Molina Medicare	$11,323.96
Rate for Payer: Multiplan Auto	$17,071.50
Rate for Payer: Multiplan Commercial	$17,071.50
Rate for Payer: Multiplan Workers Comp	$17,071.50
Rate for Payer: Scott and White EPO/PPO	$7,861.88
Rate for Payer: Scott and White Medicare	$11,323.96
Rate for Payer: Superior Health Plan EPO	$11,323.96
Rate for Payer: Superior Health Plan Medicare	$11,323.96
Rate for Payer: Universal American Dual Medicare/Medicaid	$11,323.96
Rate for Payer: Universal American Medicare	$11,323.96
Rate for Payer: Wellcare Medicare	$11,323.96
Rate for Payer: Wellmed Medicare	$11,323.96

NONTRAUMATIC STUPOR & COMA W MCC

Facility

$38,756.20

Service Code	MSDRG 080
Min. Negotiated Rate	$16,157.68
Max. Negotiated Rate	$38,756.20
Rate for Payer: BCBS of TX Blue Advantage	$16,157.68
Rate for Payer: BCBS of TX Blue Essentials	$19,387.34
Rate for Payer: BCBS of TX PPO	$21,542.32

NONTRAUMATIC STUPOR & COMA W/O MCC

Facility

$17,071.50

Service Code	MSDRG 081
Min. Negotiated Rate	$7,349.56
Max. Negotiated Rate	$17,071.50
Rate for Payer: BCBS of TX Blue Advantage	$7,349.56
Rate for Payer: BCBS of TX Blue Essentials	$8,818.62
Rate for Payer: BCBS of TX PPO	$9,798.84

norepinephrine 1 mg/mL IV Soln 4 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77729385
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

norepinephrine 1 mg/mL IV Soln 4 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	77729385
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

norepinephrine 8 mg-NaCl 0.9% 250 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78415626
Hospital Revenue Code	250
Rate for Payer: Cash Price	$87.04

norepinephrine 8 mg-NaCl 0.9% 250 mL

Facility

$128.00

Service Code	HCPCS J3490
Hospital Charge Code	78415626
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$92.16
Rate for Payer: Amerigroup CHIP/Medicaid	$11.52
Rate for Payer: BCBS of TX Blue Advantage	$38.40
Rate for Payer: BCBS of TX Blue Essentials	$46.08
Rate for Payer: BCBS of TX PPO	$51.20
Rate for Payer: Cash Price	$87.04
Rate for Payer: Cigna Medicaid	$92.16
Rate for Payer: Molina CHIP/Medicaid	$92.16
Rate for Payer: Multiplan Auto	$83.20
Rate for Payer: Multiplan Commercial	$83.20
Rate for Payer: Multiplan Workers Comp	$83.20
Rate for Payer: Parkland Medicaid	$92.16
Rate for Payer: Scott and White EPO/PPO	$64.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.16
Rate for Payer: Superior Health Plan EPO	$17.41

NO RETURN, TEST, SOFIA, SARS-ONLY, 25/BX

Facility

$119.12

Hospital Charge Code	993329
Hospital Revenue Code	270
Rate for Payer: Cash Price	$81.00

NO RETURN, TEST, SOFIA, SARS-ONLY, 25/BX

Facility

$119.12

Hospital Charge Code	993329
Hospital Revenue Code	270
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$85.77
Rate for Payer: Amerigroup CHIP/Medicaid	$10.72
Rate for Payer: BCBS of TX Blue Advantage	$35.74
Rate for Payer: BCBS of TX Blue Essentials	$42.88
Rate for Payer: BCBS of TX PPO	$47.65
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Medicaid	$85.77
Rate for Payer: Molina CHIP/Medicaid	$85.77
Rate for Payer: Multiplan Auto	$77.43
Rate for Payer: Multiplan Commercial	$77.43
Rate for Payer: Multiplan Workers Comp	$77.43
Rate for Payer: Parkland Medicaid	$85.77
Rate for Payer: Scott and White EPO/PPO	$59.56
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.77
Rate for Payer: Superior Health Plan EPO	$16.20

NORMAL NEWBORN

Facility

$6,224.42

Service Code	MSDRG 795
Min. Negotiated Rate	$1,585.84
Max. Negotiated Rate	$6,224.42
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$6,224.42
Rate for Payer: Amerigroup Medicare	$6,224.42
Rate for Payer: BCBS of TX Blue Advantage	$1,585.84
Rate for Payer: BCBS of TX Blue Essentials	$1,902.82
Rate for Payer: BCBS of TX Medicare	$6,224.42
Rate for Payer: BCBS of TX PPO	$2,114.33
Rate for Payer: Cigna Commercial	$2,573.42
Rate for Payer: Cigna Medicare	$6,224.42
Rate for Payer: Employer Direct Commercial	$6,224.42
Rate for Payer: Humana Medicare/TRICARE	$6,224.42
Rate for Payer: Molina Dual Medicare/Medicaid	$6,224.42
Rate for Payer: Molina Medicare	$6,224.42
Rate for Payer: Multiplan Auto	$3,845.60
Rate for Payer: Multiplan Commercial	$3,845.60
Rate for Payer: Multiplan Workers Comp	$3,845.60
Rate for Payer: Scott and White EPO/PPO	$1,771.00
Rate for Payer: Scott and White Medicare	$6,224.42
Rate for Payer: Superior Health Plan EPO	$6,224.42
Rate for Payer: Superior Health Plan Medicare	$6,224.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$6,224.42
Rate for Payer: Universal American Medicare	$6,224.42
Rate for Payer: Wellcare Medicare	$6,224.42
Rate for Payer: Wellmed Medicare	$6,224.42

nortriptyline 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77730046
Hospital Revenue Code	250
Rate for Payer: Cash Price	$5.44

nortriptyline 25 mg Cap

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	77730046
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

NPWT, utilizing disposable, non-durable DME, per session total wound surface area greater than 50 sq cm

Facility

$1,598.12

Service Code	HCPCS 97608
Hospital Charge Code	994065
Hospital Revenue Code	361
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$143.83
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$408.37
Rate for Payer: Amerigroup Medicare	$408.37
Rate for Payer: BCBS of TX Blue Advantage	$479.44
Rate for Payer: BCBS of TX Blue Essentials	$575.32
Rate for Payer: BCBS of TX Medicare	$408.37
Rate for Payer: BCBS of TX PPO	$639.25
Rate for Payer: Cash Price	$1,086.72
Rate for Payer: Cash Price	$1,086.72
Rate for Payer: Cash Price	$1,086.72
Rate for Payer: Cigna Commercial	$863.21
Rate for Payer: Cigna Medicaid	$1,150.65
Rate for Payer: Cigna Medicare	$408.37
Rate for Payer: Employer Direct Commercial	$408.37
Rate for Payer: Humana Medicare/TRICARE	$408.37
Rate for Payer: Molina CHIP/Medicaid	$1,150.65
Rate for Payer: Molina Dual Medicare/Medicaid	$408.37
Rate for Payer: Molina Medicare	$408.37
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,150.65
Rate for Payer: Scott and White EPO/PPO	$30.10
Rate for Payer: Scott and White Medicare	$408.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,150.65
Rate for Payer: Superior Health Plan EPO	$408.37
Rate for Payer: Superior Health Plan Medicare	$408.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$408.37
Rate for Payer: Universal American Medicare	$408.37
Rate for Payer: Wellcare Medicare	$408.37
Rate for Payer: Wellmed Medicare	$408.37

NPWT, utilizing disposable, non-durable DME, per session total wound surface area greater than 50 sq cm

Facility

$1,598.12

Service Code	HCPCS 97608
Hospital Charge Code	994065
Hospital Revenue Code	361
Rate for Payer: Cash Price	$1,086.72

Nsk power box

Facility

$2,483.38

Hospital Charge Code	993400
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,688.70

Nsk power box

Facility

$2,483.38

Hospital Charge Code	993400
Hospital Revenue Code	272
Min. Negotiated Rate	$223.50
Max. Negotiated Rate	$1,788.03
Rate for Payer: Amerigroup CHIP/Medicaid	$223.50
Rate for Payer: BCBS of TX Blue Advantage	$745.01
Rate for Payer: BCBS of TX Blue Essentials	$894.02
Rate for Payer: BCBS of TX PPO	$993.35
Rate for Payer: Cash Price	$1,688.70
Rate for Payer: Cigna Medicaid	$1,788.03
Rate for Payer: Molina CHIP/Medicaid	$1,788.03
Rate for Payer: Multiplan Auto	$1,614.20
Rate for Payer: Multiplan Commercial	$1,614.20
Rate for Payer: Multiplan Workers Comp	$1,614.20
Rate for Payer: Parkland Medicaid	$1,788.03
Rate for Payer: Scott and White EPO/PPO	$1,241.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,788.03
Rate for Payer: Superior Health Plan EPO	$337.74

NT-proBNP SO

Facility

$499.00

Service Code	HCPCS 83880
Hospital Charge Code	8486564
Hospital Revenue Code	301
Rate for Payer: Cash Price	$339.32

NT-proBNP SO

Facility

$499.00

Service Code	HCPCS 83880
Hospital Charge Code	1605807
Hospital Revenue Code	301
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$359.28
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39.26
Rate for Payer: Amerigroup Medicare	$39.26
Rate for Payer: BCBS of TX Blue Advantage	$149.70
Rate for Payer: BCBS of TX Blue Essentials	$179.64
Rate for Payer: BCBS of TX Medicare	$39.26
Rate for Payer: BCBS of TX PPO	$199.60
Rate for Payer: Cash Price	$339.32
Rate for Payer: Cash Price	$339.32
Rate for Payer: Cigna Medicaid	$359.28
Rate for Payer: Cigna Medicare	$39.26
Rate for Payer: Employer Direct Commercial	$39.26
Rate for Payer: Humana Medicare/TRICARE	$39.26
Rate for Payer: Molina CHIP/Medicaid	$359.28
Rate for Payer: Molina Dual Medicare/Medicaid	$39.26
Rate for Payer: Molina Medicare	$39.26
Rate for Payer: Multiplan Auto	$324.35
Rate for Payer: Multiplan Commercial	$324.35
Rate for Payer: Multiplan Workers Comp	$324.35
Rate for Payer: Parkland Medicaid	$359.28
Rate for Payer: Scott and White EPO/PPO	$49.08
Rate for Payer: Scott and White Medicare	$39.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$359.28
Rate for Payer: Superior Health Plan EPO	$39.26
Rate for Payer: Superior Health Plan Medicare	$39.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$39.26
Rate for Payer: Universal American Medicare	$39.26
Rate for Payer: Wellcare Medicare	$39.26
Rate for Payer: Wellmed Medicare	$39.26

NT-proBNP SO

Facility

$499.00

Service Code	HCPCS 83880
Hospital Charge Code	1605807
Hospital Revenue Code	301
Rate for Payer: Cash Price	$339.32

NT-proBNP SO

Facility

$499.00

Service Code	HCPCS 83880
Hospital Charge Code	8486564
Hospital Revenue Code	301
Min. Negotiated Rate	$15.31
Max. Negotiated Rate	$359.28
Rate for Payer: Amerigroup CHIP/Medicaid	$15.31
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$39.26
Rate for Payer: Amerigroup Medicare	$39.26
Rate for Payer: BCBS of TX Blue Advantage	$149.70
Rate for Payer: BCBS of TX Blue Essentials	$179.64
Rate for Payer: BCBS of TX Medicare	$39.26
Rate for Payer: BCBS of TX PPO	$199.60
Rate for Payer: Cash Price	$339.32
Rate for Payer: Cash Price	$339.32
Rate for Payer: Cigna Medicaid	$359.28
Rate for Payer: Cigna Medicare	$39.26
Rate for Payer: Employer Direct Commercial	$39.26
Rate for Payer: Humana Medicare/TRICARE	$39.26
Rate for Payer: Molina CHIP/Medicaid	$359.28
Rate for Payer: Molina Dual Medicare/Medicaid	$39.26
Rate for Payer: Molina Medicare	$39.26
Rate for Payer: Multiplan Auto	$324.35
Rate for Payer: Multiplan Commercial	$324.35
Rate for Payer: Multiplan Workers Comp	$324.35
Rate for Payer: Parkland Medicaid	$359.28
Rate for Payer: Scott and White EPO/PPO	$49.08
Rate for Payer: Scott and White Medicare	$39.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$359.28
Rate for Payer: Superior Health Plan EPO	$39.26
Rate for Payer: Superior Health Plan Medicare	$39.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$39.26
Rate for Payer: Universal American Medicare	$39.26
Rate for Payer: Wellcare Medicare	$39.26
Rate for Payer: Wellmed Medicare	$39.26

NTRAPX C FFR W/3D FUNCJL MAP

Facility

$11,321.53

Service Code	HCPCS 0523T
Hospital Charge Code	8850574
Hospital Revenue Code	481
Rate for Payer: Cash Price	$7,698.64

NTRAPX C FFR W/3D FUNCJL MAP

Facility

$11,321.53

Service Code	HCPCS 0523T
Hospital Charge Code	8850574
Hospital Revenue Code	481
Min. Negotiated Rate	$1,018.94
Max. Negotiated Rate	$8,151.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1,018.94
Rate for Payer: BCBS of TX Blue Advantage	$3,396.46
Rate for Payer: BCBS of TX Blue Essentials	$4,075.75
Rate for Payer: BCBS of TX PPO	$4,528.61
Rate for Payer: Cash Price	$7,698.64
Rate for Payer: Cigna Medicaid	$8,151.50
Rate for Payer: Molina CHIP/Medicaid	$8,151.50
Rate for Payer: Multiplan Auto	$7,358.99
Rate for Payer: Multiplan Commercial	$7,358.99
Rate for Payer: Multiplan Workers Comp	$7,358.99
Rate for Payer: Parkland Medicaid	$8,151.50
Rate for Payer: Scott and White EPO/PPO	$5,660.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,151.50
Rate for Payer: Superior Health Plan EPO	$1,539.73

NUT FOR RING / ROD

Facility

$122.58

Hospital Charge Code	993425
Hospital Revenue Code	272
Rate for Payer: Cash Price	$83.35

Know your out-of-pocket cost for care.

All Charges