White Rock Medical Center

All Charges

Charge

Type

Setting

Price

NONTRAUMATIC STUPOR & COMA W/O MCC

Facility

$17,016.40

Service Code	MSDRG 081
Min. Negotiated Rate	$7,349.56
Max. Negotiated Rate	$17,016.40
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
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 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 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

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

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	$3,796.20
Rate for Payer: Multiplan Commercial	$3,796.20
Rate for Payer: Multiplan Workers Comp	$3,796.20
Rate for Payer: Scott and White EPO/PPO	$1,748.25
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	$143.83
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	$799.06
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 QW
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

NT-proBNP SO

Facility

$499.00

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

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

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

NUT FOR RING / ROD

Facility

$122.58

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

NUT FOR RING / ROD

Facility

$122.58

Hospital Charge Code	993425
Hospital Revenue Code	272
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$88.26
Rate for Payer: Amerigroup CHIP/Medicaid	$11.03
Rate for Payer: BCBS of TX Blue Advantage	$36.77
Rate for Payer: BCBS of TX Blue Essentials	$44.13
Rate for Payer: BCBS of TX PPO	$49.03
Rate for Payer: Cash Price	$83.35
Rate for Payer: Cigna Medicaid	$88.26
Rate for Payer: Molina CHIP/Medicaid	$88.26
Rate for Payer: Multiplan Auto	$79.68
Rate for Payer: Multiplan Commercial	$79.68
Rate for Payer: Multiplan Workers Comp	$79.68
Rate for Payer: Parkland Medicaid	$88.26
Rate for Payer: Scott and White EPO/PPO	$61.29
Rate for Payer: Superior Health Plan CHIP/Medicaid	$88.26
Rate for Payer: Superior Health Plan EPO	$16.67

nystatin 100,000 units/g Cream 15 g

Facility

$29.90

Service Code	HCPCS J3490
Hospital Charge Code	77730258
Hospital Revenue Code	250
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$21.53
Rate for Payer: Amerigroup CHIP/Medicaid	$2.69
Rate for Payer: BCBS of TX Blue Advantage	$8.97
Rate for Payer: BCBS of TX Blue Essentials	$10.76
Rate for Payer: BCBS of TX PPO	$11.96
Rate for Payer: Cash Price	$20.33
Rate for Payer: Cigna Medicaid	$21.53
Rate for Payer: Molina CHIP/Medicaid	$21.53
Rate for Payer: Multiplan Auto	$19.43
Rate for Payer: Multiplan Commercial	$19.43
Rate for Payer: Multiplan Workers Comp	$19.43
Rate for Payer: Parkland Medicaid	$21.53
Rate for Payer: Scott and White EPO/PPO	$14.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.53
Rate for Payer: Superior Health Plan EPO	$4.07

nystatin 100,000 units/g Cream 15 g

Facility

$29.90

Service Code	HCPCS J3490
Hospital Charge Code	77730258
Hospital Revenue Code	250
Rate for Payer: Cash Price	$20.33

nystatin 100,000 units/g Topical Oint 15 g

Facility

$37.60

Service Code	HCPCS J3490
Hospital Charge Code	77730364
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.57

nystatin 100,000 units/g Topical Oint 15 g

Facility

$37.60

Service Code	HCPCS J3490
Hospital Charge Code	77730364
Hospital Revenue Code	250
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$27.07
Rate for Payer: Amerigroup CHIP/Medicaid	$3.38
Rate for Payer: BCBS of TX Blue Advantage	$11.28
Rate for Payer: BCBS of TX Blue Essentials	$13.54
Rate for Payer: BCBS of TX PPO	$15.04
Rate for Payer: Cash Price	$25.57
Rate for Payer: Cigna Medicaid	$27.07
Rate for Payer: Molina CHIP/Medicaid	$27.07
Rate for Payer: Multiplan Auto	$24.44
Rate for Payer: Multiplan Commercial	$24.44
Rate for Payer: Multiplan Workers Comp	$24.44
Rate for Payer: Parkland Medicaid	$27.07
Rate for Payer: Scott and White EPO/PPO	$18.80
Rate for Payer: Superior Health Plan CHIP/Medicaid	$27.07
Rate for Payer: Superior Health Plan EPO	$5.11

nystatin 100,000 units/g Topical Powder 15 g

Facility

$69.50

Service Code	HCPCS J3490
Hospital Charge Code	77730521
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$50.04
Rate for Payer: Amerigroup CHIP/Medicaid	$6.25
Rate for Payer: BCBS of TX Blue Advantage	$20.85
Rate for Payer: BCBS of TX Blue Essentials	$25.02
Rate for Payer: BCBS of TX PPO	$27.80
Rate for Payer: Cash Price	$47.26
Rate for Payer: Cigna Medicaid	$50.04
Rate for Payer: Molina CHIP/Medicaid	$50.04
Rate for Payer: Multiplan Auto	$45.17
Rate for Payer: Multiplan Commercial	$45.17
Rate for Payer: Multiplan Workers Comp	$45.17
Rate for Payer: Parkland Medicaid	$50.04
Rate for Payer: Scott and White EPO/PPO	$34.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$50.04
Rate for Payer: Superior Health Plan EPO	$9.45

Know your out-of-pocket cost for care.

All Charges