White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MRA Abdomen w/o Contrast BCE

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	3700853
Hospital Revenue Code	610
Rate for Payer: Cash Price	$7,422.80

MRA Abdomen w/ + w/o Contrast

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	3710092
Hospital Revenue Code	610
Min. Negotiated Rate	$396.69
Max. Negotiated Rate	$5,482.75
Rate for Payer: Aetna Commercial	$396.69
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Scott and White EPO/PPO	$4,217.50
Rate for Payer: Superior Health Plan EPO	$1,147.16

MRA Abdomen w/ + w/o Contrast BCE

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	3710092
Hospital Revenue Code	610
Min. Negotiated Rate	$396.69
Max. Negotiated Rate	$5,482.75
Rate for Payer: Aetna Commercial	$396.69
Rate for Payer: Amerigroup CHIP/Medicaid	$759.15
Rate for Payer: BCBS of TX Blue Advantage	$510.81
Rate for Payer: BCBS of TX Blue Essentials	$612.97
Rate for Payer: BCBS of TX PPO	$684.17
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Cash Price	$7,422.80
Rate for Payer: Multiplan Auto	$5,482.75
Rate for Payer: Multiplan Commercial	$5,482.75
Rate for Payer: Multiplan Workers Comp	$5,482.75
Rate for Payer: Scott and White EPO/PPO	$4,217.50
Rate for Payer: Superior Health Plan EPO	$1,147.16

MRA Abdomen w/ + w/o Contrast BCE

Facility

$8,435.00

Service Code	CPT 74185
Hospital Charge Code	3710092
Hospital Revenue Code	610
Rate for Payer: Cash Price	$7,422.80

MRA Brain/Head w/ Contrast

Facility

$6,311.00

Service Code	CPT 70545
Hospital Charge Code	3750049
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$4,102.15
Rate for Payer: Aetna Commercial	$266.09
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$237.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$351.71
Rate for Payer: Amerigroup Medicare	$351.71
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX Medicare	$351.71
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$5,553.68
Rate for Payer: Cash Price	$5,553.68
Rate for Payer: Cash Price	$5,553.68
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$237.24
Rate for Payer: Cigna Medicare	$351.71
Rate for Payer: Employer Direct Commercial	$351.71
Rate for Payer: Humana Medicare/TRICARE	$351.71
Rate for Payer: Molina CHIP/Medicaid	$237.24
Rate for Payer: Molina Dual Medicare/Medicaid	$351.71
Rate for Payer: Molina Medicare	$351.71
Rate for Payer: Multiplan Auto	$4,102.15
Rate for Payer: Multiplan Commercial	$4,102.15
Rate for Payer: Multiplan Workers Comp	$4,102.15
Rate for Payer: Parkland Medicaid	$237.24
Rate for Payer: Scott and White EPO/PPO	$6.29
Rate for Payer: Scott and White Medicare	$351.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.24
Rate for Payer: Superior Health Plan EPO	$351.71
Rate for Payer: Superior Health Plan Medicare	$351.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$351.71
Rate for Payer: Universal American Medicare	$351.71
Rate for Payer: Wellcare Medicare	$351.71
Rate for Payer: Wellmed Medicare	$351.71

MRA Brain/Head w/ Contrast BCE

Facility

$6,311.00

Service Code	CPT 70545
Hospital Charge Code	3750049
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,553.68

MRA Brain/Head w/ Contrast BCE

Facility

$6,311.00

Service Code	CPT 70545
Hospital Charge Code	3750049
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$4,102.15
Rate for Payer: Aetna Commercial	$266.09
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$237.24
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$351.71
Rate for Payer: Amerigroup Medicare	$351.71
Rate for Payer: BCBS of TX Blue Advantage	$630.05
Rate for Payer: BCBS of TX Blue Essentials	$756.06
Rate for Payer: BCBS of TX Medicare	$351.71
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$5,553.68
Rate for Payer: Cash Price	$5,553.68
Rate for Payer: Cash Price	$5,553.68
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$237.24
Rate for Payer: Cigna Medicare	$351.71
Rate for Payer: Employer Direct Commercial	$351.71
Rate for Payer: Humana Medicare/TRICARE	$351.71
Rate for Payer: Molina CHIP/Medicaid	$237.24
Rate for Payer: Molina Dual Medicare/Medicaid	$351.71
Rate for Payer: Molina Medicare	$351.71
Rate for Payer: Multiplan Auto	$4,102.15
Rate for Payer: Multiplan Commercial	$4,102.15
Rate for Payer: Multiplan Workers Comp	$4,102.15
Rate for Payer: Parkland Medicaid	$237.24
Rate for Payer: Scott and White EPO/PPO	$6.29
Rate for Payer: Scott and White Medicare	$351.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$237.24
Rate for Payer: Superior Health Plan EPO	$351.71
Rate for Payer: Superior Health Plan Medicare	$351.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$351.71
Rate for Payer: Universal American Medicare	$351.71
Rate for Payer: Wellcare Medicare	$351.71
Rate for Payer: Wellmed Medicare	$351.71

MRA Brain/Head w/o Contrast

Facility

$5,737.00

Service Code	CPT 70544
Hospital Charge Code	3750478
Hospital Revenue Code	615
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$3,729.05
Rate for Payer: Aetna Commercial	$247.43
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$224.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$224.10
Rate for Payer: Amerigroup Medicare	$224.10
Rate for Payer: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
Rate for Payer: BCBS of TX Medicare	$224.10
Rate for Payer: BCBS of TX PPO	$515.02
Rate for Payer: Cash Price	$5,048.56
Rate for Payer: Cash Price	$5,048.56
Rate for Payer: Cash Price	$5,048.56
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$224.54
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Employer Direct Commercial	$224.10
Rate for Payer: Humana Medicare/TRICARE	$224.10
Rate for Payer: Molina CHIP/Medicaid	$224.54
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$3,729.05
Rate for Payer: Multiplan Commercial	$3,729.05
Rate for Payer: Multiplan Workers Comp	$3,729.05
Rate for Payer: Parkland Medicaid	$224.54
Rate for Payer: Scott and White EPO/PPO	$4.01
Rate for Payer: Scott and White Medicare	$224.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$224.54
Rate for Payer: Superior Health Plan EPO	$224.10
Rate for Payer: Superior Health Plan Medicare	$224.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$224.10
Rate for Payer: Universal American Medicare	$224.10
Rate for Payer: Wellcare Medicare	$224.10
Rate for Payer: Wellmed Medicare	$224.10

MRA Brain/Head w/o Contrast BCE

Facility

$5,737.00

Service Code	CPT 70544
Hospital Charge Code	3750478
Hospital Revenue Code	615
Rate for Payer: Cash Price	$5,048.56

MRA Brain/Head w/o Contrast BCE

Facility

$5,737.00

Service Code	CPT 70544
Hospital Charge Code	3750478
Hospital Revenue Code	615
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$3,729.05
Rate for Payer: Aetna Commercial	$247.43
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$224.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$224.10
Rate for Payer: Amerigroup Medicare	$224.10
Rate for Payer: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
Rate for Payer: BCBS of TX Medicare	$224.10
Rate for Payer: BCBS of TX PPO	$515.02
Rate for Payer: Cash Price	$5,048.56
Rate for Payer: Cash Price	$5,048.56
Rate for Payer: Cash Price	$5,048.56
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$224.54
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Employer Direct Commercial	$224.10
Rate for Payer: Humana Medicare/TRICARE	$224.10
Rate for Payer: Molina CHIP/Medicaid	$224.54
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$3,729.05
Rate for Payer: Multiplan Commercial	$3,729.05
Rate for Payer: Multiplan Workers Comp	$3,729.05
Rate for Payer: Parkland Medicaid	$224.54
Rate for Payer: Scott and White EPO/PPO	$4.01
Rate for Payer: Scott and White Medicare	$224.10
Rate for Payer: Superior Health Plan CHIP/Medicaid	$224.54
Rate for Payer: Superior Health Plan EPO	$224.10
Rate for Payer: Superior Health Plan Medicare	$224.10
Rate for Payer: Universal American Dual Medicare/Medicaid	$224.10
Rate for Payer: Universal American Medicare	$224.10
Rate for Payer: Wellcare Medicare	$224.10
Rate for Payer: Wellmed Medicare	$224.10

MRA Chest w/ Contrast

Facility

$7,091.00

Service Code	CPT 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Min. Negotiated Rate	$392.26
Max. Negotiated Rate	$4,609.15
Rate for Payer: Aetna Commercial	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$638.19
Rate for Payer: BCBS of TX Blue Advantage	$504.85
Rate for Payer: BCBS of TX Blue Essentials	$605.82
Rate for Payer: BCBS of TX PPO	$676.19
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Multiplan Auto	$4,609.15
Rate for Payer: Multiplan Commercial	$4,609.15
Rate for Payer: Multiplan Workers Comp	$4,609.15
Rate for Payer: Scott and White EPO/PPO	$3,545.50
Rate for Payer: Superior Health Plan EPO	$964.38

MRA Chest w/ Contrast BCE

Facility

$7,091.00

Service Code	CPT 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Min. Negotiated Rate	$392.26
Max. Negotiated Rate	$4,609.15
Rate for Payer: Aetna Commercial	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$638.19
Rate for Payer: BCBS of TX Blue Advantage	$504.85
Rate for Payer: BCBS of TX Blue Essentials	$605.82
Rate for Payer: BCBS of TX PPO	$676.19
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Multiplan Auto	$4,609.15
Rate for Payer: Multiplan Commercial	$4,609.15
Rate for Payer: Multiplan Workers Comp	$4,609.15
Rate for Payer: Scott and White EPO/PPO	$3,545.50
Rate for Payer: Superior Health Plan EPO	$964.38

MRA Chest w/o Contrast

Facility

$7,091.00

Service Code	CPT 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Min. Negotiated Rate	$392.26
Max. Negotiated Rate	$4,609.15
Rate for Payer: Aetna Commercial	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$638.19
Rate for Payer: BCBS of TX Blue Advantage	$504.85
Rate for Payer: BCBS of TX Blue Essentials	$605.82
Rate for Payer: BCBS of TX PPO	$676.19
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Multiplan Auto	$4,609.15
Rate for Payer: Multiplan Commercial	$4,609.15
Rate for Payer: Multiplan Workers Comp	$4,609.15
Rate for Payer: Scott and White EPO/PPO	$3,545.50
Rate for Payer: Superior Health Plan EPO	$964.38

MRA Chest w/o Contrast BCE

Facility

$7,091.00

Service Code	CPT 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Rate for Payer: Cash Price	$6,240.08

MRA Chest w/o Contrast BCE

Facility

$7,091.00

Service Code	CPT 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Min. Negotiated Rate	$392.26
Max. Negotiated Rate	$4,609.15
Rate for Payer: Aetna Commercial	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$638.19
Rate for Payer: BCBS of TX Blue Advantage	$504.85
Rate for Payer: BCBS of TX Blue Essentials	$605.82
Rate for Payer: BCBS of TX PPO	$676.19
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Multiplan Auto	$4,609.15
Rate for Payer: Multiplan Commercial	$4,609.15
Rate for Payer: Multiplan Workers Comp	$4,609.15
Rate for Payer: Scott and White EPO/PPO	$3,545.50
Rate for Payer: Superior Health Plan EPO	$964.38

MRA Chest w/ + w/o Contrast

Facility

$7,091.00

Service Code	CPT 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Min. Negotiated Rate	$392.26
Max. Negotiated Rate	$4,609.15
Rate for Payer: Aetna Commercial	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$638.19
Rate for Payer: BCBS of TX Blue Advantage	$504.85
Rate for Payer: BCBS of TX Blue Essentials	$605.82
Rate for Payer: BCBS of TX PPO	$676.19
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Multiplan Auto	$4,609.15
Rate for Payer: Multiplan Commercial	$4,609.15
Rate for Payer: Multiplan Workers Comp	$4,609.15
Rate for Payer: Scott and White EPO/PPO	$3,545.50
Rate for Payer: Superior Health Plan EPO	$964.38

MRA Chest w/ + w/o Contrast BCE

Facility

$7,091.00

Service Code	CPT 71555
Hospital Charge Code	3740090
Hospital Revenue Code	610
Min. Negotiated Rate	$392.26
Max. Negotiated Rate	$4,609.15
Rate for Payer: Aetna Commercial	$392.26
Rate for Payer: Amerigroup CHIP/Medicaid	$638.19
Rate for Payer: BCBS of TX Blue Advantage	$504.85
Rate for Payer: BCBS of TX Blue Essentials	$605.82
Rate for Payer: BCBS of TX PPO	$676.19
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Cash Price	$6,240.08
Rate for Payer: Multiplan Auto	$4,609.15
Rate for Payer: Multiplan Commercial	$4,609.15
Rate for Payer: Multiplan Workers Comp	$4,609.15
Rate for Payer: Scott and White EPO/PPO	$3,545.50
Rate for Payer: Superior Health Plan EPO	$964.38

MRA Lower Extremity w/ Contrast Left

Facility

$5,882.00

Service Code	CPT 73725 LT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$393.24
Max. Negotiated Rate	$3,823.30
Rate for Payer: Aetna Commercial	$393.24
Rate for Payer: Amerigroup CHIP/Medicaid	$529.38
Rate for Payer: BCBS of TX Blue Advantage	$508.41
Rate for Payer: BCBS of TX Blue Essentials	$610.10
Rate for Payer: BCBS of TX PPO	$680.97
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Multiplan Auto	$3,823.30
Rate for Payer: Multiplan Commercial	$3,823.30
Rate for Payer: Multiplan Workers Comp	$3,823.30
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/ Contrast Left BCE

Facility

$5,882.00

Service Code	CPT 73725 LT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$393.24
Max. Negotiated Rate	$3,823.30
Rate for Payer: Aetna Commercial	$393.24
Rate for Payer: Amerigroup CHIP/Medicaid	$529.38
Rate for Payer: BCBS of TX Blue Advantage	$508.41
Rate for Payer: BCBS of TX Blue Essentials	$610.10
Rate for Payer: BCBS of TX PPO	$680.97
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Multiplan Auto	$3,823.30
Rate for Payer: Multiplan Commercial	$3,823.30
Rate for Payer: Multiplan Workers Comp	$3,823.30
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/ Contrast Right

Facility

$5,882.00

Service Code	CPT 73725 RT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$393.24
Max. Negotiated Rate	$3,823.30
Rate for Payer: Aetna Commercial	$393.24
Rate for Payer: Amerigroup CHIP/Medicaid	$529.38
Rate for Payer: BCBS of TX Blue Advantage	$508.41
Rate for Payer: BCBS of TX Blue Essentials	$610.10
Rate for Payer: BCBS of TX PPO	$680.97
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Multiplan Auto	$3,823.30
Rate for Payer: Multiplan Commercial	$3,823.30
Rate for Payer: Multiplan Workers Comp	$3,823.30
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/ Contrast Right BCE

Facility

$5,882.00

Service Code	CPT 73725 RT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$393.24
Max. Negotiated Rate	$3,823.30
Rate for Payer: Aetna Commercial	$393.24
Rate for Payer: Amerigroup CHIP/Medicaid	$529.38
Rate for Payer: BCBS of TX Blue Advantage	$508.41
Rate for Payer: BCBS of TX Blue Essentials	$610.10
Rate for Payer: BCBS of TX PPO	$680.97
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Multiplan Auto	$3,823.30
Rate for Payer: Multiplan Commercial	$3,823.30
Rate for Payer: Multiplan Workers Comp	$3,823.30
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/o Contrast Left

Facility

$5,882.00

Service Code	CPT 73725 LT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$393.24
Max. Negotiated Rate	$3,823.30
Rate for Payer: Aetna Commercial	$393.24
Rate for Payer: Amerigroup CHIP/Medicaid	$529.38
Rate for Payer: BCBS of TX Blue Advantage	$508.41
Rate for Payer: BCBS of TX Blue Essentials	$610.10
Rate for Payer: BCBS of TX PPO	$680.97
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Multiplan Auto	$3,823.30
Rate for Payer: Multiplan Commercial	$3,823.30
Rate for Payer: Multiplan Workers Comp	$3,823.30
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/o Contrast Left BCE

Facility

$5,882.00

Service Code	CPT 73725 LT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$393.24
Max. Negotiated Rate	$3,823.30
Rate for Payer: Aetna Commercial	$393.24
Rate for Payer: Amerigroup CHIP/Medicaid	$529.38
Rate for Payer: BCBS of TX Blue Advantage	$508.41
Rate for Payer: BCBS of TX Blue Essentials	$610.10
Rate for Payer: BCBS of TX PPO	$680.97
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Multiplan Auto	$3,823.30
Rate for Payer: Multiplan Commercial	$3,823.30
Rate for Payer: Multiplan Workers Comp	$3,823.30
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/o Contrast Right

Facility

$5,882.00

Service Code	CPT 73725 RT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$393.24
Max. Negotiated Rate	$3,823.30
Rate for Payer: Aetna Commercial	$393.24
Rate for Payer: Amerigroup CHIP/Medicaid	$529.38
Rate for Payer: BCBS of TX Blue Advantage	$508.41
Rate for Payer: BCBS of TX Blue Essentials	$610.10
Rate for Payer: BCBS of TX PPO	$680.97
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Multiplan Auto	$3,823.30
Rate for Payer: Multiplan Commercial	$3,823.30
Rate for Payer: Multiplan Workers Comp	$3,823.30
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/o Contrast Right BCE

Facility

$5,882.00

Service Code	CPT 73725 RT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$393.24
Max. Negotiated Rate	$3,823.30
Rate for Payer: Aetna Commercial	$393.24
Rate for Payer: Amerigroup CHIP/Medicaid	$529.38
Rate for Payer: BCBS of TX Blue Advantage	$508.41
Rate for Payer: BCBS of TX Blue Essentials	$610.10
Rate for Payer: BCBS of TX PPO	$680.97
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Cash Price	$5,176.16
Rate for Payer: Multiplan Auto	$3,823.30
Rate for Payer: Multiplan Commercial	$3,823.30
Rate for Payer: Multiplan Workers Comp	$3,823.30
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan EPO	$799.95

Know your out-of-pocket cost for care.

All Charges