White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$5,176.16

MRA Lower Extremity w/ + w/o Cnt Left

Facility

$5,882.00

Service Code	CPT 73725 LT
Hospital Charge Code	5258914
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/ + w/o Cnt Left BCE

Facility

$5,882.00

Service Code	CPT 73725 LT
Hospital Charge Code	5258914
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/ + w/o Cnt Right

Facility

$5,882.00

Service Code	CPT 73725 RT
Hospital Charge Code	5258914
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/ + w/o Cnt Right BCE

Facility

$5,882.00

Service Code	CPT 73725 RT
Hospital Charge Code	5258914
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/ + w/o Cnt Right BCE

Facility

$5,882.00

Service Code	CPT 73725 RT
Hospital Charge Code	5258914
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,176.16

MRA Neck w/ Contrast

Facility

$6,311.00

Service Code	CPT 70548
Hospital Charge Code	3750072
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$4,102.15
Rate for Payer: Aetna Commercial	$273.94
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$256.61
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	$256.61
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	$256.61
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	$256.61
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	$256.61
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 Neck w/ Contrast BCE

Facility

$6,311.00

Service Code	CPT 70548
Hospital Charge Code	3750072
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$4,102.15
Rate for Payer: Aetna Commercial	$273.94
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$256.61
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	$256.61
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	$256.61
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	$256.61
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	$256.61
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 Neck w/ Contrast BCE

Facility

$6,311.00

Service Code	CPT 70548
Hospital Charge Code	3750072
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,553.68

MRA Neck w/o Contrast

Facility

$5,737.00

Service Code	CPT 70547
Hospital Charge Code	3750486
Hospital Revenue Code	610
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$3,729.05
Rate for Payer: Aetna Commercial	$248.41
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$224.88
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	$224.88
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	$224.88
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	$224.88
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	$224.88
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 Neck w/o Contrast BCE

Facility

$5,737.00

Service Code	CPT 70547
Hospital Charge Code	3750486
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,048.56

MRA Neck w/o Contrast BCE

Facility

$5,737.00

Service Code	CPT 70547
Hospital Charge Code	3750486
Hospital Revenue Code	610
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$3,729.05
Rate for Payer: Aetna Commercial	$248.41
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$224.88
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	$224.88
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	$224.88
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	$224.88
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	$224.88
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 Neck w/ + w/o Contrast

Facility

$6,627.00

Service Code	CPT 70549
Hospital Charge Code	3750502
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$4,307.55
Rate for Payer: Aetna Commercial	$406.02
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$360.53
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	$5,831.76
Rate for Payer: Cash Price	$5,831.76
Rate for Payer: Cash Price	$5,831.76
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$360.53
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	$360.53
Rate for Payer: Molina Dual Medicare/Medicaid	$351.71
Rate for Payer: Molina Medicare	$351.71
Rate for Payer: Multiplan Auto	$4,307.55
Rate for Payer: Multiplan Commercial	$4,307.55
Rate for Payer: Multiplan Workers Comp	$4,307.55
Rate for Payer: Parkland Medicaid	$360.53
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	$360.53
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 Neck w/ + w/o Contrast BCE

Facility

$6,627.00

Service Code	CPT 70549
Hospital Charge Code	3750502
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$4,307.55
Rate for Payer: Aetna Commercial	$406.02
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$360.53
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	$5,831.76
Rate for Payer: Cash Price	$5,831.76
Rate for Payer: Cash Price	$5,831.76
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$360.53
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	$360.53
Rate for Payer: Molina Dual Medicare/Medicaid	$351.71
Rate for Payer: Molina Medicare	$351.71
Rate for Payer: Multiplan Auto	$4,307.55
Rate for Payer: Multiplan Commercial	$4,307.55
Rate for Payer: Multiplan Workers Comp	$4,307.55
Rate for Payer: Parkland Medicaid	$360.53
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	$360.53
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 Neck w/ + w/o Contrast BCE

Facility

$6,627.00

Service Code	CPT 70549
Hospital Charge Code	3750502
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,831.76

MRA Pelvis w/ Contrast

Facility

$7,588.00

Service Code	CPT 72198
Hospital Charge Code	5258918
Hospital Revenue Code	610
Min. Negotiated Rate	$395.71
Max. Negotiated Rate	$4,932.20
Rate for Payer: Aetna Commercial	$395.71
Rate for Payer: Amerigroup CHIP/Medicaid	$682.92
Rate for Payer: BCBS of TX Blue Advantage	$509.01
Rate for Payer: BCBS of TX Blue Essentials	$610.81
Rate for Payer: BCBS of TX PPO	$681.76
Rate for Payer: Cash Price	$6,677.44
Rate for Payer: Cash Price	$6,677.44
Rate for Payer: Multiplan Auto	$4,932.20
Rate for Payer: Multiplan Commercial	$4,932.20
Rate for Payer: Multiplan Workers Comp	$4,932.20
Rate for Payer: Scott and White EPO/PPO	$3,794.00
Rate for Payer: Superior Health Plan EPO	$1,031.97

MRA Pelvis w/ Contrast BCE

Facility

$7,588.00

Service Code	CPT 72198
Hospital Charge Code	5258918
Hospital Revenue Code	610
Rate for Payer: Cash Price	$6,677.44

MRA Pelvis w/ Contrast BCE

Facility

$7,588.00

Service Code	CPT 72198
Hospital Charge Code	5258918
Hospital Revenue Code	610
Min. Negotiated Rate	$395.71
Max. Negotiated Rate	$4,932.20
Rate for Payer: Aetna Commercial	$395.71
Rate for Payer: Amerigroup CHIP/Medicaid	$682.92
Rate for Payer: BCBS of TX Blue Advantage	$509.01
Rate for Payer: BCBS of TX Blue Essentials	$610.81
Rate for Payer: BCBS of TX PPO	$681.76
Rate for Payer: Cash Price	$6,677.44
Rate for Payer: Cash Price	$6,677.44
Rate for Payer: Multiplan Auto	$4,932.20
Rate for Payer: Multiplan Commercial	$4,932.20
Rate for Payer: Multiplan Workers Comp	$4,932.20
Rate for Payer: Scott and White EPO/PPO	$3,794.00
Rate for Payer: Superior Health Plan EPO	$1,031.97

MRA Pelvis w/ + w/o Contrast

Facility

$7,588.00

Service Code	CPT 72198
Hospital Charge Code	3701042
Hospital Revenue Code	610
Min. Negotiated Rate	$395.71
Max. Negotiated Rate	$4,932.20
Rate for Payer: Aetna Commercial	$395.71
Rate for Payer: Amerigroup CHIP/Medicaid	$682.92
Rate for Payer: BCBS of TX Blue Advantage	$509.01
Rate for Payer: BCBS of TX Blue Essentials	$610.81
Rate for Payer: BCBS of TX PPO	$681.76
Rate for Payer: Cash Price	$6,677.44
Rate for Payer: Cash Price	$6,677.44
Rate for Payer: Multiplan Auto	$4,932.20
Rate for Payer: Multiplan Commercial	$4,932.20
Rate for Payer: Multiplan Workers Comp	$4,932.20
Rate for Payer: Scott and White EPO/PPO	$3,794.00
Rate for Payer: Superior Health Plan EPO	$1,031.97

MRA Pelvis w/ + w/o Contrast BCE

Facility

$7,588.00

Service Code	CPT 72198
Hospital Charge Code	3701042
Hospital Revenue Code	610
Rate for Payer: Cash Price	$6,677.44

MRA Pelvis w/ + w/o Contrast BCE

Facility

$7,588.00

Service Code	CPT 72198
Hospital Charge Code	3701042
Hospital Revenue Code	610
Min. Negotiated Rate	$395.71
Max. Negotiated Rate	$4,932.20
Rate for Payer: Aetna Commercial	$395.71
Rate for Payer: Amerigroup CHIP/Medicaid	$682.92
Rate for Payer: BCBS of TX Blue Advantage	$509.01
Rate for Payer: BCBS of TX Blue Essentials	$610.81
Rate for Payer: BCBS of TX PPO	$681.76
Rate for Payer: Cash Price	$6,677.44
Rate for Payer: Cash Price	$6,677.44
Rate for Payer: Multiplan Auto	$4,932.20
Rate for Payer: Multiplan Commercial	$4,932.20
Rate for Payer: Multiplan Workers Comp	$4,932.20
Rate for Payer: Scott and White EPO/PPO	$3,794.00
Rate for Payer: Superior Health Plan EPO	$1,031.97

MRA Upper Extremity w/ Contrast Left

Facility

$5,069.00

Service Code	CPT 73225 LT
Hospital Charge Code	5259585
Hospital Revenue Code	610
Min. Negotiated Rate	$408.96
Max. Negotiated Rate	$3,294.85
Rate for Payer: Aetna Commercial	$408.96
Rate for Payer: Amerigroup CHIP/Medicaid	$456.21
Rate for Payer: BCBS of TX Blue Advantage	$507.82
Rate for Payer: BCBS of TX Blue Essentials	$609.38
Rate for Payer: BCBS of TX PPO	$680.17
Rate for Payer: Cash Price	$4,460.72
Rate for Payer: Cash Price	$4,460.72
Rate for Payer: Multiplan Auto	$3,294.85
Rate for Payer: Multiplan Commercial	$3,294.85
Rate for Payer: Multiplan Workers Comp	$3,294.85
Rate for Payer: Scott and White EPO/PPO	$2,534.50
Rate for Payer: Superior Health Plan EPO	$689.38

MRA Upper Extremity w/ Contrast Left BCE

Facility

$5,069.00

Service Code	CPT 73225 LT
Hospital Charge Code	5259585
Hospital Revenue Code	610
Min. Negotiated Rate	$408.96
Max. Negotiated Rate	$3,294.85
Rate for Payer: Aetna Commercial	$408.96
Rate for Payer: Amerigroup CHIP/Medicaid	$456.21
Rate for Payer: BCBS of TX Blue Advantage	$507.82
Rate for Payer: BCBS of TX Blue Essentials	$609.38
Rate for Payer: BCBS of TX PPO	$680.17
Rate for Payer: Cash Price	$4,460.72
Rate for Payer: Cash Price	$4,460.72
Rate for Payer: Multiplan Auto	$3,294.85
Rate for Payer: Multiplan Commercial	$3,294.85
Rate for Payer: Multiplan Workers Comp	$3,294.85
Rate for Payer: Scott and White EPO/PPO	$2,534.50
Rate for Payer: Superior Health Plan EPO	$689.38

MRA Upper Extremity w/ Contrast Right

Facility

$5,069.00

Service Code	CPT 73225 RT
Hospital Charge Code	5259585
Hospital Revenue Code	610
Min. Negotiated Rate	$408.96
Max. Negotiated Rate	$3,294.85
Rate for Payer: Aetna Commercial	$408.96
Rate for Payer: Amerigroup CHIP/Medicaid	$456.21
Rate for Payer: BCBS of TX Blue Advantage	$507.82
Rate for Payer: BCBS of TX Blue Essentials	$609.38
Rate for Payer: BCBS of TX PPO	$680.17
Rate for Payer: Cash Price	$4,460.72
Rate for Payer: Cash Price	$4,460.72
Rate for Payer: Multiplan Auto	$3,294.85
Rate for Payer: Multiplan Commercial	$3,294.85
Rate for Payer: Multiplan Workers Comp	$3,294.85
Rate for Payer: Scott and White EPO/PPO	$2,534.50
Rate for Payer: Superior Health Plan EPO	$689.38

MRA Upper Extremity w/ Contrast Right BCE

Facility

$5,069.00

Service Code	CPT 73225 RT
Hospital Charge Code	5259585
Hospital Revenue Code	610
Min. Negotiated Rate	$408.96
Max. Negotiated Rate	$3,294.85
Rate for Payer: Aetna Commercial	$408.96
Rate for Payer: Amerigroup CHIP/Medicaid	$456.21
Rate for Payer: BCBS of TX Blue Advantage	$507.82
Rate for Payer: BCBS of TX Blue Essentials	$609.38
Rate for Payer: BCBS of TX PPO	$680.17
Rate for Payer: Cash Price	$4,460.72
Rate for Payer: Cash Price	$4,460.72
Rate for Payer: Multiplan Auto	$3,294.85
Rate for Payer: Multiplan Commercial	$3,294.85
Rate for Payer: Multiplan Workers Comp	$3,294.85
Rate for Payer: Scott and White EPO/PPO	$2,534.50
Rate for Payer: Superior Health Plan EPO	$689.38

Know your out-of-pocket cost for care.

All Charges