White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MRA Upper Extremity w/o 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/o 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/o 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/o 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

MRA Upper Extremity w/o Contrast Right BCE

Facility

$5,069.00

Service Code	CPT 73225 RT
Hospital Charge Code	5259585
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,460.72

MRA Upper Extremity w/ + w/o Cnt 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/ + w/o Cnt 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/ + w/o Cnt 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/ + w/o Cnt 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

MRI Abdomen w/o Contrast

Facility

$6,566.00

Service Code	CPT 74181
Hospital Charge Code	3700010
Hospital Revenue Code	610
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$4,267.90
Rate for Payer: Aetna Commercial	$200.53
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$204.83
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	$5,778.08
Rate for Payer: Cash Price	$5,778.08
Rate for Payer: Cash Price	$5,778.08
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$204.83
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	$204.83
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$4,267.90
Rate for Payer: Multiplan Commercial	$4,267.90
Rate for Payer: Multiplan Workers Comp	$4,267.90
Rate for Payer: Parkland Medicaid	$204.83
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	$204.83
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

MRI Abdomen w/o Contrast BCE

Facility

$6,566.00

Service Code	CPT 74181
Hospital Charge Code	3700010
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,778.08

MRI Abdomen w/o Contrast BCE

Facility

$6,566.00

Service Code	CPT 74181
Hospital Charge Code	3700010
Hospital Revenue Code	610
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$4,267.90
Rate for Payer: Aetna Commercial	$200.53
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$204.83
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	$5,778.08
Rate for Payer: Cash Price	$5,778.08
Rate for Payer: Cash Price	$5,778.08
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$204.83
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	$204.83
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$4,267.90
Rate for Payer: Multiplan Commercial	$4,267.90
Rate for Payer: Multiplan Workers Comp	$4,267.90
Rate for Payer: Parkland Medicaid	$204.83
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	$204.83
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

MRI Abdomen w/ + w/o Contrast

Facility

$7,151.00

Service Code	CPT 74183
Hospital Charge Code	3750882
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$4,648.15
Rate for Payer: Aetna Commercial	$373.12
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$354.51
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	$6,292.88
Rate for Payer: Cash Price	$6,292.88
Rate for Payer: Cash Price	$6,292.88
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$354.51
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	$354.51
Rate for Payer: Molina Dual Medicare/Medicaid	$351.71
Rate for Payer: Molina Medicare	$351.71
Rate for Payer: Multiplan Auto	$4,648.15
Rate for Payer: Multiplan Commercial	$4,648.15
Rate for Payer: Multiplan Workers Comp	$4,648.15
Rate for Payer: Parkland Medicaid	$354.51
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	$354.51
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

MRI Abdomen w/ + w/o Contrast BCE

Facility

$7,151.00

Service Code	CPT 74183
Hospital Charge Code	3750882
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$4,648.15
Rate for Payer: Aetna Commercial	$373.12
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$354.51
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	$6,292.88
Rate for Payer: Cash Price	$6,292.88
Rate for Payer: Cash Price	$6,292.88
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$354.51
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	$354.51
Rate for Payer: Molina Dual Medicare/Medicaid	$351.71
Rate for Payer: Molina Medicare	$351.71
Rate for Payer: Multiplan Auto	$4,648.15
Rate for Payer: Multiplan Commercial	$4,648.15
Rate for Payer: Multiplan Workers Comp	$4,648.15
Rate for Payer: Parkland Medicaid	$354.51
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	$354.51
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

MRI Abdomen w/ + w/o Contrast BCE

Facility

$7,151.00

Service Code	CPT 74183
Hospital Charge Code	3750882
Hospital Revenue Code	610
Rate for Payer: Cash Price	$6,292.88

MRI Ankle w/ Contrast Left

Facility

$4,425.00

Service Code	CPT 73722 LT
Hospital Charge Code	3750783
Hospital Revenue Code	610
Min. Negotiated Rate	$13.10
Max. Negotiated Rate	$2,876.25
Rate for Payer: Aetna Commercial	$376.53
Rate for Payer: Aetna Medicare	$1,098.39
Rate for Payer: Amerigroup CHIP/Medicaid	$328.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$732.26
Rate for Payer: Amerigroup Medicare	$732.26
Rate for Payer: BCBS of TX Blue Advantage	$1,123.35
Rate for Payer: BCBS of TX Blue Essentials	$1,348.02
Rate for Payer: BCBS of TX Medicare	$732.26
Rate for Payer: BCBS of TX PPO	$1,504.61
Rate for Payer: Cash Price	$3,894.00
Rate for Payer: Cash Price	$3,894.00
Rate for Payer: Cash Price	$3,894.00
Rate for Payer: Cigna Commercial	$1,658.78
Rate for Payer: Cigna Medicaid	$328.79
Rate for Payer: Cigna Medicare	$732.26
Rate for Payer: Employer Direct Commercial	$732.26
Rate for Payer: Humana Medicare/TRICARE	$732.26
Rate for Payer: Molina CHIP/Medicaid	$328.79
Rate for Payer: Molina Dual Medicare/Medicaid	$732.26
Rate for Payer: Molina Medicare	$732.26
Rate for Payer: Multiplan Auto	$2,876.25
Rate for Payer: Multiplan Commercial	$2,876.25
Rate for Payer: Multiplan Workers Comp	$2,876.25
Rate for Payer: Parkland Medicaid	$328.79
Rate for Payer: Scott and White EPO/PPO	$13.10
Rate for Payer: Scott and White Medicare	$732.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.79
Rate for Payer: Superior Health Plan EPO	$732.26
Rate for Payer: Superior Health Plan Medicare	$732.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$732.26
Rate for Payer: Universal American Medicare	$732.26
Rate for Payer: Wellcare Medicare	$732.26
Rate for Payer: Wellmed Medicare	$732.26

MRI Ankle w/ Contrast Left

Facility

$4,425.00

Service Code	CPT 73722 LT
Hospital Charge Code	3750783
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,894.00

MRI Ankle w/ Contrast Right

Facility

$4,425.00

Service Code	CPT 73722 RT
Hospital Charge Code	3750825
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,894.00

MRI Ankle w/ Contrast Right

Facility

$4,425.00

Service Code	CPT 73722 RT
Hospital Charge Code	3750825
Hospital Revenue Code	610
Min. Negotiated Rate	$13.10
Max. Negotiated Rate	$2,876.25
Rate for Payer: Aetna Commercial	$376.53
Rate for Payer: Aetna Medicare	$1,098.39
Rate for Payer: Amerigroup CHIP/Medicaid	$328.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$732.26
Rate for Payer: Amerigroup Medicare	$732.26
Rate for Payer: BCBS of TX Blue Advantage	$1,123.35
Rate for Payer: BCBS of TX Blue Essentials	$1,348.02
Rate for Payer: BCBS of TX Medicare	$732.26
Rate for Payer: BCBS of TX PPO	$1,504.61
Rate for Payer: Cash Price	$3,894.00
Rate for Payer: Cash Price	$3,894.00
Rate for Payer: Cash Price	$3,894.00
Rate for Payer: Cigna Commercial	$1,658.78
Rate for Payer: Cigna Medicaid	$328.79
Rate for Payer: Cigna Medicare	$732.26
Rate for Payer: Employer Direct Commercial	$732.26
Rate for Payer: Humana Medicare/TRICARE	$732.26
Rate for Payer: Molina CHIP/Medicaid	$328.79
Rate for Payer: Molina Dual Medicare/Medicaid	$732.26
Rate for Payer: Molina Medicare	$732.26
Rate for Payer: Multiplan Auto	$2,876.25
Rate for Payer: Multiplan Commercial	$2,876.25
Rate for Payer: Multiplan Workers Comp	$2,876.25
Rate for Payer: Parkland Medicaid	$328.79
Rate for Payer: Scott and White EPO/PPO	$13.10
Rate for Payer: Scott and White Medicare	$732.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.79
Rate for Payer: Superior Health Plan EPO	$732.26
Rate for Payer: Superior Health Plan Medicare	$732.26
Rate for Payer: Universal American Dual Medicare/Medicaid	$732.26
Rate for Payer: Universal American Medicare	$732.26
Rate for Payer: Wellcare Medicare	$732.26
Rate for Payer: Wellmed Medicare	$732.26

MRI Ankle w/o Contrast Left

Facility

$3,907.00

Service Code	CPT 73721 LT
Hospital Charge Code	3700036
Hospital Revenue Code	610
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$2,539.55
Rate for Payer: Aetna Commercial	$215.53
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$210.84
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	$3,438.16
Rate for Payer: Cash Price	$3,438.16
Rate for Payer: Cash Price	$3,438.16
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$210.84
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	$210.84
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$2,539.55
Rate for Payer: Multiplan Commercial	$2,539.55
Rate for Payer: Multiplan Workers Comp	$2,539.55
Rate for Payer: Parkland Medicaid	$210.84
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	$210.84
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

MRI Ankle w/o Contrast Right

Facility

$3,907.00

Service Code	CPT 73721 RT
Hospital Charge Code	3700283
Hospital Revenue Code	610
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$2,539.55
Rate for Payer: Aetna Commercial	$215.53
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$210.84
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	$3,438.16
Rate for Payer: Cash Price	$3,438.16
Rate for Payer: Cash Price	$3,438.16
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$210.84
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	$210.84
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$2,539.55
Rate for Payer: Multiplan Commercial	$2,539.55
Rate for Payer: Multiplan Workers Comp	$2,539.55
Rate for Payer: Parkland Medicaid	$210.84
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	$210.84
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

MRI Ankle w/ + w/o Contrast Left

Facility

$5,347.00

Service Code	CPT 73723 LT
Hospital Charge Code	3750643
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$3,475.55
Rate for Payer: Aetna Commercial	$454.62
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$368.43
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	$4,705.36
Rate for Payer: Cash Price	$4,705.36
Rate for Payer: Cash Price	$4,705.36
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$368.43
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	$368.43
Rate for Payer: Molina Dual Medicare/Medicaid	$351.71
Rate for Payer: Molina Medicare	$351.71
Rate for Payer: Multiplan Auto	$3,475.55
Rate for Payer: Multiplan Commercial	$3,475.55
Rate for Payer: Multiplan Workers Comp	$3,475.55
Rate for Payer: Parkland Medicaid	$368.43
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	$368.43
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

MRI Ankle w/ + w/o Contrast Right

Facility

$5,347.00

Service Code	CPT 73723 RT
Hospital Charge Code	3750833
Hospital Revenue Code	610
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$3,475.55
Rate for Payer: Aetna Commercial	$454.62
Rate for Payer: Aetna Medicare	$527.56
Rate for Payer: Amerigroup CHIP/Medicaid	$368.43
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	$4,705.36
Rate for Payer: Cash Price	$4,705.36
Rate for Payer: Cash Price	$4,705.36
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$368.43
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	$368.43
Rate for Payer: Molina Dual Medicare/Medicaid	$351.71
Rate for Payer: Molina Medicare	$351.71
Rate for Payer: Multiplan Auto	$3,475.55
Rate for Payer: Multiplan Commercial	$3,475.55
Rate for Payer: Multiplan Workers Comp	$3,475.55
Rate for Payer: Parkland Medicaid	$368.43
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	$368.43
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

MRI Brain Stroke Protocol w/o Contrast

Facility

$5,026.00

Service Code	CPT 70551
Hospital Charge Code	5250802
Hospital Revenue Code	611
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$3,266.90
Rate for Payer: Aetna Commercial	$197.86
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$204.15
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	$4,422.88
Rate for Payer: Cash Price	$4,422.88
Rate for Payer: Cash Price	$4,422.88
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$204.15
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	$204.15
Rate for Payer: Molina Dual Medicare/Medicaid	$224.10
Rate for Payer: Molina Medicare	$224.10
Rate for Payer: Multiplan Auto	$3,266.90
Rate for Payer: Multiplan Commercial	$3,266.90
Rate for Payer: Multiplan Workers Comp	$3,266.90
Rate for Payer: Parkland Medicaid	$204.15
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	$204.15
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

MRI Brain Stroke Protocol w/o Contrast

Facility

$5,026.00

Service Code	CPT 70551
Hospital Charge Code	5250802
Hospital Revenue Code	611
Rate for Payer: Cash Price	$4,422.88

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