White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MRI Hip w/ Contrast Left

Facility

$4,425.00

Service Code	CPT 73722 LT
Hospital Charge Code	3740044
Hospital Revenue Code	610
Min. Negotiated Rate	$328.79
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: 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 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: Molina CHIP/Medicaid	$328.79
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	$2,212.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.79
Rate for Payer: Superior Health Plan EPO	$601.80

MRI Hip w/ Contrast Right

Facility

$4,425.00

Service Code	CPT 73722 RT
Hospital Charge Code	3740045
Hospital Revenue Code	610
Min. Negotiated Rate	$328.79
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: 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 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: Molina CHIP/Medicaid	$328.79
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	$2,212.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.79
Rate for Payer: Superior Health Plan EPO	$601.80

MRI Hip w/o Contrast Left

Facility

$3,907.00

Service Code	CPT 73721 LT
Hospital Charge Code	3700036
Hospital Revenue Code	610
Min. Negotiated Rate	$210.84
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: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
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: Molina CHIP/Medicaid	$210.84
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	$1,953.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$210.84
Rate for Payer: Superior Health Plan EPO	$531.35

MRI Hip w/o Contrast Right

Facility

$3,907.00

Service Code	CPT 73721 RT
Hospital Charge Code	3700283
Hospital Revenue Code	610
Min. Negotiated Rate	$210.84
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: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
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: Molina CHIP/Medicaid	$210.84
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	$1,953.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$210.84
Rate for Payer: Superior Health Plan EPO	$531.35

MRI Hip 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	$368.43
Max. Negotiated Rate	$3,475.55
Rate for Payer: Aetna Commercial	$454.62
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$368.43
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 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: Molina CHIP/Medicaid	$368.43
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	$2,673.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$727.19

MRI Hip 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	$368.43
Max. Negotiated Rate	$3,475.55
Rate for Payer: Aetna Commercial	$454.62
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$368.43
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 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: Molina CHIP/Medicaid	$368.43
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	$2,673.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$727.19

MRI Humerus w/o Contrast Left

Facility

$3,635.00

Service Code	CPT 73718 LT
Hospital Charge Code	3750601
Hospital Revenue Code	610
Min. Negotiated Rate	$233.52
Max. Negotiated Rate	$2,362.75
Rate for Payer: Aetna Commercial	$252.33
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$233.52
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 PPO	$515.02
Rate for Payer: Cash Price	$3,198.80
Rate for Payer: Cash Price	$3,198.80
Rate for Payer: Cash Price	$3,198.80
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$233.52
Rate for Payer: Molina CHIP/Medicaid	$233.52
Rate for Payer: Multiplan Auto	$2,362.75
Rate for Payer: Multiplan Commercial	$2,362.75
Rate for Payer: Multiplan Workers Comp	$2,362.75
Rate for Payer: Parkland Medicaid	$233.52
Rate for Payer: Scott and White EPO/PPO	$1,817.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$233.52
Rate for Payer: Superior Health Plan EPO	$494.36

MRI Humerus w/o Contrast Right

Facility

$3,635.00

Service Code	CPT 73718 RT
Hospital Charge Code	3750619
Hospital Revenue Code	610
Min. Negotiated Rate	$233.52
Max. Negotiated Rate	$2,362.75
Rate for Payer: Aetna Commercial	$252.33
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$233.52
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 PPO	$515.02
Rate for Payer: Cash Price	$3,198.80
Rate for Payer: Cash Price	$3,198.80
Rate for Payer: Cash Price	$3,198.80
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$233.52
Rate for Payer: Molina CHIP/Medicaid	$233.52
Rate for Payer: Multiplan Auto	$2,362.75
Rate for Payer: Multiplan Commercial	$2,362.75
Rate for Payer: Multiplan Workers Comp	$2,362.75
Rate for Payer: Parkland Medicaid	$233.52
Rate for Payer: Scott and White EPO/PPO	$1,817.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$233.52
Rate for Payer: Superior Health Plan EPO	$494.36

MRI Humerus w/ + w/o Contrast Left

Facility

$4,568.00

Service Code	CPT 73720 LT
Hospital Charge Code	3700028
Hospital Revenue Code	610
Min. Negotiated Rate	$353.51
Max. Negotiated Rate	$2,969.20
Rate for Payer: Aetna Commercial	$375.10
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$353.51
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 PPO	$843.89
Rate for Payer: Cash Price	$4,019.84
Rate for Payer: Cash Price	$4,019.84
Rate for Payer: Cash Price	$4,019.84
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$353.51
Rate for Payer: Molina CHIP/Medicaid	$353.51
Rate for Payer: Multiplan Auto	$2,969.20
Rate for Payer: Multiplan Commercial	$2,969.20
Rate for Payer: Multiplan Workers Comp	$2,969.20
Rate for Payer: Parkland Medicaid	$353.51
Rate for Payer: Scott and White EPO/PPO	$2,284.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$353.51
Rate for Payer: Superior Health Plan EPO	$621.25

MRI Humerus w/ + w/o Contrast Right

Facility

$4,568.00

Service Code	CPT 73720 RT
Hospital Charge Code	3700275
Hospital Revenue Code	610
Min. Negotiated Rate	$353.51
Max. Negotiated Rate	$2,969.20
Rate for Payer: Aetna Commercial	$375.10
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$353.51
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 PPO	$843.89
Rate for Payer: Cash Price	$4,019.84
Rate for Payer: Cash Price	$4,019.84
Rate for Payer: Cash Price	$4,019.84
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$353.51
Rate for Payer: Molina CHIP/Medicaid	$353.51
Rate for Payer: Multiplan Auto	$2,969.20
Rate for Payer: Multiplan Commercial	$2,969.20
Rate for Payer: Multiplan Workers Comp	$2,969.20
Rate for Payer: Parkland Medicaid	$353.51
Rate for Payer: Scott and White EPO/PPO	$2,284.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$353.51
Rate for Payer: Superior Health Plan EPO	$621.25

MRI Knee w/ Contrast Left

Facility

$4,425.00

Service Code	CPT 73722 LT
Hospital Charge Code	3740044
Hospital Revenue Code	610
Min. Negotiated Rate	$328.79
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: 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 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: Molina CHIP/Medicaid	$328.79
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	$2,212.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.79
Rate for Payer: Superior Health Plan EPO	$601.80

MRI Knee w/ Contrast Right

Facility

$4,425.00

Service Code	CPT 73722 RT
Hospital Charge Code	3740045
Hospital Revenue Code	610
Min. Negotiated Rate	$328.79
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: 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 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: Molina CHIP/Medicaid	$328.79
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	$2,212.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.79
Rate for Payer: Superior Health Plan EPO	$601.80

MRI Knee w/o Contrast Left

Facility

$3,907.00

Service Code	CPT 73721 LT
Hospital Charge Code	3700036
Hospital Revenue Code	610
Min. Negotiated Rate	$210.84
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: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
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: Molina CHIP/Medicaid	$210.84
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	$1,953.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$210.84
Rate for Payer: Superior Health Plan EPO	$531.35

MRI Knee w/o Contrast Right

Facility

$3,907.00

Service Code	CPT 73721 RT
Hospital Charge Code	3700283
Hospital Revenue Code	610
Min. Negotiated Rate	$210.84
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: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
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: Molina CHIP/Medicaid	$210.84
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	$1,953.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$210.84
Rate for Payer: Superior Health Plan EPO	$531.35

MRI Knee 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	$368.43
Max. Negotiated Rate	$3,475.55
Rate for Payer: Aetna Commercial	$454.62
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$368.43
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 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: Molina CHIP/Medicaid	$368.43
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	$2,673.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$727.19

MRI Knee 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	$368.43
Max. Negotiated Rate	$3,475.55
Rate for Payer: Aetna Commercial	$454.62
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$368.43
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 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: Molina CHIP/Medicaid	$368.43
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	$2,673.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$727.19

MRI Lower Extremity Joint w/ contrast Left BCE

Facility

$4,425.00

Service Code	CPT 73722 LT
Hospital Charge Code	3740044
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,894.00

MRI Lower Extremity Joint w/ contrast Left BCE

Facility

$4,425.00

Service Code	CPT 73722 LT
Hospital Charge Code	3740044
Hospital Revenue Code	610
Min. Negotiated Rate	$328.79
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: 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 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: Molina CHIP/Medicaid	$328.79
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	$2,212.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.79
Rate for Payer: Superior Health Plan EPO	$601.80

MRI Lower Extremity Joint w/ contrast Right BCE

Facility

$4,425.00

Service Code	CPT 73722 RT
Hospital Charge Code	3740045
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,894.00

MRI Lower Extremity Joint w/ contrast Right BCE

Facility

$4,425.00

Service Code	CPT 73722 RT
Hospital Charge Code	3740045
Hospital Revenue Code	610
Min. Negotiated Rate	$328.79
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: 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 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: Molina CHIP/Medicaid	$328.79
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	$2,212.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.79
Rate for Payer: Superior Health Plan EPO	$601.80

MRI Lower Extremity Joint w/o Contrast Left BCE

Facility

$3,907.00

Service Code	CPT 73721 LT
Hospital Charge Code	3700036
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,438.16

MRI Lower Extremity Joint w/o Contrast Left BCE

Facility

$3,907.00

Service Code	CPT 73721 LT
Hospital Charge Code	3700036
Hospital Revenue Code	610
Min. Negotiated Rate	$210.84
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: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
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: Molina CHIP/Medicaid	$210.84
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	$1,953.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$210.84
Rate for Payer: Superior Health Plan EPO	$531.35

MRI Lower Extremity Joint w/o Contrast Right BCE

Facility

$3,907.00

Service Code	CPT 73721 RT
Hospital Charge Code	3700283
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,438.16

MRI Lower Extremity Joint w/o Contrast Right BCE

Facility

$3,907.00

Service Code	CPT 73721 RT
Hospital Charge Code	3700283
Hospital Revenue Code	610
Min. Negotiated Rate	$210.84
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: BCBS of TX Blue Advantage	$384.52
Rate for Payer: BCBS of TX Blue Essentials	$461.42
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: Molina CHIP/Medicaid	$210.84
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	$1,953.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$210.84
Rate for Payer: Superior Health Plan EPO	$531.35

MRI Lower Extremity Joint w + w/o Conttast Left BCE

Facility

$5,347.00

Service Code	CPT 73723 LT
Hospital Charge Code	3750643
Hospital Revenue Code	610
Min. Negotiated Rate	$368.43
Max. Negotiated Rate	$3,475.55
Rate for Payer: Aetna Commercial	$454.62
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$368.43
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 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: Molina CHIP/Medicaid	$368.43
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	$2,673.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$727.19

Know your out-of-pocket cost for care.

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