White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MRI TMJ BCE

Facility

$2,866.00

Service Code	CPT 70336
Hospital Charge Code	3701018
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,522.08

MRI Upper Extremity Joint w/ contrast Left BCE

Facility

$3,722.00

Service Code	CPT 73222 LT
Hospital Charge Code	3740071
Hospital Revenue Code	610
Min. Negotiated Rate	$328.45
Max. Negotiated Rate	$2,419.30
Rate for Payer: Aetna Commercial	$375.55
Rate for Payer: Aetna Medicare	$1,098.39
Rate for Payer: Amerigroup CHIP/Medicaid	$328.45
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	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cigna Commercial	$1,658.78
Rate for Payer: Cigna Medicaid	$328.45
Rate for Payer: Molina CHIP/Medicaid	$328.45
Rate for Payer: Multiplan Auto	$2,419.30
Rate for Payer: Multiplan Commercial	$2,419.30
Rate for Payer: Multiplan Workers Comp	$2,419.30
Rate for Payer: Parkland Medicaid	$328.45
Rate for Payer: Scott and White EPO/PPO	$1,861.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.45
Rate for Payer: Superior Health Plan EPO	$506.19

MRI Upper Extremity Joint w/ contrast Right BCE

Facility

$3,722.00

Service Code	CPT 73222 RT
Hospital Charge Code	3740072
Hospital Revenue Code	610
Min. Negotiated Rate	$328.45
Max. Negotiated Rate	$2,419.30
Rate for Payer: Aetna Commercial	$375.55
Rate for Payer: Aetna Medicare	$1,098.39
Rate for Payer: Amerigroup CHIP/Medicaid	$328.45
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	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cigna Commercial	$1,658.78
Rate for Payer: Cigna Medicaid	$328.45
Rate for Payer: Molina CHIP/Medicaid	$328.45
Rate for Payer: Multiplan Auto	$2,419.30
Rate for Payer: Multiplan Commercial	$2,419.30
Rate for Payer: Multiplan Workers Comp	$2,419.30
Rate for Payer: Parkland Medicaid	$328.45
Rate for Payer: Scott and White EPO/PPO	$1,861.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.45
Rate for Payer: Superior Health Plan EPO	$506.19

MRI Upper Extremity Joint w/o Contrast Left BCE

Facility

$3,350.00

Service Code	CPT 73221 LT
Hospital Charge Code	3700051
Hospital Revenue Code	610
Min. Negotiated Rate	$211.18
Max. Negotiated Rate	$2,177.50
Rate for Payer: Aetna Commercial	$216.02
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$211.18
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	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$211.18
Rate for Payer: Molina CHIP/Medicaid	$211.18
Rate for Payer: Multiplan Auto	$2,177.50
Rate for Payer: Multiplan Commercial	$2,177.50
Rate for Payer: Multiplan Workers Comp	$2,177.50
Rate for Payer: Parkland Medicaid	$211.18
Rate for Payer: Scott and White EPO/PPO	$1,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$211.18
Rate for Payer: Superior Health Plan EPO	$455.60

MRI Upper Extremity Joint w/o Contrast Right BCE

Facility

$3,350.00

Service Code	CPT 73221 RT
Hospital Charge Code	3700267
Hospital Revenue Code	610
Min. Negotiated Rate	$211.18
Max. Negotiated Rate	$2,177.50
Rate for Payer: Aetna Commercial	$216.02
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$211.18
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	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$211.18
Rate for Payer: Molina CHIP/Medicaid	$211.18
Rate for Payer: Multiplan Auto	$2,177.50
Rate for Payer: Multiplan Commercial	$2,177.50
Rate for Payer: Multiplan Workers Comp	$2,177.50
Rate for Payer: Parkland Medicaid	$211.18
Rate for Payer: Scott and White EPO/PPO	$1,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$211.18
Rate for Payer: Superior Health Plan EPO	$455.60

MRI Upper Extremity Joint w + w/o Contrast Left BCE

Facility

$3,908.00

Service Code	CPT 73223 LT
Hospital Charge Code	3750585
Hospital Revenue Code	610
Min. Negotiated Rate	$368.43
Max. Negotiated Rate	$2,540.20
Rate for Payer: Aetna Commercial	$456.08
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	$3,439.04
Rate for Payer: Cash Price	$3,439.04
Rate for Payer: Cash Price	$3,439.04
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	$2,540.20
Rate for Payer: Multiplan Commercial	$2,540.20
Rate for Payer: Multiplan Workers Comp	$2,540.20
Rate for Payer: Parkland Medicaid	$368.43
Rate for Payer: Scott and White EPO/PPO	$1,954.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$531.49

MRI Upper Extremity Joint w + w/o Contrast Right BCE

Facility

$3,908.00

Service Code	CPT 73223 RT
Hospital Charge Code	3750593
Hospital Revenue Code	610
Min. Negotiated Rate	$368.43
Max. Negotiated Rate	$2,540.20
Rate for Payer: Aetna Commercial	$456.08
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	$3,439.04
Rate for Payer: Cash Price	$3,439.04
Rate for Payer: Cash Price	$3,439.04
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	$2,540.20
Rate for Payer: Multiplan Commercial	$2,540.20
Rate for Payer: Multiplan Workers Comp	$2,540.20
Rate for Payer: Parkland Medicaid	$368.43
Rate for Payer: Scott and White EPO/PPO	$1,954.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$531.49

MRI Upper Extremity Non Joint w/ Contast Right BCE

Facility

$3,958.00

Service Code	CPT 73219 RT
Hospital Charge Code	3750866
Hospital Revenue Code	610
Min. Negotiated Rate	$348.50
Max. Negotiated Rate	$2,572.70
Rate for Payer: Aetna Commercial	$403.04
Rate for Payer: Aetna Medicare	$527.57
Rate for Payer: Amerigroup CHIP/Medicaid	$348.50
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	$3,483.04
Rate for Payer: Cash Price	$3,483.04
Rate for Payer: Cash Price	$3,483.04
Rate for Payer: Cigna Commercial	$796.73
Rate for Payer: Cigna Medicaid	$348.50
Rate for Payer: Molina CHIP/Medicaid	$348.50
Rate for Payer: Multiplan Auto	$2,572.70
Rate for Payer: Multiplan Commercial	$2,572.70
Rate for Payer: Multiplan Workers Comp	$2,572.70
Rate for Payer: Parkland Medicaid	$348.50
Rate for Payer: Scott and White EPO/PPO	$1,979.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$348.50
Rate for Payer: Superior Health Plan EPO	$538.29

MRI Upper Extremity Non Joint w/ Contast Right BCE

Facility

$3,958.00

Service Code	CPT 73219 RT
Hospital Charge Code	3750866
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,483.04

MRI Upper Extremity Non Joint w/o Contrast Left BCE

Facility

$3,722.00

Service Code	CPT 73218 LT
Hospital Charge Code	3750536
Hospital Revenue Code	610
Min. Negotiated Rate	$233.52
Max. Negotiated Rate	$2,419.30
Rate for Payer: Aetna Commercial	$332.85
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	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cash Price	$3,275.36
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	$2,419.30
Rate for Payer: Multiplan Commercial	$2,419.30
Rate for Payer: Multiplan Workers Comp	$2,419.30
Rate for Payer: Parkland Medicaid	$233.52
Rate for Payer: Scott and White EPO/PPO	$1,861.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$233.52
Rate for Payer: Superior Health Plan EPO	$506.19

MRI Upper Extremity Non Joint w/o Contrast Left BCE

Facility

$3,722.00

Service Code	CPT 73218 LT
Hospital Charge Code	3750536
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,275.36

MRI Upper Extremity Non Joint w/o Contrast Right BCE

Facility

$3,722.00

Service Code	CPT 73218 RT
Hospital Charge Code	3750551
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,275.36

MRI Upper Extremity Non Joint w/o Contrast Right BCE

Facility

$3,722.00

Service Code	CPT 73218 RT
Hospital Charge Code	3750551
Hospital Revenue Code	610
Min. Negotiated Rate	$233.52
Max. Negotiated Rate	$2,419.30
Rate for Payer: Aetna Commercial	$332.85
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	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cash Price	$3,275.36
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	$2,419.30
Rate for Payer: Multiplan Commercial	$2,419.30
Rate for Payer: Multiplan Workers Comp	$2,419.30
Rate for Payer: Parkland Medicaid	$233.52
Rate for Payer: Scott and White EPO/PPO	$1,861.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$233.52
Rate for Payer: Superior Health Plan EPO	$506.19

MRI Upper Extremity Non Joint w/ + w/o Contrast Left BCE

Facility

$4,608.00

Service Code	CPT 73220 LT
Hospital Charge Code	3700044
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,055.04

MRI Upper Extremity Non Joint w/ + w/o Contrast Left BCE

Facility

$4,608.00

Service Code	CPT 73220 LT
Hospital Charge Code	3700044
Hospital Revenue Code	610
Min. Negotiated Rate	$368.43
Max. Negotiated Rate	$2,995.20
Rate for Payer: Aetna Commercial	$491.42
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	$4,055.04
Rate for Payer: Cash Price	$4,055.04
Rate for Payer: Cash Price	$4,055.04
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	$2,995.20
Rate for Payer: Multiplan Commercial	$2,995.20
Rate for Payer: Multiplan Workers Comp	$2,995.20
Rate for Payer: Parkland Medicaid	$368.43
Rate for Payer: Scott and White EPO/PPO	$2,304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$626.69

MRI Upper Extremity Non Joint w/ +w/o Contrast Right BCE

Facility

$4,608.00

Service Code	CPT 73220 RT
Hospital Charge Code	3700259
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,055.04

MRI Upper Extremity Non Joint w/ +w/o Contrast Right BCE

Facility

$4,608.00

Service Code	CPT 73220 RT
Hospital Charge Code	3700259
Hospital Revenue Code	610
Min. Negotiated Rate	$368.43
Max. Negotiated Rate	$2,995.20
Rate for Payer: Aetna Commercial	$491.42
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	$4,055.04
Rate for Payer: Cash Price	$4,055.04
Rate for Payer: Cash Price	$4,055.04
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	$2,995.20
Rate for Payer: Multiplan Commercial	$2,995.20
Rate for Payer: Multiplan Workers Comp	$2,995.20
Rate for Payer: Parkland Medicaid	$368.43
Rate for Payer: Scott and White EPO/PPO	$2,304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$368.43
Rate for Payer: Superior Health Plan EPO	$626.69

MRI Wrist w/ Contrast Left

Facility

$3,722.00

Service Code	CPT 73222 LT
Hospital Charge Code	3740071
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,275.36

MRI Wrist w/ Contrast Left

Facility

$3,722.00

Service Code	CPT 73222 LT
Hospital Charge Code	3740071
Hospital Revenue Code	610
Min. Negotiated Rate	$328.45
Max. Negotiated Rate	$2,419.30
Rate for Payer: Aetna Commercial	$375.55
Rate for Payer: Aetna Medicare	$1,098.39
Rate for Payer: Amerigroup CHIP/Medicaid	$328.45
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	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cigna Commercial	$1,658.78
Rate for Payer: Cigna Medicaid	$328.45
Rate for Payer: Molina CHIP/Medicaid	$328.45
Rate for Payer: Multiplan Auto	$2,419.30
Rate for Payer: Multiplan Commercial	$2,419.30
Rate for Payer: Multiplan Workers Comp	$2,419.30
Rate for Payer: Parkland Medicaid	$328.45
Rate for Payer: Scott and White EPO/PPO	$1,861.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.45
Rate for Payer: Superior Health Plan EPO	$506.19

MRI Wrist w/ Contrast Right

Facility

$3,722.00

Service Code	CPT 73222 RT
Hospital Charge Code	3740072
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,275.36

MRI Wrist w/ Contrast Right

Facility

$3,722.00

Service Code	CPT 73222 RT
Hospital Charge Code	3740072
Hospital Revenue Code	610
Min. Negotiated Rate	$328.45
Max. Negotiated Rate	$2,419.30
Rate for Payer: Aetna Commercial	$375.55
Rate for Payer: Aetna Medicare	$1,098.39
Rate for Payer: Amerigroup CHIP/Medicaid	$328.45
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	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cash Price	$3,275.36
Rate for Payer: Cigna Commercial	$1,658.78
Rate for Payer: Cigna Medicaid	$328.45
Rate for Payer: Molina CHIP/Medicaid	$328.45
Rate for Payer: Multiplan Auto	$2,419.30
Rate for Payer: Multiplan Commercial	$2,419.30
Rate for Payer: Multiplan Workers Comp	$2,419.30
Rate for Payer: Parkland Medicaid	$328.45
Rate for Payer: Scott and White EPO/PPO	$1,861.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$328.45
Rate for Payer: Superior Health Plan EPO	$506.19

MRI Wrist w/o Contrast Left

Facility

$3,350.00

Service Code	CPT 73221 LT
Hospital Charge Code	3700051
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,948.00

MRI Wrist w/o Contrast Left

Facility

$3,350.00

Service Code	CPT 73221 LT
Hospital Charge Code	3700051
Hospital Revenue Code	610
Min. Negotiated Rate	$211.18
Max. Negotiated Rate	$2,177.50
Rate for Payer: Aetna Commercial	$216.02
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$211.18
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	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$211.18
Rate for Payer: Molina CHIP/Medicaid	$211.18
Rate for Payer: Multiplan Auto	$2,177.50
Rate for Payer: Multiplan Commercial	$2,177.50
Rate for Payer: Multiplan Workers Comp	$2,177.50
Rate for Payer: Parkland Medicaid	$211.18
Rate for Payer: Scott and White EPO/PPO	$1,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$211.18
Rate for Payer: Superior Health Plan EPO	$455.60

MRI Wrist w/o Contrast Right

Facility

$3,350.00

Service Code	CPT 73221 RT
Hospital Charge Code	3700267
Hospital Revenue Code	610
Min. Negotiated Rate	$211.18
Max. Negotiated Rate	$2,177.50
Rate for Payer: Aetna Commercial	$216.02
Rate for Payer: Aetna Medicare	$336.15
Rate for Payer: Amerigroup CHIP/Medicaid	$211.18
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	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cigna Commercial	$507.64
Rate for Payer: Cigna Medicaid	$211.18
Rate for Payer: Molina CHIP/Medicaid	$211.18
Rate for Payer: Multiplan Auto	$2,177.50
Rate for Payer: Multiplan Commercial	$2,177.50
Rate for Payer: Multiplan Workers Comp	$2,177.50
Rate for Payer: Parkland Medicaid	$211.18
Rate for Payer: Scott and White EPO/PPO	$1,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$211.18
Rate for Payer: Superior Health Plan EPO	$455.60

MRI Wrist w/o Contrast Right

Facility

$3,350.00

Service Code	CPT 73221 RT
Hospital Charge Code	3700267
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,948.00

Know your out-of-pocket cost for care.

All Charges