White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MRA Lower Extremity w/o Contrast Right

Facility

$5,882.00

Service Code	HCPCS 73725 RT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Min. Negotiated Rate	$508.41
Max. Negotiated Rate	$4,235.04
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	$3,999.76
Rate for Payer: Cash Price	$3,999.76
Rate for Payer: Cigna Medicaid	$4,235.04
Rate for Payer: Molina CHIP/Medicaid	$4,235.04
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: Parkland Medicaid	$4,235.04
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,235.04
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/o Contrast Right

Facility

$5,882.00

Service Code	HCPCS 73725 RT
Hospital Charge Code	5258913
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,999.76

MRA Lower Extremity w/ + w/o Cnt Right

Facility

$5,882.00

Service Code	HCPCS 73725 RT
Hospital Charge Code	5258914
Hospital Revenue Code	610
Min. Negotiated Rate	$508.41
Max. Negotiated Rate	$4,235.04
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	$3,999.76
Rate for Payer: Cash Price	$3,999.76
Rate for Payer: Cigna Medicaid	$4,235.04
Rate for Payer: Molina CHIP/Medicaid	$4,235.04
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: Parkland Medicaid	$4,235.04
Rate for Payer: Scott and White EPO/PPO	$2,941.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,235.04
Rate for Payer: Superior Health Plan EPO	$799.95

MRA Lower Extremity w/ + w/o Cnt Right

Facility

$5,882.00

Service Code	HCPCS 73725 RT
Hospital Charge Code	5258914
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,999.76

MRA Neck w/ Contrast

Facility

$6,311.00

Service Code	HCPCS 70548
Hospital Charge Code	3750072
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,291.48

MRA Neck w/ Contrast

Facility

$6,311.00

Service Code	HCPCS 70548
Hospital Charge Code	3750072
Hospital Revenue Code	610
Min. Negotiated Rate	$253.60
Max. Negotiated Rate	$4,543.92
Rate for Payer: Amerigroup CHIP/Medicaid	$253.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
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	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$4,291.48
Rate for Payer: Cash Price	$4,291.48
Rate for Payer: Cash Price	$4,291.48
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$4,543.92
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$4,543.92
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
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	$4,543.92
Rate for Payer: Scott and White EPO/PPO	$312.50
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,543.92
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

MRA Neck w/o Contrast

Facility

$5,737.00

Service Code	HCPCS 70547
Hospital Charge Code	3750486
Hospital Revenue Code	610
Min. Negotiated Rate	$222.54
Max. Negotiated Rate	$4,130.64
Rate for Payer: Amerigroup CHIP/Medicaid	$222.54
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
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	$239.69
Rate for Payer: BCBS of TX PPO	$515.02
Rate for Payer: Cash Price	$3,901.16
Rate for Payer: Cash Price	$3,901.16
Rate for Payer: Cash Price	$3,901.16
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$4,130.64
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$4,130.64
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
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	$4,130.64
Rate for Payer: Scott and White EPO/PPO	$274.23
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,130.64
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

MRA Neck w/o Contrast

Facility

$5,737.00

Service Code	HCPCS 70547
Hospital Charge Code	3750486
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,901.16

MRA Neck w/ + w/o Contrast

Facility

$6,627.00

Service Code	HCPCS 70549
Hospital Charge Code	3750502
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,506.36

MRA Neck w/ + w/o Contrast

Facility

$6,627.00

Service Code	HCPCS 70549
Hospital Charge Code	3750502
Hospital Revenue Code	610
Min. Negotiated Rate	$350.46
Max. Negotiated Rate	$4,771.44
Rate for Payer: Amerigroup CHIP/Medicaid	$356.19
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
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	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$4,506.36
Rate for Payer: Cash Price	$4,506.36
Rate for Payer: Cash Price	$4,506.36
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$4,771.44
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$4,771.44
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
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	$4,771.44
Rate for Payer: Scott and White EPO/PPO	$438.98
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,771.44
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

MRA Pelvis w/ Contrast

Facility

$7,588.00

Service Code	HCPCS 72198
Hospital Charge Code	3701042
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,159.84

MRA Pelvis w/ Contrast

Facility

$7,588.00

Service Code	HCPCS 72198
Hospital Charge Code	5258918
Hospital Revenue Code	610
Min. Negotiated Rate	$429.50
Max. Negotiated Rate	$5,463.36
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	$5,159.84
Rate for Payer: Cash Price	$5,159.84
Rate for Payer: Cigna Medicaid	$5,463.36
Rate for Payer: Molina CHIP/Medicaid	$5,463.36
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: Parkland Medicaid	$5,463.36
Rate for Payer: Scott and White EPO/PPO	$429.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,463.36
Rate for Payer: Superior Health Plan EPO	$1,031.97

MRA Pelvis w/ Contrast

Facility

$7,588.00

Service Code	HCPCS 72198
Hospital Charge Code	3701042
Hospital Revenue Code	610
Min. Negotiated Rate	$429.50
Max. Negotiated Rate	$5,463.36
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	$5,159.84
Rate for Payer: Cash Price	$5,159.84
Rate for Payer: Cigna Medicaid	$5,463.36
Rate for Payer: Molina CHIP/Medicaid	$5,463.36
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: Parkland Medicaid	$5,463.36
Rate for Payer: Scott and White EPO/PPO	$429.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,463.36
Rate for Payer: Superior Health Plan EPO	$1,031.97

MRA Pelvis w/ Contrast

Facility

$7,588.00

Service Code	HCPCS 72198
Hospital Charge Code	5258918
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,159.84

MRA Upper Extremity w/o Contrast Right

Facility

$5,069.00

Service Code	HCPCS 73225 RT
Hospital Charge Code	5259585
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,446.92

MRA Upper Extremity w/o Contrast Right

Facility

$5,069.00

Service Code	HCPCS 73225 RT
Hospital Charge Code	5259585
Hospital Revenue Code	610
Min. Negotiated Rate	$456.21
Max. Negotiated Rate	$3,649.68
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	$3,446.92
Rate for Payer: Cash Price	$3,446.92
Rate for Payer: Cigna Medicaid	$3,649.68
Rate for Payer: Molina CHIP/Medicaid	$3,649.68
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: Parkland Medicaid	$3,649.68
Rate for Payer: Scott and White EPO/PPO	$2,534.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,649.68
Rate for Payer: Superior Health Plan EPO	$689.38

MRI Abdomen w/o Contrast

Facility

$6,566.00

Service Code	HCPCS 74181
Hospital Charge Code	3700010
Hospital Revenue Code	610
Min. Negotiated Rate	$201.81
Max. Negotiated Rate	$4,727.52
Rate for Payer: Amerigroup CHIP/Medicaid	$201.81
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$239.69
Rate for Payer: Amerigroup Medicare	$239.69
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	$239.69
Rate for Payer: BCBS of TX PPO	$515.02
Rate for Payer: Cash Price	$4,464.88
Rate for Payer: Cash Price	$4,464.88
Rate for Payer: Cash Price	$4,464.88
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$4,727.52
Rate for Payer: Cigna Medicare	$239.69
Rate for Payer: Employer Direct Commercial	$239.69
Rate for Payer: Humana Medicare/TRICARE	$239.69
Rate for Payer: Molina CHIP/Medicaid	$4,727.52
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
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	$4,727.52
Rate for Payer: Scott and White EPO/PPO	$248.65
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,727.52
Rate for Payer: Superior Health Plan EPO	$239.69
Rate for Payer: Superior Health Plan Medicare	$239.69
Rate for Payer: Universal American Dual Medicare/Medicaid	$239.69
Rate for Payer: Universal American Medicare	$239.69
Rate for Payer: Wellcare Medicare	$239.69
Rate for Payer: Wellmed Medicare	$239.69

MRI Abdomen w/o Contrast

Facility

$6,566.00

Service Code	HCPCS 74181
Hospital Charge Code	3700010
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,464.88

MRI Abdomen w/ + w/o Contrast

Facility

$7,151.00

Service Code	HCPCS 74183
Hospital Charge Code	3750882
Hospital Revenue Code	610
Min. Negotiated Rate	$348.50
Max. Negotiated Rate	$5,148.72
Rate for Payer: Amerigroup CHIP/Medicaid	$348.50
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$350.46
Rate for Payer: Amerigroup Medicare	$350.46
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	$350.46
Rate for Payer: BCBS of TX PPO	$843.89
Rate for Payer: Cash Price	$4,862.68
Rate for Payer: Cash Price	$4,862.68
Rate for Payer: Cash Price	$4,862.68
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$5,148.72
Rate for Payer: Cigna Medicare	$350.46
Rate for Payer: Employer Direct Commercial	$350.46
Rate for Payer: Humana Medicare/TRICARE	$350.46
Rate for Payer: Molina CHIP/Medicaid	$5,148.72
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
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	$5,148.72
Rate for Payer: Scott and White EPO/PPO	$429.50
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,148.72
Rate for Payer: Superior Health Plan EPO	$350.46
Rate for Payer: Superior Health Plan Medicare	$350.46
Rate for Payer: Universal American Dual Medicare/Medicaid	$350.46
Rate for Payer: Universal American Medicare	$350.46
Rate for Payer: Wellcare Medicare	$350.46
Rate for Payer: Wellmed Medicare	$350.46

MRI Abdomen w/ + w/o Contrast

Facility

$7,151.00

Service Code	HCPCS 74183
Hospital Charge Code	3750882
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,862.68

MRI Ankle w/ Contrast Left

Facility

$4,425.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	3750783
Hospital Revenue Code	610
Min. Negotiated Rate	$323.44
Max. Negotiated Rate	$3,186.00
Rate for Payer: Amerigroup CHIP/Medicaid	$323.44
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	$3,009.00
Rate for Payer: Cash Price	$3,009.00
Rate for Payer: Cash Price	$3,009.00
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$3,186.00
Rate for Payer: Molina CHIP/Medicaid	$3,186.00
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	$3,186.00
Rate for Payer: Scott and White EPO/PPO	$2,212.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,186.00
Rate for Payer: Superior Health Plan EPO	$601.80

MRI Ankle w/ Contrast Left

Facility

$4,425.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	3750783
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,009.00

MRI Ankle w/ Contrast Right

Facility

$4,425.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	3750825
Hospital Revenue Code	610
Min. Negotiated Rate	$323.44
Max. Negotiated Rate	$3,186.00
Rate for Payer: Amerigroup CHIP/Medicaid	$323.44
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	$3,009.00
Rate for Payer: Cash Price	$3,009.00
Rate for Payer: Cash Price	$3,009.00
Rate for Payer: Cigna Commercial	$1,664.61
Rate for Payer: Cigna Medicaid	$3,186.00
Rate for Payer: Molina CHIP/Medicaid	$3,186.00
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	$3,186.00
Rate for Payer: Scott and White EPO/PPO	$2,212.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,186.00
Rate for Payer: Superior Health Plan EPO	$601.80

MRI Ankle w/ Contrast Right

Facility

$4,425.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	3750825
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,009.00

MRI Ankle w/o Contrast Left

Facility

$3,907.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	3700036
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,656.76

Know your out-of-pocket cost for care.

All Charges