White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MRI Face Neck Orbit w/ + w/o Contrast

Facility

$7,561.00

Service Code	HCPCS 70543
Hospital Charge Code	3750460
Hospital Revenue Code	610
Min. Negotiated Rate	$349.16
Max. Negotiated Rate	$5,443.92
Rate for Payer: Amerigroup CHIP/Medicaid	$349.16
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	$5,141.48
Rate for Payer: Cash Price	$5,141.48
Rate for Payer: Cash Price	$5,141.48
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$5,443.92
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	$5,443.92
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$4,914.65
Rate for Payer: Multiplan Commercial	$4,914.65
Rate for Payer: Multiplan Workers Comp	$4,914.65
Rate for Payer: Parkland Medicaid	$5,443.92
Rate for Payer: Scott and White EPO/PPO	$430.32
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,443.92
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

MRI Face Neck Orbit w/ + w/o Contrast

Facility

$7,561.00

Service Code	HCPCS 70543
Hospital Charge Code	3750460
Hospital Revenue Code	610
Rate for Payer: Cash Price	$5,141.48

MRI Forearm w/ Contrast Left

Facility

$3,958.00

Service Code	HCPCS 73219 LT
Hospital Charge Code	3750866
Hospital Revenue Code	610
Min. Negotiated Rate	$341.81
Max. Negotiated Rate	$2,849.76
Rate for Payer: Amerigroup CHIP/Medicaid	$341.81
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	$2,691.44
Rate for Payer: Cash Price	$2,691.44
Rate for Payer: Cash Price	$2,691.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$2,849.76
Rate for Payer: Molina CHIP/Medicaid	$2,849.76
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	$2,849.76
Rate for Payer: Scott and White EPO/PPO	$1,979.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,849.76
Rate for Payer: Superior Health Plan EPO	$538.29

MRI Forearm w/ Contrast Left

Facility

$3,958.00

Service Code	HCPCS 73219 LT
Hospital Charge Code	3750866
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,691.44

MRI Forearm w/ Contrast Right

Facility

$3,958.00

Service Code	HCPCS 73219 RT
Hospital Charge Code	5250842
Hospital Revenue Code	610
Min. Negotiated Rate	$341.81
Max. Negotiated Rate	$2,849.76
Rate for Payer: Amerigroup CHIP/Medicaid	$341.81
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	$2,691.44
Rate for Payer: Cash Price	$2,691.44
Rate for Payer: Cash Price	$2,691.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$2,849.76
Rate for Payer: Molina CHIP/Medicaid	$2,849.76
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	$2,849.76
Rate for Payer: Scott and White EPO/PPO	$1,979.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,849.76
Rate for Payer: Superior Health Plan EPO	$538.29

MRI Forearm w/ Contrast Right

Facility

$3,958.00

Service Code	HCPCS 73219 RT
Hospital Charge Code	5250842
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,691.44

MRI Forearm w/o Contrast Right

Facility

$3,722.00

Service Code	HCPCS 73218 RT
Hospital Charge Code	3750536
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,530.96

MRI Forearm w/o Contrast Right

Facility

$3,722.00

Service Code	HCPCS 73218 RT
Hospital Charge Code	3750551
Hospital Revenue Code	610
Min. Negotiated Rate	$233.47
Max. Negotiated Rate	$2,679.84
Rate for Payer: Amerigroup CHIP/Medicaid	$233.47
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	$2,530.96
Rate for Payer: Cash Price	$2,530.96
Rate for Payer: Cash Price	$2,530.96
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,679.84
Rate for Payer: Molina CHIP/Medicaid	$2,679.84
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	$2,679.84
Rate for Payer: Scott and White EPO/PPO	$1,861.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,679.84
Rate for Payer: Superior Health Plan EPO	$506.19

MRI Forearm w/o Contrast Right

Facility

$3,722.00

Service Code	HCPCS 73218 RT
Hospital Charge Code	3750536
Hospital Revenue Code	610
Min. Negotiated Rate	$233.47
Max. Negotiated Rate	$2,679.84
Rate for Payer: Amerigroup CHIP/Medicaid	$233.47
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	$2,530.96
Rate for Payer: Cash Price	$2,530.96
Rate for Payer: Cash Price	$2,530.96
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,679.84
Rate for Payer: Molina CHIP/Medicaid	$2,679.84
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	$2,679.84
Rate for Payer: Scott and White EPO/PPO	$1,861.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,679.84
Rate for Payer: Superior Health Plan EPO	$506.19

MRI Forearm w/o Contrast Right

Facility

$3,722.00

Service Code	HCPCS 73218 RT
Hospital Charge Code	3750551
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,530.96

MRI Forearm w/ + w/o Contrast Left

Facility

$4,608.00

Service Code	HCPCS 73220 LT
Hospital Charge Code	3700259
Hospital Revenue Code	610
Min. Negotiated Rate	$366.42
Max. Negotiated Rate	$3,317.76
Rate for Payer: Amerigroup CHIP/Medicaid	$366.42
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	$3,133.44
Rate for Payer: Cash Price	$3,133.44
Rate for Payer: Cash Price	$3,133.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$3,317.76
Rate for Payer: Molina CHIP/Medicaid	$3,317.76
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	$3,317.76
Rate for Payer: Scott and White EPO/PPO	$2,304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,317.76
Rate for Payer: Superior Health Plan EPO	$626.69

MRI Forearm w/ + w/o Contrast Left

Facility

$4,608.00

Service Code	HCPCS 73220 LT
Hospital Charge Code	3700259
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,133.44

MRI Forearm w/ + w/o Contrast Right

Facility

$4,608.00

Service Code	HCPCS 73220 RT
Hospital Charge Code	3700044
Hospital Revenue Code	610
Min. Negotiated Rate	$366.42
Max. Negotiated Rate	$3,317.76
Rate for Payer: Amerigroup CHIP/Medicaid	$366.42
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	$3,133.44
Rate for Payer: Cash Price	$3,133.44
Rate for Payer: Cash Price	$3,133.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$3,317.76
Rate for Payer: Molina CHIP/Medicaid	$3,317.76
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	$3,317.76
Rate for Payer: Scott and White EPO/PPO	$2,304.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,317.76
Rate for Payer: Superior Health Plan EPO	$626.69

MRI Forearm w/ + w/o Contrast Right

Facility

$4,608.00

Service Code	HCPCS 73220 RT
Hospital Charge Code	3700044
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,133.44

MRI Knee w/ Contrast Left

Facility

$4,425.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	3740044
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,009.00

MRI Knee w/ Contrast Left

Facility

$4,425.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	3740044
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 Knee w/ Contrast Right

Facility

$4,425.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	3740045
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 Knee w/ Contrast Right

Facility

$4,425.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	3740045
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,009.00

MRI LEFT HIP W/O CONTRAST

Facility

$3,907.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	994106
Hospital Revenue Code	610
Min. Negotiated Rate	$208.84
Max. Negotiated Rate	$2,813.04
Rate for Payer: Amerigroup CHIP/Medicaid	$208.84
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	$2,656.76
Rate for Payer: Cash Price	$2,656.76
Rate for Payer: Cash Price	$2,656.76
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,813.04
Rate for Payer: Molina CHIP/Medicaid	$2,813.04
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	$2,813.04
Rate for Payer: Scott and White EPO/PPO	$1,953.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,813.04
Rate for Payer: Superior Health Plan EPO	$531.35

MRI LEFT HIP W/O CONTRAST

Facility

$3,907.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	994106
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,656.76

MRI LEFT KNEE W/O CONTRAST

Facility

$3,907.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	994108
Hospital Revenue Code	610
Min. Negotiated Rate	$208.84
Max. Negotiated Rate	$2,813.04
Rate for Payer: Amerigroup CHIP/Medicaid	$208.84
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	$2,656.76
Rate for Payer: Cash Price	$2,656.76
Rate for Payer: Cash Price	$2,656.76
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,813.04
Rate for Payer: Molina CHIP/Medicaid	$2,813.04
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	$2,813.04
Rate for Payer: Scott and White EPO/PPO	$1,953.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,813.04
Rate for Payer: Superior Health Plan EPO	$531.35

MRI LEFT KNEE W/O CONTRAST

Facility

$3,907.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	994108
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,656.76

MRI Pelvis w/ Contrast

Facility

$5,770.00

Service Code	HCPCS 72196
Hospital Charge Code	3700168
Hospital Revenue Code	612
Min. Negotiated Rate	$276.66
Max. Negotiated Rate	$4,154.40
Rate for Payer: Amerigroup CHIP/Medicaid	$276.66
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	$3,923.60
Rate for Payer: Cash Price	$3,923.60
Rate for Payer: Cash Price	$3,923.60
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$4,154.40
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	$4,154.40
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$3,750.50
Rate for Payer: Multiplan Commercial	$3,750.50
Rate for Payer: Multiplan Workers Comp	$3,750.50
Rate for Payer: Parkland Medicaid	$4,154.40
Rate for Payer: Scott and White EPO/PPO	$340.93
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,154.40
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 Pelvis w/ Contrast

Facility

$5,770.00

Service Code	HCPCS 72196
Hospital Charge Code	3700168
Hospital Revenue Code	612
Rate for Payer: Cash Price	$3,923.60

MRI Pelvis w/o Contrast

Facility

$5,478.00

Service Code	HCPCS 72195
Hospital Charge Code	3750510
Hospital Revenue Code	610
Min. Negotiated Rate	$233.47
Max. Negotiated Rate	$3,944.16
Rate for Payer: Amerigroup CHIP/Medicaid	$233.47
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	$3,725.04
Rate for Payer: Cash Price	$3,725.04
Rate for Payer: Cash Price	$3,725.04
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$3,944.16
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	$3,944.16
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$3,560.70
Rate for Payer: Multiplan Commercial	$3,560.70
Rate for Payer: Multiplan Workers Comp	$3,560.70
Rate for Payer: Parkland Medicaid	$3,944.16
Rate for Payer: Scott and White EPO/PPO	$291.11
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,944.16
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

Know your out-of-pocket cost for care.

All Charges