White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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

MRI Pelvis w/ + w/o Contrast

Facility

$7,227.00

Service Code	HCPCS 72197
Hospital Charge Code	3750528
Hospital Revenue Code	610
Rate for Payer: Cash Price	$4,914.36

MRI Pelvis w/ + w/o Contrast

Facility

$7,227.00

Service Code	HCPCS 72197
Hospital Charge Code	3750528
Hospital Revenue Code	610
Min. Negotiated Rate	$347.16
Max. Negotiated Rate	$5,203.44
Rate for Payer: Amerigroup CHIP/Medicaid	$347.16
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	$4,914.36
Rate for Payer: Cash Price	$4,914.36
Rate for Payer: Cash Price	$4,914.36
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$5,203.44
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	$5,203.44
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$4,697.55
Rate for Payer: Multiplan Commercial	$4,697.55
Rate for Payer: Multiplan Workers Comp	$4,697.55
Rate for Payer: Parkland Medicaid	$5,203.44
Rate for Payer: Scott and White EPO/PPO	$427.86
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,203.44
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

MRI RIGHT HIP W/O CONTRAST

Facility

$3,907.00

Service Code	HCPCS 73721 RT
Hospital Charge Code	994107
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,656.76

MRI RIGHT HIP W/O CONTRAST

Facility

$3,907.00

Service Code	HCPCS 73721 RT
Hospital Charge Code	994107
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 RIGHT KNEE W/O CONTRAST

Facility

$3,907.00

Service Code	HCPCS 73721 RT
Hospital Charge Code	994109
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 RIGHT KNEE W/O CONTRAST

Facility

$3,907.00

Service Code	HCPCS 73721 RT
Hospital Charge Code	994109
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,656.76

MRI Shoulder w/ Contrast Left

Facility

$3,722.00

Service Code	HCPCS 73222 LT
Hospital Charge Code	3700739
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,530.96

MRI Shoulder w/ Contrast Left

Facility

$3,722.00

Service Code	HCPCS 73222 LT
Hospital Charge Code	3700739
Hospital Revenue Code	610
Min. Negotiated Rate	$323.10
Max. Negotiated Rate	$2,679.84
Rate for Payer: Amerigroup CHIP/Medicaid	$323.10
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	$2,530.96
Rate for Payer: Cash Price	$2,530.96
Rate for Payer: Cash Price	$2,530.96
Rate for Payer: Cigna Commercial	$1,664.61
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 Shoulder w/ Contrast Right

Facility

$3,722.00

Service Code	HCPCS 73222 RT
Hospital Charge Code	3740071
Hospital Revenue Code	610
Min. Negotiated Rate	$323.10
Max. Negotiated Rate	$2,679.84
Rate for Payer: Amerigroup CHIP/Medicaid	$323.10
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	$2,530.96
Rate for Payer: Cash Price	$2,530.96
Rate for Payer: Cash Price	$2,530.96
Rate for Payer: Cigna Commercial	$1,664.61
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 Shoulder w/ Contrast Right

Facility

$3,722.00

Service Code	HCPCS 73222 RT
Hospital Charge Code	3740071
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,530.96

MRI Shoulder w/o Contrast Left

Facility

$3,350.00

Service Code	HCPCS 73221 LT
Hospital Charge Code	3700051
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,278.00

MRI Shoulder w/o Contrast Left

Facility

$3,350.00

Service Code	HCPCS 73221 LT
Hospital Charge Code	3700051
Hospital Revenue Code	610
Min. Negotiated Rate	$209.16
Max. Negotiated Rate	$2,412.00
Rate for Payer: Amerigroup CHIP/Medicaid	$209.16
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	$2,278.00
Rate for Payer: Cash Price	$2,278.00
Rate for Payer: Cash Price	$2,278.00
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,412.00
Rate for Payer: Molina CHIP/Medicaid	$2,412.00
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	$2,412.00
Rate for Payer: Scott and White EPO/PPO	$1,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,412.00
Rate for Payer: Superior Health Plan EPO	$455.60

MRI Shoulder w/o Contrast Right

Facility

$3,350.00

Service Code	HCPCS 73221 RT
Hospital Charge Code	3700267
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,278.00

MRI Shoulder w/o Contrast Right

Facility

$3,350.00

Service Code	HCPCS 73221 RT
Hospital Charge Code	3700267
Hospital Revenue Code	610
Min. Negotiated Rate	$209.16
Max. Negotiated Rate	$2,412.00
Rate for Payer: Amerigroup CHIP/Medicaid	$209.16
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	$2,278.00
Rate for Payer: Cash Price	$2,278.00
Rate for Payer: Cash Price	$2,278.00
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,412.00
Rate for Payer: Molina CHIP/Medicaid	$2,412.00
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	$2,412.00
Rate for Payer: Scott and White EPO/PPO	$1,675.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,412.00
Rate for Payer: Superior Health Plan EPO	$455.60

MRI Shoulder w/ + w/o Contrast Left

Facility

$3,908.00

Service Code	HCPCS 73223 LT
Hospital Charge Code	3750585
Hospital Revenue Code	610
Min. Negotiated Rate	$366.42
Max. Negotiated Rate	$2,813.76
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	$2,657.44
Rate for Payer: Cash Price	$2,657.44
Rate for Payer: Cash Price	$2,657.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$2,813.76
Rate for Payer: Molina CHIP/Medicaid	$2,813.76
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	$2,813.76
Rate for Payer: Scott and White EPO/PPO	$1,954.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,813.76
Rate for Payer: Superior Health Plan EPO	$531.49

MRI Shoulder w/ + w/o Contrast Left

Facility

$3,908.00

Service Code	HCPCS 73223 LT
Hospital Charge Code	3750585
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,657.44

MRI Shoulder w/ + w/o Contrast Right

Facility

$3,908.00

Service Code	HCPCS 73223 RT
Hospital Charge Code	3750593
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,657.44

MRI Shoulder w/ + w/o Contrast Right

Facility

$3,908.00

Service Code	HCPCS 73223 RT
Hospital Charge Code	3750593
Hospital Revenue Code	610
Min. Negotiated Rate	$366.42
Max. Negotiated Rate	$2,813.76
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	$2,657.44
Rate for Payer: Cash Price	$2,657.44
Rate for Payer: Cash Price	$2,657.44
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$2,813.76
Rate for Payer: Molina CHIP/Medicaid	$2,813.76
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	$2,813.76
Rate for Payer: Scott and White EPO/PPO	$1,954.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,813.76
Rate for Payer: Superior Health Plan EPO	$531.49

MRI Spine Cervical w/o Contrast

Facility

$6,546.00

Service Code	HCPCS 72141
Hospital Charge Code	3700143
Hospital Revenue Code	612
Rate for Payer: Cash Price	$4,451.28

MRI Spine Cervical w/o Contrast

Facility

$6,546.00

Service Code	HCPCS 72141
Hospital Charge Code	3700143
Hospital Revenue Code	612
Min. Negotiated Rate	$196.48
Max. Negotiated Rate	$4,713.12
Rate for Payer: Amerigroup CHIP/Medicaid	$196.48
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	$4,451.28
Rate for Payer: Cash Price	$4,451.28
Rate for Payer: Cash Price	$4,451.28
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$4,713.12
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	$4,713.12
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$4,254.90
Rate for Payer: Multiplan Commercial	$4,254.90
Rate for Payer: Multiplan Workers Comp	$4,254.90
Rate for Payer: Parkland Medicaid	$4,713.12
Rate for Payer: Scott and White EPO/PPO	$242.06
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,713.12
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 Spine Cervical w/ + w/o Contrast

Facility

$10,611.00

Service Code	HCPCS 72156
Hospital Charge Code	3700218
Hospital Revenue Code	612
Min. Negotiated Rate	$329.79
Max. Negotiated Rate	$7,639.92
Rate for Payer: Amerigroup CHIP/Medicaid	$329.79
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	$7,215.48
Rate for Payer: Cash Price	$7,215.48
Rate for Payer: Cash Price	$7,215.48
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$7,639.92
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	$7,639.92
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$6,897.15
Rate for Payer: Multiplan Commercial	$6,897.15
Rate for Payer: Multiplan Workers Comp	$6,897.15
Rate for Payer: Parkland Medicaid	$7,639.92
Rate for Payer: Scott and White EPO/PPO	$406.39
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,639.92
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 Spine Cervical w/ + w/o Contrast

Facility

$10,611.00

Service Code	HCPCS 72156
Hospital Charge Code	3700218
Hospital Revenue Code	612
Rate for Payer: Cash Price	$7,215.48

MRI Spine Lumbar w/o Contrast

Facility

$6,239.00

Service Code	HCPCS 72148
Hospital Charge Code	3700234
Hospital Revenue Code	612
Min. Negotiated Rate	$197.14
Max. Negotiated Rate	$4,492.08
Rate for Payer: Amerigroup CHIP/Medicaid	$197.14
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	$4,242.52
Rate for Payer: Cash Price	$4,242.52
Rate for Payer: Cash Price	$4,242.52
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$4,492.08
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	$4,492.08
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$4,055.35
Rate for Payer: Multiplan Commercial	$4,055.35
Rate for Payer: Multiplan Workers Comp	$4,055.35
Rate for Payer: Parkland Medicaid	$4,492.08
Rate for Payer: Scott and White EPO/PPO	$242.89
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,492.08
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 Spine Lumbar w/o Contrast

Facility

$6,239.00

Service Code	HCPCS 72148
Hospital Charge Code	3700234
Hospital Revenue Code	612
Rate for Payer: Cash Price	$4,242.52

Know your out-of-pocket cost for care.

All Charges