White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MRI Spine Lumbar w/ + w/o Contrast

Facility

$10,113.00

Service Code	HCPCS 72158
Hospital Charge Code	3700127
Hospital Revenue Code	612
Min. Negotiated Rate	$329.13
Max. Negotiated Rate	$7,281.36
Rate for Payer: Amerigroup CHIP/Medicaid	$329.13
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	$6,876.84
Rate for Payer: Cash Price	$6,876.84
Rate for Payer: Cash Price	$6,876.84
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$7,281.36
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	$7,281.36
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$6,573.45
Rate for Payer: Multiplan Commercial	$6,573.45
Rate for Payer: Multiplan Workers Comp	$6,573.45
Rate for Payer: Parkland Medicaid	$7,281.36
Rate for Payer: Scott and White EPO/PPO	$405.56
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,281.36
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 Lumbar w/ + w/o Contrast

Facility

$10,113.00

Service Code	HCPCS 72158
Hospital Charge Code	3700127
Hospital Revenue Code	612
Rate for Payer: Cash Price	$6,876.84

MRI Spine Thoracic w/o Contrast

Facility

$6,239.00

Service Code	HCPCS 72146
Hospital Charge Code	3700101
Hospital Revenue Code	612
Rate for Payer: Cash Price	$4,242.52

MRI Spine Thoracic w/o Contrast

Facility

$6,239.00

Service Code	HCPCS 72146
Hospital Charge Code	3700101
Hospital Revenue Code	612
Min. Negotiated Rate	$196.14
Max. Negotiated Rate	$4,492.08
Rate for Payer: Amerigroup CHIP/Medicaid	$196.14
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	$241.65
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 Thoracic w/ + w/o Contrast

Facility

$10,113.00

Service Code	HCPCS 72157
Hospital Charge Code	3700093
Hospital Revenue Code	612
Rate for Payer: Cash Price	$6,876.84

MRI Spine Thoracic w/ + w/o Contrast

Facility

$10,113.00

Service Code	HCPCS 72157
Hospital Charge Code	3700093
Hospital Revenue Code	612
Min. Negotiated Rate	$330.45
Max. Negotiated Rate	$7,281.36
Rate for Payer: Amerigroup CHIP/Medicaid	$330.45
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	$6,876.84
Rate for Payer: Cash Price	$6,876.84
Rate for Payer: Cash Price	$6,876.84
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$7,281.36
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	$7,281.36
Rate for Payer: Molina Dual Medicare/Medicaid	$350.46
Rate for Payer: Molina Medicare	$350.46
Rate for Payer: Multiplan Auto	$6,573.45
Rate for Payer: Multiplan Commercial	$6,573.45
Rate for Payer: Multiplan Workers Comp	$6,573.45
Rate for Payer: Parkland Medicaid	$7,281.36
Rate for Payer: Scott and White EPO/PPO	$407.21
Rate for Payer: Scott and White Medicare	$350.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,281.36
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 Tibia Fibula w/o Contrast Left

Facility

$3,635.00

Service Code	HCPCS 73718 LT
Hospital Charge Code	3750619
Hospital Revenue Code	610
Min. Negotiated Rate	$230.21
Max. Negotiated Rate	$2,617.20
Rate for Payer: Amerigroup CHIP/Medicaid	$230.21
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	$2,471.80
Rate for Payer: Cash Price	$2,471.80
Rate for Payer: Cash Price	$2,471.80
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,617.20
Rate for Payer: Molina CHIP/Medicaid	$2,617.20
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	$2,617.20
Rate for Payer: Scott and White EPO/PPO	$1,817.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,617.20
Rate for Payer: Superior Health Plan EPO	$494.36

MRI Tibia Fibula w/o Contrast Left

Facility

$3,635.00

Service Code	HCPCS 73718 LT
Hospital Charge Code	3750619
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,471.80

MRI Tibia Fibula w/o Contrast Right

Facility

$3,635.00

Service Code	HCPCS 73718 RT
Hospital Charge Code	3750601
Hospital Revenue Code	610
Min. Negotiated Rate	$230.21
Max. Negotiated Rate	$2,617.20
Rate for Payer: Amerigroup CHIP/Medicaid	$230.21
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	$2,471.80
Rate for Payer: Cash Price	$2,471.80
Rate for Payer: Cash Price	$2,471.80
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,617.20
Rate for Payer: Molina CHIP/Medicaid	$2,617.20
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	$2,617.20
Rate for Payer: Scott and White EPO/PPO	$1,817.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,617.20
Rate for Payer: Superior Health Plan EPO	$494.36

MRI Tibia Fibula w/o Contrast Right

Facility

$3,635.00

Service Code	HCPCS 73718 RT
Hospital Charge Code	3750601
Hospital Revenue Code	610
Rate for Payer: Cash Price	$2,471.80

MRI Tibia Fibula w/ + w/o Contrast Left

Facility

$4,568.00

Service Code	HCPCS 73720 LT
Hospital Charge Code	3700028
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,106.24

MRI Tibia Fibula w/ + w/o Contrast Left

Facility

$4,568.00

Service Code	HCPCS 73720 LT
Hospital Charge Code	3700028
Hospital Revenue Code	610
Min. Negotiated Rate	$347.50
Max. Negotiated Rate	$3,288.96
Rate for Payer: Amerigroup CHIP/Medicaid	$347.50
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	$3,106.24
Rate for Payer: Cash Price	$3,106.24
Rate for Payer: Cash Price	$3,106.24
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$3,288.96
Rate for Payer: Molina CHIP/Medicaid	$3,288.96
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	$3,288.96
Rate for Payer: Scott and White EPO/PPO	$2,284.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,288.96
Rate for Payer: Superior Health Plan EPO	$621.25

MRI Tibia Fibula w/ + w/o Contrast Right

Facility

$4,568.00

Service Code	HCPCS 73720 RT
Hospital Charge Code	3700275
Hospital Revenue Code	610
Min. Negotiated Rate	$347.50
Max. Negotiated Rate	$3,288.96
Rate for Payer: Amerigroup CHIP/Medicaid	$347.50
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	$3,106.24
Rate for Payer: Cash Price	$3,106.24
Rate for Payer: Cash Price	$3,106.24
Rate for Payer: Cigna Commercial	$740.81
Rate for Payer: Cigna Medicaid	$3,288.96
Rate for Payer: Molina CHIP/Medicaid	$3,288.96
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	$3,288.96
Rate for Payer: Scott and White EPO/PPO	$2,284.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,288.96
Rate for Payer: Superior Health Plan EPO	$621.25

MRI Tibia Fibula w/ + w/o Contrast Right

Facility

$4,568.00

Service Code	HCPCS 73720 RT
Hospital Charge Code	3700275
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,106.24

MRI TMJ

Facility

$2,866.00

Service Code	HCPCS 70336
Hospital Charge Code	3701018
Hospital Revenue Code	610
Rate for Payer: Cash Price	$1,948.88

MRI TMJ

Facility

$2,866.00

Service Code	HCPCS 70336
Hospital Charge Code	3701018
Hospital Revenue Code	610
Min. Negotiated Rate	$233.47
Max. Negotiated Rate	$2,063.52
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	$1,948.88
Rate for Payer: Cash Price	$1,948.88
Rate for Payer: Cash Price	$1,948.88
Rate for Payer: Cigna Commercial	$506.65
Rate for Payer: Cigna Medicaid	$2,063.52
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	$2,063.52
Rate for Payer: Molina Dual Medicare/Medicaid	$239.69
Rate for Payer: Molina Medicare	$239.69
Rate for Payer: Multiplan Auto	$1,862.90
Rate for Payer: Multiplan Commercial	$1,862.90
Rate for Payer: Multiplan Workers Comp	$1,862.90
Rate for Payer: Parkland Medicaid	$2,063.52
Rate for Payer: Scott and White EPO/PPO	$335.62
Rate for Payer: Scott and White Medicare	$239.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,063.52
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

MRSA PCR

Facility

$253.00

Service Code	HCPCS 87641
Hospital Charge Code	8554471
Hospital Revenue Code	306
Rate for Payer: Cash Price	$172.04

MRSA PCR

Facility

$253.00

Service Code	HCPCS 87641
Hospital Charge Code	8554471
Hospital Revenue Code	306
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$182.16
Rate for Payer: Amerigroup CHIP/Medicaid	$13.69
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$35.09
Rate for Payer: Amerigroup Medicare	$35.09
Rate for Payer: BCBS of TX Blue Advantage	$75.90
Rate for Payer: BCBS of TX Blue Essentials	$91.08
Rate for Payer: BCBS of TX Medicare	$35.09
Rate for Payer: BCBS of TX PPO	$101.20
Rate for Payer: Cash Price	$172.04
Rate for Payer: Cash Price	$172.04
Rate for Payer: Cigna Medicaid	$182.16
Rate for Payer: Cigna Medicare	$35.09
Rate for Payer: Employer Direct Commercial	$35.09
Rate for Payer: Humana Medicare/TRICARE	$35.09
Rate for Payer: Molina CHIP/Medicaid	$182.16
Rate for Payer: Molina Dual Medicare/Medicaid	$35.09
Rate for Payer: Molina Medicare	$35.09
Rate for Payer: Multiplan Auto	$164.45
Rate for Payer: Multiplan Commercial	$164.45
Rate for Payer: Multiplan Workers Comp	$164.45
Rate for Payer: Parkland Medicaid	$182.16
Rate for Payer: Scott and White EPO/PPO	$43.86
Rate for Payer: Scott and White Medicare	$35.09
Rate for Payer: Superior Health Plan CHIP/Medicaid	$182.16
Rate for Payer: Superior Health Plan EPO	$35.09
Rate for Payer: Superior Health Plan Medicare	$35.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$35.09
Rate for Payer: Universal American Medicare	$35.09
Rate for Payer: Wellcare Medicare	$35.09
Rate for Payer: Wellmed Medicare	$35.09

MSI Upper Arm Left

Facility

$532.00

Service Code	HCPCS 73060 LT
Hospital Charge Code	3100625
Hospital Revenue Code	320
Min. Negotiated Rate	$32.08
Max. Negotiated Rate	$383.04
Rate for Payer: Amerigroup CHIP/Medicaid	$32.08
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$361.76
Rate for Payer: Cash Price	$361.76
Rate for Payer: Cash Price	$361.76
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$383.04
Rate for Payer: Molina CHIP/Medicaid	$383.04
Rate for Payer: Multiplan Auto	$345.80
Rate for Payer: Multiplan Commercial	$345.80
Rate for Payer: Multiplan Workers Comp	$345.80
Rate for Payer: Parkland Medicaid	$383.04
Rate for Payer: Scott and White EPO/PPO	$266.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$383.04
Rate for Payer: Superior Health Plan EPO	$72.35

MSI Upper Arm Left

Facility

$532.00

Service Code	HCPCS 73060 LT
Hospital Charge Code	3100625
Hospital Revenue Code	320
Rate for Payer: Cash Price	$361.76

MSI Upper Arm Right

Facility

$532.00

Service Code	HCPCS 73060 RT
Hospital Charge Code	3100641
Hospital Revenue Code	320
Min. Negotiated Rate	$32.08
Max. Negotiated Rate	$383.04
Rate for Payer: Amerigroup CHIP/Medicaid	$32.08
Rate for Payer: BCBS of TX Blue Advantage	$131.69
Rate for Payer: BCBS of TX Blue Essentials	$158.02
Rate for Payer: BCBS of TX PPO	$176.38
Rate for Payer: Cash Price	$361.76
Rate for Payer: Cash Price	$361.76
Rate for Payer: Cash Price	$361.76
Rate for Payer: Cigna Commercial	$184.79
Rate for Payer: Cigna Medicaid	$383.04
Rate for Payer: Molina CHIP/Medicaid	$383.04
Rate for Payer: Multiplan Auto	$345.80
Rate for Payer: Multiplan Commercial	$345.80
Rate for Payer: Multiplan Workers Comp	$345.80
Rate for Payer: Parkland Medicaid	$383.04
Rate for Payer: Scott and White EPO/PPO	$266.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$383.04
Rate for Payer: Superior Health Plan EPO	$72.35

MSI Upper Arm Right

Facility

$532.00

Service Code	HCPCS 73060 RT
Hospital Charge Code	3100641
Hospital Revenue Code	320
Rate for Payer: Cash Price	$361.76

MSK AMBU INFANT -- DHF

Facility

$67.43

Hospital Charge Code	82055658
Hospital Revenue Code	270
Min. Negotiated Rate	$6.07
Max. Negotiated Rate	$48.55
Rate for Payer: Amerigroup CHIP/Medicaid	$6.07
Rate for Payer: BCBS of TX Blue Advantage	$20.23
Rate for Payer: BCBS of TX Blue Essentials	$24.27
Rate for Payer: BCBS of TX PPO	$26.97
Rate for Payer: Cash Price	$45.85
Rate for Payer: Cigna Medicaid	$48.55
Rate for Payer: Molina CHIP/Medicaid	$48.55
Rate for Payer: Multiplan Auto	$43.83
Rate for Payer: Multiplan Commercial	$43.83
Rate for Payer: Multiplan Workers Comp	$43.83
Rate for Payer: Parkland Medicaid	$48.55
Rate for Payer: Scott and White EPO/PPO	$33.72
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.55
Rate for Payer: Superior Health Plan EPO	$9.17

MSK AMBU INFANT -- DHF

Facility

$67.43

Hospital Charge Code	82055658
Hospital Revenue Code	270
Rate for Payer: Cash Price	$45.85

MSK NASAL CPAP -- DHF

Facility

$75.16

Hospital Charge Code	82056979
Hospital Revenue Code	271
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$54.12
Rate for Payer: Amerigroup CHIP/Medicaid	$6.76
Rate for Payer: BCBS of TX Blue Advantage	$22.55
Rate for Payer: BCBS of TX Blue Essentials	$27.06
Rate for Payer: BCBS of TX PPO	$30.06
Rate for Payer: Cash Price	$51.11
Rate for Payer: Cigna Medicaid	$54.12
Rate for Payer: Molina CHIP/Medicaid	$54.12
Rate for Payer: Multiplan Auto	$48.85
Rate for Payer: Multiplan Commercial	$48.85
Rate for Payer: Multiplan Workers Comp	$48.85
Rate for Payer: Parkland Medicaid	$54.12
Rate for Payer: Scott and White EPO/PPO	$37.58
Rate for Payer: Superior Health Plan CHIP/Medicaid	$54.12
Rate for Payer: Superior Health Plan EPO	$10.22

Know your out-of-pocket cost for care.

All Charges