White Rock Medical Center

All Charges

Charge

Type

Setting

Price

STENT ABSOLUTE PRO 6X30X135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	136051
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Aetna Commercial	$1,771.08
Rate for Payer: Cash Price	$5,195.18
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

STENT ABSOLUTE PRO 6X30X135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	136051
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$2,951.80
Rate for Payer: Aetna Commercial	$1,771.08
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$5,195.18
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan EPO	$802.89

STENT ABSOLUTE PRO 6X40X135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	135877
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$2,951.80
Rate for Payer: Aetna Commercial	$1,771.08
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$5,195.18
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan EPO	$802.89

STENT ABSOLUTE PRO 6X40X135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	135877
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Aetna Commercial	$1,771.08
Rate for Payer: Cash Price	$5,195.18
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

STENT ABSOLUTE PRO 6X60X135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	135878
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$2,951.80
Rate for Payer: Aetna Commercial	$1,771.08
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$5,195.18
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan EPO	$802.89

STENT ABSOLUTE PRO 6X60X135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	135878
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Aetna Commercial	$1,771.08
Rate for Payer: Cash Price	$5,195.18
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

STENT ABSOLUTE PRO 6X80X135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	131687
Hospital Revenue Code	278
Min. Negotiated Rate	$1,475.90
Max. Negotiated Rate	$2,951.80
Rate for Payer: Aetna Commercial	$1,771.08
Rate for Payer: Cash Price	$5,195.18
Rate for Payer: Cigna Commercial	$1,475.90
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80

STENT ABSOLUTE PRO 6X80X135

Facility

$5,903.61

Service Code	HCPCS C1876
Hospital Charge Code	131687
Hospital Revenue Code	278
Min. Negotiated Rate	$531.32
Max. Negotiated Rate	$2,951.80
Rate for Payer: Aetna Commercial	$1,771.08
Rate for Payer: Amerigroup CHIP/Medicaid	$531.32
Rate for Payer: BCBS of TX Blue Advantage	$1,771.08
Rate for Payer: BCBS of TX Blue Essentials	$2,125.30
Rate for Payer: BCBS of TX PPO	$2,361.44
Rate for Payer: Cash Price	$5,195.18
Rate for Payer: Multiplan Auto	$2,951.80
Rate for Payer: Multiplan Commercial	$2,951.80
Rate for Payer: Multiplan Workers Comp	$2,951.80
Rate for Payer: Scott and White EPO/PPO	$2,951.80
Rate for Payer: Superior Health Plan EPO	$802.89

stent advanix biliary w/naviflex dbl pigtail 7fr 7cm

Facility

$313.25

Service Code	HCPCS C2617
Hospital Charge Code	109607
Hospital Revenue Code	278
Min. Negotiated Rate	$78.31
Max. Negotiated Rate	$156.62
Rate for Payer: Aetna Commercial	$93.98
Rate for Payer: Cash Price	$275.66
Rate for Payer: Cigna Commercial	$78.31
Rate for Payer: Multiplan Auto	$156.62
Rate for Payer: Multiplan Commercial	$156.62
Rate for Payer: Multiplan Workers Comp	$156.62
Rate for Payer: Scott and White EPO/PPO	$156.62

stent advanix biliary w/naviflex dbl pigtail 7fr 7cm

Facility

$313.25

Service Code	HCPCS C2617
Hospital Charge Code	109607
Hospital Revenue Code	278
Min. Negotiated Rate	$28.19
Max. Negotiated Rate	$156.62
Rate for Payer: Aetna Commercial	$93.98
Rate for Payer: Amerigroup CHIP/Medicaid	$28.19
Rate for Payer: BCBS of TX Blue Advantage	$93.98
Rate for Payer: BCBS of TX Blue Essentials	$112.77
Rate for Payer: BCBS of TX PPO	$125.30
Rate for Payer: Cash Price	$275.66
Rate for Payer: Multiplan Auto	$156.62
Rate for Payer: Multiplan Commercial	$156.62
Rate for Payer: Multiplan Workers Comp	$156.62
Rate for Payer: Scott and White EPO/PPO	$156.62
Rate for Payer: Superior Health Plan EPO	$42.60

stent advanix duodenal bend preloaded 10frx9cm

Facility

$777.11

Service Code	HCPCS C2625
Hospital Charge Code	109495
Hospital Revenue Code	278
Min. Negotiated Rate	$69.94
Max. Negotiated Rate	$388.56
Rate for Payer: Aetna Commercial	$233.13
Rate for Payer: Amerigroup CHIP/Medicaid	$69.94
Rate for Payer: BCBS of TX Blue Advantage	$233.13
Rate for Payer: BCBS of TX Blue Essentials	$279.76
Rate for Payer: BCBS of TX PPO	$310.84
Rate for Payer: Cash Price	$683.86
Rate for Payer: Multiplan Auto	$388.56
Rate for Payer: Multiplan Commercial	$388.56
Rate for Payer: Multiplan Workers Comp	$388.56
Rate for Payer: Scott and White EPO/PPO	$388.56
Rate for Payer: Superior Health Plan EPO	$105.69

stent advanix duodenal bend preloaded 10frx9cm

Facility

$777.11

Service Code	HCPCS C2625
Hospital Charge Code	109495
Hospital Revenue Code	278
Min. Negotiated Rate	$194.28
Max. Negotiated Rate	$388.56
Rate for Payer: Aetna Commercial	$233.13
Rate for Payer: Cash Price	$683.86
Rate for Payer: Cigna Commercial	$194.28
Rate for Payer: Multiplan Auto	$388.56
Rate for Payer: Multiplan Commercial	$388.56
Rate for Payer: Multiplan Workers Comp	$388.56
Rate for Payer: Scott and White EPO/PPO	$388.56

STENT ADVANTIX DOUBLE PIGTAIL SINGLE

Facility

$313.25

Service Code	HCPCS C2625
Hospital Charge Code	144808
Hospital Revenue Code	278
Min. Negotiated Rate	$78.31
Max. Negotiated Rate	$156.62
Rate for Payer: Aetna Commercial	$93.98
Rate for Payer: Cash Price	$275.66
Rate for Payer: Cigna Commercial	$78.31
Rate for Payer: Multiplan Auto	$156.62
Rate for Payer: Multiplan Commercial	$156.62
Rate for Payer: Multiplan Workers Comp	$156.62
Rate for Payer: Scott and White EPO/PPO	$156.62

STENT ADVANTIX DOUBLE PIGTAIL SINGLE

Facility

$313.25

Service Code	HCPCS C2625
Hospital Charge Code	144808
Hospital Revenue Code	278
Min. Negotiated Rate	$28.19
Max. Negotiated Rate	$156.62
Rate for Payer: Aetna Commercial	$93.98
Rate for Payer: Amerigroup CHIP/Medicaid	$28.19
Rate for Payer: BCBS of TX Blue Advantage	$93.98
Rate for Payer: BCBS of TX Blue Essentials	$112.77
Rate for Payer: BCBS of TX PPO	$125.30
Rate for Payer: Cash Price	$275.66
Rate for Payer: Multiplan Auto	$156.62
Rate for Payer: Multiplan Commercial	$156.62
Rate for Payer: Multiplan Workers Comp	$156.62
Rate for Payer: Scott and White EPO/PPO	$156.62
Rate for Payer: Superior Health Plan EPO	$42.60

stent advantix duodenal bend preloaded 10fr

Facility

$777.11

Service Code	HCPCS C1876
Hospital Charge Code	109494
Hospital Revenue Code	278
Min. Negotiated Rate	$194.28
Max. Negotiated Rate	$388.56
Rate for Payer: Aetna Commercial	$233.13
Rate for Payer: Cash Price	$683.86
Rate for Payer: Cigna Commercial	$194.28
Rate for Payer: Multiplan Auto	$388.56
Rate for Payer: Multiplan Commercial	$388.56
Rate for Payer: Multiplan Workers Comp	$388.56
Rate for Payer: Scott and White EPO/PPO	$388.56

stent advantix duodenal bend preloaded 10fr

Facility

$777.11

Service Code	HCPCS C1876
Hospital Charge Code	109494
Hospital Revenue Code	278
Min. Negotiated Rate	$69.94
Max. Negotiated Rate	$388.56
Rate for Payer: Aetna Commercial	$233.13
Rate for Payer: Amerigroup CHIP/Medicaid	$69.94
Rate for Payer: BCBS of TX Blue Advantage	$233.13
Rate for Payer: BCBS of TX Blue Essentials	$279.76
Rate for Payer: BCBS of TX PPO	$310.84
Rate for Payer: Cash Price	$683.86
Rate for Payer: Multiplan Auto	$388.56
Rate for Payer: Multiplan Commercial	$388.56
Rate for Payer: Multiplan Workers Comp	$388.56
Rate for Payer: Scott and White EPO/PPO	$388.56
Rate for Payer: Superior Health Plan EPO	$105.69

stent biomimics 3d 100/125/150 mm

Facility

$8,132.53

Service Code	HCPCS C1876
Hospital Charge Code	144800
Hospital Revenue Code	278
Min. Negotiated Rate	$2,033.13
Max. Negotiated Rate	$4,066.26
Rate for Payer: Aetna Commercial	$2,439.76
Rate for Payer: Cash Price	$7,156.63
Rate for Payer: Cigna Commercial	$2,033.13
Rate for Payer: Multiplan Auto	$4,066.26
Rate for Payer: Multiplan Commercial	$4,066.26
Rate for Payer: Multiplan Workers Comp	$4,066.26
Rate for Payer: Scott and White EPO/PPO	$4,066.26

stent biomimics 3d 100/125/150 mm

Facility

$8,132.53

Service Code	HCPCS C1876
Hospital Charge Code	144800
Hospital Revenue Code	278
Min. Negotiated Rate	$731.93
Max. Negotiated Rate	$4,066.26
Rate for Payer: Aetna Commercial	$2,439.76
Rate for Payer: Amerigroup CHIP/Medicaid	$731.93
Rate for Payer: BCBS of TX Blue Advantage	$2,439.76
Rate for Payer: BCBS of TX Blue Essentials	$2,927.71
Rate for Payer: BCBS of TX PPO	$3,253.01
Rate for Payer: Cash Price	$7,156.63
Rate for Payer: Multiplan Auto	$4,066.26
Rate for Payer: Multiplan Commercial	$4,066.26
Rate for Payer: Multiplan Workers Comp	$4,066.26
Rate for Payer: Scott and White EPO/PPO	$4,066.26
Rate for Payer: Superior Health Plan EPO	$1,106.02

stent biomimics 3d 60/80mm

Facility

$6,927.71

Service Code	HCPCS C1876
Hospital Charge Code	144798
Hospital Revenue Code	278
Min. Negotiated Rate	$623.49
Max. Negotiated Rate	$3,463.86
Rate for Payer: Aetna Commercial	$2,078.31
Rate for Payer: Amerigroup CHIP/Medicaid	$623.49
Rate for Payer: BCBS of TX Blue Advantage	$2,078.31
Rate for Payer: BCBS of TX Blue Essentials	$2,493.98
Rate for Payer: BCBS of TX PPO	$2,771.08
Rate for Payer: Cash Price	$6,096.38
Rate for Payer: Multiplan Auto	$3,463.86
Rate for Payer: Multiplan Commercial	$3,463.86
Rate for Payer: Multiplan Workers Comp	$3,463.86
Rate for Payer: Scott and White EPO/PPO	$3,463.86
Rate for Payer: Superior Health Plan EPO	$942.17

stent biomimics 3d 60/80mm

Facility

$6,927.71

Service Code	HCPCS C1876
Hospital Charge Code	144798
Hospital Revenue Code	278
Min. Negotiated Rate	$1,731.93
Max. Negotiated Rate	$3,463.86
Rate for Payer: Aetna Commercial	$2,078.31
Rate for Payer: Cash Price	$6,096.38
Rate for Payer: Cigna Commercial	$1,731.93
Rate for Payer: Multiplan Auto	$3,463.86
Rate for Payer: Multiplan Commercial	$3,463.86
Rate for Payer: Multiplan Workers Comp	$3,463.86
Rate for Payer: Scott and White EPO/PPO	$3,463.86

stent biotronic pk papyrus

Facility

$18,072.29

Service Code	HCPCS C1874
Hospital Charge Code	144822
Hospital Revenue Code	278
Min. Negotiated Rate	$4,518.07
Max. Negotiated Rate	$9,036.14
Rate for Payer: Aetna Commercial	$5,421.69
Rate for Payer: Cash Price	$15,903.62
Rate for Payer: Cigna Commercial	$4,518.07
Rate for Payer: Multiplan Auto	$9,036.14
Rate for Payer: Multiplan Commercial	$9,036.14
Rate for Payer: Multiplan Workers Comp	$9,036.14
Rate for Payer: Scott and White EPO/PPO	$9,036.14

stent biotronic pk papyrus

Facility

$18,072.29

Service Code	HCPCS C1874
Hospital Charge Code	144822
Hospital Revenue Code	278
Min. Negotiated Rate	$1,626.51
Max. Negotiated Rate	$9,036.14
Rate for Payer: Aetna Commercial	$5,421.69
Rate for Payer: Amerigroup CHIP/Medicaid	$1,626.51
Rate for Payer: BCBS of TX Blue Advantage	$5,421.69
Rate for Payer: BCBS of TX Blue Essentials	$6,506.02
Rate for Payer: BCBS of TX PPO	$7,228.92
Rate for Payer: Cash Price	$15,903.62
Rate for Payer: Multiplan Auto	$9,036.14
Rate for Payer: Multiplan Commercial	$9,036.14
Rate for Payer: Multiplan Workers Comp	$9,036.14
Rate for Payer: Scott and White EPO/PPO	$9,036.14
Rate for Payer: Superior Health Plan EPO	$2,457.83

STENT BIOTRONIK PULSAR-18 6X150X135

Facility

$3,614.46

Service Code	HCPCS C1876
Hospital Charge Code	145567
Hospital Revenue Code	278
Min. Negotiated Rate	$903.62
Max. Negotiated Rate	$1,807.23
Rate for Payer: Aetna Commercial	$1,084.34
Rate for Payer: Cash Price	$3,180.72
Rate for Payer: Cigna Commercial	$903.62
Rate for Payer: Multiplan Auto	$1,807.23
Rate for Payer: Multiplan Commercial	$1,807.23
Rate for Payer: Multiplan Workers Comp	$1,807.23
Rate for Payer: Scott and White EPO/PPO	$1,807.23

STENT BIOTRONIK PULSAR-18 6X150X135

Facility

$3,614.46

Service Code	HCPCS C1876
Hospital Charge Code	145567
Hospital Revenue Code	278
Min. Negotiated Rate	$325.30
Max. Negotiated Rate	$1,807.23
Rate for Payer: Aetna Commercial	$1,084.34
Rate for Payer: Amerigroup CHIP/Medicaid	$325.30
Rate for Payer: BCBS of TX Blue Advantage	$1,084.34
Rate for Payer: BCBS of TX Blue Essentials	$1,301.21
Rate for Payer: BCBS of TX PPO	$1,445.78
Rate for Payer: Cash Price	$3,180.72
Rate for Payer: Multiplan Auto	$1,807.23
Rate for Payer: Multiplan Commercial	$1,807.23
Rate for Payer: Multiplan Workers Comp	$1,807.23
Rate for Payer: Scott and White EPO/PPO	$1,807.23
Rate for Payer: Superior Health Plan EPO	$491.57

STENT BIOTRONIK PULSAR-18 7X12X135

Facility

$3,614.46

Service Code	HCPCS C1876
Hospital Charge Code	145467
Hospital Revenue Code	278
Min. Negotiated Rate	$325.30
Max. Negotiated Rate	$1,807.23
Rate for Payer: Aetna Commercial	$1,084.34
Rate for Payer: Amerigroup CHIP/Medicaid	$325.30
Rate for Payer: BCBS of TX Blue Advantage	$1,084.34
Rate for Payer: BCBS of TX Blue Essentials	$1,301.21
Rate for Payer: BCBS of TX PPO	$1,445.78
Rate for Payer: Cash Price	$3,180.72
Rate for Payer: Multiplan Auto	$1,807.23
Rate for Payer: Multiplan Commercial	$1,807.23
Rate for Payer: Multiplan Workers Comp	$1,807.23
Rate for Payer: Scott and White EPO/PPO	$1,807.23
Rate for Payer: Superior Health Plan EPO	$491.57

Know your out-of-pocket cost for care.

All Charges