White Rock Medical Center

All Charges

Charge

Type

Setting

Price

STENT BIOTRONIK PULSAR-18 7X12X135

Facility

$3,614.46

Service Code	HCPCS C1876
Hospital Charge Code	145467
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 7X15X135

Facility

$3,614.46

Service Code	HCPCS C1876
Hospital Charge Code	145466
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 7X15X135

Facility

$3,614.46

Service Code	HCPCS C1876
Hospital Charge Code	145466
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 CORDIS PALMAZ BLUE 6MMX18

Facility

$5,319.28

Service Code	HCPCS C1876
Hospital Charge Code	109507
Hospital Revenue Code	278
Min. Negotiated Rate	$1,329.82
Max. Negotiated Rate	$2,659.64
Rate for Payer: Aetna Commercial	$1,595.78
Rate for Payer: Cash Price	$4,680.97
Rate for Payer: Cigna Commercial	$1,329.82
Rate for Payer: Multiplan Auto	$2,659.64
Rate for Payer: Multiplan Commercial	$2,659.64
Rate for Payer: Multiplan Workers Comp	$2,659.64
Rate for Payer: Scott and White EPO/PPO	$2,659.64

STENT CORDIS PALMAZ BLUE 6MMX18

Facility

$5,319.28

Service Code	HCPCS C1876
Hospital Charge Code	109507
Hospital Revenue Code	278
Min. Negotiated Rate	$478.74
Max. Negotiated Rate	$2,659.64
Rate for Payer: Aetna Commercial	$1,595.78
Rate for Payer: Amerigroup CHIP/Medicaid	$478.74
Rate for Payer: BCBS of TX Blue Advantage	$1,595.78
Rate for Payer: BCBS of TX Blue Essentials	$1,914.94
Rate for Payer: BCBS of TX PPO	$2,127.71
Rate for Payer: Cash Price	$4,680.97
Rate for Payer: Multiplan Auto	$2,659.64
Rate for Payer: Multiplan Commercial	$2,659.64
Rate for Payer: Multiplan Workers Comp	$2,659.64
Rate for Payer: Scott and White EPO/PPO	$2,659.64
Rate for Payer: Superior Health Plan EPO	$723.42

STENT ENDOPROS VIABAHN VBX 6X59

Facility

$21,530.12

Service Code	HCPCS C1874
Hospital Charge Code	8568960
Hospital Revenue Code	278
Min. Negotiated Rate	$1,937.71
Max. Negotiated Rate	$10,765.06
Rate for Payer: Aetna Commercial	$6,459.04
Rate for Payer: Amerigroup CHIP/Medicaid	$1,937.71
Rate for Payer: BCBS of TX Blue Advantage	$6,459.04
Rate for Payer: BCBS of TX Blue Essentials	$7,750.84
Rate for Payer: BCBS of TX PPO	$8,612.05
Rate for Payer: Cash Price	$18,946.51
Rate for Payer: Multiplan Auto	$10,765.06
Rate for Payer: Multiplan Commercial	$10,765.06
Rate for Payer: Multiplan Workers Comp	$10,765.06
Rate for Payer: Scott and White EPO/PPO	$10,765.06
Rate for Payer: Superior Health Plan EPO	$2,928.10

STENT ENDOPROS VIABAHN VBX 6X59

Facility

$21,530.12

Service Code	HCPCS C1874
Hospital Charge Code	8568960
Hospital Revenue Code	278
Min. Negotiated Rate	$5,382.53
Max. Negotiated Rate	$10,765.06
Rate for Payer: Aetna Commercial	$6,459.04
Rate for Payer: Cash Price	$18,946.51
Rate for Payer: Cigna Commercial	$5,382.53
Rate for Payer: Multiplan Auto	$10,765.06
Rate for Payer: Multiplan Commercial	$10,765.06
Rate for Payer: Multiplan Workers Comp	$10,765.06
Rate for Payer: Scott and White EPO/PPO	$10,765.06

STENT ENDOPROS VIABAHN VBX 7X135

Facility

$18,512.05

Service Code	HCPCS C1876
Hospital Charge Code	145426
Hospital Revenue Code	278
Min. Negotiated Rate	$4,628.01
Max. Negotiated Rate	$9,256.02
Rate for Payer: Aetna Commercial	$5,553.62
Rate for Payer: Cash Price	$16,290.60
Rate for Payer: Cigna Commercial	$4,628.01
Rate for Payer: Multiplan Auto	$9,256.02
Rate for Payer: Multiplan Commercial	$9,256.02
Rate for Payer: Multiplan Workers Comp	$9,256.02
Rate for Payer: Scott and White EPO/PPO	$9,256.02

STENT ENDOPROS VIABAHN VBX 7X135

Facility

$18,512.05

Service Code	HCPCS C1876
Hospital Charge Code	145426
Hospital Revenue Code	278
Min. Negotiated Rate	$1,666.08
Max. Negotiated Rate	$9,256.02
Rate for Payer: Aetna Commercial	$5,553.62
Rate for Payer: Amerigroup CHIP/Medicaid	$1,666.08
Rate for Payer: BCBS of TX Blue Advantage	$5,553.62
Rate for Payer: BCBS of TX Blue Essentials	$6,664.34
Rate for Payer: BCBS of TX PPO	$7,404.82
Rate for Payer: Cash Price	$16,290.60
Rate for Payer: Multiplan Auto	$9,256.02
Rate for Payer: Multiplan Commercial	$9,256.02
Rate for Payer: Multiplan Workers Comp	$9,256.02
Rate for Payer: Scott and White EPO/PPO	$9,256.02
Rate for Payer: Superior Health Plan EPO	$2,517.64

STENT ENDOPROS VIABAHN VBX 7X59

Facility

$21,530.12

Service Code	HCPCS C1874
Hospital Charge Code	8568961
Hospital Revenue Code	278
Min. Negotiated Rate	$5,382.53
Max. Negotiated Rate	$10,765.06
Rate for Payer: Aetna Commercial	$6,459.04
Rate for Payer: Cash Price	$18,946.51
Rate for Payer: Cigna Commercial	$5,382.53
Rate for Payer: Multiplan Auto	$10,765.06
Rate for Payer: Multiplan Commercial	$10,765.06
Rate for Payer: Multiplan Workers Comp	$10,765.06
Rate for Payer: Scott and White EPO/PPO	$10,765.06

STENT ENDOPROS VIABAHN VBX 7X59

Facility

$21,530.12

Service Code	HCPCS C1874
Hospital Charge Code	8568961
Hospital Revenue Code	278
Min. Negotiated Rate	$1,937.71
Max. Negotiated Rate	$10,765.06
Rate for Payer: Aetna Commercial	$6,459.04
Rate for Payer: Amerigroup CHIP/Medicaid	$1,937.71
Rate for Payer: BCBS of TX Blue Advantage	$6,459.04
Rate for Payer: BCBS of TX Blue Essentials	$7,750.84
Rate for Payer: BCBS of TX PPO	$8,612.05
Rate for Payer: Cash Price	$18,946.51
Rate for Payer: Multiplan Auto	$10,765.06
Rate for Payer: Multiplan Commercial	$10,765.06
Rate for Payer: Multiplan Workers Comp	$10,765.06
Rate for Payer: Scott and White EPO/PPO	$10,765.06
Rate for Payer: Superior Health Plan EPO	$2,928.10

STENT ENDOPROS VIATOR CX

Facility

$30,975.90

Service Code	HCPCS C1874
Hospital Charge Code	8482468
Hospital Revenue Code	278
Min. Negotiated Rate	$7,743.98
Max. Negotiated Rate	$15,487.95
Rate for Payer: Aetna Commercial	$9,292.77
Rate for Payer: Cash Price	$27,258.79
Rate for Payer: Cigna Commercial	$7,743.98
Rate for Payer: Multiplan Auto	$15,487.95
Rate for Payer: Multiplan Commercial	$15,487.95
Rate for Payer: Multiplan Workers Comp	$15,487.95
Rate for Payer: Scott and White EPO/PPO	$15,487.95

STENT ENDOPROS VIATOR CX

Facility

$30,975.90

Service Code	HCPCS C1874
Hospital Charge Code	8482468
Hospital Revenue Code	278
Min. Negotiated Rate	$2,787.83
Max. Negotiated Rate	$15,487.95
Rate for Payer: Aetna Commercial	$9,292.77
Rate for Payer: Amerigroup CHIP/Medicaid	$2,787.83
Rate for Payer: BCBS of TX Blue Advantage	$9,292.77
Rate for Payer: BCBS of TX Blue Essentials	$11,151.32
Rate for Payer: BCBS of TX PPO	$12,390.36
Rate for Payer: Cash Price	$27,258.79
Rate for Payer: Multiplan Auto	$15,487.95
Rate for Payer: Multiplan Commercial	$15,487.95
Rate for Payer: Multiplan Workers Comp	$15,487.95
Rate for Payer: Scott and White EPO/PPO	$15,487.95
Rate for Payer: Superior Health Plan EPO	$4,212.72

STENT INTEGRITY RX-BMS

Facility

$3,012.04

Service Code	HCPCS C1876
Hospital Charge Code	8574472
Hospital Revenue Code	278
Min. Negotiated Rate	$753.01
Max. Negotiated Rate	$1,506.02
Rate for Payer: Aetna Commercial	$903.61
Rate for Payer: Cash Price	$2,650.60
Rate for Payer: Cigna Commercial	$753.01
Rate for Payer: Multiplan Auto	$1,506.02
Rate for Payer: Multiplan Commercial	$1,506.02
Rate for Payer: Multiplan Workers Comp	$1,506.02
Rate for Payer: Scott and White EPO/PPO	$1,506.02

STENT INTEGRITY RX-BMS

Facility

$3,012.04

Service Code	HCPCS C1876
Hospital Charge Code	8574472
Hospital Revenue Code	278
Min. Negotiated Rate	$271.08
Max. Negotiated Rate	$1,506.02
Rate for Payer: Aetna Commercial	$903.61
Rate for Payer: Amerigroup CHIP/Medicaid	$271.08
Rate for Payer: BCBS of TX Blue Advantage	$903.61
Rate for Payer: BCBS of TX Blue Essentials	$1,084.33
Rate for Payer: BCBS of TX PPO	$1,204.82
Rate for Payer: Cash Price	$2,650.60
Rate for Payer: Multiplan Auto	$1,506.02
Rate for Payer: Multiplan Commercial	$1,506.02
Rate for Payer: Multiplan Workers Comp	$1,506.02
Rate for Payer: Scott and White EPO/PPO	$1,506.02
Rate for Payer: Superior Health Plan EPO	$409.64

STENT PK PAPYRUS 2.5X15 434887

Facility

$18,072.29

Service Code	HCPCS C1874
Hospital Charge Code	145221
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 PK PAPYRUS 2.5X15 434887

Facility

$18,072.29

Service Code	HCPCS C1874
Hospital Charge Code	145221
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 PK PAPYRUS 3.5X15 434889

Facility

$18,072.29

Service Code	HCPCS C1874
Hospital Charge Code	145223
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 PK PAPYRUS 3.5X15 434889

Facility

$18,072.29

Service Code	HCPCS C1874
Hospital Charge Code	145223
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 PK PAPYRUS 3.5X26 434900

Facility

$18,072.29

Service Code	HCPCS C1874
Hospital Charge Code	145224
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 PK PAPYRUS 3.5X26 434900

Facility

$18,072.29

Service Code	HCPCS C1874
Hospital Charge Code	145224
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 PLMT CTR DIALYSIS SEG

Facility

$10,677.00

Service Code	CPT 36908
Hospital Charge Code	2351107
Hospital Revenue Code	360
Min. Negotiated Rate	$960.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$5,872.35
Rate for Payer: Amerigroup CHIP/Medicaid	$960.93
Rate for Payer: Cash Price	$9,395.76
Rate for Payer: Cash Price	$9,395.76
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$5,338.50
Rate for Payer: Superior Health Plan EPO	$1,452.07

STENT PLMT CTR DIALYSIS SEG

Facility

$10,677.00

Service Code	CPT 36908
Hospital Charge Code	2351107
Hospital Revenue Code	360
Rate for Payer: Cash Price	$9,395.76

STENT STRAIGHT ADVANTIX 3FRX5CM

Facility

$451.81

Service Code	HCPCS C2625
Hospital Charge Code	144809
Hospital Revenue Code	278
Min. Negotiated Rate	$112.95
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna Commercial	$135.54
Rate for Payer: Cash Price	$397.59
Rate for Payer: Cigna Commercial	$112.95
Rate for Payer: Multiplan Auto	$225.90
Rate for Payer: Multiplan Commercial	$225.90
Rate for Payer: Multiplan Workers Comp	$225.90
Rate for Payer: Scott and White EPO/PPO	$225.90

STENT STRAIGHT ADVANTIX 3FRX5CM

Facility

$451.81

Service Code	HCPCS C2625
Hospital Charge Code	144809
Hospital Revenue Code	278
Min. Negotiated Rate	$40.66
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna Commercial	$135.54
Rate for Payer: Amerigroup CHIP/Medicaid	$40.66
Rate for Payer: BCBS of TX Blue Advantage	$135.54
Rate for Payer: BCBS of TX Blue Essentials	$162.65
Rate for Payer: BCBS of TX PPO	$180.72
Rate for Payer: Cash Price	$397.59
Rate for Payer: Multiplan Auto	$225.90
Rate for Payer: Multiplan Commercial	$225.90
Rate for Payer: Multiplan Workers Comp	$225.90
Rate for Payer: Scott and White EPO/PPO	$225.90
Rate for Payer: Superior Health Plan EPO	$61.45

Know your out-of-pocket cost for care.

All Charges