White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ST NDL INTRAOSS ADLT -- DHF

Facility

$577.49

Hospital Charge Code	81786501
Hospital Revenue Code	272
Min. Negotiated Rate	$51.97
Max. Negotiated Rate	$375.37
Rate for Payer: Aetna Commercial	$317.62
Rate for Payer: Amerigroup CHIP/Medicaid	$51.97
Rate for Payer: BCBS of TX Blue Advantage	$173.25
Rate for Payer: BCBS of TX Blue Essentials	$207.90
Rate for Payer: BCBS of TX PPO	$231.00
Rate for Payer: Cash Price	$508.19
Rate for Payer: Multiplan Auto	$375.37
Rate for Payer: Multiplan Commercial	$375.37
Rate for Payer: Multiplan Workers Comp	$375.37
Rate for Payer: Scott and White EPO/PPO	$288.74
Rate for Payer: Superior Health Plan EPO	$78.54

ST NDL INTRAOSS ADLT -- DHF

Facility

$577.49

Hospital Charge Code	81786501
Hospital Revenue Code	272
Rate for Payer: Cash Price	$508.19

STNT B EXPRESS LD -- DHF

Facility

$8,856.10

Service Code	HCPCS C1876
Hospital Charge Code	82431362
Hospital Revenue Code	278
Min. Negotiated Rate	$2,214.02
Max. Negotiated Rate	$4,428.05
Rate for Payer: Aetna Commercial	$2,656.83
Rate for Payer: Cash Price	$7,793.37
Rate for Payer: Cigna Commercial	$2,214.02
Rate for Payer: Multiplan Auto	$4,428.05
Rate for Payer: Multiplan Commercial	$4,428.05
Rate for Payer: Multiplan Workers Comp	$4,428.05
Rate for Payer: Scott and White EPO/PPO	$4,428.05

STNT B EXPRESS LD -- DHF

Facility

$8,856.10

Service Code	HCPCS C1876
Hospital Charge Code	82431362
Hospital Revenue Code	278
Min. Negotiated Rate	$797.05
Max. Negotiated Rate	$4,428.05
Rate for Payer: Aetna Commercial	$2,656.83
Rate for Payer: Amerigroup CHIP/Medicaid	$797.05
Rate for Payer: BCBS of TX Blue Advantage	$2,656.83
Rate for Payer: BCBS of TX Blue Essentials	$3,188.20
Rate for Payer: BCBS of TX PPO	$3,542.44
Rate for Payer: Cash Price	$7,793.37
Rate for Payer: Multiplan Auto	$4,428.05
Rate for Payer: Multiplan Commercial	$4,428.05
Rate for Payer: Multiplan Workers Comp	$4,428.05
Rate for Payer: Scott and White EPO/PPO	$4,428.05
Rate for Payer: Superior Health Plan EPO	$1,204.43

STNT C DRIVER RAP EXCH -- DHF

Facility

$4,687.99

Service Code	HCPCS C1876
Hospital Charge Code	40248213
Hospital Revenue Code	278
Min. Negotiated Rate	$1,172.00
Max. Negotiated Rate	$2,344.00
Rate for Payer: Aetna Commercial	$1,406.40
Rate for Payer: Cash Price	$4,125.43
Rate for Payer: Cigna Commercial	$1,172.00
Rate for Payer: Multiplan Auto	$2,344.00
Rate for Payer: Multiplan Commercial	$2,344.00
Rate for Payer: Multiplan Workers Comp	$2,344.00
Rate for Payer: Scott and White EPO/PPO	$2,344.00

STNT C DRIVER RAP EXCH -- DHF

Facility

$4,687.99

Service Code	HCPCS C1876
Hospital Charge Code	40248213
Hospital Revenue Code	278
Min. Negotiated Rate	$421.92
Max. Negotiated Rate	$2,344.00
Rate for Payer: Aetna Commercial	$1,406.40
Rate for Payer: Amerigroup CHIP/Medicaid	$421.92
Rate for Payer: BCBS of TX Blue Advantage	$1,406.40
Rate for Payer: BCBS of TX Blue Essentials	$1,687.68
Rate for Payer: BCBS of TX PPO	$1,875.20
Rate for Payer: Cash Price	$4,125.43
Rate for Payer: Multiplan Auto	$2,344.00
Rate for Payer: Multiplan Commercial	$2,344.00
Rate for Payer: Multiplan Workers Comp	$2,344.00
Rate for Payer: Scott and White EPO/PPO	$2,344.00
Rate for Payer: Superior Health Plan EPO	$637.57

STNT COR XIENCE SIERRA EE RX -- DHF

Facility

$11,157.02

Service Code	HCPCS C1874
Hospital Charge Code	80622053
Hospital Revenue Code	278
Min. Negotiated Rate	$1,004.13
Max. Negotiated Rate	$5,578.51
Rate for Payer: Aetna Commercial	$3,347.11
Rate for Payer: Amerigroup CHIP/Medicaid	$1,004.13
Rate for Payer: BCBS of TX Blue Advantage	$3,347.11
Rate for Payer: BCBS of TX Blue Essentials	$4,016.53
Rate for Payer: BCBS of TX PPO	$4,462.81
Rate for Payer: Cash Price	$9,818.18
Rate for Payer: Multiplan Auto	$5,578.51
Rate for Payer: Multiplan Commercial	$5,578.51
Rate for Payer: Multiplan Workers Comp	$5,578.51
Rate for Payer: Scott and White EPO/PPO	$5,578.51
Rate for Payer: Superior Health Plan EPO	$1,517.35

STNT COR XIENCE SIERRA EE RX -- DHF

Facility

$11,157.02

Service Code	HCPCS C1874
Hospital Charge Code	80622053
Hospital Revenue Code	278
Min. Negotiated Rate	$2,789.26
Max. Negotiated Rate	$5,578.51
Rate for Payer: Aetna Commercial	$3,347.11
Rate for Payer: Cash Price	$9,818.18
Rate for Payer: Cigna Commercial	$2,789.26
Rate for Payer: Multiplan Auto	$5,578.51
Rate for Payer: Multiplan Commercial	$5,578.51
Rate for Payer: Multiplan Workers Comp	$5,578.51
Rate for Payer: Scott and White EPO/PPO	$5,578.51

STNT C RESOLUT INTEG DES -- DHF

Facility

$4,518.07

Service Code	HCPCS C1874
Hospital Charge Code	80620693
Hospital Revenue Code	278
Min. Negotiated Rate	$406.63
Max. Negotiated Rate	$2,259.04
Rate for Payer: Aetna Commercial	$1,355.42
Rate for Payer: Amerigroup CHIP/Medicaid	$406.63
Rate for Payer: BCBS of TX Blue Advantage	$1,355.42
Rate for Payer: BCBS of TX Blue Essentials	$1,626.51
Rate for Payer: BCBS of TX PPO	$1,807.23
Rate for Payer: Cash Price	$3,975.90
Rate for Payer: Multiplan Auto	$2,259.04
Rate for Payer: Multiplan Commercial	$2,259.04
Rate for Payer: Multiplan Workers Comp	$2,259.04
Rate for Payer: Scott and White EPO/PPO	$2,259.04
Rate for Payer: Superior Health Plan EPO	$614.46

STNT C RESOLUT INTEG DES -- DHF

Facility

$4,518.07

Service Code	HCPCS C1874
Hospital Charge Code	80620693
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.52
Max. Negotiated Rate	$2,259.04
Rate for Payer: Aetna Commercial	$1,355.42
Rate for Payer: Cash Price	$3,975.90
Rate for Payer: Cigna Commercial	$1,129.52
Rate for Payer: Multiplan Auto	$2,259.04
Rate for Payer: Multiplan Commercial	$2,259.04
Rate for Payer: Multiplan Workers Comp	$2,259.04
Rate for Payer: Scott and White EPO/PPO	$2,259.04

STNT C XIENCE ALPINE RX -- DHF

Facility

$10,330.57

Service Code	HCPCS C1874
Hospital Charge Code	80622103
Hospital Revenue Code	278
Min. Negotiated Rate	$929.75
Max. Negotiated Rate	$5,165.28
Rate for Payer: Aetna Commercial	$3,099.17
Rate for Payer: Amerigroup CHIP/Medicaid	$929.75
Rate for Payer: BCBS of TX Blue Advantage	$3,099.17
Rate for Payer: BCBS of TX Blue Essentials	$3,719.01
Rate for Payer: BCBS of TX PPO	$4,132.23
Rate for Payer: Cash Price	$9,090.90
Rate for Payer: Multiplan Auto	$5,165.28
Rate for Payer: Multiplan Commercial	$5,165.28
Rate for Payer: Multiplan Workers Comp	$5,165.28
Rate for Payer: Scott and White EPO/PPO	$5,165.28
Rate for Payer: Superior Health Plan EPO	$1,404.96

STNT C XIENCE ALPINE RX -- DHF

Facility

$10,330.57

Service Code	HCPCS C1874
Hospital Charge Code	80622103
Hospital Revenue Code	278
Min. Negotiated Rate	$2,582.64
Max. Negotiated Rate	$5,165.28
Rate for Payer: Aetna Commercial	$3,099.17
Rate for Payer: Cash Price	$9,090.90
Rate for Payer: Cigna Commercial	$2,582.64
Rate for Payer: Multiplan Auto	$5,165.28
Rate for Payer: Multiplan Commercial	$5,165.28
Rate for Payer: Multiplan Workers Comp	$5,165.28
Rate for Payer: Scott and White EPO/PPO	$5,165.28

STNT ENDOPROS VIABAHN SX 7X120

Facility

$22,632.53

Service Code	HCPCS C1876
Hospital Charge Code	119940
Hospital Revenue Code	278
Min. Negotiated Rate	$5,658.13
Max. Negotiated Rate	$11,316.26
Rate for Payer: Aetna Commercial	$6,789.76
Rate for Payer: Cash Price	$19,916.63
Rate for Payer: Cigna Commercial	$5,658.13
Rate for Payer: Multiplan Auto	$11,316.26
Rate for Payer: Multiplan Commercial	$11,316.26
Rate for Payer: Multiplan Workers Comp	$11,316.26
Rate for Payer: Scott and White EPO/PPO	$11,316.26

STNT ENDOPROS VIABAHN SX 7X120

Facility

$22,632.53

Service Code	HCPCS C1876
Hospital Charge Code	119940
Hospital Revenue Code	278
Min. Negotiated Rate	$2,036.93
Max. Negotiated Rate	$11,316.26
Rate for Payer: Aetna Commercial	$6,789.76
Rate for Payer: Amerigroup CHIP/Medicaid	$2,036.93
Rate for Payer: BCBS of TX Blue Advantage	$6,789.76
Rate for Payer: BCBS of TX Blue Essentials	$8,147.71
Rate for Payer: BCBS of TX PPO	$9,053.01
Rate for Payer: Cash Price	$19,916.63
Rate for Payer: Multiplan Auto	$11,316.26
Rate for Payer: Multiplan Commercial	$11,316.26
Rate for Payer: Multiplan Workers Comp	$11,316.26
Rate for Payer: Scott and White EPO/PPO	$11,316.26
Rate for Payer: Superior Health Plan EPO	$3,078.02

STNT OMNILINK ELITE 101262-29

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	138719
Hospital Revenue Code	278
Min. Negotiated Rate	$504.76
Max. Negotiated Rate	$2,804.22
Rate for Payer: Aetna Commercial	$1,682.53
Rate for Payer: Amerigroup CHIP/Medicaid	$504.76
Rate for Payer: BCBS of TX Blue Advantage	$1,682.53
Rate for Payer: BCBS of TX Blue Essentials	$2,019.03
Rate for Payer: BCBS of TX PPO	$2,243.37
Rate for Payer: Cash Price	$4,935.42
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22
Rate for Payer: Superior Health Plan EPO	$762.75

STNT OMNILINK ELITE 101262-29

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	138719
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.11
Max. Negotiated Rate	$2,804.22
Rate for Payer: Aetna Commercial	$1,682.53
Rate for Payer: Cash Price	$4,935.42
Rate for Payer: Cigna Commercial	$1,402.11
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22

STNT OMNILINK ELITE 1012632-39

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	136038
Hospital Revenue Code	278
Min. Negotiated Rate	$504.76
Max. Negotiated Rate	$2,804.22
Rate for Payer: Aetna Commercial	$1,682.53
Rate for Payer: Amerigroup CHIP/Medicaid	$504.76
Rate for Payer: BCBS of TX Blue Advantage	$1,682.53
Rate for Payer: BCBS of TX Blue Essentials	$2,019.03
Rate for Payer: BCBS of TX PPO	$2,243.37
Rate for Payer: Cash Price	$4,935.42
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22
Rate for Payer: Superior Health Plan EPO	$762.75

STNT OMNILINK ELITE 1012632-39

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	136038
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.11
Max. Negotiated Rate	$2,804.22
Rate for Payer: Aetna Commercial	$1,682.53
Rate for Payer: Cash Price	$4,935.42
Rate for Payer: Cigna Commercial	$1,402.11
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22

STNT OMNILINK ELITE 101263-29

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	82431321
Hospital Revenue Code	278
Min. Negotiated Rate	$504.76
Max. Negotiated Rate	$2,804.22
Rate for Payer: Aetna Commercial	$1,682.53
Rate for Payer: Amerigroup CHIP/Medicaid	$504.76
Rate for Payer: BCBS of TX Blue Advantage	$1,682.53
Rate for Payer: BCBS of TX Blue Essentials	$2,019.03
Rate for Payer: BCBS of TX PPO	$2,243.37
Rate for Payer: Cash Price	$4,935.42
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22
Rate for Payer: Superior Health Plan EPO	$762.75

STNT OMNILINK ELITE 101263-29

Facility

$5,608.43

Service Code	HCPCS C1876
Hospital Charge Code	82431321
Hospital Revenue Code	278
Min. Negotiated Rate	$1,402.11
Max. Negotiated Rate	$2,804.22
Rate for Payer: Aetna Commercial	$1,682.53
Rate for Payer: Cash Price	$4,935.42
Rate for Payer: Cigna Commercial	$1,402.11
Rate for Payer: Multiplan Auto	$2,804.22
Rate for Payer: Multiplan Commercial	$2,804.22
Rate for Payer: Multiplan Workers Comp	$2,804.22
Rate for Payer: Scott and White EPO/PPO	$2,804.22

STNT PERIPHERAL SUPERA -- DHF

Facility

$11,111.11

Service Code	HCPCS C1876
Hospital Charge Code	80622723
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$5,555.56
Rate for Payer: Aetna Commercial	$3,333.33
Rate for Payer: Amerigroup CHIP/Medicaid	$1,000.00
Rate for Payer: BCBS of TX Blue Advantage	$3,333.33
Rate for Payer: BCBS of TX Blue Essentials	$4,000.00
Rate for Payer: BCBS of TX PPO	$4,444.44
Rate for Payer: Cash Price	$9,777.78
Rate for Payer: Multiplan Auto	$5,555.56
Rate for Payer: Multiplan Commercial	$5,555.56
Rate for Payer: Multiplan Workers Comp	$5,555.56
Rate for Payer: Scott and White EPO/PPO	$5,555.56
Rate for Payer: Superior Health Plan EPO	$1,511.11

STNT PERIPHERAL SUPERA -- DHF

Facility

$11,111.11

Service Code	HCPCS C1876
Hospital Charge Code	80622723
Hospital Revenue Code	278
Min. Negotiated Rate	$2,777.78
Max. Negotiated Rate	$5,555.56
Rate for Payer: Aetna Commercial	$3,333.33
Rate for Payer: Cash Price	$9,777.78
Rate for Payer: Cigna Commercial	$2,777.78
Rate for Payer: Multiplan Auto	$5,555.56
Rate for Payer: Multiplan Commercial	$5,555.56
Rate for Payer: Multiplan Workers Comp	$5,555.56
Rate for Payer: Scott and White EPO/PPO	$5,555.56

STNT VASCULAR SE INNOVA -- DHF

Facility

$7,379.52

Service Code	HCPCS C1876
Hospital Charge Code	80621816
Hospital Revenue Code	278
Min. Negotiated Rate	$1,844.88
Max. Negotiated Rate	$3,689.76
Rate for Payer: Aetna Commercial	$2,213.86
Rate for Payer: Cash Price	$6,493.98
Rate for Payer: Cigna Commercial	$1,844.88
Rate for Payer: Multiplan Auto	$3,689.76
Rate for Payer: Multiplan Commercial	$3,689.76
Rate for Payer: Multiplan Workers Comp	$3,689.76
Rate for Payer: Scott and White EPO/PPO	$3,689.76

STNT VASCULAR SE INNOVA -- DHF

Facility

$7,379.52

Service Code	HCPCS C1876
Hospital Charge Code	80621816
Hospital Revenue Code	278
Min. Negotiated Rate	$664.16
Max. Negotiated Rate	$3,689.76
Rate for Payer: Aetna Commercial	$2,213.86
Rate for Payer: Amerigroup CHIP/Medicaid	$664.16
Rate for Payer: BCBS of TX Blue Advantage	$2,213.86
Rate for Payer: BCBS of TX Blue Essentials	$2,656.63
Rate for Payer: BCBS of TX PPO	$2,951.81
Rate for Payer: Cash Price	$6,493.98
Rate for Payer: Multiplan Auto	$3,689.76
Rate for Payer: Multiplan Commercial	$3,689.76
Rate for Payer: Multiplan Workers Comp	$3,689.76
Rate for Payer: Scott and White EPO/PPO	$3,689.76
Rate for Payer: Superior Health Plan EPO	$1,003.61

STOCKINETTE, IMPERVIOUS SMALL 6'''' X 30'''' STERILE -- DHF

Facility

$354.16

Hospital Charge Code	80241557
Hospital Revenue Code	270
Min. Negotiated Rate	$31.87
Max. Negotiated Rate	$230.20
Rate for Payer: Aetna Commercial	$194.79
Rate for Payer: Amerigroup CHIP/Medicaid	$31.87
Rate for Payer: BCBS of TX Blue Advantage	$106.25
Rate for Payer: BCBS of TX Blue Essentials	$127.50
Rate for Payer: BCBS of TX PPO	$141.66
Rate for Payer: Cash Price	$311.66
Rate for Payer: Multiplan Auto	$230.20
Rate for Payer: Multiplan Commercial	$230.20
Rate for Payer: Multiplan Workers Comp	$230.20
Rate for Payer: Scott and White EPO/PPO	$177.08
Rate for Payer: Superior Health Plan EPO	$48.17

Know your out-of-pocket cost for care.

All Charges