White Rock Medical Center

All Charges

Charge

Type

Setting

Price

ST BLD FENWAL -- DHF

Facility

$379.76

Hospital Charge Code	54201116
Hospital Revenue Code	270
Min. Negotiated Rate	$34.18
Max. Negotiated Rate	$273.43
Rate for Payer: Amerigroup CHIP/Medicaid	$34.18
Rate for Payer: BCBS of TX Blue Advantage	$113.93
Rate for Payer: BCBS of TX Blue Essentials	$136.71
Rate for Payer: BCBS of TX PPO	$151.90
Rate for Payer: Cash Price	$258.24
Rate for Payer: Cigna Medicaid	$273.43
Rate for Payer: Molina CHIP/Medicaid	$273.43
Rate for Payer: Multiplan Auto	$246.84
Rate for Payer: Multiplan Commercial	$246.84
Rate for Payer: Multiplan Workers Comp	$246.84
Rate for Payer: Parkland Medicaid	$273.43
Rate for Payer: Scott and White EPO/PPO	$189.88
Rate for Payer: Superior Health Plan CHIP/Medicaid	$273.43
Rate for Payer: Superior Health Plan EPO	$51.65

STENT ABSOLUTE PRO 6X60X135

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	135878
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.00
Max. Negotiated Rate	$2,952.00
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Commercial	$1,476.00
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Scott and White EPO/PPO	$2,952.00

STENT ABSOLUTE PRO 6X60X135

Facility

$5,904.00

Service Code	HCPCS C1874
Hospital Charge Code	135878
Hospital Revenue Code	278
Min. Negotiated Rate	$531.36
Max. Negotiated Rate	$4,250.88
Rate for Payer: Amerigroup CHIP/Medicaid	$531.36
Rate for Payer: BCBS of TX Blue Advantage	$1,771.20
Rate for Payer: BCBS of TX Blue Essentials	$2,125.44
Rate for Payer: BCBS of TX PPO	$2,361.60
Rate for Payer: Cash Price	$4,014.72
Rate for Payer: Cigna Medicaid	$4,250.88
Rate for Payer: Molina CHIP/Medicaid	$4,250.88
Rate for Payer: Multiplan Auto	$2,952.00
Rate for Payer: Multiplan Commercial	$2,952.00
Rate for Payer: Multiplan Workers Comp	$2,952.00
Rate for Payer: Parkland Medicaid	$4,250.88
Rate for Payer: Scott and White EPO/PPO	$2,952.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,250.88
Rate for Payer: Superior Health Plan EPO	$802.94

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

Facility

$313.00

Service Code	HCPCS C1874
Hospital Charge Code	109607
Hospital Revenue Code	278
Min. Negotiated Rate	$78.25
Max. Negotiated Rate	$156.50
Rate for Payer: Cash Price	$212.84
Rate for Payer: Cigna Commercial	$78.25
Rate for Payer: Multiplan Auto	$156.50
Rate for Payer: Multiplan Commercial	$156.50
Rate for Payer: Multiplan Workers Comp	$156.50
Rate for Payer: Scott and White EPO/PPO	$156.50

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

Facility

$313.00

Service Code	HCPCS C1874
Hospital Charge Code	109607
Hospital Revenue Code	278
Min. Negotiated Rate	$28.17
Max. Negotiated Rate	$225.36
Rate for Payer: Amerigroup CHIP/Medicaid	$28.17
Rate for Payer: BCBS of TX Blue Advantage	$93.90
Rate for Payer: BCBS of TX Blue Essentials	$112.68
Rate for Payer: BCBS of TX PPO	$125.20
Rate for Payer: Cash Price	$212.84
Rate for Payer: Cigna Medicaid	$225.36
Rate for Payer: Molina CHIP/Medicaid	$225.36
Rate for Payer: Multiplan Auto	$156.50
Rate for Payer: Multiplan Commercial	$156.50
Rate for Payer: Multiplan Workers Comp	$156.50
Rate for Payer: Parkland Medicaid	$225.36
Rate for Payer: Scott and White EPO/PPO	$156.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$225.36
Rate for Payer: Superior Health Plan EPO	$42.57

stent advanix duodenal bend preloaded 10frx9cm

Facility

$777.00

Service Code	HCPCS C1874
Hospital Charge Code	109495
Hospital Revenue Code	278
Min. Negotiated Rate	$69.93
Max. Negotiated Rate	$559.44
Rate for Payer: Amerigroup CHIP/Medicaid	$69.93
Rate for Payer: BCBS of TX Blue Advantage	$233.10
Rate for Payer: BCBS of TX Blue Essentials	$279.72
Rate for Payer: BCBS of TX PPO	$310.80
Rate for Payer: Cash Price	$528.36
Rate for Payer: Cigna Medicaid	$559.44
Rate for Payer: Molina CHIP/Medicaid	$559.44
Rate for Payer: Multiplan Auto	$388.50
Rate for Payer: Multiplan Commercial	$388.50
Rate for Payer: Multiplan Workers Comp	$388.50
Rate for Payer: Parkland Medicaid	$559.44
Rate for Payer: Scott and White EPO/PPO	$388.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$559.44
Rate for Payer: Superior Health Plan EPO	$105.67

stent advanix duodenal bend preloaded 10frx9cm

Facility

$777.00

Service Code	HCPCS C1874
Hospital Charge Code	109495
Hospital Revenue Code	278
Min. Negotiated Rate	$194.25
Max. Negotiated Rate	$388.50
Rate for Payer: Cash Price	$528.36
Rate for Payer: Cigna Commercial	$194.25
Rate for Payer: Multiplan Auto	$388.50
Rate for Payer: Multiplan Commercial	$388.50
Rate for Payer: Multiplan Workers Comp	$388.50
Rate for Payer: Scott and White EPO/PPO	$388.50

STENT ADVANTIX DOUBLE PIGTAIL SINGLE

Facility

$313.00

Service Code	HCPCS C1874
Hospital Charge Code	144808
Hospital Revenue Code	278
Min. Negotiated Rate	$78.25
Max. Negotiated Rate	$156.50
Rate for Payer: Cash Price	$212.84
Rate for Payer: Cigna Commercial	$78.25
Rate for Payer: Multiplan Auto	$156.50
Rate for Payer: Multiplan Commercial	$156.50
Rate for Payer: Multiplan Workers Comp	$156.50
Rate for Payer: Scott and White EPO/PPO	$156.50

STENT ADVANTIX DOUBLE PIGTAIL SINGLE

Facility

$313.00

Service Code	HCPCS C1874
Hospital Charge Code	144808
Hospital Revenue Code	278
Min. Negotiated Rate	$28.17
Max. Negotiated Rate	$225.36
Rate for Payer: Amerigroup CHIP/Medicaid	$28.17
Rate for Payer: BCBS of TX Blue Advantage	$93.90
Rate for Payer: BCBS of TX Blue Essentials	$112.68
Rate for Payer: BCBS of TX PPO	$125.20
Rate for Payer: Cash Price	$212.84
Rate for Payer: Cigna Medicaid	$225.36
Rate for Payer: Molina CHIP/Medicaid	$225.36
Rate for Payer: Multiplan Auto	$156.50
Rate for Payer: Multiplan Commercial	$156.50
Rate for Payer: Multiplan Workers Comp	$156.50
Rate for Payer: Parkland Medicaid	$225.36
Rate for Payer: Scott and White EPO/PPO	$156.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$225.36
Rate for Payer: Superior Health Plan EPO	$42.57

stent advantix duodenal bend preloaded 10fr

Facility

$777.00

Service Code	HCPCS C1874
Hospital Charge Code	109494
Hospital Revenue Code	278
Min. Negotiated Rate	$194.25
Max. Negotiated Rate	$388.50
Rate for Payer: Cash Price	$528.36
Rate for Payer: Cigna Commercial	$194.25
Rate for Payer: Multiplan Auto	$388.50
Rate for Payer: Multiplan Commercial	$388.50
Rate for Payer: Multiplan Workers Comp	$388.50
Rate for Payer: Scott and White EPO/PPO	$388.50

stent advantix duodenal bend preloaded 10fr

Facility

$777.00

Service Code	HCPCS C1874
Hospital Charge Code	109494
Hospital Revenue Code	278
Min. Negotiated Rate	$69.93
Max. Negotiated Rate	$559.44
Rate for Payer: Amerigroup CHIP/Medicaid	$69.93
Rate for Payer: BCBS of TX Blue Advantage	$233.10
Rate for Payer: BCBS of TX Blue Essentials	$279.72
Rate for Payer: BCBS of TX PPO	$310.80
Rate for Payer: Cash Price	$528.36
Rate for Payer: Cigna Medicaid	$559.44
Rate for Payer: Molina CHIP/Medicaid	$559.44
Rate for Payer: Multiplan Auto	$388.50
Rate for Payer: Multiplan Commercial	$388.50
Rate for Payer: Multiplan Workers Comp	$388.50
Rate for Payer: Parkland Medicaid	$559.44
Rate for Payer: Scott and White EPO/PPO	$388.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$559.44
Rate for Payer: Superior Health Plan EPO	$105.67

stent biomimics 3d 100/125/150 mm

Facility

$8,133.00

Service Code	HCPCS C1874
Hospital Charge Code	144800
Hospital Revenue Code	278
Min. Negotiated Rate	$731.97
Max. Negotiated Rate	$5,855.76
Rate for Payer: Amerigroup CHIP/Medicaid	$731.97
Rate for Payer: BCBS of TX Blue Advantage	$2,439.90
Rate for Payer: BCBS of TX Blue Essentials	$2,927.88
Rate for Payer: BCBS of TX PPO	$3,253.20
Rate for Payer: Cash Price	$5,530.44
Rate for Payer: Cigna Medicaid	$5,855.76
Rate for Payer: Molina CHIP/Medicaid	$5,855.76
Rate for Payer: Multiplan Auto	$4,066.50
Rate for Payer: Multiplan Commercial	$4,066.50
Rate for Payer: Multiplan Workers Comp	$4,066.50
Rate for Payer: Parkland Medicaid	$5,855.76
Rate for Payer: Scott and White EPO/PPO	$4,066.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,855.76
Rate for Payer: Superior Health Plan EPO	$1,106.09

stent biomimics 3d 100/125/150 mm

Facility

$8,133.00

Service Code	HCPCS C1874
Hospital Charge Code	144800
Hospital Revenue Code	278
Min. Negotiated Rate	$2,033.25
Max. Negotiated Rate	$4,066.50
Rate for Payer: Cash Price	$5,530.44
Rate for Payer: Cigna Commercial	$2,033.25
Rate for Payer: Multiplan Auto	$4,066.50
Rate for Payer: Multiplan Commercial	$4,066.50
Rate for Payer: Multiplan Workers Comp	$4,066.50
Rate for Payer: Scott and White EPO/PPO	$4,066.50

stent biomimics 3d 60/80mm

Facility

$6,928.00

Service Code	HCPCS C1874
Hospital Charge Code	144798
Hospital Revenue Code	278
Min. Negotiated Rate	$1,732.00
Max. Negotiated Rate	$3,464.00
Rate for Payer: Cash Price	$4,711.04
Rate for Payer: Cigna Commercial	$1,732.00
Rate for Payer: Multiplan Auto	$3,464.00
Rate for Payer: Multiplan Commercial	$3,464.00
Rate for Payer: Multiplan Workers Comp	$3,464.00
Rate for Payer: Scott and White EPO/PPO	$3,464.00

stent biomimics 3d 60/80mm

Facility

$6,928.00

Service Code	HCPCS C1874
Hospital Charge Code	144798
Hospital Revenue Code	278
Min. Negotiated Rate	$623.52
Max. Negotiated Rate	$4,988.16
Rate for Payer: Amerigroup CHIP/Medicaid	$623.52
Rate for Payer: BCBS of TX Blue Advantage	$2,078.40
Rate for Payer: BCBS of TX Blue Essentials	$2,494.08
Rate for Payer: BCBS of TX PPO	$2,771.20
Rate for Payer: Cash Price	$4,711.04
Rate for Payer: Cigna Medicaid	$4,988.16
Rate for Payer: Molina CHIP/Medicaid	$4,988.16
Rate for Payer: Multiplan Auto	$3,464.00
Rate for Payer: Multiplan Commercial	$3,464.00
Rate for Payer: Multiplan Workers Comp	$3,464.00
Rate for Payer: Parkland Medicaid	$4,988.16
Rate for Payer: Scott and White EPO/PPO	$3,464.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,988.16
Rate for Payer: Superior Health Plan EPO	$942.21

stent biotronic pk papyrus

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	144822
Hospital Revenue Code	278
Min. Negotiated Rate	$1,626.48
Max. Negotiated Rate	$13,011.84
Rate for Payer: Amerigroup CHIP/Medicaid	$1,626.48
Rate for Payer: BCBS of TX Blue Advantage	$5,421.60
Rate for Payer: BCBS of TX Blue Essentials	$6,505.92
Rate for Payer: BCBS of TX PPO	$7,228.80
Rate for Payer: Cash Price	$12,288.96
Rate for Payer: Cigna Medicaid	$13,011.84
Rate for Payer: Molina CHIP/Medicaid	$13,011.84
Rate for Payer: Multiplan Auto	$9,036.00
Rate for Payer: Multiplan Commercial	$9,036.00
Rate for Payer: Multiplan Workers Comp	$9,036.00
Rate for Payer: Parkland Medicaid	$13,011.84
Rate for Payer: Scott and White EPO/PPO	$9,036.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,011.84
Rate for Payer: Superior Health Plan EPO	$2,457.79

stent biotronic pk papyrus

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	144822
Hospital Revenue Code	278
Min. Negotiated Rate	$4,518.00
Max. Negotiated Rate	$9,036.00
Rate for Payer: Cash Price	$12,288.96
Rate for Payer: Cigna Commercial	$4,518.00
Rate for Payer: Multiplan Auto	$9,036.00
Rate for Payer: Multiplan Commercial	$9,036.00
Rate for Payer: Multiplan Workers Comp	$9,036.00
Rate for Payer: Scott and White EPO/PPO	$9,036.00

STENT BIOTRONIC PULSAR-18 4X60X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145642
Hospital Revenue Code	278
Min. Negotiated Rate	$903.50
Max. Negotiated Rate	$1,807.00
Rate for Payer: Cash Price	$2,457.52
Rate for Payer: Cigna Commercial	$903.50
Rate for Payer: Multiplan Auto	$1,807.00
Rate for Payer: Multiplan Commercial	$1,807.00
Rate for Payer: Multiplan Workers Comp	$1,807.00
Rate for Payer: Scott and White EPO/PPO	$1,807.00

STENT BIOTRONIC PULSAR-18 4X60X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145642
Hospital Revenue Code	278
Min. Negotiated Rate	$325.26
Max. Negotiated Rate	$2,602.08
Rate for Payer: Amerigroup CHIP/Medicaid	$325.26
Rate for Payer: BCBS of TX Blue Advantage	$1,084.20
Rate for Payer: BCBS of TX Blue Essentials	$1,301.04
Rate for Payer: BCBS of TX PPO	$1,445.60
Rate for Payer: Cash Price	$2,457.52
Rate for Payer: Cigna Medicaid	$2,602.08
Rate for Payer: Molina CHIP/Medicaid	$2,602.08
Rate for Payer: Multiplan Auto	$1,807.00
Rate for Payer: Multiplan Commercial	$1,807.00
Rate for Payer: Multiplan Workers Comp	$1,807.00
Rate for Payer: Parkland Medicaid	$2,602.08
Rate for Payer: Scott and White EPO/PPO	$1,807.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,602.08
Rate for Payer: Superior Health Plan EPO	$491.50

STENT BIOTRONIK PULSAR-18 390716

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145648
Hospital Revenue Code	278
Min. Negotiated Rate	$325.26
Max. Negotiated Rate	$2,602.08
Rate for Payer: Amerigroup CHIP/Medicaid	$325.26
Rate for Payer: BCBS of TX Blue Advantage	$1,084.20
Rate for Payer: BCBS of TX Blue Essentials	$1,301.04
Rate for Payer: BCBS of TX PPO	$1,445.60
Rate for Payer: Cash Price	$2,457.52
Rate for Payer: Cigna Medicaid	$2,602.08
Rate for Payer: Molina CHIP/Medicaid	$2,602.08
Rate for Payer: Multiplan Auto	$1,807.00
Rate for Payer: Multiplan Commercial	$1,807.00
Rate for Payer: Multiplan Workers Comp	$1,807.00
Rate for Payer: Parkland Medicaid	$2,602.08
Rate for Payer: Scott and White EPO/PPO	$1,807.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,602.08
Rate for Payer: Superior Health Plan EPO	$491.50

STENT BIOTRONIK PULSAR-18 390716

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145648
Hospital Revenue Code	278
Min. Negotiated Rate	$903.50
Max. Negotiated Rate	$1,807.00
Rate for Payer: Cash Price	$2,457.52
Rate for Payer: Cigna Commercial	$903.50
Rate for Payer: Multiplan Auto	$1,807.00
Rate for Payer: Multiplan Commercial	$1,807.00
Rate for Payer: Multiplan Workers Comp	$1,807.00
Rate for Payer: Scott and White EPO/PPO	$1,807.00

STENT BIOTRONIK PULSAR-18 4X100X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145644
Hospital Revenue Code	278
Min. Negotiated Rate	$325.26
Max. Negotiated Rate	$2,602.08
Rate for Payer: Amerigroup CHIP/Medicaid	$325.26
Rate for Payer: BCBS of TX Blue Advantage	$1,084.20
Rate for Payer: BCBS of TX Blue Essentials	$1,301.04
Rate for Payer: BCBS of TX PPO	$1,445.60
Rate for Payer: Cash Price	$2,457.52
Rate for Payer: Cigna Medicaid	$2,602.08
Rate for Payer: Molina CHIP/Medicaid	$2,602.08
Rate for Payer: Multiplan Auto	$1,807.00
Rate for Payer: Multiplan Commercial	$1,807.00
Rate for Payer: Multiplan Workers Comp	$1,807.00
Rate for Payer: Parkland Medicaid	$2,602.08
Rate for Payer: Scott and White EPO/PPO	$1,807.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,602.08
Rate for Payer: Superior Health Plan EPO	$491.50

STENT BIOTRONIK PULSAR-18 4X100X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145644
Hospital Revenue Code	278
Min. Negotiated Rate	$903.50
Max. Negotiated Rate	$1,807.00
Rate for Payer: Cash Price	$2,457.52
Rate for Payer: Cigna Commercial	$903.50
Rate for Payer: Multiplan Auto	$1,807.00
Rate for Payer: Multiplan Commercial	$1,807.00
Rate for Payer: Multiplan Workers Comp	$1,807.00
Rate for Payer: Scott and White EPO/PPO	$1,807.00

STENT BIOTRONIK PULSAR-18 4X120X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145645
Hospital Revenue Code	278
Min. Negotiated Rate	$325.26
Max. Negotiated Rate	$2,602.08
Rate for Payer: Amerigroup CHIP/Medicaid	$325.26
Rate for Payer: BCBS of TX Blue Advantage	$1,084.20
Rate for Payer: BCBS of TX Blue Essentials	$1,301.04
Rate for Payer: BCBS of TX PPO	$1,445.60
Rate for Payer: Cash Price	$2,457.52
Rate for Payer: Cigna Medicaid	$2,602.08
Rate for Payer: Molina CHIP/Medicaid	$2,602.08
Rate for Payer: Multiplan Auto	$1,807.00
Rate for Payer: Multiplan Commercial	$1,807.00
Rate for Payer: Multiplan Workers Comp	$1,807.00
Rate for Payer: Parkland Medicaid	$2,602.08
Rate for Payer: Scott and White EPO/PPO	$1,807.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,602.08
Rate for Payer: Superior Health Plan EPO	$491.50

STENT BIOTRONIK PULSAR-18 4X120X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145645
Hospital Revenue Code	278
Min. Negotiated Rate	$903.50
Max. Negotiated Rate	$1,807.00
Rate for Payer: Cash Price	$2,457.52
Rate for Payer: Cigna Commercial	$903.50
Rate for Payer: Multiplan Auto	$1,807.00
Rate for Payer: Multiplan Commercial	$1,807.00
Rate for Payer: Multiplan Workers Comp	$1,807.00
Rate for Payer: Scott and White EPO/PPO	$1,807.00

Know your out-of-pocket cost for care.

All Charges