White Rock Medical Center

All Charges

Charge

Type

Setting

Price

STENT BIOTRONIK PULSAR-18 4X150X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145646
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 4X150X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145646
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 4X80X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145643
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 4X80X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145643
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 5X100X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145649
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 5X100X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145649
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 5X120X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145650
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 5X120X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145650
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 5X150X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145652
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 5X150X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145652
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 5X60X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145647
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 5X60X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145647
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 6X100X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145654
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 6X100X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145654
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 6X120X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145655
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 6X120X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145655
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 6X150X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145567
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 6X150X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145567
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 6X80X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145653
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 6X80X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145653
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 7X100X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145626
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 7X100X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145626
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 7X12X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145467
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 7X12X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145467
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 7X15X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145466
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

Know your out-of-pocket cost for care.

All Charges