White Rock Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 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	$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

STENT BIOTRONIK PULSAR-18 7X60X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145624
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 7X60X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145624
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 BIOTRONIKPULSAR-18 7X80X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145625
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 BIOTRONIKPULSAR-18 7X80X135

Facility

$3,614.00

Service Code	HCPCS C1874
Hospital Charge Code	145625
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, coated/covered, with delivery system

Facility

$27,217.29

Service Code	HCPCS C1874
Hospital Charge Code	990977
Hospital Revenue Code	275
Min. Negotiated Rate	$6,804.32
Max. Negotiated Rate	$13,608.65
Rate for Payer: Cash Price	$18,507.76
Rate for Payer: Cigna Commercial	$6,804.32
Rate for Payer: Multiplan Auto	$13,608.65
Rate for Payer: Multiplan Commercial	$13,608.65
Rate for Payer: Multiplan Workers Comp	$13,608.65
Rate for Payer: Scott and White EPO/PPO	$13,608.65

Stent, coated/covered, with delivery system

Facility

$27,217.29

Service Code	HCPCS C1874
Hospital Charge Code	990977
Hospital Revenue Code	275
Min. Negotiated Rate	$2,449.56
Max. Negotiated Rate	$19,596.45
Rate for Payer: Amerigroup CHIP/Medicaid	$2,449.56
Rate for Payer: BCBS of TX Blue Advantage	$8,165.19
Rate for Payer: BCBS of TX Blue Essentials	$9,798.22
Rate for Payer: BCBS of TX PPO	$10,886.92
Rate for Payer: Cash Price	$18,507.76
Rate for Payer: Cigna Medicaid	$19,596.45
Rate for Payer: Molina CHIP/Medicaid	$19,596.45
Rate for Payer: Multiplan Auto	$13,608.65
Rate for Payer: Multiplan Commercial	$13,608.65
Rate for Payer: Multiplan Workers Comp	$13,608.65
Rate for Payer: Parkland Medicaid	$19,596.45
Rate for Payer: Scott and White EPO/PPO	$13,608.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$19,596.45
Rate for Payer: Superior Health Plan EPO	$3,701.55

STENT CORDIS PALMAZ 7MMx29MM

Facility

$4,269.58

Service Code	HCPCS C1878
Hospital Charge Code	109511
Hospital Revenue Code	278
Min. Negotiated Rate	$384.26
Max. Negotiated Rate	$3,074.10
Rate for Payer: Amerigroup CHIP/Medicaid	$384.26
Rate for Payer: BCBS of TX Blue Advantage	$1,280.87
Rate for Payer: BCBS of TX Blue Essentials	$1,537.05
Rate for Payer: BCBS of TX PPO	$1,707.83
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Medicaid	$3,074.10
Rate for Payer: Molina CHIP/Medicaid	$3,074.10
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Parkland Medicaid	$3,074.10
Rate for Payer: Scott and White EPO/PPO	$2,134.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,074.10
Rate for Payer: Superior Health Plan EPO	$580.66

STENT CORDIS PALMAZ 7MMx29MM

Facility

$4,269.58

Service Code	HCPCS C1878
Hospital Charge Code	109511
Hospital Revenue Code	278
Min. Negotiated Rate	$1,067.39
Max. Negotiated Rate	$2,134.79
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Commercial	$1,067.39
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Scott and White EPO/PPO	$2,134.79

STENT CORDIS PALMAZ 7MMx39MM

Facility

$4,269.58

Service Code	HCPCS c1878
Hospital Charge Code	109510
Hospital Revenue Code	278
Min. Negotiated Rate	$384.26
Max. Negotiated Rate	$3,074.10
Rate for Payer: Amerigroup CHIP/Medicaid	$384.26
Rate for Payer: BCBS of TX Blue Advantage	$1,280.87
Rate for Payer: BCBS of TX Blue Essentials	$1,537.05
Rate for Payer: BCBS of TX PPO	$1,707.83
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Medicaid	$3,074.10
Rate for Payer: Molina CHIP/Medicaid	$3,074.10
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Parkland Medicaid	$3,074.10
Rate for Payer: Scott and White EPO/PPO	$2,134.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,074.10
Rate for Payer: Superior Health Plan EPO	$580.66

STENT CORDIS PALMAZ 7MMx39MM

Facility

$4,269.58

Service Code	HCPCS c1878
Hospital Charge Code	109510
Hospital Revenue Code	278
Min. Negotiated Rate	$1,067.39
Max. Negotiated Rate	$2,134.79
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Commercial	$1,067.39
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Scott and White EPO/PPO	$2,134.79

STENT CORDIS PALMAZ 8MMx29MM

Facility

$4,269.58

Service Code	HCPCS C1876
Hospital Charge Code	109509
Hospital Revenue Code	278
Min. Negotiated Rate	$384.26
Max. Negotiated Rate	$3,074.10
Rate for Payer: Amerigroup CHIP/Medicaid	$384.26
Rate for Payer: BCBS of TX Blue Advantage	$1,280.87
Rate for Payer: BCBS of TX Blue Essentials	$1,537.05
Rate for Payer: BCBS of TX PPO	$1,707.83
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Medicaid	$3,074.10
Rate for Payer: Molina CHIP/Medicaid	$3,074.10
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Parkland Medicaid	$3,074.10
Rate for Payer: Scott and White EPO/PPO	$2,134.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,074.10
Rate for Payer: Superior Health Plan EPO	$580.66

STENT CORDIS PALMAZ 8MMx29MM

Facility

$4,269.58

Service Code	HCPCS C1876
Hospital Charge Code	109509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,067.39
Max. Negotiated Rate	$2,134.79
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Commercial	$1,067.39
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Scott and White EPO/PPO	$2,134.79

STENT CORDIS PALMAZ 8MMx39

Facility

$4,269.58

Service Code	HCPCS C1878
Hospital Charge Code	109508
Hospital Revenue Code	278
Min. Negotiated Rate	$384.26
Max. Negotiated Rate	$3,074.10
Rate for Payer: Amerigroup CHIP/Medicaid	$384.26
Rate for Payer: BCBS of TX Blue Advantage	$1,280.87
Rate for Payer: BCBS of TX Blue Essentials	$1,537.05
Rate for Payer: BCBS of TX PPO	$1,707.83
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Medicaid	$3,074.10
Rate for Payer: Molina CHIP/Medicaid	$3,074.10
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Parkland Medicaid	$3,074.10
Rate for Payer: Scott and White EPO/PPO	$2,134.79
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,074.10
Rate for Payer: Superior Health Plan EPO	$580.66

STENT CORDIS PALMAZ 8MMx39

Facility

$4,269.58

Service Code	HCPCS C1878
Hospital Charge Code	109508
Hospital Revenue Code	278
Min. Negotiated Rate	$1,067.39
Max. Negotiated Rate	$2,134.79
Rate for Payer: Cash Price	$2,903.31
Rate for Payer: Cigna Commercial	$1,067.39
Rate for Payer: Multiplan Auto	$2,134.79
Rate for Payer: Multiplan Commercial	$2,134.79
Rate for Payer: Multiplan Workers Comp	$2,134.79
Rate for Payer: Scott and White EPO/PPO	$2,134.79

STENT CORDIS PALMAZ BLUE 6MMX18

Facility

$5,319.00

Service Code	HCPCS C1874
Hospital Charge Code	109507
Hospital Revenue Code	278
Min. Negotiated Rate	$478.71
Max. Negotiated Rate	$3,829.68
Rate for Payer: Amerigroup CHIP/Medicaid	$478.71
Rate for Payer: BCBS of TX Blue Advantage	$1,595.70
Rate for Payer: BCBS of TX Blue Essentials	$1,914.84
Rate for Payer: BCBS of TX PPO	$2,127.60
Rate for Payer: Cash Price	$3,616.92
Rate for Payer: Cigna Medicaid	$3,829.68
Rate for Payer: Molina CHIP/Medicaid	$3,829.68
Rate for Payer: Multiplan Auto	$2,659.50
Rate for Payer: Multiplan Commercial	$2,659.50
Rate for Payer: Multiplan Workers Comp	$2,659.50
Rate for Payer: Parkland Medicaid	$3,829.68
Rate for Payer: Scott and White EPO/PPO	$2,659.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,829.68
Rate for Payer: Superior Health Plan EPO	$723.38

STENT CORDIS PALMAZ BLUE 6MMX18

Facility

$5,319.00

Service Code	HCPCS C1874
Hospital Charge Code	109507
Hospital Revenue Code	278
Min. Negotiated Rate	$1,329.75
Max. Negotiated Rate	$2,659.50
Rate for Payer: Cash Price	$3,616.92
Rate for Payer: Cigna Commercial	$1,329.75
Rate for Payer: Multiplan Auto	$2,659.50
Rate for Payer: Multiplan Commercial	$2,659.50
Rate for Payer: Multiplan Workers Comp	$2,659.50
Rate for Payer: Scott and White EPO/PPO	$2,659.50

STENT CORONARY DES RESOLUTE ONYX 3.50 X 22 RX

Facility

$602.00

Service Code	HCPCS C1874
Hospital Charge Code	80560931
Hospital Revenue Code	278
Min. Negotiated Rate	$54.18
Max. Negotiated Rate	$433.44
Rate for Payer: Amerigroup CHIP/Medicaid	$54.18
Rate for Payer: BCBS of TX Blue Advantage	$180.60
Rate for Payer: BCBS of TX Blue Essentials	$216.72
Rate for Payer: BCBS of TX PPO	$240.80
Rate for Payer: Cash Price	$409.36
Rate for Payer: Cigna Medicaid	$433.44
Rate for Payer: Molina CHIP/Medicaid	$433.44
Rate for Payer: Multiplan Auto	$301.00
Rate for Payer: Multiplan Commercial	$301.00
Rate for Payer: Multiplan Workers Comp	$301.00
Rate for Payer: Parkland Medicaid	$433.44
Rate for Payer: Scott and White EPO/PPO	$301.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$433.44
Rate for Payer: Superior Health Plan EPO	$81.87

Know your out-of-pocket cost for care.

All Charges