White Rock Medical Center

All Charges

Charge

Type

Setting

Price

STENT ENDOPROS VIATOR CX

Facility

$30,976.00

Service Code	HCPCS C1874
Hospital Charge Code	8482468
Hospital Revenue Code	278
Min. Negotiated Rate	$7,744.00
Max. Negotiated Rate	$15,488.00
Rate for Payer: Cash Price	$21,063.68
Rate for Payer: Cigna Commercial	$7,744.00
Rate for Payer: Multiplan Auto	$15,488.00
Rate for Payer: Multiplan Commercial	$15,488.00
Rate for Payer: Multiplan Workers Comp	$15,488.00
Rate for Payer: Scott and White EPO/PPO	$15,488.00

STENT ENDOPROS VIATOR CX

Facility

$30,976.00

Service Code	HCPCS C1874
Hospital Charge Code	8482468
Hospital Revenue Code	278
Min. Negotiated Rate	$2,787.84
Max. Negotiated Rate	$22,302.72
Rate for Payer: Amerigroup CHIP/Medicaid	$2,787.84
Rate for Payer: BCBS of TX Blue Advantage	$9,292.80
Rate for Payer: BCBS of TX Blue Essentials	$11,151.36
Rate for Payer: BCBS of TX PPO	$12,390.40
Rate for Payer: Cash Price	$21,063.68
Rate for Payer: Cigna Medicaid	$22,302.72
Rate for Payer: Molina CHIP/Medicaid	$22,302.72
Rate for Payer: Multiplan Auto	$15,488.00
Rate for Payer: Multiplan Commercial	$15,488.00
Rate for Payer: Multiplan Workers Comp	$15,488.00
Rate for Payer: Parkland Medicaid	$22,302.72
Rate for Payer: Scott and White EPO/PPO	$15,488.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$22,302.72
Rate for Payer: Superior Health Plan EPO	$4,212.74

STENT INTEGRITY RX-BMS

Facility

$3,012.00

Service Code	HCPCS C1874
Hospital Charge Code	8574472
Hospital Revenue Code	278
Min. Negotiated Rate	$271.08
Max. Negotiated Rate	$2,168.64
Rate for Payer: Amerigroup CHIP/Medicaid	$271.08
Rate for Payer: BCBS of TX Blue Advantage	$903.60
Rate for Payer: BCBS of TX Blue Essentials	$1,084.32
Rate for Payer: BCBS of TX PPO	$1,204.80
Rate for Payer: Cash Price	$2,048.16
Rate for Payer: Cigna Medicaid	$2,168.64
Rate for Payer: Molina CHIP/Medicaid	$2,168.64
Rate for Payer: Multiplan Auto	$1,506.00
Rate for Payer: Multiplan Commercial	$1,506.00
Rate for Payer: Multiplan Workers Comp	$1,506.00
Rate for Payer: Parkland Medicaid	$2,168.64
Rate for Payer: Scott and White EPO/PPO	$1,506.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,168.64
Rate for Payer: Superior Health Plan EPO	$409.63

STENT INTEGRITY RX-BMS

Facility

$3,012.00

Service Code	HCPCS C1874
Hospital Charge Code	8574472
Hospital Revenue Code	278
Min. Negotiated Rate	$753.00
Max. Negotiated Rate	$1,506.00
Rate for Payer: Cash Price	$2,048.16
Rate for Payer: Cigna Commercial	$753.00
Rate for Payer: Multiplan Auto	$1,506.00
Rate for Payer: Multiplan Commercial	$1,506.00
Rate for Payer: Multiplan Workers Comp	$1,506.00
Rate for Payer: Scott and White EPO/PPO	$1,506.00

Stent, non-coated/non-covered, with delivery system

Facility

$35,563.92

Service Code	HCPCS C1876
Hospital Charge Code	990968
Hospital Revenue Code	278
Min. Negotiated Rate	$3,200.75
Max. Negotiated Rate	$25,606.02
Rate for Payer: Amerigroup CHIP/Medicaid	$3,200.75
Rate for Payer: BCBS of TX Blue Advantage	$10,669.18
Rate for Payer: BCBS of TX Blue Essentials	$12,803.01
Rate for Payer: BCBS of TX PPO	$14,225.57
Rate for Payer: Cash Price	$24,183.47
Rate for Payer: Cigna Medicaid	$25,606.02
Rate for Payer: Molina CHIP/Medicaid	$25,606.02
Rate for Payer: Multiplan Auto	$17,781.96
Rate for Payer: Multiplan Commercial	$17,781.96
Rate for Payer: Multiplan Workers Comp	$17,781.96
Rate for Payer: Parkland Medicaid	$25,606.02
Rate for Payer: Scott and White EPO/PPO	$17,781.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$25,606.02
Rate for Payer: Superior Health Plan EPO	$4,836.69

Stent, non-coated/non-covered, with delivery system

Facility

$35,563.92

Service Code	HCPCS C1876
Hospital Charge Code	990968
Hospital Revenue Code	278
Min. Negotiated Rate	$8,890.98
Max. Negotiated Rate	$17,781.96
Rate for Payer: Cash Price	$24,183.47
Rate for Payer: Cigna Commercial	$8,890.98
Rate for Payer: Multiplan Auto	$17,781.96
Rate for Payer: Multiplan Commercial	$17,781.96
Rate for Payer: Multiplan Workers Comp	$17,781.96
Rate for Payer: Scott and White EPO/PPO	$17,781.96

STENT ONYXNG22515UX

Facility

$2,710.84

Service Code	HCPCS C1876
Hospital Charge Code	991295
Hospital Revenue Code	278
Min. Negotiated Rate	$677.71
Max. Negotiated Rate	$1,355.42
Rate for Payer: Cash Price	$1,843.37
Rate for Payer: Cigna Commercial	$677.71
Rate for Payer: Multiplan Auto	$1,355.42
Rate for Payer: Multiplan Commercial	$1,355.42
Rate for Payer: Multiplan Workers Comp	$1,355.42
Rate for Payer: Scott and White EPO/PPO	$1,355.42

STENT ONYXNG22515UX

Facility

$2,710.84

Service Code	HCPCS C1876
Hospital Charge Code	991295
Hospital Revenue Code	278
Min. Negotiated Rate	$243.98
Max. Negotiated Rate	$1,951.80
Rate for Payer: Amerigroup CHIP/Medicaid	$243.98
Rate for Payer: BCBS of TX Blue Advantage	$813.25
Rate for Payer: BCBS of TX Blue Essentials	$975.90
Rate for Payer: BCBS of TX PPO	$1,084.34
Rate for Payer: Cash Price	$1,843.37
Rate for Payer: Cigna Medicaid	$1,951.80
Rate for Payer: Molina CHIP/Medicaid	$1,951.80
Rate for Payer: Multiplan Auto	$1,355.42
Rate for Payer: Multiplan Commercial	$1,355.42
Rate for Payer: Multiplan Workers Comp	$1,355.42
Rate for Payer: Parkland Medicaid	$1,951.80
Rate for Payer: Scott and White EPO/PPO	$1,355.42
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,951.80
Rate for Payer: Superior Health Plan EPO	$368.67

STENT PANC 4.5FR PUSHER

Facility

$342.00

Service Code	HCPCS C1874
Hospital Charge Code	109498
Hospital Revenue Code	278
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$171.00
Rate for Payer: Cash Price	$232.56
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Multiplan Auto	$171.00
Rate for Payer: Multiplan Commercial	$171.00
Rate for Payer: Multiplan Workers Comp	$171.00
Rate for Payer: Scott and White EPO/PPO	$171.00

STENT PANC 4.5FR PUSHER

Facility

$342.00

Service Code	HCPCS C1874
Hospital Charge Code	109498
Hospital Revenue Code	278
Min. Negotiated Rate	$30.78
Max. Negotiated Rate	$246.24
Rate for Payer: Amerigroup CHIP/Medicaid	$30.78
Rate for Payer: BCBS of TX Blue Advantage	$102.60
Rate for Payer: BCBS of TX Blue Essentials	$123.12
Rate for Payer: BCBS of TX PPO	$136.80
Rate for Payer: Cash Price	$232.56
Rate for Payer: Cigna Medicaid	$246.24
Rate for Payer: Molina CHIP/Medicaid	$246.24
Rate for Payer: Multiplan Auto	$171.00
Rate for Payer: Multiplan Commercial	$171.00
Rate for Payer: Multiplan Workers Comp	$171.00
Rate for Payer: Parkland Medicaid	$246.24
Rate for Payer: Scott and White EPO/PPO	$171.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$246.24
Rate for Payer: Superior Health Plan EPO	$46.51

STENT PK PAPYRUS 2.5X15 434887

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	145221
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 PK PAPYRUS 2.5X15 434887

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	145221
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 PK PAPYRUS 2.5X20 434893

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	145222
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 PK PAPYRUS 2.5X20 434893

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	145222
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 PK PAPYRUS 3.5X15 434889

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	145223
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 PK PAPYRUS 3.5X15 434889

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	145223
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 PK PAPYRUS 3.5X26 434900

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	145224
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 PK PAPYRUS 3.5X26 434900

Facility

$18,072.00

Service Code	HCPCS C1876
Hospital Charge Code	145224
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 PLMT CTR DIALYSIS SEG

Facility

$10,677.00

Service Code	HCPCS 36908
Hospital Charge Code	2351107
Hospital Revenue Code	360
Rate for Payer: Cash Price	$7,260.36

STENT PLMT CTR DIALYSIS SEG

Facility

$10,677.00

Service Code	HCPCS 36908
Hospital Charge Code	2351107
Hospital Revenue Code	360
Min. Negotiated Rate	$960.93
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$960.93
Rate for Payer: BCBS of TX Blue Advantage	$3,203.10
Rate for Payer: BCBS of TX Blue Essentials	$3,843.72
Rate for Payer: BCBS of TX PPO	$4,270.80
Rate for Payer: Cash Price	$7,260.36
Rate for Payer: Cash Price	$7,260.36
Rate for Payer: Cigna Medicaid	$7,687.44
Rate for Payer: Molina CHIP/Medicaid	$7,687.44
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: Parkland Medicaid	$7,687.44
Rate for Payer: Scott and White EPO/PPO	$5,338.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,687.44
Rate for Payer: Superior Health Plan EPO	$1,452.07

STENT STRAIGHT ADVANTIX 3FRX5CM

Facility

$452.00

Service Code	HCPCS C1874
Hospital Charge Code	144809
Hospital Revenue Code	278
Min. Negotiated Rate	$113.00
Max. Negotiated Rate	$226.00
Rate for Payer: Cash Price	$307.36
Rate for Payer: Cigna Commercial	$113.00
Rate for Payer: Multiplan Auto	$226.00
Rate for Payer: Multiplan Commercial	$226.00
Rate for Payer: Multiplan Workers Comp	$226.00
Rate for Payer: Scott and White EPO/PPO	$226.00

STENT STRAIGHT ADVANTIX 3FRX5CM

Facility

$452.00

Service Code	HCPCS C1874
Hospital Charge Code	144809
Hospital Revenue Code	278
Min. Negotiated Rate	$40.68
Max. Negotiated Rate	$325.44
Rate for Payer: Amerigroup CHIP/Medicaid	$40.68
Rate for Payer: BCBS of TX Blue Advantage	$135.60
Rate for Payer: BCBS of TX Blue Essentials	$162.72
Rate for Payer: BCBS of TX PPO	$180.80
Rate for Payer: Cash Price	$307.36
Rate for Payer: Cigna Medicaid	$325.44
Rate for Payer: Molina CHIP/Medicaid	$325.44
Rate for Payer: Multiplan Auto	$226.00
Rate for Payer: Multiplan Commercial	$226.00
Rate for Payer: Multiplan Workers Comp	$226.00
Rate for Payer: Parkland Medicaid	$325.44
Rate for Payer: Scott and White EPO/PPO	$226.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$325.44
Rate for Payer: Superior Health Plan EPO	$61.47

STENT SYSTEM CORONARY ONYX FRONTIER RX 2.00 x 08MM

Facility

$8,253.01

Service Code	HCPCS C1876
Hospital Charge Code	991284
Hospital Revenue Code	278
Min. Negotiated Rate	$742.77
Max. Negotiated Rate	$5,942.17
Rate for Payer: Amerigroup CHIP/Medicaid	$742.77
Rate for Payer: BCBS of TX Blue Advantage	$2,475.90
Rate for Payer: BCBS of TX Blue Essentials	$2,971.08
Rate for Payer: BCBS of TX PPO	$3,301.20
Rate for Payer: Cash Price	$5,612.05
Rate for Payer: Cigna Medicaid	$5,942.17
Rate for Payer: Molina CHIP/Medicaid	$5,942.17
Rate for Payer: Multiplan Auto	$4,126.51
Rate for Payer: Multiplan Commercial	$4,126.51
Rate for Payer: Multiplan Workers Comp	$4,126.51
Rate for Payer: Parkland Medicaid	$5,942.17
Rate for Payer: Scott and White EPO/PPO	$4,126.51
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,942.17
Rate for Payer: Superior Health Plan EPO	$1,122.41

STENT SYSTEM CORONARY ONYX FRONTIER RX 2.00 x 08MM

Facility

$8,253.01

Service Code	HCPCS C1876
Hospital Charge Code	991284
Hospital Revenue Code	278
Min. Negotiated Rate	$2,063.25
Max. Negotiated Rate	$4,126.51
Rate for Payer: Cash Price	$5,612.05
Rate for Payer: Cigna Commercial	$2,063.25
Rate for Payer: Multiplan Auto	$4,126.51
Rate for Payer: Multiplan Commercial	$4,126.51
Rate for Payer: Multiplan Workers Comp	$4,126.51
Rate for Payer: Scott and White EPO/PPO	$4,126.51

STENT SYSTEM CORONARY ONYX FRONTIER RX 2.00 x 12MM

Facility

$8,253.01

Service Code	HCPCS C1876
Hospital Charge Code	991252
Hospital Revenue Code	278
Min. Negotiated Rate	$2,063.25
Max. Negotiated Rate	$4,126.51
Rate for Payer: Cash Price	$5,612.05
Rate for Payer: Cigna Commercial	$2,063.25
Rate for Payer: Multiplan Auto	$4,126.51
Rate for Payer: Multiplan Commercial	$4,126.51
Rate for Payer: Multiplan Workers Comp	$4,126.51
Rate for Payer: Scott and White EPO/PPO	$4,126.51

Know your out-of-pocket cost for care.

All Charges