White Rock Medical Center

All Charges

Charge

Type

Setting

Price

STENT SYSTEM CORONARY ONYX FRONTIER RX 2.75 x 38MM

Facility

$4,518.07

Service Code	HCPCS C1876
Hospital Charge Code	991268
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.52
Max. Negotiated Rate	$2,259.03
Rate for Payer: Cash Price	$3,072.29
Rate for Payer: Cigna Commercial	$1,129.52
Rate for Payer: Multiplan Auto	$2,259.03
Rate for Payer: Multiplan Commercial	$2,259.03
Rate for Payer: Multiplan Workers Comp	$2,259.03
Rate for Payer: Scott and White EPO/PPO	$2,259.03

STENT SYSTEM CORONARY ONYX FRONTIER RX 2.75 x 38MM

Facility

$4,518.07

Service Code	HCPCS C1876
Hospital Charge Code	991268
Hospital Revenue Code	278
Min. Negotiated Rate	$406.63
Max. Negotiated Rate	$3,253.01
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	$3,072.29
Rate for Payer: Cigna Medicaid	$3,253.01
Rate for Payer: Molina CHIP/Medicaid	$3,253.01
Rate for Payer: Multiplan Auto	$2,259.03
Rate for Payer: Multiplan Commercial	$2,259.03
Rate for Payer: Multiplan Workers Comp	$2,259.03
Rate for Payer: Parkland Medicaid	$3,253.01
Rate for Payer: Scott and White EPO/PPO	$2,259.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,253.01
Rate for Payer: Superior Health Plan EPO	$614.46

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 12MM

Facility

$4,518.07

Service Code	HCPCS C1876
Hospital Charge Code	991256
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.52
Max. Negotiated Rate	$2,259.03
Rate for Payer: Cash Price	$3,072.29
Rate for Payer: Cigna Commercial	$1,129.52
Rate for Payer: Multiplan Auto	$2,259.03
Rate for Payer: Multiplan Commercial	$2,259.03
Rate for Payer: Multiplan Workers Comp	$2,259.03
Rate for Payer: Scott and White EPO/PPO	$2,259.03

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 12MM

Facility

$4,518.07

Service Code	HCPCS C1876
Hospital Charge Code	991256
Hospital Revenue Code	278
Min. Negotiated Rate	$406.63
Max. Negotiated Rate	$3,253.01
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	$3,072.29
Rate for Payer: Cigna Medicaid	$3,253.01
Rate for Payer: Molina CHIP/Medicaid	$3,253.01
Rate for Payer: Multiplan Auto	$2,259.03
Rate for Payer: Multiplan Commercial	$2,259.03
Rate for Payer: Multiplan Workers Comp	$2,259.03
Rate for Payer: Parkland Medicaid	$3,253.01
Rate for Payer: Scott and White EPO/PPO	$2,259.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,253.01
Rate for Payer: Superior Health Plan EPO	$614.46

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 15MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991269
Hospital Revenue Code	278
Min. Negotiated Rate	$702.11
Max. Negotiated Rate	$5,616.86
Rate for Payer: Amerigroup CHIP/Medicaid	$702.11
Rate for Payer: BCBS of TX Blue Advantage	$2,340.36
Rate for Payer: BCBS of TX Blue Essentials	$2,808.43
Rate for Payer: BCBS of TX PPO	$3,120.48
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Medicaid	$5,616.86
Rate for Payer: Molina CHIP/Medicaid	$5,616.86
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Parkland Medicaid	$5,616.86
Rate for Payer: Scott and White EPO/PPO	$3,900.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,616.86
Rate for Payer: Superior Health Plan EPO	$1,060.96

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 15MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991269
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Commercial	$1,950.30
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Scott and White EPO/PPO	$3,900.60

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 18MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991270
Hospital Revenue Code	278
Min. Negotiated Rate	$702.11
Max. Negotiated Rate	$5,616.86
Rate for Payer: Amerigroup CHIP/Medicaid	$702.11
Rate for Payer: BCBS of TX Blue Advantage	$2,340.36
Rate for Payer: BCBS of TX Blue Essentials	$2,808.43
Rate for Payer: BCBS of TX PPO	$3,120.48
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Medicaid	$5,616.86
Rate for Payer: Molina CHIP/Medicaid	$5,616.86
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Parkland Medicaid	$5,616.86
Rate for Payer: Scott and White EPO/PPO	$3,900.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,616.86
Rate for Payer: Superior Health Plan EPO	$1,060.96

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 18MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991270
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Commercial	$1,950.30
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Scott and White EPO/PPO	$3,900.60

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 22MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991271
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Commercial	$1,950.30
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Scott and White EPO/PPO	$3,900.60

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 22MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991271
Hospital Revenue Code	278
Min. Negotiated Rate	$702.11
Max. Negotiated Rate	$5,616.86
Rate for Payer: Amerigroup CHIP/Medicaid	$702.11
Rate for Payer: BCBS of TX Blue Advantage	$2,340.36
Rate for Payer: BCBS of TX Blue Essentials	$2,808.43
Rate for Payer: BCBS of TX PPO	$3,120.48
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Medicaid	$5,616.86
Rate for Payer: Molina CHIP/Medicaid	$5,616.86
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Parkland Medicaid	$5,616.86
Rate for Payer: Scott and White EPO/PPO	$3,900.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,616.86
Rate for Payer: Superior Health Plan EPO	$1,060.96

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 26MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991272
Hospital Revenue Code	278
Min. Negotiated Rate	$702.11
Max. Negotiated Rate	$5,616.86
Rate for Payer: Amerigroup CHIP/Medicaid	$702.11
Rate for Payer: BCBS of TX Blue Advantage	$2,340.36
Rate for Payer: BCBS of TX Blue Essentials	$2,808.43
Rate for Payer: BCBS of TX PPO	$3,120.48
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Medicaid	$5,616.86
Rate for Payer: Molina CHIP/Medicaid	$5,616.86
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Parkland Medicaid	$5,616.86
Rate for Payer: Scott and White EPO/PPO	$3,900.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,616.86
Rate for Payer: Superior Health Plan EPO	$1,060.96

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 26MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991272
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Commercial	$1,950.30
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Scott and White EPO/PPO	$3,900.60

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 34MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991281
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Commercial	$1,950.30
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Scott and White EPO/PPO	$3,900.60

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 34MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991281
Hospital Revenue Code	278
Min. Negotiated Rate	$702.11
Max. Negotiated Rate	$5,616.86
Rate for Payer: Amerigroup CHIP/Medicaid	$702.11
Rate for Payer: BCBS of TX Blue Advantage	$2,340.36
Rate for Payer: BCBS of TX Blue Essentials	$2,808.43
Rate for Payer: BCBS of TX PPO	$3,120.48
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Medicaid	$5,616.86
Rate for Payer: Molina CHIP/Medicaid	$5,616.86
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Parkland Medicaid	$5,616.86
Rate for Payer: Scott and White EPO/PPO	$3,900.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,616.86
Rate for Payer: Superior Health Plan EPO	$1,060.96

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 38MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991282
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Commercial	$1,950.30
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Scott and White EPO/PPO	$3,900.60

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.0 x 38MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991282
Hospital Revenue Code	278
Min. Negotiated Rate	$702.11
Max. Negotiated Rate	$5,616.86
Rate for Payer: Amerigroup CHIP/Medicaid	$702.11
Rate for Payer: BCBS of TX Blue Advantage	$2,340.36
Rate for Payer: BCBS of TX Blue Essentials	$2,808.43
Rate for Payer: BCBS of TX PPO	$3,120.48
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Medicaid	$5,616.86
Rate for Payer: Molina CHIP/Medicaid	$5,616.86
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Parkland Medicaid	$5,616.86
Rate for Payer: Scott and White EPO/PPO	$3,900.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,616.86
Rate for Payer: Superior Health Plan EPO	$1,060.96

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.5 x 12MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991257
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Commercial	$1,950.30
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Scott and White EPO/PPO	$3,900.60

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.5 x 12MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991257
Hospital Revenue Code	278
Min. Negotiated Rate	$702.11
Max. Negotiated Rate	$5,616.86
Rate for Payer: Amerigroup CHIP/Medicaid	$702.11
Rate for Payer: BCBS of TX Blue Advantage	$2,340.36
Rate for Payer: BCBS of TX Blue Essentials	$2,808.43
Rate for Payer: BCBS of TX PPO	$3,120.48
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Medicaid	$5,616.86
Rate for Payer: Molina CHIP/Medicaid	$5,616.86
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Parkland Medicaid	$5,616.86
Rate for Payer: Scott and White EPO/PPO	$3,900.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,616.86
Rate for Payer: Superior Health Plan EPO	$1,060.96

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.5 x 18MM

Facility

$4,518.07

Service Code	HCPCS C1876
Hospital Charge Code	991283
Hospital Revenue Code	278
Min. Negotiated Rate	$406.63
Max. Negotiated Rate	$3,253.01
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	$3,072.29
Rate for Payer: Cigna Medicaid	$3,253.01
Rate for Payer: Molina CHIP/Medicaid	$3,253.01
Rate for Payer: Multiplan Auto	$2,259.03
Rate for Payer: Multiplan Commercial	$2,259.03
Rate for Payer: Multiplan Workers Comp	$2,259.03
Rate for Payer: Parkland Medicaid	$3,253.01
Rate for Payer: Scott and White EPO/PPO	$2,259.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,253.01
Rate for Payer: Superior Health Plan EPO	$614.46

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.5 x 18MM

Facility

$4,518.07

Service Code	HCPCS C1876
Hospital Charge Code	991283
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.52
Max. Negotiated Rate	$2,259.03
Rate for Payer: Cash Price	$3,072.29
Rate for Payer: Cigna Commercial	$1,129.52
Rate for Payer: Multiplan Auto	$2,259.03
Rate for Payer: Multiplan Commercial	$2,259.03
Rate for Payer: Multiplan Workers Comp	$2,259.03
Rate for Payer: Scott and White EPO/PPO	$2,259.03

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.5 x 22MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991273
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Commercial	$1,950.30
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Scott and White EPO/PPO	$3,900.60

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.5 x 22MM

Facility

$7,801.20

Service Code	HCPCS C1876
Hospital Charge Code	991273
Hospital Revenue Code	278
Min. Negotiated Rate	$702.11
Max. Negotiated Rate	$5,616.86
Rate for Payer: Amerigroup CHIP/Medicaid	$702.11
Rate for Payer: BCBS of TX Blue Advantage	$2,340.36
Rate for Payer: BCBS of TX Blue Essentials	$2,808.43
Rate for Payer: BCBS of TX PPO	$3,120.48
Rate for Payer: Cash Price	$5,304.82
Rate for Payer: Cigna Medicaid	$5,616.86
Rate for Payer: Molina CHIP/Medicaid	$5,616.86
Rate for Payer: Multiplan Auto	$3,900.60
Rate for Payer: Multiplan Commercial	$3,900.60
Rate for Payer: Multiplan Workers Comp	$3,900.60
Rate for Payer: Parkland Medicaid	$5,616.86
Rate for Payer: Scott and White EPO/PPO	$3,900.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,616.86
Rate for Payer: Superior Health Plan EPO	$1,060.96

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.5 x 26MM

Facility

$4,518.07

Service Code	HCPCS C1876
Hospital Charge Code	991258
Hospital Revenue Code	278
Min. Negotiated Rate	$406.63
Max. Negotiated Rate	$3,253.01
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	$3,072.29
Rate for Payer: Cigna Medicaid	$3,253.01
Rate for Payer: Molina CHIP/Medicaid	$3,253.01
Rate for Payer: Multiplan Auto	$2,259.03
Rate for Payer: Multiplan Commercial	$2,259.03
Rate for Payer: Multiplan Workers Comp	$2,259.03
Rate for Payer: Parkland Medicaid	$3,253.01
Rate for Payer: Scott and White EPO/PPO	$2,259.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,253.01
Rate for Payer: Superior Health Plan EPO	$614.46

STENT SYSTEM CORONARY ONYX FRONTIER RX 3.5 x 26MM

Facility

$4,518.07

Service Code	HCPCS C1876
Hospital Charge Code	991258
Hospital Revenue Code	278
Min. Negotiated Rate	$1,129.52
Max. Negotiated Rate	$2,259.03
Rate for Payer: Cash Price	$3,072.29
Rate for Payer: Cigna Commercial	$1,129.52
Rate for Payer: Multiplan Auto	$2,259.03
Rate for Payer: Multiplan Commercial	$2,259.03
Rate for Payer: Multiplan Workers Comp	$2,259.03
Rate for Payer: Scott and White EPO/PPO	$2,259.03

STENT URETERAL 6FR 26CM WITH GUIDEWIRE PERCUFLEX

Facility

$597.33

Hospital Charge Code	119753
Hospital Revenue Code	272
Rate for Payer: Cash Price	$406.18

Know your out-of-pocket cost for care.

All Charges