White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Admin Vaccine Charge - Covid-19 Moderna -> Booster Dose 2 Moderna 0064A

Facility

$40.00

Service Code	HCPCS 0064A
Hospital Charge Code	8812543
Hospital Revenue Code	771
Rate for Payer: Cash Price	$27.20

Admin Vaccine Charge - Covid-19 Moderna -> Booster Dose 2 Moderna 0064A

Facility

$40.00

Service Code	HCPCS 0064A
Hospital Charge Code	8734592
Hospital Revenue Code	771
Rate for Payer: Cash Price	$27.20

Admin Vaccine Charge - Covid-19 Moderna -> First Dose Moderna 0011A

Facility

$60.00

Service Code	HCPCS 0011A
Hospital Charge Code	8686557
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Covid-19 Moderna -> First Dose Moderna 0011A

Facility

$60.00

Service Code	HCPCS 0011A
Hospital Charge Code	8686557
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Moderna -> Second Dose Moderna 0012A

Facility

$60.00

Service Code	HCPCS 0012A
Hospital Charge Code	8686558
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Covid-19 Moderna -> Second Dose Moderna 0012A

Facility

$60.00

Service Code	HCPCS 0012A
Hospital Charge Code	8686558
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Moderna -> Third Dose Moderna 0013A

Facility

$60.00

Service Code	HCPCS 0031A
Hospital Charge Code	8686559
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Moderna -> Third Dose Moderna 0013A

Facility

$60.00

Service Code	HCPCS 0031A
Hospital Charge Code	8686559
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Covid-19 Pfizer -> Booster Dose 2 Pfizer 0004A

Facility

$40.00

Service Code	HCPCS 0004A
Hospital Charge Code	8810545
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$28.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna Medicaid	$28.80
Rate for Payer: Molina CHIP/Medicaid	$28.80
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Parkland Medicaid	$28.80
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.80
Rate for Payer: Superior Health Plan EPO	$5.44

Admin Vaccine Charge - Covid-19 Pfizer -> Booster Dose 2 Pfizer 0004A

Facility

$40.00

Service Code	HCPCS 0004A
Hospital Charge Code	8810545
Hospital Revenue Code	771
Rate for Payer: Cash Price	$27.20

Admin Vaccine Charge - Covid-19 Pfizer -> Booster Dose 2 Pfizer 0004A

Facility

$40.00

Service Code	HCPCS 0004A
Hospital Charge Code	8832580
Hospital Revenue Code	771
Rate for Payer: Cash Price	$27.20

Admin Vaccine Charge - Covid-19 Pfizer -> Booster Dose 2 Pfizer 0004A

Facility

$40.00

Service Code	HCPCS 0004A
Hospital Charge Code	8832580
Hospital Revenue Code	771
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$28.80
Rate for Payer: Amerigroup CHIP/Medicaid	$3.60
Rate for Payer: BCBS of TX Blue Advantage	$12.00
Rate for Payer: BCBS of TX Blue Essentials	$14.40
Rate for Payer: BCBS of TX PPO	$16.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna Medicaid	$28.80
Rate for Payer: Molina CHIP/Medicaid	$28.80
Rate for Payer: Multiplan Auto	$26.00
Rate for Payer: Multiplan Commercial	$26.00
Rate for Payer: Multiplan Workers Comp	$26.00
Rate for Payer: Parkland Medicaid	$28.80
Rate for Payer: Scott and White EPO/PPO	$20.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$28.80
Rate for Payer: Superior Health Plan EPO	$5.44

Admin Vaccine Charge - Covid-19 Pfizer -> Booster Dose Pfizer 0004A

Facility

$60.00

Service Code	HCPCS 0004A
Hospital Charge Code	8734593
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Pfizer -> Booster Dose Pfizer 0004A

Facility

$60.00

Service Code	HCPCS 0004A
Hospital Charge Code	8734593
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Covid-19 Pfizer -> First Dose Pfizer 0001A

Facility

$60.00

Service Code	HCPCS 0001A
Hospital Charge Code	1500010
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Covid-19 Pfizer -> First Dose Pfizer 0001A

Facility

$60.00

Service Code	HCPCS 0001A
Hospital Charge Code	1500010
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Pfizer -> First Dose Pfizer Peds 0071A

Facility

$60.00

Service Code	HCPCS 0071A
Hospital Charge Code	8734594
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Pfizer -> First Dose Pfizer Peds 0071A

Facility

$60.00

Service Code	HCPCS 0071A
Hospital Charge Code	8734594
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Covid-19 Pfizer -> Second Dose Pfizer 0002A

Facility

$60.00

Service Code	HCPCS 0002A
Hospital Charge Code	1500011
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Covid-19 Pfizer -> Second Dose Pfizer 0002A

Facility

$60.00

Service Code	HCPCS 0002A
Hospital Charge Code	1500011
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Pfizer -> Second Dose Pfizer Peds 0072A

Facility

$60.00

Service Code	HCPCS 0072A
Hospital Charge Code	8734595
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Pfizer -> Second Dose Pfizer Peds 0072A

Facility

$60.00

Service Code	HCPCS 0072A
Hospital Charge Code	8734595
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Covid-19 Pfizer -> Third Dose Pfizer 0003A

Facility

$60.00

Service Code	HCPCS 0003A
Hospital Charge Code	8684535
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Admin Vaccine Charge - Covid-19 Pfizer -> Third Dose Pfizer 0003A

Facility

$60.00

Service Code	HCPCS 0003A
Hospital Charge Code	8684535
Hospital Revenue Code	771
Rate for Payer: Cash Price	$40.80

Admin Vaccine Charge - Pfizer-BioNTech Biv Boost -> Pfizer-BioNTech Bivalent Booster (12 years and older) - 0124A

Facility

$60.00

Service Code	HCPCS 0124A
Hospital Charge Code	8962549
Hospital Revenue Code	771
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$43.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.40
Rate for Payer: BCBS of TX Blue Advantage	$18.00
Rate for Payer: BCBS of TX Blue Essentials	$21.60
Rate for Payer: BCBS of TX PPO	$24.00
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna Medicaid	$43.20
Rate for Payer: Molina CHIP/Medicaid	$43.20
Rate for Payer: Multiplan Auto	$39.00
Rate for Payer: Multiplan Commercial	$39.00
Rate for Payer: Multiplan Workers Comp	$39.00
Rate for Payer: Parkland Medicaid	$43.20
Rate for Payer: Scott and White EPO/PPO	$30.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$43.20
Rate for Payer: Superior Health Plan EPO	$8.16

Know your out-of-pocket cost for care.

All Charges