Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PRIMIDONE 250 MG TABLET

Facility

$4.38

Service Code	NDC 50268-687-11
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$3.94
Rate for Payer: Aetna Commercial	$3.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.85
Rate for Payer: Cash Price	$3.50
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Cofinity Commercial	$3.77
Rate for Payer: Healthscope Commercial	$3.94
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.72
Rate for Payer: PHP Commercial	$3.72
Rate for Payer: Priority Health Cigna Priority Health	$3.07
Rate for Payer: Priority Health SBD	$2.76

PRIMIDONE 250 MG TABLET

Facility

$3.14

Service Code	NDC 68084-203-11
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna Commercial	$2.67
Rate for Payer: Aetna New Business (MI Preferred)	$2.04
Rate for Payer: Cash Price	$2.51
Rate for Payer: Cofinity Commercial	$2.20
Rate for Payer: Cofinity Commercial	$2.70
Rate for Payer: Healthscope Commercial	$2.83
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.67
Rate for Payer: PHP Commercial	$2.67
Rate for Payer: Priority Health Cigna Priority Health	$2.20
Rate for Payer: Priority Health SBD	$1.98

PRIMIDONE 250 MG TABLET

Facility

$257.45

Service Code	NDC 0527-1231-01
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$162.19
Max. Negotiated Rate	$231.70
Rate for Payer: Aetna Commercial	$218.83
Rate for Payer: Aetna New Business (MI Preferred)	$167.34
Rate for Payer: Cash Price	$205.96
Rate for Payer: Cofinity Commercial	$180.22
Rate for Payer: Cofinity Commercial	$221.41
Rate for Payer: Healthscope Commercial	$231.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$218.83
Rate for Payer: PHP Commercial	$218.83
Rate for Payer: Priority Health Cigna Priority Health	$180.22
Rate for Payer: Priority Health SBD	$162.19

PRIMIDONE 50 MG TABLET

Facility

$3.11

Service Code	NDC 68084-202-11
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna Commercial	$2.64
Rate for Payer: Aetna New Business (MI Preferred)	$2.02
Rate for Payer: Cash Price	$2.49
Rate for Payer: Cofinity Commercial	$2.18
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Healthscope Commercial	$2.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.64
Rate for Payer: PHP Commercial	$2.64
Rate for Payer: Priority Health Cigna Priority Health	$2.18
Rate for Payer: Priority Health SBD	$1.96

PRIMIDONE 50 MG TABLET

Facility

$228.00

Service Code	NDC 65162-544-10
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$143.64
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna Commercial	$193.80
Rate for Payer: Aetna New Business (MI Preferred)	$148.20
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cofinity Commercial	$159.60
Rate for Payer: Cofinity Commercial	$196.08
Rate for Payer: Healthscope Commercial	$205.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$193.80
Rate for Payer: PHP Commercial	$193.80
Rate for Payer: Priority Health Cigna Priority Health	$159.60
Rate for Payer: Priority Health SBD	$143.64

PRIMIDONE 50 MG TABLET

Facility

$310.56

Service Code	NDC 68084-202-01
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$195.65
Max. Negotiated Rate	$279.50
Rate for Payer: Aetna Commercial	$263.98
Rate for Payer: Aetna New Business (MI Preferred)	$201.86
Rate for Payer: Cash Price	$248.45
Rate for Payer: Cofinity Commercial	$217.39
Rate for Payer: Cofinity Commercial	$267.08
Rate for Payer: Healthscope Commercial	$279.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$263.98
Rate for Payer: PHP Commercial	$263.98
Rate for Payer: Priority Health Cigna Priority Health	$217.39
Rate for Payer: Priority Health SBD	$195.65

PRIMIDONE 50 MG TABLET

Facility

$3.28

Service Code	NDC 50268-686-11
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$2.07
Max. Negotiated Rate	$2.95
Rate for Payer: Aetna Commercial	$2.79
Rate for Payer: Aetna New Business (MI Preferred)	$2.13
Rate for Payer: Cash Price	$2.62
Rate for Payer: Cofinity Commercial	$2.30
Rate for Payer: Cofinity Commercial	$2.82
Rate for Payer: Healthscope Commercial	$2.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.79
Rate for Payer: PHP Commercial	$2.79
Rate for Payer: Priority Health Cigna Priority Health	$2.30
Rate for Payer: Priority Health SBD	$2.07

PRIMIDONE 50 MG TABLET

Facility

$163.88

Service Code	NDC 50268-686-15
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$103.24
Max. Negotiated Rate	$147.49
Rate for Payer: Aetna Commercial	$139.30
Rate for Payer: Aetna New Business (MI Preferred)	$106.52
Rate for Payer: Cash Price	$131.10
Rate for Payer: Cofinity Commercial	$114.72
Rate for Payer: Cofinity Commercial	$140.94
Rate for Payer: Healthscope Commercial	$147.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$139.30
Rate for Payer: PHP Commercial	$139.30
Rate for Payer: Priority Health Cigna Priority Health	$114.72
Rate for Payer: Priority Health SBD	$103.24

PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 1ST DOSE

Professional

Both

$40.00

Service Code	HCPCS 0011A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$18.75
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 2ND DOSE

Professional

Both

$40.00

Service Code	HCPCS 0012A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.95
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 3RD DOSE

Professional

Both

$40.00

Service Code	HCPCS 0013A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$377.55
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$377.55
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 1ST

Professional

Both

$40.00

Service Code	HCPCS 0071A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$320.45
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$320.45
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 2ND

Professional

Both

$40.00

Service Code	HCPCS 0072A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.95
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 3RD

Professional

Both

$40.00

Service Code	HCPCS 0073A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$570.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$570.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE BST

Professional

Both

$40.00

Service Code	HCPCS 0074A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$85.82
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$85.82
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 1ST DOSE

Professional

Both

$40.00

Service Code	HCPCS 0111A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$979.03
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$979.03
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 2ND DOSE

Professional

Both

$40.00

Service Code	HCPCS 0112A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$2,617.22
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$2,617.22
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 1ST DOSE

Professional

Both

$40.00

Service Code	HCPCS 0001A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.95
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 2ND DOSE

Professional

Both

$40.00

Service Code	HCPCS 0002A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$540.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$540.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 3RD DOSE

Professional

Both

$40.00

Service Code	HCPCS 0003A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.95
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON BST DOSE

Professional

Both

$40.00

Service Code	HCPCS 0004A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$377.55
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$377.55
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 1ST

Professional

Both

$40.00

Service Code	HCPCS 0051A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$59.25
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$59.25
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 2ND

Professional

Both

$40.00

Service Code	HCPCS 0052A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$570.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$570.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 3RD

Professional

Both

$40.00

Service Code	HCPCS 0053A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$112.50
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$112.50
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE BST

Professional

Both

$40.00

Service Code	HCPCS 0054A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$281.25
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$281.25
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

Know your out-of-pocket cost for care.

All Charges