Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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: BCN Commercial	$26.78
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 3MCG/0.2ML TRIS-SUCROSE 1ST

Professional

Both

$40.00

Service Code	HCPCS 0081A
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: BCN Commercial	$26.78
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 3MCG/0.2ML TRIS-SUCROSE 2ND

Professional

Both

$40.00

Service Code	HCPCS 0082A
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: BCN Commercial	$26.78
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 3MCG/0.2ML TRIS-SUCROSE 3RD

Professional

Both

$40.00

Service Code	HCPCS 0083A
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: BCN Commercial	$26.78
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 50 MCG/0.25 ML BOOSTER DOSE

Professional

Both

$40.00

Service Code	HCPCS 0064A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$80.25
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$80.25
Rate for Payer: BCN Commercial	$26.78
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 AD26 5X1010 VP/0.5 ML 1 DOSE

Professional

Both

$40.00

Service Code	HCPCS 0031A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$712.50
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$712.50
Rate for Payer: BCN Commercial	$26.78
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 AD26 5X1010 VP/0.5 ML BST DOSE

Professional

Both

$40.00

Service Code	HCPCS 0034A
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: BCN Commercial	$26.78
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 BIVALENT 10 MCG/0.2 ML 1ST

Professional

Both

$40.00

Service Code	HCPCS 0151A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCN Commercial	$26.78
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 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$40.00

Service Code	HCPCS 0154A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$480.55
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$480.55
Rate for Payer: BCN Commercial	$26.78
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 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$40.00

Service Code	HCPCS 0164A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$3,002.09
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$3,002.09
Rate for Payer: BCN Commercial	$26.78
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 BIVALENT 25 MCG/0.25 ML ADDL

Professional

Both

$40.00

Service Code	HCPCS 0144A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$68.75
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$68.75
Rate for Payer: BCN Commercial	$26.78
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 BIVALENT 30 MCG/0.3 ML 1 DOSE

Professional

Both

$40.00

Service Code	HCPCS 0121A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCN Commercial	$26.78
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 BIVALENT 30 MCG/0.3 ML ADDL

Professional

Both

$40.00

Service Code	HCPCS 0124A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$122.97
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$122.97
Rate for Payer: BCN Commercial	$26.78
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 BIVALENT 3 MCG/0.2 ML 1ST

Professional

Both

$40.00

Service Code	HCPCS 0171A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCN Commercial	$26.78
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 BIVALENT 3 MCG/0.2 ML 2ND

Professional

Both

$40.00

Service Code	HCPCS 0172A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCN Commercial	$26.78
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 BIVALENT 3 MCG/0.2 ML 3RD

Professional

Both

$40.00

Service Code	HCPCS 0173A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$2,756.25
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$2,756.25
Rate for Payer: BCN Commercial	$26.78
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