Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

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

Professional

Both

$42.00

Service Code	HCPCS 0052A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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

Professional

Both

$42.00

Service Code	HCPCS 0053A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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

Professional

Both

$42.00

Service Code	HCPCS 0054A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 3MCG/0.2ML TRIS-SUCROSE 1ST

Professional

Both

$42.00

Service Code	HCPCS 0081A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 3MCG/0.2ML TRIS-SUCROSE 2ND

Professional

Both

$42.00

Service Code	HCPCS 0082A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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

Professional

Both

$42.00

Service Code	HCPCS 0083A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 50 MCG/0.25 ML BOOSTER DOSE

Professional

Both

$42.00

Service Code	HCPCS 0064A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 AD26 5X1010 VP/0.5 ML 1 DOSE

Professional

Both

$42.00

Service Code	HCPCS 0031A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 AD26 5X1010 VP/0.5 ML BST DOSE

Professional

Both

$42.00

Service Code	HCPCS 0034A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 10 MCG/0.2 ML 1ST

Professional

Both

$42.00

Service Code	HCPCS 0151A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0164A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0154A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 25 MCG/0.25 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0144A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 30 MCG/0.3 ML 1 DOSE

Professional

Both

$42.00

Service Code	HCPCS 0121A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 30 MCG/0.3 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0124A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 3 MCG/0.2 ML 1ST

Professional

Both

$42.00

Service Code	HCPCS 0171A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 3 MCG/0.2 ML 2ND

Professional

Both

$42.00

Service Code	HCPCS 0172A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 3 MCG/0.2 ML 3RD

Professional

Both

$42.00

Service Code	HCPCS 0173A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 3 MCG/0.2 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0174A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 BIVALENT 50 MCG/0.5 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0134A
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR IMM ADMN SARSCOV2 VACCINE 1ST/ONLY COMPONENT

Professional

Both

$88.00

Service Code	HCPCS 90480
Min. Negotiated Rate	$27.07
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$40.00
Rate for Payer: Aetna Medicare	$44.00
Rate for Payer: BCN Commercial	$27.07
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$61.53
Rate for Payer: Priority Health Narrow/Tiered Network	$61.53

PR IMM CNSL PHYS/QHP IMM NOT ADMN SAME DOS>20 MIN

Professional

Both

$101.00

Service Code	HCPCS 90484
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$75.75
Rate for Payer: Aetna Medicare	$50.50
Rate for Payer: BCBS Complete	$22.14
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cash Price	$80.80
Rate for Payer: Mclaren Medicaid	$21.09
Rate for Payer: Meridian Medicaid	$22.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$75.75
Rate for Payer: Priority Health Choice Medicaid	$21.09
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$48.76
Rate for Payer: Priority Health Narrow/Tiered Network	$48.76
Rate for Payer: UHC Medicaid	$21.09
Rate for Payer: UHCCP Medicaid	$21.09

PR IMM CNSL PHYS/QHP IMM NOT ADMN SAME DOS 3<10 MIN

Professional

Both

$36.00

Service Code	HCPCS 90482
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS Complete	$7.16
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Mclaren Medicaid	$6.82
Rate for Payer: Meridian Medicaid	$7.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$27.00
Rate for Payer: Priority Health Choice Medicaid	$6.82
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$15.76
Rate for Payer: Priority Health Narrow/Tiered Network	$15.76
Rate for Payer: UHC Medicaid	$6.82
Rate for Payer: UHCCP Medicaid	$6.82

PR IMM CNSL PHYS/QHP IMM NOT ADMN SM DOS>10<20 MIN

Professional

Both

$69.00

Service Code	HCPCS 90483
Min. Negotiated Rate	$14.06
Max. Negotiated Rate	$51.75
Rate for Payer: Aetna Medicare	$34.50
Rate for Payer: BCBS Complete	$14.76
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.20
Rate for Payer: Mclaren Medicaid	$14.06
Rate for Payer: Meridian Medicaid	$14.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$51.75
Rate for Payer: Priority Health Choice Medicaid	$14.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$32.50
Rate for Payer: Priority Health Narrow/Tiered Network	$32.50
Rate for Payer: UHC Medicaid	$14.06
Rate for Payer: UHCCP Medicaid	$14.06

PR IMMUNIZE COUNS < 21YR 5-15 M

Professional

Both

$32.00

Service Code	HCPCS G0312
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Medicare	$16.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.00

Know your out-of-pocket cost for care.

All Charges