Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

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

Professional

Both

$41.00

Service Code	HCPCS 0053A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0054A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0081A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0082A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0083A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 50 MCG/0.25 ML BOOSTER DOSE

Professional

Both

$41.00

Service Code	HCPCS 0064A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0031A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0034A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0151A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$41.00

Service Code	HCPCS 0164A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$41.00

Service Code	HCPCS 0154A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 BIVALENT 25 MCG/0.25 ML ADDL

Professional

Both

$41.00

Service Code	HCPCS 0144A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0121A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 BIVALENT 30 MCG/0.3 ML ADDL

Professional

Both

$41.00

Service Code	HCPCS 0124A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0171A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0172A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0173A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 BIVALENT 3 MCG/0.2 ML ADDL

Professional

Both

$41.00

Service Code	HCPCS 0174A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 BIVALENT 50 MCG/0.5 ML ADDL

Professional

Both

$41.00

Service Code	HCPCS 0134A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 VACCINE SINGLE DOSE

Professional

Both

$85.00

Service Code	HCPCS 90480
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$55.25
Rate for Payer: Aetna Medicare	$42.50
Rate for Payer: BCBS Complete	$34.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$55.25

PR IMMUNIZE COUNS < 21YR 5-15 M

Professional

Both

$31.00

Service Code	HCPCS G0312
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$20.15

PR IMMUNIZE COUNS < 21YR 6-30 M

Professional

Both

$46.00

Service Code	HCPCS G0313
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$29.90
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$29.90

PR IMMUNIZE COUNSEL 16-30 MINS

Professional

Both

$46.00

Service Code	HCPCS G0311
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$29.90
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$29.90

PR IMMUNIZE COUNSEL 5-15 MIN

Professional

Both

$31.00

Service Code	HCPCS G0310
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$20.15

PR IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA

Professional

Both

$802.00

Service Code	HCPCS 15778
Min. Negotiated Rate	$320.80
Max. Negotiated Rate	$549.23
Rate for Payer: Aetna Commercial	$511.09
Rate for Payer: Aetna Medicare	$396.67
Rate for Payer: BCBS Complete	$320.80
Rate for Payer: BCBS MAPPO	$381.41
Rate for Payer: BCN Medicare Advantage	$381.41
Rate for Payer: Cash Price	$641.60
Rate for Payer: Cash Price	$641.60
Rate for Payer: Cofinity Commercial	$511.09
Rate for Payer: Cofinity Commercial	$549.23
Rate for Payer: Health Alliance Plan Medicare Advantage	$381.41
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$400.48
Rate for Payer: Nomi Health Commercial	$457.69
Rate for Payer: PACE SWMI	$381.41
Rate for Payer: PHP Medicare Advantage	$381.41
Rate for Payer: Priority Health Cigna Priority Health	$521.30
Rate for Payer: Priority Health Medicare	$385.22
Rate for Payer: UHC All Payor (Choice/PPO)	$381.41
Rate for Payer: UHC Dual Complete DSNP	$381.41
Rate for Payer: UHC Exchange	$381.41
Rate for Payer: UHC Medicare Advantage	$381.41

Know your out-of-pocket cost for care.

All Charges