Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PRIMIDONE 50 MG TABLET

Facility

$362.88

Service Code	NDC 68084020201
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$159.67
Max. Negotiated Rate	$326.59
Rate for Payer: Aetna American Axle	$235.87
Rate for Payer: Aetna Commercial	$308.45
Rate for Payer: Aetna New Business (MI Preferred)	$235.87
Rate for Payer: Cash Price	$290.30
Rate for Payer: Cofinity Advantage	$254.02
Rate for Payer: Cofinity Commercial	$312.08
Rate for Payer: Encore Health Key Benefits Commercial	$290.30
Rate for Payer: Healthscope Commercial	$326.59
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$254.02
Rate for Payer: Lakeland Regional Health Systems Commercial	$272.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$308.45
Rate for Payer: Opus (Opus Packaging Group) HMA	$272.16
Rate for Payer: PHP Commercial	$308.45
Rate for Payer: Priority Health SBD	$228.61
Rate for Payer: UMR Bronson Commercial	$159.67
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$272.16

PRIMIDONE 50 MG TABLET

Facility

$188.10

Service Code	NDC 50268068615
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$69.60
Max. Negotiated Rate	$169.29
Rate for Payer: Aetna American Axle	$122.27
Rate for Payer: Aetna Commercial	$159.88
Rate for Payer: Aetna Medicare	$94.05
Rate for Payer: Aetna New Business (MI Preferred)	$122.27
Rate for Payer: BCBS Complete	$75.24
Rate for Payer: Cash Price	$150.48
Rate for Payer: Cofinity Advantage	$131.67
Rate for Payer: Cofinity Commercial	$161.77
Rate for Payer: Encore Health Key Benefits Commercial	$150.48
Rate for Payer: Healthscope Commercial	$169.29
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$131.67
Rate for Payer: Lakeland Regional Health Systems Commercial	$141.07
Rate for Payer: MI Amish Medical Board Commercial	$150.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$159.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$141.07
Rate for Payer: PHP Commercial	$159.88
Rate for Payer: Priority Health SBD	$118.50
Rate for Payer: UHC All Payor (Choice/PPO)	$122.27
Rate for Payer: UHC Core	$98.00
Rate for Payer: UHC Exchange	$73.92
Rate for Payer: UMR Bronson Commercial	$69.60
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$141.07

PRIMIDONE 50 MG TABLET

Facility

$3.63

Service Code	NDC 68084020211
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.27
Rate for Payer: Aetna American Axle	$2.36
Rate for Payer: Aetna Commercial	$3.09
Rate for Payer: Aetna New Business (MI Preferred)	$2.36
Rate for Payer: Cash Price	$2.90
Rate for Payer: Cofinity Advantage	$2.54
Rate for Payer: Cofinity Commercial	$3.12
Rate for Payer: Encore Health Key Benefits Commercial	$2.90
Rate for Payer: Healthscope Commercial	$3.27
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$2.54
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.09
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.72
Rate for Payer: PHP Commercial	$3.09
Rate for Payer: Priority Health SBD	$2.29
Rate for Payer: UMR Bronson Commercial	$1.60
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.72

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

Professional

Both

$42.00

Service Code	HCPCS 0011A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0012A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0013A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0071A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0072A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0073A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0074A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0111A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0112A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0001A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0002A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0003A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0004A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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

Professional

Both

$42.00

Service Code	HCPCS 0051A
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
Rate for Payer: UMR Bronson Commercial	$19.32

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
Rate for Payer: UMR Bronson Commercial	$19.32

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
Rate for Payer: UMR Bronson Commercial	$19.32

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
Rate for Payer: UMR Bronson Commercial	$19.32

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
Rate for Payer: UMR Bronson Commercial	$19.32

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
Rate for Payer: UMR Bronson Commercial	$19.32

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
Rate for Payer: UMR Bronson Commercial	$19.32

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
Rate for Payer: UMR Bronson Commercial	$19.32

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
Rate for Payer: UMR Bronson Commercial	$19.32

Know your out-of-pocket cost for care.

All Charges