Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

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

Professional

Both

$41.00

Service Code	HCPCS 0004A
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
Rate for Payer: UMR Bronson Commercial	$18.86

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

Professional

Both

$41.00

Service Code	HCPCS 0051A
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
Rate for Payer: UMR Bronson Commercial	$18.86

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

Professional

Both

$41.00

Service Code	HCPCS 0052A
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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$18.86

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
Rate for Payer: UMR Bronson Commercial	$39.10

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
Rate for Payer: UMR Bronson Commercial	$14.26

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
Rate for Payer: UMR Bronson Commercial	$21.16

Know your out-of-pocket cost for care.

All Charges