Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PRIMIDONE 250 MG TABLET

Facility

$3.14

Service Code	NDC 68084-203-11
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna American Axle	$2.04
Rate for Payer: Aetna Commercial	$2.67
Rate for Payer: Aetna New Business (MI Preferred)	$2.04
Rate for Payer: Cash Price	$2.51
Rate for Payer: Cofinity Commercial	$2.20
Rate for Payer: Cofinity Commercial	$2.70
Rate for Payer: Encore Health Key Benefits Commercial	$2.51
Rate for Payer: Healthscope Commercial	$2.83
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$2.20
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.67
Rate for Payer: PHP Commercial	$2.67
Rate for Payer: Priority Health Cigna Priority Health	$2.20
Rate for Payer: Priority Health SBD	$1.98
Rate for Payer: UMR Bronson Commercial	$1.38
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.36

PRIMIDONE 250 MG TABLET

Facility

$210.90

Service Code	NDC 53746-545-01
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$92.80
Max. Negotiated Rate	$189.81
Rate for Payer: Aetna American Axle	$137.08
Rate for Payer: Aetna Commercial	$179.26
Rate for Payer: Aetna New Business (MI Preferred)	$137.08
Rate for Payer: Cash Price	$168.72
Rate for Payer: Cofinity Commercial	$147.63
Rate for Payer: Cofinity Commercial	$181.37
Rate for Payer: Encore Health Key Benefits Commercial	$168.72
Rate for Payer: Healthscope Commercial	$189.81
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$147.63
Rate for Payer: Lakeland Regional Health Systems Commercial	$158.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$179.26
Rate for Payer: PHP Commercial	$179.26
Rate for Payer: Priority Health Cigna Priority Health	$147.63
Rate for Payer: Priority Health SBD	$132.87
Rate for Payer: UMR Bronson Commercial	$92.80
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$158.18

PRIMIDONE 250 MG TABLET

Facility

$320.15

Service Code	NDC 0591-5321-01
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$140.87
Max. Negotiated Rate	$288.14
Rate for Payer: Aetna American Axle	$208.10
Rate for Payer: Aetna Commercial	$272.13
Rate for Payer: Aetna New Business (MI Preferred)	$208.10
Rate for Payer: Cash Price	$256.12
Rate for Payer: Cofinity Commercial	$224.10
Rate for Payer: Cofinity Commercial	$275.33
Rate for Payer: Encore Health Key Benefits Commercial	$256.12
Rate for Payer: Healthscope Commercial	$288.14
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$224.10
Rate for Payer: Lakeland Regional Health Systems Commercial	$240.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$272.13
Rate for Payer: PHP Commercial	$272.13
Rate for Payer: Priority Health Cigna Priority Health	$224.10
Rate for Payer: Priority Health SBD	$201.69
Rate for Payer: UMR Bronson Commercial	$140.87
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$240.11

PRIMIDONE 250 MG TABLET

Facility

$257.45

Service Code	NDC 0527-1231-01
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$113.28
Max. Negotiated Rate	$231.70
Rate for Payer: Aetna American Axle	$167.34
Rate for Payer: Aetna Commercial	$218.83
Rate for Payer: Aetna New Business (MI Preferred)	$167.34
Rate for Payer: Cash Price	$205.96
Rate for Payer: Cofinity Commercial	$180.22
Rate for Payer: Cofinity Commercial	$221.41
Rate for Payer: Encore Health Key Benefits Commercial	$205.96
Rate for Payer: Healthscope Commercial	$231.70
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$180.22
Rate for Payer: Lakeland Regional Health Systems Commercial	$193.09
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$218.83
Rate for Payer: PHP Commercial	$218.83
Rate for Payer: Priority Health Cigna Priority Health	$180.22
Rate for Payer: Priority Health SBD	$162.19
Rate for Payer: UMR Bronson Commercial	$113.28
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$193.09

PRIMIDONE 250 MG TABLET

Facility

$313.92

Service Code	NDC 68084-203-01
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$138.12
Max. Negotiated Rate	$282.53
Rate for Payer: Aetna American Axle	$204.05
Rate for Payer: Aetna Commercial	$266.83
Rate for Payer: Aetna New Business (MI Preferred)	$204.05
Rate for Payer: Cash Price	$251.14
Rate for Payer: Cofinity Commercial	$219.74
Rate for Payer: Cofinity Commercial	$269.97
Rate for Payer: Encore Health Key Benefits Commercial	$251.14
Rate for Payer: Healthscope Commercial	$282.53
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$219.74
Rate for Payer: Lakeland Regional Health Systems Commercial	$235.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$266.83
Rate for Payer: PHP Commercial	$266.83
Rate for Payer: Priority Health Cigna Priority Health	$219.74
Rate for Payer: Priority Health SBD	$197.77
Rate for Payer: UMR Bronson Commercial	$138.12
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$235.44

PRIMIDONE 50 MG TABLET

Facility

$163.88

Service Code	NDC 50268-686-15
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$72.11
Max. Negotiated Rate	$147.49
Rate for Payer: Aetna American Axle	$106.52
Rate for Payer: Aetna Commercial	$139.30
Rate for Payer: Aetna New Business (MI Preferred)	$106.52
Rate for Payer: Cash Price	$131.10
Rate for Payer: Cofinity Commercial	$114.72
Rate for Payer: Cofinity Commercial	$140.94
Rate for Payer: Encore Health Key Benefits Commercial	$131.10
Rate for Payer: Healthscope Commercial	$147.49
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$114.72
Rate for Payer: Lakeland Regional Health Systems Commercial	$122.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$139.30
Rate for Payer: PHP Commercial	$139.30
Rate for Payer: Priority Health Cigna Priority Health	$114.72
Rate for Payer: Priority Health SBD	$103.24
Rate for Payer: UMR Bronson Commercial	$72.11
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$122.91

PRIMIDONE 50 MG TABLET

Facility

$228.00

Service Code	NDC 65162-544-10
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$100.32
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna American Axle	$148.20
Rate for Payer: Aetna Commercial	$193.80
Rate for Payer: Aetna New Business (MI Preferred)	$148.20
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cofinity Commercial	$159.60
Rate for Payer: Cofinity Commercial	$196.08
Rate for Payer: Encore Health Key Benefits Commercial	$182.40
Rate for Payer: Healthscope Commercial	$205.20
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$159.60
Rate for Payer: Lakeland Regional Health Systems Commercial	$171.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$193.80
Rate for Payer: PHP Commercial	$193.80
Rate for Payer: Priority Health Cigna Priority Health	$159.60
Rate for Payer: Priority Health SBD	$143.64
Rate for Payer: UMR Bronson Commercial	$100.32
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$171.00

PRIMIDONE 50 MG TABLET

Facility

$347.80

Service Code	NDC 0527-1301-01
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$153.03
Max. Negotiated Rate	$313.02
Rate for Payer: Aetna American Axle	$226.07
Rate for Payer: Aetna Commercial	$295.63
Rate for Payer: Aetna New Business (MI Preferred)	$226.07
Rate for Payer: Cash Price	$278.24
Rate for Payer: Cofinity Commercial	$243.46
Rate for Payer: Cofinity Commercial	$299.11
Rate for Payer: Encore Health Key Benefits Commercial	$278.24
Rate for Payer: Healthscope Commercial	$313.02
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$243.46
Rate for Payer: Lakeland Regional Health Systems Commercial	$260.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$295.63
Rate for Payer: PHP Commercial	$295.63
Rate for Payer: Priority Health Cigna Priority Health	$243.46
Rate for Payer: Priority Health SBD	$219.11
Rate for Payer: UMR Bronson Commercial	$153.03
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$260.85

PRIMIDONE 50 MG TABLET

Facility

$310.56

Service Code	NDC 68084-202-01
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$136.65
Max. Negotiated Rate	$279.50
Rate for Payer: Aetna American Axle	$201.86
Rate for Payer: Aetna Commercial	$263.98
Rate for Payer: Aetna New Business (MI Preferred)	$201.86
Rate for Payer: Cash Price	$248.45
Rate for Payer: Cofinity Commercial	$217.39
Rate for Payer: Cofinity Commercial	$267.08
Rate for Payer: Encore Health Key Benefits Commercial	$248.45
Rate for Payer: Healthscope Commercial	$279.50
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$217.39
Rate for Payer: Lakeland Regional Health Systems Commercial	$232.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$263.98
Rate for Payer: PHP Commercial	$263.98
Rate for Payer: Priority Health Cigna Priority Health	$217.39
Rate for Payer: Priority Health SBD	$195.65
Rate for Payer: UMR Bronson Commercial	$136.65
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$232.92

PRIMIDONE 50 MG TABLET

Facility

$2,279.50

Service Code	NDC 65162-544-50
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$1,002.98
Max. Negotiated Rate	$2,051.55
Rate for Payer: Aetna American Axle	$1,481.68
Rate for Payer: Aetna Commercial	$1,937.58
Rate for Payer: Aetna New Business (MI Preferred)	$1,481.68
Rate for Payer: Cash Price	$1,823.60
Rate for Payer: Cofinity Commercial	$1,595.65
Rate for Payer: Cofinity Commercial	$1,960.37
Rate for Payer: Encore Health Key Benefits Commercial	$1,823.60
Rate for Payer: Healthscope Commercial	$2,051.55
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$1,595.65
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,709.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,937.58
Rate for Payer: PHP Commercial	$1,937.58
Rate for Payer: Priority Health Cigna Priority Health	$1,595.65
Rate for Payer: Priority Health SBD	$1,436.08
Rate for Payer: UMR Bronson Commercial	$1,002.98
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,709.62

PRIMIDONE 50 MG TABLET

Facility

$3.11

Service Code	NDC 68084-202-11
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna American Axle	$2.02
Rate for Payer: Aetna Commercial	$2.64
Rate for Payer: Aetna New Business (MI Preferred)	$2.02
Rate for Payer: Cash Price	$2.49
Rate for Payer: Cofinity Commercial	$2.18
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Encore Health Key Benefits Commercial	$2.49
Rate for Payer: Healthscope Commercial	$2.80
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$2.18
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.64
Rate for Payer: PHP Commercial	$2.64
Rate for Payer: Priority Health Cigna Priority Health	$2.18
Rate for Payer: Priority Health SBD	$1.96
Rate for Payer: UMR Bronson Commercial	$1.37
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.33

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

Professional

Both

$40.00

Service Code	HCPCS 0011A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$28.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$18.75
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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

Professional

Both

$40.00

Service Code	HCPCS 0012A
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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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

Professional

Both

$40.00

Service Code	HCPCS 0013A
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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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

Professional

Both

$40.00

Service Code	HCPCS 0071A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$320.45
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$320.45
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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

Professional

Both

$40.00

Service Code	HCPCS 0072A
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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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

Professional

Both

$40.00

Service Code	HCPCS 0073A
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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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

Professional

Both

$40.00

Service Code	HCPCS 0074A
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$85.82
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$85.82
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

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: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

Know your out-of-pocket cost for care.

All Charges