Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE

Professional

Both

$23.00

Service Code	HCPCS 90472
Min. Negotiated Rate	$9.20
Max. Negotiated Rate	$1,006.41
Rate for Payer: Aetna Commercial	$18.47
Rate for Payer: Aetna Medicare	$13.78
Rate for Payer: BCBS Complete	$9.20
Rate for Payer: BCBS MAPPO	$13.78
Rate for Payer: BCBS Trust/PPO	$1,006.41
Rate for Payer: BCN Commercial	$16.88
Rate for Payer: BCN Medicare Advantage	$13.78
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cofinity Commercial	$19.84
Rate for Payer: Cofinity Commercial	$18.47
Rate for Payer: Health Alliance Plan Medicare Advantage	$13.78
Rate for Payer: Healthscope Commercial	$16.54
Rate for Payer: Healthscope Whirlpool	$16.54
Rate for Payer: Meridian Wellcare - Medicare Advantage	$14.47
Rate for Payer: PACE SWMI	$13.78
Rate for Payer: PHP Medicare Advantage	$13.78
Rate for Payer: Priority Health Cigna Priority Health	$16.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19.31
Rate for Payer: Priority Health Medicare	$13.78
Rate for Payer: Priority Health Narrow Network	$19.31
Rate for Payer: UHC Medicare Advantage	$14.19

PR IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX

Professional

Both

$35.00

Service Code	HCPCS 90460
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$519.85
Rate for Payer: Aetna Commercial	$28.84
Rate for Payer: Aetna Medicare	$21.52
Rate for Payer: BCBS Complete	$14.00
Rate for Payer: BCBS MAPPO	$21.52
Rate for Payer: BCBS Trust/PPO	$519.85
Rate for Payer: BCN Commercial	$25.68
Rate for Payer: BCN Medicare Advantage	$21.52
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cofinity Commercial	$28.84
Rate for Payer: Cofinity Commercial	$30.99
Rate for Payer: Health Alliance Plan Medicare Advantage	$21.52
Rate for Payer: Healthscope Commercial	$25.82
Rate for Payer: Healthscope Whirlpool	$25.82
Rate for Payer: Meridian Wellcare - Medicare Advantage	$22.60
Rate for Payer: PACE SWMI	$21.52
Rate for Payer: PHP Medicare Advantage	$21.52
Rate for Payer: Priority Health Cigna Priority Health	$24.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$26.75
Rate for Payer: Priority Health Medicare	$21.52
Rate for Payer: Priority Health Narrow Network	$26.75
Rate for Payer: UHC Medicare Advantage	$22.17

PR IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT

Professional

Both

$23.00

Service Code	HCPCS 90461
Min. Negotiated Rate	$9.20
Max. Negotiated Rate	$544.68
Rate for Payer: Aetna Commercial	$13.21
Rate for Payer: Aetna Medicare	$9.86
Rate for Payer: BCBS Complete	$9.20
Rate for Payer: BCBS MAPPO	$9.86
Rate for Payer: BCBS Trust/PPO	$544.68
Rate for Payer: BCN Commercial	$13.65
Rate for Payer: BCN Medicare Advantage	$9.86
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cofinity Commercial	$13.21
Rate for Payer: Cofinity Commercial	$14.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$9.86
Rate for Payer: Healthscope Commercial	$11.83
Rate for Payer: Healthscope Whirlpool	$11.83
Rate for Payer: Meridian Wellcare - Medicare Advantage	$10.35
Rate for Payer: PACE SWMI	$9.86
Rate for Payer: PHP Medicare Advantage	$9.86
Rate for Payer: Priority Health Cigna Priority Health	$16.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13.48
Rate for Payer: Priority Health Medicare	$9.86
Rate for Payer: Priority Health Narrow Network	$13.48
Rate for Payer: UHC Medicare Advantage	$10.16

PR IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE

Professional

Both

$739.00

Service Code	HCPCS 10030
Min. Negotiated Rate	$84.56
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$177.93
Rate for Payer: Aetna Medicare	$132.78
Rate for Payer: BCBS Complete	$88.79
Rate for Payer: BCBS MAPPO	$132.78
Rate for Payer: BCBS Trust/PPO	$2,625.00
Rate for Payer: BCN Commercial	$952.93
Rate for Payer: BCN Medicare Advantage	$132.78
Rate for Payer: Cash Price	$591.20
Rate for Payer: Cash Price	$591.20
Rate for Payer: Cofinity Commercial	$191.20
Rate for Payer: Cofinity Commercial	$177.93
Rate for Payer: Health Alliance Plan Medicare Advantage	$132.78
Rate for Payer: Healthscope Commercial	$159.34
Rate for Payer: Healthscope Whirlpool	$159.34
Rate for Payer: Meridian Medicaid	$88.79
Rate for Payer: Meridian Wellcare - Medicare Advantage	$139.42
Rate for Payer: PACE SWMI	$132.78
Rate for Payer: PHP Medicare Advantage	$132.78
Rate for Payer: Priority Health Choice Medicaid	$84.56
Rate for Payer: Priority Health Cigna Priority Health	$517.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$163.59
Rate for Payer: Priority Health Medicare	$132.78
Rate for Payer: Priority Health Narrow Network	$163.59
Rate for Payer: UHC Medicare Advantage	$136.76

PR IMBRICATION DIAPHRAGM EVENTRATION

Professional

Both

$5,313.00

Service Code	HCPCS 39545
Min. Negotiated Rate	$568.07
Max. Negotiated Rate	$3,719.10
Rate for Payer: Aetna Commercial	$1,182.50
Rate for Payer: Aetna Medicare	$882.46
Rate for Payer: BCBS Complete	$596.47
Rate for Payer: BCBS MAPPO	$882.46
Rate for Payer: BCBS Trust/PPO	$671.47
Rate for Payer: BCN Commercial	$1,295.97
Rate for Payer: BCN Medicare Advantage	$882.46
Rate for Payer: Cash Price	$4,250.40
Rate for Payer: Cash Price	$4,250.40
Rate for Payer: Cofinity Commercial	$1,270.74
Rate for Payer: Cofinity Commercial	$1,182.50
Rate for Payer: Health Alliance Plan Medicare Advantage	$882.46
Rate for Payer: Healthscope Commercial	$1,058.95
Rate for Payer: Healthscope Whirlpool	$1,058.95
Rate for Payer: Meridian Medicaid	$596.47
Rate for Payer: Meridian Wellcare - Medicare Advantage	$926.58
Rate for Payer: PACE SWMI	$882.46
Rate for Payer: PHP Medicare Advantage	$882.46
Rate for Payer: Priority Health Choice Medicaid	$568.07
Rate for Payer: Priority Health Cigna Priority Health	$3,719.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,410.75
Rate for Payer: Priority Health Medicare	$882.46
Rate for Payer: Priority Health Narrow Network	$1,410.75
Rate for Payer: UHC Medicare Advantage	$908.93

PR IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ

Professional

Both

$400.00

Service Code	HCPCS 49406
Min. Negotiated Rate	$120.77
Max. Negotiated Rate	$2,515.24
Rate for Payer: Aetna Commercial	$253.98
Rate for Payer: Aetna Medicare	$189.54
Rate for Payer: BCBS Complete	$126.81
Rate for Payer: BCBS MAPPO	$189.54
Rate for Payer: BCBS Trust/PPO	$2,515.24
Rate for Payer: BCN Commercial	$1,311.61
Rate for Payer: BCN Medicare Advantage	$189.54
Rate for Payer: Cash Price	$320.00
Rate for Payer: Cash Price	$320.00
Rate for Payer: Cofinity Commercial	$272.94
Rate for Payer: Cofinity Commercial	$253.98
Rate for Payer: Health Alliance Plan Medicare Advantage	$189.54
Rate for Payer: Healthscope Commercial	$227.45
Rate for Payer: Healthscope Whirlpool	$227.45
Rate for Payer: Meridian Medicaid	$126.81
Rate for Payer: Meridian Wellcare - Medicare Advantage	$199.02
Rate for Payer: PACE SWMI	$189.54
Rate for Payer: PHP Medicare Advantage	$189.54
Rate for Payer: Priority Health Choice Medicaid	$120.77
Rate for Payer: Priority Health Cigna Priority Health	$280.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$333.97
Rate for Payer: Priority Health Medicare	$189.54
Rate for Payer: Priority Health Narrow Network	$333.97
Rate for Payer: UHC Medicare Advantage	$195.23

PRIMIDONE 250 MG TABLET

Facility

$4.38

Service Code	NDC 50268-687-11
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$4.38
Rate for Payer: Aetna Commercial	$3.94
Rate for Payer: ASR ASR	$4.25
Rate for Payer: BCBS Trust/PPO	$3.40
Rate for Payer: BCN Commercial	$3.40
Rate for Payer: Cash Price	$3.50
Rate for Payer: Cofinity Commercial	$4.12
Rate for Payer: Encore Health Key Benefits Commercial	$3.50
Rate for Payer: Healthscope Commercial	$4.38
Rate for Payer: Healthscope Whirlpool	$4.25
Rate for Payer: Mclaren Commercial	$3.94
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.72
Rate for Payer: Priority Health Cigna Priority Health	$3.07
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.85

PRIMIDONE 250 MG TABLET

Facility

$218.98

Service Code	NDC 50268-687-15
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$153.29
Max. Negotiated Rate	$218.98
Rate for Payer: Aetna Commercial	$197.08
Rate for Payer: ASR ASR	$212.41
Rate for Payer: BCBS Trust/PPO	$169.78
Rate for Payer: BCN Commercial	$169.78
Rate for Payer: Cash Price	$175.18
Rate for Payer: Cofinity Commercial	$205.84
Rate for Payer: Encore Health Key Benefits Commercial	$175.18
Rate for Payer: Healthscope Commercial	$218.98
Rate for Payer: Healthscope Whirlpool	$212.41
Rate for Payer: Mclaren Commercial	$197.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$186.13
Rate for Payer: Priority Health Cigna Priority Health	$153.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$192.70

PRIMIDONE 50 MG TABLET

Facility

$3.28

Service Code	NDC 50268-686-11
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$3.28
Rate for Payer: Aetna Commercial	$2.95
Rate for Payer: ASR ASR	$3.18
Rate for Payer: BCBS Trust/PPO	$2.54
Rate for Payer: BCN Commercial	$2.54
Rate for Payer: Cash Price	$2.62
Rate for Payer: Cofinity Commercial	$3.08
Rate for Payer: Encore Health Key Benefits Commercial	$2.62
Rate for Payer: Healthscope Commercial	$3.28
Rate for Payer: Healthscope Whirlpool	$3.18
Rate for Payer: Mclaren Commercial	$2.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.79
Rate for Payer: Priority Health Cigna Priority Health	$2.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.89

PRIMIDONE 50 MG TABLET

Facility

$163.88

Service Code	NDC 50268-686-15
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$114.72
Max. Negotiated Rate	$163.88
Rate for Payer: Aetna Commercial	$147.49
Rate for Payer: ASR ASR	$158.96
Rate for Payer: BCBS Trust/PPO	$127.06
Rate for Payer: BCN Commercial	$127.06
Rate for Payer: Cash Price	$131.10
Rate for Payer: Cofinity Commercial	$154.05
Rate for Payer: Encore Health Key Benefits Commercial	$131.10
Rate for Payer: Healthscope Commercial	$163.88
Rate for Payer: Healthscope Whirlpool	$158.96
Rate for Payer: Mclaren Commercial	$147.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$139.30
Rate for Payer: Priority Health Cigna Priority Health	$114.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$144.21

PRIMIDONE 50 MG TABLET

Facility

$185.65

Service Code	NDC 0904-5559-60
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$129.96
Max. Negotiated Rate	$185.65
Rate for Payer: Aetna Commercial	$167.08
Rate for Payer: ASR ASR	$180.08
Rate for Payer: BCBS Trust/PPO	$143.93
Rate for Payer: BCN Commercial	$143.93
Rate for Payer: Cash Price	$148.52
Rate for Payer: Cofinity Commercial	$174.51
Rate for Payer: Encore Health Key Benefits Commercial	$148.52
Rate for Payer: Healthscope Commercial	$185.65
Rate for Payer: Healthscope Whirlpool	$180.08
Rate for Payer: Mclaren Commercial	$167.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$157.80
Rate for Payer: Priority Health Cigna Priority Health	$129.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$163.37

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

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: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00

Know your out-of-pocket cost for care.

All Charges