Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PRIMIDONE 50 MG TABLET

Facility

$3.76

Service Code	NDC 50268068611
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$3.76
Rate for Payer: Aetna Commercial	$3.39
Rate for Payer: ASR ASR	$3.65
Rate for Payer: BCBS Trust/PPO	$3.09
Rate for Payer: BCN Commercial	$3.09
Rate for Payer: Cash Price	$3.01
Rate for Payer: Cofinity Commercial	$3.54
Rate for Payer: Encore Health Key Benefits Commercial	$3.01
Rate for Payer: Healthscope Commercial	$3.65
Rate for Payer: Healthscope Whirlpool	$3.76
Rate for Payer: Mclaren Commercial	$3.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.20
Rate for Payer: Nomi Health Commercial	$3.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.31

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	$188.10
Rate for Payer: Aetna Commercial	$169.29
Rate for Payer: Aetna Medicare	$69.60
Rate for Payer: ASR ASR	$182.46
Rate for Payer: BCBS Complete	$75.24
Rate for Payer: BCBS Trust/PPO	$155.09
Rate for Payer: BCN Commercial	$155.09
Rate for Payer: Cash Price	$150.48
Rate for Payer: Cofinity Commercial	$176.81
Rate for Payer: Encore Health Key Benefits Commercial	$150.48
Rate for Payer: Healthscope Commercial	$182.46
Rate for Payer: Healthscope Whirlpool	$188.10
Rate for Payer: Mclaren Commercial	$169.29
Rate for Payer: MI Amish Medical Board Commercial	$150.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$159.88
Rate for Payer: Nomi Health Commercial	$154.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$141.07
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$164.81
Rate for Payer: Priority Health Narrow Network	$131.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$165.53

PRIMIDONE 50 MG TABLET

Facility

$188.10

Service Code	NDC 50268068615
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$141.07
Max. Negotiated Rate	$188.10
Rate for Payer: Aetna Commercial	$169.29
Rate for Payer: ASR ASR	$182.46
Rate for Payer: BCBS Trust/PPO	$154.47
Rate for Payer: BCN Commercial	$154.47
Rate for Payer: Cash Price	$150.48
Rate for Payer: Cofinity Commercial	$176.81
Rate for Payer: Encore Health Key Benefits Commercial	$150.48
Rate for Payer: Healthscope Commercial	$182.46
Rate for Payer: Healthscope Whirlpool	$188.10
Rate for Payer: Mclaren Commercial	$169.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$159.88
Rate for Payer: Nomi Health Commercial	$154.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$141.07
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$165.53

PRIMIDONE 50 MG TABLET

Facility

$3.76

Service Code	NDC 50268068611
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$3.76
Rate for Payer: Aetna Commercial	$3.39
Rate for Payer: Aetna Medicare	$1.39
Rate for Payer: ASR ASR	$3.65
Rate for Payer: BCBS Complete	$1.50
Rate for Payer: BCBS Trust/PPO	$3.10
Rate for Payer: BCN Commercial	$3.10
Rate for Payer: Cash Price	$3.01
Rate for Payer: Cofinity Commercial	$3.54
Rate for Payer: Encore Health Key Benefits Commercial	$3.01
Rate for Payer: Healthscope Commercial	$3.65
Rate for Payer: Healthscope Whirlpool	$3.76
Rate for Payer: Mclaren Commercial	$3.39
Rate for Payer: MI Amish Medical Board Commercial	$3.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.20
Rate for Payer: Nomi Health Commercial	$3.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.82
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$3.30
Rate for Payer: Priority Health Narrow Network	$2.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.31

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

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: BCBS Complete	$16.80
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

Know your out-of-pocket cost for care.

All Charges