Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

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: 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 AD26 5X1010 VP/0.5 ML BST DOSE

Professional

Both

$42.00

Service Code	HCPCS 0034A
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 BIVALENT 10 MCG/0.2 ML 1ST

Professional

Both

$42.00

Service Code	HCPCS 0151A
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 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0154A
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 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0164A
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 BIVALENT 25 MCG/0.25 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0144A
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 BIVALENT 30 MCG/0.3 ML 1 DOSE

Professional

Both

$42.00

Service Code	HCPCS 0121A
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 BIVALENT 30 MCG/0.3 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0124A
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 BIVALENT 3 MCG/0.2 ML 1ST

Professional

Both

$42.00

Service Code	HCPCS 0171A
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 BIVALENT 3 MCG/0.2 ML 2ND

Professional

Both

$42.00

Service Code	HCPCS 0172A
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 BIVALENT 3 MCG/0.2 ML 3RD

Professional

Both

$42.00

Service Code	HCPCS 0173A
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 BIVALENT 3 MCG/0.2 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0174A
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 BIVALENT 50 MCG/0.5 ML ADDL

Professional

Both

$42.00

Service Code	HCPCS 0134A
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 VACCINE 1ST/ONLY COMPONENT

Professional

Both

$88.00

Service Code	HCPCS 90480
Min. Negotiated Rate	$27.07
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$40.00
Rate for Payer: BCN Commercial	$27.07
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$61.53
Rate for Payer: Priority Health Narrow Network	$61.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.98
Rate for Payer: UHC Exchange	$39.98

PR IMM CNSL PHYS/QHP IMM NOT ADMN SAME DOS>20 MIN

Professional

Both

$101.00

Service Code	HCPCS 90484
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$75.75
Rate for Payer: BCBS Complete	$22.14
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cash Price	$80.80
Rate for Payer: Meridian Medicaid	$22.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$75.75
Rate for Payer: Priority Health Choice Medicaid	$21.09
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$48.76
Rate for Payer: Priority Health Narrow Network	$48.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$49.94
Rate for Payer: UHC Exchange	$49.94
Rate for Payer: UHC Medicaid	$21.09
Rate for Payer: UHCCP Medicaid	$21.09

PR IMM CNSL PHYS/QHP IMM NOT ADMN SAME DOS 3<10 MIN

Professional

Both

$36.00

Service Code	HCPCS 90482
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$27.00
Rate for Payer: BCBS Complete	$7.16
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Meridian Medicaid	$7.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$27.00
Rate for Payer: Priority Health Choice Medicaid	$6.82
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$15.76
Rate for Payer: Priority Health Narrow Network	$15.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$16.13
Rate for Payer: UHC Exchange	$16.13
Rate for Payer: UHC Medicaid	$6.82
Rate for Payer: UHCCP Medicaid	$6.82

PR IMM CNSL PHYS/QHP IMM NOT ADMN SM DOS>10<20 MIN

Professional

Both

$69.00

Service Code	HCPCS 90483
Min. Negotiated Rate	$14.06
Max. Negotiated Rate	$51.75
Rate for Payer: BCBS Complete	$14.76
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.20
Rate for Payer: Meridian Medicaid	$14.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$51.75
Rate for Payer: Priority Health Choice Medicaid	$14.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$32.50
Rate for Payer: Priority Health Narrow Network	$32.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$33.30
Rate for Payer: UHC Exchange	$33.30
Rate for Payer: UHC Medicaid	$14.06
Rate for Payer: UHCCP Medicaid	$14.06

PR IMMUNIZE COUNS < 21YR 5-15 M

Professional

Both

$32.00

Service Code	HCPCS G0312
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$24.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.00

PR IMMUNIZE COUNS < 21YR 6-30 M

Professional

Both

$47.00

Service Code	HCPCS G0313
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$35.25
Rate for Payer: BCBS Complete	$18.80
Rate for Payer: Cash Price	$37.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$35.25

PR IMMUNIZE COUNSEL 16-30 MINS

Professional

Both

$47.00

Service Code	HCPCS G0311
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$35.25
Rate for Payer: BCBS Complete	$18.80
Rate for Payer: Cash Price	$37.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$35.25

PR IMMUNIZE COUNSEL 5-15 MIN

Professional

Both

$32.00

Service Code	HCPCS G0310
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$24.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.00

PR IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA

Professional

Both

$826.00

Service Code	HCPCS 15778
Min. Negotiated Rate	$225.35
Max. Negotiated Rate	$703.19
Rate for Payer: Aetna Commercial	$475.53
Rate for Payer: Aetna Medicare	$354.87
Rate for Payer: BCBS Complete	$236.62
Rate for Payer: BCBS MAPPO	$354.87
Rate for Payer: BCN Commercial	$585.63
Rate for Payer: BCN Medicare Advantage	$354.87
Rate for Payer: Cash Price	$660.80
Rate for Payer: Cash Price	$660.80
Rate for Payer: Cofinity Commercial	$511.01
Rate for Payer: Cofinity Commercial	$475.53
Rate for Payer: Health Alliance Plan Medicare Advantage	$354.87
Rate for Payer: Healthscope Commercial	$425.84
Rate for Payer: Healthscope Whirlpool	$425.84
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$372.61
Rate for Payer: Meridian Medicaid	$236.62
Rate for Payer: Molina Medicare/Medicaid	$390.36
Rate for Payer: Nomi Health Commercial	$425.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$619.50
Rate for Payer: PACE SWMI	$354.87
Rate for Payer: PHP Medicare Advantage	$354.87
Rate for Payer: Priority Health Choice Medicaid	$225.35
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$535.99
Rate for Payer: Priority Health Medicare	$354.87
Rate for Payer: Priority Health Narrow Network	$535.99
Rate for Payer: Railroad Medicare Medicare	$354.87
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$703.19
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$354.87
Rate for Payer: UHC Exchange	$703.19
Rate for Payer: UHC Medicaid	$225.35
Rate for Payer: UHCCP DNSP	$354.87
Rate for Payer: UHCCP Medicaid	$225.35

PR IMPLANTABLE TISSUE MARKER

Professional

Both

$1,261.00

Service Code	HCPCS A4648
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$945.75
Rate for Payer: Aetna Commercial	$102.14
Rate for Payer: BCBS Complete	$504.40
Rate for Payer: BCN Commercial	$136.96
Rate for Payer: Cash Price	$1,008.80
Rate for Payer: Cash Price	$1,008.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$945.75

PR IMPLANTATION NERVE END BONE/MUSCLE

Professional

Both

$1,909.00

Service Code	HCPCS 64787
Min. Negotiated Rate	$129.93
Max. Negotiated Rate	$1,431.75
Rate for Payer: Aetna Commercial	$272.80
Rate for Payer: Aetna Medicare	$203.58
Rate for Payer: BCBS Complete	$136.43
Rate for Payer: BCBS MAPPO	$203.58
Rate for Payer: BCN Commercial	$350.08
Rate for Payer: BCN Medicare Advantage	$203.58
Rate for Payer: Cash Price	$1,527.20
Rate for Payer: Cash Price	$1,527.20
Rate for Payer: Cofinity Commercial	$293.16
Rate for Payer: Cofinity Commercial	$272.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$203.58
Rate for Payer: Healthscope Commercial	$244.30
Rate for Payer: Healthscope Whirlpool	$244.30
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$213.76
Rate for Payer: Meridian Medicaid	$136.43
Rate for Payer: Molina Medicare/Medicaid	$223.94
Rate for Payer: Nomi Health Commercial	$244.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,431.75
Rate for Payer: PACE SWMI	$203.58
Rate for Payer: PHP Medicare Advantage	$203.58
Rate for Payer: Priority Health Choice Medicaid	$129.93
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$406.62
Rate for Payer: Priority Health Medicare	$203.58
Rate for Payer: Priority Health Narrow Network	$406.62
Rate for Payer: Railroad Medicare Medicare	$203.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$426.33
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$203.58
Rate for Payer: UHC Exchange	$426.33
Rate for Payer: UHC Medicaid	$129.93
Rate for Payer: UHCCP DNSP	$203.58
Rate for Payer: UHCCP Medicaid	$129.93

PR IMPLANTATION PT-ACTIVATED CARDIAC EVENT RECORDER

Professional

Both

$649.00

Service Code	HCPCS 33282
Min. Negotiated Rate	$259.60
Max. Negotiated Rate	$486.75
Rate for Payer: BCBS Complete	$259.60
Rate for Payer: Cash Price	$519.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$486.75

Know your out-of-pocket cost for care.

All Charges