Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

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

Professional

Both

$23.00

Service Code	HCPCS 90461
Min. Negotiated Rate	$8.26
Max. Negotiated Rate	$14.95
Rate for Payer: Aetna Commercial	$11.07
Rate for Payer: Aetna Medicare	$8.26
Rate for Payer: BCBS Complete	$9.20
Rate for Payer: BCBS MAPPO	$8.26
Rate for Payer: BCN Medicare Advantage	$8.26
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cofinity Commercial	$11.89
Rate for Payer: Cofinity Commercial	$11.07
Rate for Payer: Health Alliance Plan Medicare Advantage	$8.26
Rate for Payer: Healthscope Commercial	$9.91
Rate for Payer: Healthscope Whirlpool	$9.91
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$8.67
Rate for Payer: Nomi Health Commercial	$9.91
Rate for Payer: PACE SWMI	$8.26
Rate for Payer: PHP Medicare Advantage	$8.26
Rate for Payer: Priority Health Cigna Priority Health	$14.95
Rate for Payer: Priority Health Medicare	$8.26
Rate for Payer: UHC Dual Complete DSNP	$8.26
Rate for Payer: UHC Medicare Advantage	$8.26
Rate for Payer: UHCCP DNSP	$8.26

PR IMBRICATION DIAPHRAGM EVENTRATION

Professional

Both

$5,419.00

Service Code	HCPCS 39545
Min. Negotiated Rate	$863.44
Max. Negotiated Rate	$3,522.35
Rate for Payer: Aetna Commercial	$1,157.01
Rate for Payer: Aetna Medicare	$863.44
Rate for Payer: BCBS Complete	$2,167.60
Rate for Payer: BCBS MAPPO	$863.44
Rate for Payer: BCN Medicare Advantage	$863.44
Rate for Payer: Cash Price	$4,335.20
Rate for Payer: Cash Price	$4,335.20
Rate for Payer: Cofinity Commercial	$1,243.35
Rate for Payer: Cofinity Commercial	$1,157.01
Rate for Payer: Health Alliance Plan Medicare Advantage	$863.44
Rate for Payer: Healthscope Commercial	$1,036.13
Rate for Payer: Healthscope Whirlpool	$1,036.13
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$906.61
Rate for Payer: Nomi Health Commercial	$1,036.13
Rate for Payer: PACE SWMI	$863.44
Rate for Payer: PHP Medicare Advantage	$863.44
Rate for Payer: Priority Health Cigna Priority Health	$3,522.35
Rate for Payer: Priority Health Medicare	$863.44
Rate for Payer: UHC Dual Complete DSNP	$863.44
Rate for Payer: UHC Medicare Advantage	$863.44
Rate for Payer: UHCCP DNSP	$863.44

PR IMG-GUIDED FLU COLLJ DRG CATH SOFT TISS PERQ

Professional

Both

$754.00

Service Code	HCPCS 10030
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$490.10
Rate for Payer: Aetna Commercial	$171.45
Rate for Payer: Aetna Medicare	$127.95
Rate for Payer: BCBS Complete	$301.60
Rate for Payer: BCBS MAPPO	$127.95
Rate for Payer: BCN Medicare Advantage	$127.95
Rate for Payer: Cash Price	$603.20
Rate for Payer: Cash Price	$603.20
Rate for Payer: Cofinity Commercial	$184.25
Rate for Payer: Cofinity Commercial	$171.45
Rate for Payer: Health Alliance Plan Medicare Advantage	$127.95
Rate for Payer: Healthscope Commercial	$153.54
Rate for Payer: Healthscope Whirlpool	$153.54
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$134.35
Rate for Payer: Nomi Health Commercial	$153.54
Rate for Payer: PACE SWMI	$127.95
Rate for Payer: PHP Medicare Advantage	$127.95
Rate for Payer: Priority Health Cigna Priority Health	$490.10
Rate for Payer: Priority Health Medicare	$127.95
Rate for Payer: UHC Dual Complete DSNP	$127.95
Rate for Payer: UHC Medicare Advantage	$127.95
Rate for Payer: UHCCP DNSP	$127.95

PR IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ

Professional

Both

$408.00

Service Code	HCPCS 49406
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$265.20
Rate for Payer: Aetna Commercial	$245.45
Rate for Payer: Aetna Medicare	$183.17
Rate for Payer: BCBS Complete	$163.20
Rate for Payer: BCBS MAPPO	$183.17
Rate for Payer: BCN Medicare Advantage	$183.17
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cofinity Commercial	$263.76
Rate for Payer: Cofinity Commercial	$245.45
Rate for Payer: Health Alliance Plan Medicare Advantage	$183.17
Rate for Payer: Healthscope Commercial	$219.80
Rate for Payer: Healthscope Whirlpool	$219.80
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$192.33
Rate for Payer: Nomi Health Commercial	$219.80
Rate for Payer: PACE SWMI	$183.17
Rate for Payer: PHP Medicare Advantage	$183.17
Rate for Payer: Priority Health Cigna Priority Health	$265.20
Rate for Payer: Priority Health Medicare	$183.17
Rate for Payer: UHC Dual Complete DSNP	$183.17
Rate for Payer: UHC Medicare Advantage	$183.17
Rate for Payer: UHCCP DNSP	$183.17

PRIMIDONE 250 MG TABLET

Facility

$222.30

Service Code	NDC 50268068715
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$88.92
Max. Negotiated Rate	$222.30
Rate for Payer: Aetna Commercial	$200.07
Rate for Payer: Aetna Medicare	$111.15
Rate for Payer: ASR ASR	$215.63
Rate for Payer: ASR Commercial	$215.63
Rate for Payer: BCBS Complete	$88.92
Rate for Payer: BCBS Trust/PPO	$182.04
Rate for Payer: BCN Commercial	$172.35
Rate for Payer: Cash Price	$177.84
Rate for Payer: Cofinity Commercial	$208.96
Rate for Payer: Encore Health Key Benefits Commercial	$177.84
Rate for Payer: Healthscope Commercial	$222.30
Rate for Payer: Healthscope Whirlpool	$215.63
Rate for Payer: Mclaren Commercial	$200.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.96
Rate for Payer: Nomi Health Commercial	$182.29
Rate for Payer: Priority Health Cigna Priority Health	$144.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$194.78
Rate for Payer: Priority Health Narrow Network	$155.83
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$195.62

PRIMIDONE 250 MG TABLET

Facility

$4.45

Service Code	NDC 50268068711
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$4.45
Rate for Payer: Aetna Commercial	$4.00
Rate for Payer: ASR ASR	$4.32
Rate for Payer: ASR Commercial	$4.32
Rate for Payer: BCBS Trust/PPO	$3.63
Rate for Payer: BCN Commercial	$3.45
Rate for Payer: Cash Price	$3.56
Rate for Payer: Cofinity Commercial	$4.18
Rate for Payer: Encore Health Key Benefits Commercial	$3.56
Rate for Payer: Healthscope Commercial	$4.45
Rate for Payer: Healthscope Whirlpool	$4.32
Rate for Payer: Mclaren Commercial	$4.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.78
Rate for Payer: Nomi Health Commercial	$3.65
Rate for Payer: Priority Health Cigna Priority Health	$2.89
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.92

PRIMIDONE 250 MG TABLET

Facility

$222.30

Service Code	NDC 50268068715
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$222.30
Rate for Payer: Aetna Commercial	$200.07
Rate for Payer: ASR ASR	$215.63
Rate for Payer: ASR Commercial	$215.63
Rate for Payer: BCBS Trust/PPO	$181.15
Rate for Payer: BCN Commercial	$172.35
Rate for Payer: Cash Price	$177.84
Rate for Payer: Cofinity Commercial	$208.96
Rate for Payer: Encore Health Key Benefits Commercial	$177.84
Rate for Payer: Healthscope Commercial	$222.30
Rate for Payer: Healthscope Whirlpool	$215.63
Rate for Payer: Mclaren Commercial	$200.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.96
Rate for Payer: Nomi Health Commercial	$182.29
Rate for Payer: Priority Health Cigna Priority Health	$144.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$195.62

PRIMIDONE 250 MG TABLET

Facility

$4.45

Service Code	NDC 50268068711
Hospital Charge Code	6544
Hospital Revenue Code	637
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$4.45
Rate for Payer: Aetna Commercial	$4.00
Rate for Payer: Aetna Medicare	$2.23
Rate for Payer: ASR ASR	$4.32
Rate for Payer: ASR Commercial	$4.32
Rate for Payer: BCBS Complete	$1.78
Rate for Payer: BCBS Trust/PPO	$3.64
Rate for Payer: BCN Commercial	$3.45
Rate for Payer: Cash Price	$3.56
Rate for Payer: Cofinity Commercial	$4.18
Rate for Payer: Encore Health Key Benefits Commercial	$3.56
Rate for Payer: Healthscope Commercial	$4.45
Rate for Payer: Healthscope Whirlpool	$4.32
Rate for Payer: Mclaren Commercial	$4.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.78
Rate for Payer: Nomi Health Commercial	$3.65
Rate for Payer: Priority Health Cigna Priority Health	$2.89
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.90
Rate for Payer: Priority Health Narrow Network	$3.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.92

PRIMIDONE 50 MG TABLET

Facility

$3.37

Service Code	NDC 50268068611
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$3.37
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: Aetna Medicare	$1.69
Rate for Payer: ASR ASR	$3.27
Rate for Payer: ASR Commercial	$3.27
Rate for Payer: BCBS Complete	$1.35
Rate for Payer: BCBS Trust/PPO	$2.76
Rate for Payer: BCN Commercial	$2.61
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cofinity Commercial	$3.17
Rate for Payer: Encore Health Key Benefits Commercial	$2.70
Rate for Payer: Healthscope Commercial	$3.37
Rate for Payer: Healthscope Whirlpool	$3.27
Rate for Payer: Mclaren Commercial	$3.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.86
Rate for Payer: Nomi Health Commercial	$2.76
Rate for Payer: Priority Health Cigna Priority Health	$2.19
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.95
Rate for Payer: Priority Health Narrow Network	$2.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.97

PRIMIDONE 50 MG TABLET

Facility

$168.62

Service Code	NDC 50268068615
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$67.45
Max. Negotiated Rate	$168.62
Rate for Payer: Aetna Commercial	$151.76
Rate for Payer: Aetna Medicare	$84.31
Rate for Payer: ASR ASR	$163.56
Rate for Payer: ASR Commercial	$163.56
Rate for Payer: BCBS Complete	$67.45
Rate for Payer: BCBS Trust/PPO	$138.08
Rate for Payer: BCN Commercial	$130.73
Rate for Payer: Cash Price	$134.90
Rate for Payer: Cofinity Commercial	$158.50
Rate for Payer: Encore Health Key Benefits Commercial	$134.90
Rate for Payer: Healthscope Commercial	$168.62
Rate for Payer: Healthscope Whirlpool	$163.56
Rate for Payer: Mclaren Commercial	$151.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.33
Rate for Payer: Nomi Health Commercial	$138.27
Rate for Payer: Priority Health Cigna Priority Health	$109.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$147.74
Rate for Payer: Priority Health Narrow Network	$118.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$148.39

PRIMIDONE 50 MG TABLET

Facility

$3.37

Service Code	NDC 50268068611
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$3.37
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: ASR ASR	$3.27
Rate for Payer: ASR Commercial	$3.27
Rate for Payer: BCBS Trust/PPO	$2.75
Rate for Payer: BCN Commercial	$2.61
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cofinity Commercial	$3.17
Rate for Payer: Encore Health Key Benefits Commercial	$2.70
Rate for Payer: Healthscope Commercial	$3.37
Rate for Payer: Healthscope Whirlpool	$3.27
Rate for Payer: Mclaren Commercial	$3.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.86
Rate for Payer: Nomi Health Commercial	$2.76
Rate for Payer: Priority Health Cigna Priority Health	$2.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.97

PRIMIDONE 50 MG TABLET

Facility

$168.62

Service Code	NDC 50268068615
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$109.60
Max. Negotiated Rate	$168.62
Rate for Payer: Aetna Commercial	$151.76
Rate for Payer: ASR ASR	$163.56
Rate for Payer: ASR Commercial	$163.56
Rate for Payer: BCBS Trust/PPO	$137.41
Rate for Payer: BCN Commercial	$130.73
Rate for Payer: Cash Price	$134.90
Rate for Payer: Cofinity Commercial	$158.50
Rate for Payer: Encore Health Key Benefits Commercial	$134.90
Rate for Payer: Healthscope Commercial	$168.62
Rate for Payer: Healthscope Whirlpool	$163.56
Rate for Payer: Mclaren Commercial	$151.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.33
Rate for Payer: Nomi Health Commercial	$138.27
Rate for Payer: Priority Health Cigna Priority Health	$109.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$148.39

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

Professional

Both

$41.00

Service Code	HCPCS 0011A
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

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

Professional

Both

$41.00

Service Code	HCPCS 0012A
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

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

Professional

Both

$41.00

Service Code	HCPCS 0013A
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

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

Professional

Both

$41.00

Service Code	HCPCS 0071A
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

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

Professional

Both

$41.00

Service Code	HCPCS 0072A
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

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

Professional

Both

$41.00

Service Code	HCPCS 0073A
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

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

Professional

Both

$41.00

Service Code	HCPCS 0074A
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

PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 1ST DOSE

Professional

Both

$41.00

Service Code	HCPCS 0111A
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

PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 2ND DOSE

Professional

Both

$41.00

Service Code	HCPCS 0112A
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

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 1ST DOSE

Professional

Both

$41.00

Service Code	HCPCS 0001A
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

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 2ND DOSE

Professional

Both

$41.00

Service Code	HCPCS 0002A
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

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 3RD DOSE

Professional

Both

$41.00

Service Code	HCPCS 0003A
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

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

Know your out-of-pocket cost for care.

All Charges