Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

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	$1.68
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	$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

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

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	$26.78
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$18.75
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$28.95
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$377.55
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$377.55
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$320.45
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$320.45
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$28.95
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$570.00
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$570.00
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$85.82
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$85.82
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$979.03
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$979.03
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$2,617.22
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$2,617.22
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$28.95
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$540.00
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$540.00
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$28.95
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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	$377.55
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$377.55
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 1ST

Professional

Both

$41.00

Service Code	HCPCS 0051A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$59.25
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$59.25
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 2ND

Professional

Both

$41.00

Service Code	HCPCS 0052A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$570.00
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$570.00
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 3RD

Professional

Both

$41.00

Service Code	HCPCS 0053A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$112.50
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE BST

Professional

Both

$41.00

Service Code	HCPCS 0054A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$281.25
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$281.25
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 3MCG/0.2ML TRIS-SUCROSE 1ST

Professional

Both

$41.00

Service Code	HCPCS 0081A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$570.00
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$570.00
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 3MCG/0.2ML TRIS-SUCROSE 2ND

Professional

Both

$41.00

Service Code	HCPCS 0082A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$28.95
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

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

Professional

Both

$41.00

Service Code	HCPCS 0083A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$570.00
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$570.00
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 50 MCG/0.25 ML BOOSTER DOSE

Professional

Both

$41.00

Service Code	HCPCS 0064A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$80.25
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$80.25
Rate for Payer: BCN Commercial	$26.78
Rate for Payer: Cash Price	$32.80
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