Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR IMM ADMN SARSCOV2 AD26 5X1010 VP/0.5 ML 1 DOSE

Professional

Both

$41.00

Service Code	HCPCS 0031A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$712.50
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$712.50
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 AD26 5X1010 VP/0.5 ML BST DOSE

Professional

Both

$41.00

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

Professional

Both

$41.00

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

Professional

Both

$41.00

Service Code	HCPCS 0164A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$3,002.09
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$3,002.09
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 BIVALENT 10 MCG/0.2 ML ADDL

Professional

Both

$41.00

Service Code	HCPCS 0154A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$480.55
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$480.55
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 BIVALENT 25 MCG/0.25 ML ADDL

Professional

Both

$41.00

Service Code	HCPCS 0144A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$68.75
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$68.75
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 BIVALENT 30 MCG/0.3 ML 1 DOSE

Professional

Both

$41.00

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

Professional

Both

$41.00

Service Code	HCPCS 0124A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$122.97
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$122.97
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 BIVALENT 3 MCG/0.2 ML 1ST

Professional

Both

$41.00

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

Professional

Both

$41.00

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

Professional

Both

$41.00

Service Code	HCPCS 0173A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$2,756.25
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$2,756.25
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 BIVALENT 3 MCG/0.2 ML ADDL

Professional

Both

$41.00

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

Professional

Both

$41.00

Service Code	HCPCS 0134A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$1,882.66
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$1,882.66
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 VACCINE SINGLE DOSE

Professional

Both

$85.00

Service Code	HCPCS 90480
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$58.80
Rate for Payer: Aetna Commercial	$40.00
Rate for Payer: Aetna Medicare	$42.50
Rate for Payer: BCBS Complete	$34.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$55.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$58.80
Rate for Payer: Priority Health Narrow Network	$58.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.98
Rate for Payer: UHC Exchange	$39.98

PR IMMUNIZE COUNS < 21YR 5-15 M

Professional

Both

$31.00

Service Code	HCPCS G0312
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$20.15

PR IMMUNIZE COUNS < 21YR 6-30 M

Professional

Both

$46.00

Service Code	HCPCS G0313
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$29.90
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$29.90

PR IMMUNIZE COUNSEL 16-30 MINS

Professional

Both

$46.00

Service Code	HCPCS G0311
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$29.90
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$29.90

PR IMMUNIZE COUNSEL 5-15 MIN

Professional

Both

$31.00

Service Code	HCPCS G0310
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$20.15

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

Professional

Both

$802.00

Service Code	HCPCS 15778
Min. Negotiated Rate	$250.49
Max. Negotiated Rate	$559.05
Rate for Payer: Aetna Commercial	$421.47
Rate for Payer: Aetna Medicare	$401.00
Rate for Payer: BCBS Complete	$263.01
Rate for Payer: BCN Commercial	$559.05
Rate for Payer: Cash Price	$641.60
Rate for Payer: Cash Price	$641.60
Rate for Payer: Meridian Medicaid	$263.01
Rate for Payer: Priority Health Choice Medicaid	$250.49
Rate for Payer: Priority Health Cigna Priority Health	$521.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$518.79
Rate for Payer: Priority Health Narrow Network	$518.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$464.89
Rate for Payer: UHC Exchange	$464.89
Rate for Payer: UHCCP Medicaid	$250.49

PR IMPLANTABLE TISSUE MARKER

Professional

Both

$1,224.00

Service Code	HCPCS A4648
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$795.60
Rate for Payer: Aetna Commercial	$102.14
Rate for Payer: Aetna Medicare	$612.00
Rate for Payer: BCBS Complete	$489.60
Rate for Payer: BCN Commercial	$136.96
Rate for Payer: Cash Price	$979.20
Rate for Payer: Cash Price	$979.20
Rate for Payer: Priority Health Cigna Priority Health	$795.60

PR IMPLANTATION NERVE END BONE/MUSCLE

Professional

Both

$1,853.00

Service Code	HCPCS 64787
Min. Negotiated Rate	$136.83
Max. Negotiated Rate	$1,204.45
Rate for Payer: Aetna Commercial	$310.40
Rate for Payer: Aetna Medicare	$926.50
Rate for Payer: BCBS Complete	$157.23
Rate for Payer: BCBS Trust/PPO	$136.83
Rate for Payer: BCN Commercial	$341.58
Rate for Payer: Cash Price	$1,482.40
Rate for Payer: Cash Price	$1,482.40
Rate for Payer: Meridian Medicaid	$157.23
Rate for Payer: Priority Health Choice Medicaid	$149.74
Rate for Payer: Priority Health Cigna Priority Health	$1,204.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$394.70
Rate for Payer: Priority Health Narrow Network	$394.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$293.38
Rate for Payer: UHC Exchange	$293.38
Rate for Payer: UHCCP Medicaid	$149.74

PR IMPLANTATION PT-ACTIVATED CARDIAC EVENT RECORDER

Professional

Both

$630.00

Service Code	HCPCS 33282
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$409.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS Complete	$252.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Priority Health Cigna Priority Health	$409.50

PR IMPLANT MESH OPN HERNIA RPR/DEBRIDEMENT CLOSURE

Professional

Both

$1,010.00

Service Code	HCPCS 49568
Min. Negotiated Rate	$404.00
Max. Negotiated Rate	$656.50
Rate for Payer: Aetna Medicare	$505.00
Rate for Payer: BCBS Complete	$404.00
Rate for Payer: Cash Price	$808.00
Rate for Payer: Priority Health Cigna Priority Health	$656.50

PR IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT

Professional

Both

$448.00

Service Code	HCPCS 15777
Min. Negotiated Rate	$136.75
Max. Negotiated Rate	$311.29
Rate for Payer: Aetna Commercial	$234.53
Rate for Payer: Aetna Medicare	$224.00
Rate for Payer: BCBS Complete	$143.59
Rate for Payer: BCBS Trust/PPO	$150.00
Rate for Payer: BCN Commercial	$311.29
Rate for Payer: Cash Price	$358.40
Rate for Payer: Cash Price	$358.40
Rate for Payer: Meridian Medicaid	$143.59
Rate for Payer: Priority Health Choice Medicaid	$136.75
Rate for Payer: Priority Health Cigna Priority Health	$291.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$287.61
Rate for Payer: Priority Health Narrow Network	$287.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$254.84
Rate for Payer: UHC Exchange	$254.84
Rate for Payer: UHCCP Medicaid	$136.75

PR IMPL OI IMPLT SKULL MAG TC ATTACHMENT ESP<100

Professional

Both

$1,343.00

Service Code	HCPCS 69716
Min. Negotiated Rate	$176.45
Max. Negotiated Rate	$910.40
Rate for Payer: Aetna Commercial	$688.61
Rate for Payer: Aetna Medicare	$671.50
Rate for Payer: BCBS Complete	$418.00
Rate for Payer: BCBS Trust/PPO	$176.45
Rate for Payer: BCN Commercial	$910.40
Rate for Payer: Cash Price	$1,074.40
Rate for Payer: Cash Price	$1,074.40
Rate for Payer: Meridian Medicaid	$418.00
Rate for Payer: Priority Health Choice Medicaid	$398.10
Rate for Payer: Priority Health Cigna Priority Health	$872.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$908.55
Rate for Payer: Priority Health Narrow Network	$908.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$753.25
Rate for Payer: UHC Exchange	$753.25
Rate for Payer: UHCCP Medicaid	$398.10

Know your out-of-pocket cost for care.

All Charges