Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$46.47

Service Code	NDC 66689079001
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$18.59
Max. Negotiated Rate	$41.82
Rate for Payer: Aetna Commercial	$39.50
Rate for Payer: Aetna Medicare	$23.24
Rate for Payer: Aetna New Business (MI Preferred)	$30.21
Rate for Payer: BCBS Complete	$18.59
Rate for Payer: Cash Price	$37.18
Rate for Payer: Cofinity Commercial	$32.53
Rate for Payer: Cofinity Commercial	$39.96
Rate for Payer: Cofinity Medicare Advantage	$32.53
Rate for Payer: Encore Health Key Benefits Commercial	$37.18
Rate for Payer: Healthscope Commercial	$41.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$39.50
Rate for Payer: PHP Commercial	$39.50
Rate for Payer: Priority Health Cigna Priority Health	$30.21
Rate for Payer: Priority Health SBD	$29.28

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$29.86

Service Code	NDC 60687073856
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$11.94
Max. Negotiated Rate	$26.87
Rate for Payer: Aetna Commercial	$25.38
Rate for Payer: Aetna Medicare	$14.93
Rate for Payer: Aetna New Business (MI Preferred)	$19.41
Rate for Payer: BCBS Complete	$11.94
Rate for Payer: Cash Price	$23.89
Rate for Payer: Cofinity Commercial	$20.90
Rate for Payer: Cofinity Commercial	$25.68
Rate for Payer: Cofinity Medicare Advantage	$20.90
Rate for Payer: Encore Health Key Benefits Commercial	$23.89
Rate for Payer: Healthscope Commercial	$26.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.38
Rate for Payer: PHP Commercial	$25.38
Rate for Payer: Priority Health Cigna Priority Health	$19.41
Rate for Payer: Priority Health SBD	$18.81

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$46.47

Service Code	NDC 66689079001
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$29.28
Max. Negotiated Rate	$41.82
Rate for Payer: Aetna Commercial	$39.50
Rate for Payer: Aetna New Business (MI Preferred)	$30.21
Rate for Payer: Cash Price	$37.18
Rate for Payer: Cofinity Commercial	$32.53
Rate for Payer: Cofinity Commercial	$39.96
Rate for Payer: Cofinity Medicare Advantage	$32.53
Rate for Payer: Encore Health Key Benefits Commercial	$37.18
Rate for Payer: Healthscope Commercial	$41.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$39.50
Rate for Payer: PHP Commercial	$39.50
Rate for Payer: Priority Health Cigna Priority Health	$30.21
Rate for Payer: Priority Health SBD	$29.28

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$32.88

Service Code	NDC 60687073842
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$13.15
Max. Negotiated Rate	$29.59
Rate for Payer: Aetna Commercial	$27.95
Rate for Payer: Aetna Medicare	$16.44
Rate for Payer: Aetna New Business (MI Preferred)	$21.37
Rate for Payer: BCBS Complete	$13.15
Rate for Payer: Cash Price	$26.30
Rate for Payer: Cofinity Commercial	$23.02
Rate for Payer: Cofinity Commercial	$28.28
Rate for Payer: Cofinity Medicare Advantage	$23.02
Rate for Payer: Encore Health Key Benefits Commercial	$26.30
Rate for Payer: Healthscope Commercial	$29.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$27.95
Rate for Payer: PHP Commercial	$27.95
Rate for Payer: Priority Health Cigna Priority Health	$21.37
Rate for Payer: Priority Health SBD	$20.71

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$34.18

Service Code	NDC 69339014817
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$13.67
Max. Negotiated Rate	$30.76
Rate for Payer: Aetna Commercial	$29.05
Rate for Payer: Aetna Medicare	$17.09
Rate for Payer: Aetna New Business (MI Preferred)	$22.22
Rate for Payer: BCBS Complete	$13.67
Rate for Payer: Cash Price	$27.34
Rate for Payer: Cofinity Commercial	$23.93
Rate for Payer: Cofinity Commercial	$29.39
Rate for Payer: Cofinity Medicare Advantage	$23.93
Rate for Payer: Encore Health Key Benefits Commercial	$27.34
Rate for Payer: Healthscope Commercial	$30.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$29.05
Rate for Payer: PHP Commercial	$29.05
Rate for Payer: Priority Health Cigna Priority Health	$22.22
Rate for Payer: Priority Health SBD	$21.53

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$36.63

Service Code	NDC 50268073212
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$23.08
Max. Negotiated Rate	$32.97
Rate for Payer: Aetna Commercial	$31.14
Rate for Payer: Aetna New Business (MI Preferred)	$23.81
Rate for Payer: Cash Price	$29.30
Rate for Payer: Cofinity Commercial	$25.64
Rate for Payer: Cofinity Commercial	$31.50
Rate for Payer: Cofinity Medicare Advantage	$25.64
Rate for Payer: Encore Health Key Benefits Commercial	$29.30
Rate for Payer: Healthscope Commercial	$32.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$31.14
Rate for Payer: PHP Commercial	$31.14
Rate for Payer: Priority Health Cigna Priority Health	$23.81
Rate for Payer: Priority Health SBD	$23.08

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$36.63

Service Code	NDC 50268073211
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$14.65
Max. Negotiated Rate	$32.97
Rate for Payer: Aetna Commercial	$31.14
Rate for Payer: Aetna Medicare	$18.32
Rate for Payer: Aetna New Business (MI Preferred)	$23.81
Rate for Payer: BCBS Complete	$14.65
Rate for Payer: Cash Price	$29.30
Rate for Payer: Cofinity Commercial	$25.64
Rate for Payer: Cofinity Commercial	$31.50
Rate for Payer: Cofinity Medicare Advantage	$25.64
Rate for Payer: Encore Health Key Benefits Commercial	$29.30
Rate for Payer: Healthscope Commercial	$32.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$31.14
Rate for Payer: PHP Commercial	$31.14
Rate for Payer: Priority Health Cigna Priority Health	$23.81
Rate for Payer: Priority Health SBD	$23.08

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$46.23

Service Code	NDC 66689079050
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$29.12
Max. Negotiated Rate	$41.61
Rate for Payer: Aetna Commercial	$39.30
Rate for Payer: Aetna New Business (MI Preferred)	$30.05
Rate for Payer: Cash Price	$36.98
Rate for Payer: Cofinity Commercial	$32.36
Rate for Payer: Cofinity Commercial	$39.76
Rate for Payer: Cofinity Medicare Advantage	$32.36
Rate for Payer: Encore Health Key Benefits Commercial	$36.98
Rate for Payer: Healthscope Commercial	$41.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$39.30
Rate for Payer: PHP Commercial	$39.30
Rate for Payer: Priority Health Cigna Priority Health	$30.05
Rate for Payer: Priority Health SBD	$29.12

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$29.91

Service Code	NDC 00904747066
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$26.92
Rate for Payer: Aetna Commercial	$25.42
Rate for Payer: Aetna New Business (MI Preferred)	$19.44
Rate for Payer: Cash Price	$23.93
Rate for Payer: Cofinity Commercial	$20.94
Rate for Payer: Cofinity Commercial	$25.72
Rate for Payer: Cofinity Medicare Advantage	$20.94
Rate for Payer: Encore Health Key Benefits Commercial	$23.93
Rate for Payer: Healthscope Commercial	$26.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.42
Rate for Payer: PHP Commercial	$25.42
Rate for Payer: Priority Health Cigna Priority Health	$19.44
Rate for Payer: Priority Health SBD	$18.84

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$46.36

Service Code	NDC 00904747072
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$18.54
Max. Negotiated Rate	$41.72
Rate for Payer: Aetna Commercial	$39.41
Rate for Payer: Aetna Medicare	$23.18
Rate for Payer: Aetna New Business (MI Preferred)	$30.13
Rate for Payer: BCBS Complete	$18.54
Rate for Payer: Cash Price	$37.09
Rate for Payer: Cofinity Commercial	$32.45
Rate for Payer: Cofinity Commercial	$39.87
Rate for Payer: Cofinity Medicare Advantage	$32.45
Rate for Payer: Encore Health Key Benefits Commercial	$37.09
Rate for Payer: Healthscope Commercial	$41.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$39.41
Rate for Payer: PHP Commercial	$39.41
Rate for Payer: Priority Health Cigna Priority Health	$30.13
Rate for Payer: Priority Health SBD	$29.21

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$29.86

Service Code	NDC 60687073856
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$18.81
Max. Negotiated Rate	$26.87
Rate for Payer: Aetna Commercial	$25.38
Rate for Payer: Aetna New Business (MI Preferred)	$19.41
Rate for Payer: Cash Price	$23.89
Rate for Payer: Cofinity Commercial	$20.90
Rate for Payer: Cofinity Commercial	$25.68
Rate for Payer: Cofinity Medicare Advantage	$20.90
Rate for Payer: Encore Health Key Benefits Commercial	$23.89
Rate for Payer: Healthscope Commercial	$26.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.38
Rate for Payer: PHP Commercial	$25.38
Rate for Payer: Priority Health Cigna Priority Health	$19.41
Rate for Payer: Priority Health SBD	$18.81

SUCRALFATE 100 MG/ML ORAL SUSPENSION

Facility

$29.91

Service Code	NDC 00904747066
Hospital Charge Code	11441
Hospital Revenue Code	637
Min. Negotiated Rate	$11.96
Max. Negotiated Rate	$26.92
Rate for Payer: Aetna Commercial	$25.42
Rate for Payer: Aetna Medicare	$14.96
Rate for Payer: Aetna New Business (MI Preferred)	$19.44
Rate for Payer: BCBS Complete	$11.96
Rate for Payer: Cash Price	$23.93
Rate for Payer: Cofinity Commercial	$20.94
Rate for Payer: Cofinity Commercial	$25.72
Rate for Payer: Cofinity Medicare Advantage	$20.94
Rate for Payer: Encore Health Key Benefits Commercial	$23.93
Rate for Payer: Healthscope Commercial	$26.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.42
Rate for Payer: PHP Commercial	$25.42
Rate for Payer: Priority Health Cigna Priority Health	$19.44
Rate for Payer: Priority Health SBD	$18.84

SUCRALFATE 1 GRAM TABLET

Facility

$234.65

Service Code	NDC 00093221001
Hospital Charge Code	11442
Hospital Revenue Code	637
Min. Negotiated Rate	$147.83
Max. Negotiated Rate	$211.18
Rate for Payer: Aetna Commercial	$199.45
Rate for Payer: Aetna New Business (MI Preferred)	$152.52
Rate for Payer: Cash Price	$187.72
Rate for Payer: Cofinity Commercial	$164.26
Rate for Payer: Cofinity Commercial	$201.80
Rate for Payer: Cofinity Medicare Advantage	$164.26
Rate for Payer: Encore Health Key Benefits Commercial	$187.72
Rate for Payer: Healthscope Commercial	$211.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$199.45
Rate for Payer: PHP Commercial	$199.45
Rate for Payer: Priority Health Cigna Priority Health	$152.52
Rate for Payer: Priority Health SBD	$147.83

SUCRALFATE 1 GRAM TABLET

Facility

$364.25

Service Code	NDC 59762040101
Hospital Charge Code	11442
Hospital Revenue Code	637
Min. Negotiated Rate	$145.70
Max. Negotiated Rate	$327.82
Rate for Payer: Aetna Commercial	$309.61
Rate for Payer: Aetna Medicare	$182.12
Rate for Payer: Aetna New Business (MI Preferred)	$236.76
Rate for Payer: BCBS Complete	$145.70
Rate for Payer: Cash Price	$291.40
Rate for Payer: Cofinity Commercial	$254.98
Rate for Payer: Cofinity Commercial	$313.26
Rate for Payer: Cofinity Medicare Advantage	$254.98
Rate for Payer: Encore Health Key Benefits Commercial	$291.40
Rate for Payer: Healthscope Commercial	$327.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$309.61
Rate for Payer: PHP Commercial	$309.61
Rate for Payer: Priority Health Cigna Priority Health	$236.76
Rate for Payer: Priority Health SBD	$229.48

SUCRALFATE 1 GRAM TABLET

Facility

$234.65

Service Code	NDC 00093221001
Hospital Charge Code	11442
Hospital Revenue Code	637
Min. Negotiated Rate	$93.86
Max. Negotiated Rate	$211.18
Rate for Payer: Aetna Commercial	$199.45
Rate for Payer: Aetna Medicare	$117.32
Rate for Payer: Aetna New Business (MI Preferred)	$152.52
Rate for Payer: BCBS Complete	$93.86
Rate for Payer: Cash Price	$187.72
Rate for Payer: Cofinity Commercial	$164.26
Rate for Payer: Cofinity Commercial	$201.80
Rate for Payer: Cofinity Medicare Advantage	$164.26
Rate for Payer: Encore Health Key Benefits Commercial	$187.72
Rate for Payer: Healthscope Commercial	$211.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$199.45
Rate for Payer: PHP Commercial	$199.45
Rate for Payer: Priority Health Cigna Priority Health	$152.52
Rate for Payer: Priority Health SBD	$147.83

SUCRALFATE 1 GRAM TABLET

Facility

$954.75

Service Code	NDC 00093221005
Hospital Charge Code	11442
Hospital Revenue Code	637
Min. Negotiated Rate	$381.90
Max. Negotiated Rate	$859.28
Rate for Payer: Aetna Commercial	$811.54
Rate for Payer: Aetna Medicare	$477.38
Rate for Payer: Aetna New Business (MI Preferred)	$620.59
Rate for Payer: BCBS Complete	$381.90
Rate for Payer: Cash Price	$763.80
Rate for Payer: Cofinity Commercial	$668.32
Rate for Payer: Cofinity Commercial	$821.08
Rate for Payer: Cofinity Medicare Advantage	$668.32
Rate for Payer: Encore Health Key Benefits Commercial	$763.80
Rate for Payer: Healthscope Commercial	$859.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$811.54
Rate for Payer: PHP Commercial	$811.54
Rate for Payer: Priority Health Cigna Priority Health	$620.59
Rate for Payer: Priority Health SBD	$601.49

SUCRALFATE 1 GRAM TABLET

Facility

$954.75

Service Code	NDC 00093221005
Hospital Charge Code	11442
Hospital Revenue Code	637
Min. Negotiated Rate	$601.49
Max. Negotiated Rate	$859.28
Rate for Payer: Aetna Commercial	$811.54
Rate for Payer: Aetna New Business (MI Preferred)	$620.59
Rate for Payer: Cash Price	$763.80
Rate for Payer: Cofinity Commercial	$668.32
Rate for Payer: Cofinity Commercial	$821.08
Rate for Payer: Cofinity Medicare Advantage	$668.32
Rate for Payer: Encore Health Key Benefits Commercial	$763.80
Rate for Payer: Healthscope Commercial	$859.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$811.54
Rate for Payer: PHP Commercial	$811.54
Rate for Payer: Priority Health Cigna Priority Health	$620.59
Rate for Payer: Priority Health SBD	$601.49

SUCRALFATE 1 GRAM TABLET

Facility

$314.45

Service Code	NDC 51079075320
Hospital Charge Code	11442
Hospital Revenue Code	637
Min. Negotiated Rate	$198.10
Max. Negotiated Rate	$283.00
Rate for Payer: Aetna Commercial	$267.28
Rate for Payer: Aetna New Business (MI Preferred)	$204.39
Rate for Payer: Cash Price	$251.56
Rate for Payer: Cofinity Commercial	$220.12
Rate for Payer: Cofinity Commercial	$270.43
Rate for Payer: Cofinity Medicare Advantage	$220.12
Rate for Payer: Encore Health Key Benefits Commercial	$251.56
Rate for Payer: Healthscope Commercial	$283.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$267.28
Rate for Payer: PHP Commercial	$267.28
Rate for Payer: Priority Health Cigna Priority Health	$204.39
Rate for Payer: Priority Health SBD	$198.10

SUCRALFATE 1 GRAM TABLET

Facility

$364.25

Service Code	NDC 59762040101
Hospital Charge Code	11442
Hospital Revenue Code	637
Min. Negotiated Rate	$229.48
Max. Negotiated Rate	$327.82
Rate for Payer: Aetna Commercial	$309.61
Rate for Payer: Aetna New Business (MI Preferred)	$236.76
Rate for Payer: Cash Price	$291.40
Rate for Payer: Cofinity Commercial	$254.98
Rate for Payer: Cofinity Commercial	$313.26
Rate for Payer: Cofinity Medicare Advantage	$254.98
Rate for Payer: Encore Health Key Benefits Commercial	$291.40
Rate for Payer: Healthscope Commercial	$327.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$309.61
Rate for Payer: PHP Commercial	$309.61
Rate for Payer: Priority Health Cigna Priority Health	$236.76
Rate for Payer: Priority Health SBD	$229.48

SUCRALFATE 1 GRAM TABLET

Facility

$314.45

Service Code	NDC 51079075320
Hospital Charge Code	11442
Hospital Revenue Code	637
Min. Negotiated Rate	$125.78
Max. Negotiated Rate	$283.00
Rate for Payer: Aetna Commercial	$267.28
Rate for Payer: Aetna Medicare	$157.22
Rate for Payer: Aetna New Business (MI Preferred)	$204.39
Rate for Payer: BCBS Complete	$125.78
Rate for Payer: Cash Price	$251.56
Rate for Payer: Cofinity Commercial	$220.12
Rate for Payer: Cofinity Commercial	$270.43
Rate for Payer: Cofinity Medicare Advantage	$220.12
Rate for Payer: Encore Health Key Benefits Commercial	$251.56
Rate for Payer: Healthscope Commercial	$283.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$267.28
Rate for Payer: PHP Commercial	$267.28
Rate for Payer: Priority Health Cigna Priority Health	$204.39
Rate for Payer: Priority Health SBD	$198.10

SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION

Facility

$449.46

Service Code	NDC 00006542312
Hospital Charge Code	177099
Hospital Revenue Code	250
Min. Negotiated Rate	$283.16
Max. Negotiated Rate	$404.51
Rate for Payer: Aetna Commercial	$382.04
Rate for Payer: Aetna New Business (MI Preferred)	$292.15
Rate for Payer: Cash Price	$359.57
Rate for Payer: Cofinity Commercial	$314.62
Rate for Payer: Cofinity Commercial	$386.54
Rate for Payer: Cofinity Medicare Advantage	$314.62
Rate for Payer: Encore Health Key Benefits Commercial	$359.57
Rate for Payer: Healthscope Commercial	$404.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$382.04
Rate for Payer: PHP Commercial	$382.04
Rate for Payer: Priority Health Cigna Priority Health	$292.15
Rate for Payer: Priority Health SBD	$283.16

SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION

Facility

$449.46

Service Code	NDC 00006542302
Hospital Charge Code	177099
Hospital Revenue Code	250
Min. Negotiated Rate	$283.16
Max. Negotiated Rate	$404.51
Rate for Payer: Aetna Commercial	$382.04
Rate for Payer: Aetna New Business (MI Preferred)	$292.15
Rate for Payer: Cash Price	$359.57
Rate for Payer: Cofinity Commercial	$314.62
Rate for Payer: Cofinity Commercial	$386.54
Rate for Payer: Cofinity Medicare Advantage	$314.62
Rate for Payer: Encore Health Key Benefits Commercial	$359.57
Rate for Payer: Healthscope Commercial	$404.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$382.04
Rate for Payer: PHP Commercial	$382.04
Rate for Payer: Priority Health Cigna Priority Health	$292.15
Rate for Payer: Priority Health SBD	$283.16

SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION

Facility

$449.46

Service Code	NDC 00006542312
Hospital Charge Code	177099
Hospital Revenue Code	250
Min. Negotiated Rate	$179.78
Max. Negotiated Rate	$404.51
Rate for Payer: Aetna Commercial	$382.04
Rate for Payer: Aetna Medicare	$224.73
Rate for Payer: Aetna New Business (MI Preferred)	$292.15
Rate for Payer: BCBS Complete	$179.78
Rate for Payer: Cash Price	$359.57
Rate for Payer: Cofinity Commercial	$314.62
Rate for Payer: Cofinity Commercial	$386.54
Rate for Payer: Cofinity Medicare Advantage	$314.62
Rate for Payer: Encore Health Key Benefits Commercial	$359.57
Rate for Payer: Healthscope Commercial	$404.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$382.04
Rate for Payer: PHP Commercial	$382.04
Rate for Payer: Priority Health Cigna Priority Health	$292.15
Rate for Payer: Priority Health SBD	$283.16

SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION

Facility

$449.46

Service Code	NDC 00006542302
Hospital Charge Code	177099
Hospital Revenue Code	250
Min. Negotiated Rate	$179.78
Max. Negotiated Rate	$404.51
Rate for Payer: Aetna Commercial	$382.04
Rate for Payer: Aetna Medicare	$224.73
Rate for Payer: Aetna New Business (MI Preferred)	$292.15
Rate for Payer: BCBS Complete	$179.78
Rate for Payer: Cash Price	$359.57
Rate for Payer: Cofinity Commercial	$314.62
Rate for Payer: Cofinity Commercial	$386.54
Rate for Payer: Cofinity Medicare Advantage	$314.62
Rate for Payer: Encore Health Key Benefits Commercial	$359.57
Rate for Payer: Healthscope Commercial	$404.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$382.04
Rate for Payer: PHP Commercial	$382.04
Rate for Payer: Priority Health Cigna Priority Health	$292.15
Rate for Payer: Priority Health SBD	$283.16

SULFACETAMIDE SODIUM 10 % EYE DROPS

Facility

$139.71

Service Code	NDC 24208067004
Hospital Charge Code	7359
Hospital Revenue Code	637
Min. Negotiated Rate	$55.88
Max. Negotiated Rate	$125.74
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$69.86
Rate for Payer: Aetna New Business (MI Preferred)	$90.81
Rate for Payer: BCBS Complete	$55.88
Rate for Payer: Cash Price	$111.77
Rate for Payer: Cofinity Commercial	$120.15
Rate for Payer: Cofinity Commercial	$97.80
Rate for Payer: Cofinity Medicare Advantage	$97.80
Rate for Payer: Encore Health Key Benefits Commercial	$111.77
Rate for Payer: Healthscope Commercial	$125.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$118.75
Rate for Payer: PHP Commercial	$118.75
Rate for Payer: Priority Health Cigna Priority Health	$90.81
Rate for Payer: Priority Health SBD	$88.02

Know your out-of-pocket cost for care.

All Charges