Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

ACETAMINOPHEN 500 MG TABLET

Facility

$882.00

Service Code	NDC 00904673080
Hospital Charge Code	102
Hospital Revenue Code	637
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$793.80
Rate for Payer: Aetna Commercial	$749.70
Rate for Payer: Aetna Medicare	$441.00
Rate for Payer: Aetna New Business (MI Preferred)	$573.30
Rate for Payer: BCBS Complete	$352.80
Rate for Payer: Cash Price	$705.60
Rate for Payer: Cofinity Commercial	$617.40
Rate for Payer: Cofinity Commercial	$758.52
Rate for Payer: Cofinity Medicare Advantage	$617.40
Rate for Payer: Encore Health Key Benefits Commercial	$705.60
Rate for Payer: Healthscope Commercial	$793.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$749.70
Rate for Payer: PHP Commercial	$749.70
Rate for Payer: Priority Health Cigna Priority Health	$573.30
Rate for Payer: Priority Health SBD	$555.66

ACETAMINOPHEN 500 MG TABLET

Facility

$409.50

Service Code	NDC 00904672040
Hospital Charge Code	102
Hospital Revenue Code	637
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$368.55
Rate for Payer: Aetna Commercial	$348.08
Rate for Payer: Aetna Medicare	$204.75
Rate for Payer: Aetna New Business (MI Preferred)	$266.18
Rate for Payer: BCBS Complete	$163.80
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cofinity Commercial	$286.65
Rate for Payer: Cofinity Commercial	$352.17
Rate for Payer: Cofinity Medicare Advantage	$286.65
Rate for Payer: Encore Health Key Benefits Commercial	$327.60
Rate for Payer: Healthscope Commercial	$368.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$348.08
Rate for Payer: PHP Commercial	$348.08
Rate for Payer: Priority Health Cigna Priority Health	$266.18
Rate for Payer: Priority Health SBD	$257.98

ACETAMINOPHEN 500 MG TABLET

Facility

$119.70

Service Code	NDC 00904672060
Hospital Charge Code	102
Hospital Revenue Code	637
Min. Negotiated Rate	$47.88
Max. Negotiated Rate	$107.73
Rate for Payer: Aetna Commercial	$101.74
Rate for Payer: Aetna Medicare	$59.85
Rate for Payer: Aetna New Business (MI Preferred)	$77.80
Rate for Payer: BCBS Complete	$47.88
Rate for Payer: Cash Price	$95.76
Rate for Payer: Cofinity Commercial	$102.94
Rate for Payer: Cofinity Commercial	$83.79
Rate for Payer: Cofinity Medicare Advantage	$83.79
Rate for Payer: Encore Health Key Benefits Commercial	$95.76
Rate for Payer: Healthscope Commercial	$107.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$101.74
Rate for Payer: PHP Commercial	$101.74
Rate for Payer: Priority Health Cigna Priority Health	$77.80
Rate for Payer: Priority Health SBD	$75.41

ACETAMINOPHEN 500 MG TABLET

Facility

$409.50

Service Code	NDC 00904672040
Hospital Charge Code	102
Hospital Revenue Code	637
Min. Negotiated Rate	$257.98
Max. Negotiated Rate	$368.55
Rate for Payer: Aetna Commercial	$348.08
Rate for Payer: Aetna New Business (MI Preferred)	$266.18
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cofinity Commercial	$286.65
Rate for Payer: Cofinity Commercial	$352.17
Rate for Payer: Cofinity Medicare Advantage	$286.65
Rate for Payer: Encore Health Key Benefits Commercial	$327.60
Rate for Payer: Healthscope Commercial	$368.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$348.08
Rate for Payer: PHP Commercial	$348.08
Rate for Payer: Priority Health Cigna Priority Health	$266.18
Rate for Payer: Priority Health SBD	$257.98

ACETAMINOPHEN 500 MG TABLET

Facility

$1,449.00

Service Code	NDC 00450045045
Hospital Charge Code	102
Hospital Revenue Code	637
Min. Negotiated Rate	$912.87
Max. Negotiated Rate	$1,304.10
Rate for Payer: Aetna Commercial	$1,231.65
Rate for Payer: Aetna New Business (MI Preferred)	$941.85
Rate for Payer: Cash Price	$1,159.20
Rate for Payer: Cofinity Commercial	$1,014.30
Rate for Payer: Cofinity Commercial	$1,246.14
Rate for Payer: Cofinity Medicare Advantage	$1,014.30
Rate for Payer: Encore Health Key Benefits Commercial	$1,159.20
Rate for Payer: Healthscope Commercial	$1,304.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,231.65
Rate for Payer: PHP Commercial	$1,231.65
Rate for Payer: Priority Health Cigna Priority Health	$941.85
Rate for Payer: Priority Health SBD	$912.87

ACETAMINOPHEN 500 MG TABLET

Facility

$280.00

Service Code	NDC 50580045711
Hospital Charge Code	102
Hospital Revenue Code	637
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$252.00
Rate for Payer: Aetna Commercial	$238.00
Rate for Payer: Aetna New Business (MI Preferred)	$182.00
Rate for Payer: Cash Price	$224.00
Rate for Payer: Cofinity Commercial	$196.00
Rate for Payer: Cofinity Commercial	$240.80
Rate for Payer: Cofinity Medicare Advantage	$196.00
Rate for Payer: Encore Health Key Benefits Commercial	$224.00
Rate for Payer: Healthscope Commercial	$252.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$238.00
Rate for Payer: PHP Commercial	$238.00
Rate for Payer: Priority Health Cigna Priority Health	$182.00
Rate for Payer: Priority Health SBD	$176.40

ACETAMINOPHEN 500 MG TABLET

Facility

$756.00

Service Code	NDC 00904672080
Hospital Charge Code	102
Hospital Revenue Code	637
Min. Negotiated Rate	$476.28
Max. Negotiated Rate	$680.40
Rate for Payer: Aetna Commercial	$642.60
Rate for Payer: Aetna New Business (MI Preferred)	$491.40
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cofinity Commercial	$529.20
Rate for Payer: Cofinity Commercial	$650.16
Rate for Payer: Cofinity Medicare Advantage	$529.20
Rate for Payer: Encore Health Key Benefits Commercial	$604.80
Rate for Payer: Healthscope Commercial	$680.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$642.60
Rate for Payer: PHP Commercial	$642.60
Rate for Payer: Priority Health Cigna Priority Health	$491.40
Rate for Payer: Priority Health SBD	$476.28

ACETAMINOPHEN 500 MG TABLET

Facility

$119.70

Service Code	NDC 00904672060
Hospital Charge Code	102
Hospital Revenue Code	637
Min. Negotiated Rate	$75.41
Max. Negotiated Rate	$107.73
Rate for Payer: Aetna Commercial	$101.74
Rate for Payer: Aetna New Business (MI Preferred)	$77.80
Rate for Payer: Cash Price	$95.76
Rate for Payer: Cofinity Commercial	$102.94
Rate for Payer: Cofinity Commercial	$83.79
Rate for Payer: Cofinity Medicare Advantage	$83.79
Rate for Payer: Encore Health Key Benefits Commercial	$95.76
Rate for Payer: Healthscope Commercial	$107.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$101.74
Rate for Payer: PHP Commercial	$101.74
Rate for Payer: Priority Health Cigna Priority Health	$77.80
Rate for Payer: Priority Health SBD	$75.41

ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION

Facility

$4.44

Service Code	NDC 00121197100
Hospital Charge Code	119323
Hospital Revenue Code	637
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.77
Rate for Payer: Aetna New Business (MI Preferred)	$2.89
Rate for Payer: Cash Price	$3.55
Rate for Payer: Cofinity Commercial	$3.11
Rate for Payer: Cofinity Commercial	$3.82
Rate for Payer: Cofinity Medicare Advantage	$3.11
Rate for Payer: Encore Health Key Benefits Commercial	$3.55
Rate for Payer: Healthscope Commercial	$4.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.77
Rate for Payer: PHP Commercial	$3.77
Rate for Payer: Priority Health Cigna Priority Health	$2.89
Rate for Payer: Priority Health SBD	$2.80

ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION

Facility

$4.44

Service Code	NDC 00121197121
Hospital Charge Code	119323
Hospital Revenue Code	637
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.77
Rate for Payer: Aetna New Business (MI Preferred)	$2.89
Rate for Payer: Cash Price	$3.55
Rate for Payer: Cofinity Commercial	$3.11
Rate for Payer: Cofinity Commercial	$3.82
Rate for Payer: Cofinity Medicare Advantage	$3.11
Rate for Payer: Encore Health Key Benefits Commercial	$3.55
Rate for Payer: Healthscope Commercial	$4.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.77
Rate for Payer: PHP Commercial	$3.77
Rate for Payer: Priority Health Cigna Priority Health	$2.89
Rate for Payer: Priority Health SBD	$2.80

ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION

Facility

$5.01

Service Code	NDC 66689005699
Hospital Charge Code	119323
Hospital Revenue Code	637
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$4.51
Rate for Payer: Aetna Commercial	$4.26
Rate for Payer: Aetna New Business (MI Preferred)	$3.26
Rate for Payer: Cash Price	$4.01
Rate for Payer: Cofinity Commercial	$3.51
Rate for Payer: Cofinity Commercial	$4.31
Rate for Payer: Cofinity Medicare Advantage	$3.51
Rate for Payer: Encore Health Key Benefits Commercial	$4.01
Rate for Payer: Healthscope Commercial	$4.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.26
Rate for Payer: PHP Commercial	$4.26
Rate for Payer: Priority Health Cigna Priority Health	$3.26
Rate for Payer: Priority Health SBD	$3.16

ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION

Facility

$4.44

Service Code	NDC 00121197100
Hospital Charge Code	119323
Hospital Revenue Code	637
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.77
Rate for Payer: Aetna Medicare	$2.22
Rate for Payer: Aetna New Business (MI Preferred)	$2.89
Rate for Payer: BCBS Complete	$1.78
Rate for Payer: Cash Price	$3.55
Rate for Payer: Cofinity Commercial	$3.11
Rate for Payer: Cofinity Commercial	$3.82
Rate for Payer: Cofinity Medicare Advantage	$3.11
Rate for Payer: Encore Health Key Benefits Commercial	$3.55
Rate for Payer: Healthscope Commercial	$4.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.77
Rate for Payer: PHP Commercial	$3.77
Rate for Payer: Priority Health Cigna Priority Health	$2.89
Rate for Payer: Priority Health SBD	$2.80

ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION

Facility

$5.01

Service Code	NDC 66689005699
Hospital Charge Code	119323
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.51
Rate for Payer: Aetna Commercial	$4.26
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: Aetna New Business (MI Preferred)	$3.26
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.01
Rate for Payer: Cofinity Commercial	$3.51
Rate for Payer: Cofinity Commercial	$4.31
Rate for Payer: Cofinity Medicare Advantage	$3.51
Rate for Payer: Encore Health Key Benefits Commercial	$4.01
Rate for Payer: Healthscope Commercial	$4.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.26
Rate for Payer: PHP Commercial	$4.26
Rate for Payer: Priority Health Cigna Priority Health	$3.26
Rate for Payer: Priority Health SBD	$3.16

ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION

Facility

$4.44

Service Code	NDC 00121197121
Hospital Charge Code	119323
Hospital Revenue Code	637
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.77
Rate for Payer: Aetna Medicare	$2.22
Rate for Payer: Aetna New Business (MI Preferred)	$2.89
Rate for Payer: BCBS Complete	$1.78
Rate for Payer: Cash Price	$3.55
Rate for Payer: Cofinity Commercial	$3.11
Rate for Payer: Cofinity Commercial	$3.82
Rate for Payer: Cofinity Medicare Advantage	$3.11
Rate for Payer: Encore Health Key Benefits Commercial	$3.55
Rate for Payer: Healthscope Commercial	$4.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.77
Rate for Payer: PHP Commercial	$3.77
Rate for Payer: Priority Health Cigna Priority Health	$2.89
Rate for Payer: Priority Health SBD	$2.80

ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION

Facility

$5.01

Service Code	NDC 66689005601
Hospital Charge Code	119323
Hospital Revenue Code	637
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$4.51
Rate for Payer: Aetna Commercial	$4.26
Rate for Payer: Aetna New Business (MI Preferred)	$3.26
Rate for Payer: Cash Price	$4.01
Rate for Payer: Cofinity Commercial	$3.51
Rate for Payer: Cofinity Commercial	$4.31
Rate for Payer: Cofinity Medicare Advantage	$3.51
Rate for Payer: Encore Health Key Benefits Commercial	$4.01
Rate for Payer: Healthscope Commercial	$4.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.26
Rate for Payer: PHP Commercial	$4.26
Rate for Payer: Priority Health Cigna Priority Health	$3.26
Rate for Payer: Priority Health SBD	$3.16

ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION

Facility

$5.01

Service Code	NDC 66689005601
Hospital Charge Code	119323
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.51
Rate for Payer: Aetna Commercial	$4.26
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: Aetna New Business (MI Preferred)	$3.26
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.01
Rate for Payer: Cofinity Commercial	$3.51
Rate for Payer: Cofinity Commercial	$4.31
Rate for Payer: Cofinity Medicare Advantage	$3.51
Rate for Payer: Encore Health Key Benefits Commercial	$4.01
Rate for Payer: Healthscope Commercial	$4.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.26
Rate for Payer: PHP Commercial	$4.26
Rate for Payer: Priority Health Cigna Priority Health	$3.26
Rate for Payer: Priority Health SBD	$3.16

ACETAMINOPHEN 650 MG/20.3 ML ORAL SUSPENSION

Facility

$7.61

Service Code	NDC 00121282321
Hospital Charge Code	88505
Hospital Revenue Code	637
Min. Negotiated Rate	$4.79
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna Commercial	$6.47
Rate for Payer: Aetna New Business (MI Preferred)	$4.95
Rate for Payer: Cash Price	$6.09
Rate for Payer: Cofinity Commercial	$6.54
Rate for Payer: Cofinity Commercial	$5.33
Rate for Payer: Cofinity Medicare Advantage	$5.33
Rate for Payer: Encore Health Key Benefits Commercial	$6.09
Rate for Payer: Healthscope Commercial	$6.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.47
Rate for Payer: PHP Commercial	$6.47
Rate for Payer: Priority Health Cigna Priority Health	$4.95
Rate for Payer: Priority Health SBD	$4.79

ACETAMINOPHEN 650 MG/20.3 ML ORAL SUSPENSION

Facility

$7.61

Service Code	NDC 00121282394
Hospital Charge Code	88505
Hospital Revenue Code	637
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna Commercial	$6.47
Rate for Payer: Aetna Medicare	$3.80
Rate for Payer: Aetna New Business (MI Preferred)	$4.95
Rate for Payer: BCBS Complete	$3.04
Rate for Payer: Cash Price	$6.09
Rate for Payer: Cofinity Commercial	$5.33
Rate for Payer: Cofinity Commercial	$6.54
Rate for Payer: Cofinity Medicare Advantage	$5.33
Rate for Payer: Encore Health Key Benefits Commercial	$6.09
Rate for Payer: Healthscope Commercial	$6.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.47
Rate for Payer: PHP Commercial	$6.47
Rate for Payer: Priority Health Cigna Priority Health	$4.95
Rate for Payer: Priority Health SBD	$4.79

ACETAMINOPHEN 650 MG/20.3 ML ORAL SUSPENSION

Facility

$7.61

Service Code	NDC 00121282394
Hospital Charge Code	88505
Hospital Revenue Code	637
Min. Negotiated Rate	$4.79
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna Commercial	$6.47
Rate for Payer: Aetna New Business (MI Preferred)	$4.95
Rate for Payer: Cash Price	$6.09
Rate for Payer: Cofinity Commercial	$5.33
Rate for Payer: Cofinity Commercial	$6.54
Rate for Payer: Cofinity Medicare Advantage	$5.33
Rate for Payer: Encore Health Key Benefits Commercial	$6.09
Rate for Payer: Healthscope Commercial	$6.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.47
Rate for Payer: PHP Commercial	$6.47
Rate for Payer: Priority Health Cigna Priority Health	$4.95
Rate for Payer: Priority Health SBD	$4.79

ACETAMINOPHEN 650 MG/20.3 ML ORAL SUSPENSION

Facility

$7.61

Service Code	NDC 00121282321
Hospital Charge Code	88505
Hospital Revenue Code	637
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna Commercial	$6.47
Rate for Payer: Aetna Medicare	$3.80
Rate for Payer: Aetna New Business (MI Preferred)	$4.95
Rate for Payer: BCBS Complete	$3.04
Rate for Payer: Cash Price	$6.09
Rate for Payer: Cofinity Commercial	$5.33
Rate for Payer: Cofinity Commercial	$6.54
Rate for Payer: Cofinity Medicare Advantage	$5.33
Rate for Payer: Encore Health Key Benefits Commercial	$6.09
Rate for Payer: Healthscope Commercial	$6.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.47
Rate for Payer: PHP Commercial	$6.47
Rate for Payer: Priority Health Cigna Priority Health	$4.95
Rate for Payer: Priority Health SBD	$4.79

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY

Facility

$18.40

Service Code	NDC 45802073030
Hospital Charge Code	105
Hospital Revenue Code	637
Min. Negotiated Rate	$11.59
Max. Negotiated Rate	$16.56
Rate for Payer: Aetna Commercial	$15.64
Rate for Payer: Aetna New Business (MI Preferred)	$11.96
Rate for Payer: Cash Price	$14.72
Rate for Payer: Cofinity Commercial	$12.88
Rate for Payer: Cofinity Commercial	$15.82
Rate for Payer: Cofinity Medicare Advantage	$12.88
Rate for Payer: Encore Health Key Benefits Commercial	$14.72
Rate for Payer: Healthscope Commercial	$16.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.64
Rate for Payer: PHP Commercial	$15.64
Rate for Payer: Priority Health Cigna Priority Health	$11.96
Rate for Payer: Priority Health SBD	$11.59

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY

Facility

$18.40

Service Code	NDC 45802073030
Hospital Charge Code	105
Hospital Revenue Code	637
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$16.56
Rate for Payer: Aetna Commercial	$15.64
Rate for Payer: Aetna Medicare	$9.20
Rate for Payer: Aetna New Business (MI Preferred)	$11.96
Rate for Payer: BCBS Complete	$7.36
Rate for Payer: Cash Price	$14.72
Rate for Payer: Cofinity Commercial	$12.88
Rate for Payer: Cofinity Commercial	$15.82
Rate for Payer: Cofinity Medicare Advantage	$12.88
Rate for Payer: Encore Health Key Benefits Commercial	$14.72
Rate for Payer: Healthscope Commercial	$16.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.64
Rate for Payer: PHP Commercial	$15.64
Rate for Payer: Priority Health Cigna Priority Health	$11.96
Rate for Payer: Priority Health SBD	$11.59

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY

Facility

$103.95

Service Code	NDC 45802073032
Hospital Charge Code	105
Hospital Revenue Code	637
Min. Negotiated Rate	$65.49
Max. Negotiated Rate	$93.56
Rate for Payer: Aetna Commercial	$88.36
Rate for Payer: Aetna New Business (MI Preferred)	$67.57
Rate for Payer: Cash Price	$83.16
Rate for Payer: Cofinity Commercial	$72.76
Rate for Payer: Cofinity Commercial	$89.40
Rate for Payer: Cofinity Medicare Advantage	$72.76
Rate for Payer: Encore Health Key Benefits Commercial	$83.16
Rate for Payer: Healthscope Commercial	$93.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$88.36
Rate for Payer: PHP Commercial	$88.36
Rate for Payer: Priority Health Cigna Priority Health	$67.57
Rate for Payer: Priority Health SBD	$65.49

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY

Facility

$103.95

Service Code	NDC 45802073032
Hospital Charge Code	105
Hospital Revenue Code	637
Min. Negotiated Rate	$41.58
Max. Negotiated Rate	$93.56
Rate for Payer: Aetna Commercial	$88.36
Rate for Payer: Aetna Medicare	$51.98
Rate for Payer: Aetna New Business (MI Preferred)	$67.57
Rate for Payer: BCBS Complete	$41.58
Rate for Payer: Cash Price	$83.16
Rate for Payer: Cofinity Commercial	$72.76
Rate for Payer: Cofinity Commercial	$89.40
Rate for Payer: Cofinity Medicare Advantage	$72.76
Rate for Payer: Encore Health Key Benefits Commercial	$83.16
Rate for Payer: Healthscope Commercial	$93.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$88.36
Rate for Payer: PHP Commercial	$88.36
Rate for Payer: Priority Health Cigna Priority Health	$67.57
Rate for Payer: Priority Health SBD	$65.49

ACETAZOLAMIDE 250 MG TABLET

Facility

$309.70

Service Code	NDC 23155028801
Hospital Charge Code	113
Hospital Revenue Code	637
Min. Negotiated Rate	$123.88
Max. Negotiated Rate	$278.73
Rate for Payer: Aetna Commercial	$263.24
Rate for Payer: Aetna Medicare	$154.85
Rate for Payer: Aetna New Business (MI Preferred)	$201.30
Rate for Payer: BCBS Complete	$123.88
Rate for Payer: Cash Price	$247.76
Rate for Payer: Cofinity Commercial	$216.79
Rate for Payer: Cofinity Commercial	$266.34
Rate for Payer: Cofinity Medicare Advantage	$216.79
Rate for Payer: Encore Health Key Benefits Commercial	$247.76
Rate for Payer: Healthscope Commercial	$278.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$263.24
Rate for Payer: PHP Commercial	$263.24
Rate for Payer: Priority Health Cigna Priority Health	$201.30
Rate for Payer: Priority Health SBD	$195.11

Know your out-of-pocket cost for care.

All Charges