Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$65.28

Service Code	NDC 00406051262
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$26.11
Max. Negotiated Rate	$58.75
Rate for Payer: Aetna Commercial	$55.49
Rate for Payer: Aetna Medicare	$32.64
Rate for Payer: Aetna New Business (MI Preferred)	$42.43
Rate for Payer: BCBS Complete	$26.11
Rate for Payer: Cash Price	$52.22
Rate for Payer: Cofinity Commercial	$45.70
Rate for Payer: Cofinity Commercial	$56.14
Rate for Payer: Cofinity Medicare Advantage	$45.70
Rate for Payer: Encore Health Key Benefits Commercial	$52.22
Rate for Payer: Healthscope Commercial	$58.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$55.49
Rate for Payer: PHP Commercial	$55.49
Rate for Payer: Priority Health Cigna Priority Health	$42.43
Rate for Payer: Priority Health SBD	$41.13

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$637.00

Service Code	NDC 68084035501
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$401.31
Max. Negotiated Rate	$573.30
Rate for Payer: Aetna Commercial	$541.45
Rate for Payer: Aetna New Business (MI Preferred)	$414.05
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cofinity Commercial	$445.90
Rate for Payer: Cofinity Commercial	$547.82
Rate for Payer: Cofinity Medicare Advantage	$445.90
Rate for Payer: Encore Health Key Benefits Commercial	$509.60
Rate for Payer: Healthscope Commercial	$573.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$541.45
Rate for Payer: PHP Commercial	$541.45
Rate for Payer: Priority Health Cigna Priority Health	$414.05
Rate for Payer: Priority Health SBD	$401.31

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$637.00

Service Code	NDC 68084035501
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$573.30
Rate for Payer: Aetna Commercial	$541.45
Rate for Payer: Aetna Medicare	$318.50
Rate for Payer: Aetna New Business (MI Preferred)	$414.05
Rate for Payer: BCBS Complete	$254.80
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cofinity Commercial	$445.90
Rate for Payer: Cofinity Commercial	$547.82
Rate for Payer: Cofinity Medicare Advantage	$445.90
Rate for Payer: Encore Health Key Benefits Commercial	$509.60
Rate for Payer: Healthscope Commercial	$573.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$541.45
Rate for Payer: PHP Commercial	$541.45
Rate for Payer: Priority Health Cigna Priority Health	$414.05
Rate for Payer: Priority Health SBD	$401.31

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$637.00

Service Code	NDC 68084035511
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$401.31
Max. Negotiated Rate	$573.30
Rate for Payer: Aetna Commercial	$541.45
Rate for Payer: Aetna New Business (MI Preferred)	$414.05
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cofinity Commercial	$445.90
Rate for Payer: Cofinity Commercial	$547.82
Rate for Payer: Cofinity Medicare Advantage	$445.90
Rate for Payer: Encore Health Key Benefits Commercial	$509.60
Rate for Payer: Healthscope Commercial	$573.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$541.45
Rate for Payer: PHP Commercial	$541.45
Rate for Payer: Priority Health Cigna Priority Health	$414.05
Rate for Payer: Priority Health SBD	$401.31

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$637.00

Service Code	NDC 68084035511
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$573.30
Rate for Payer: Aetna Commercial	$541.45
Rate for Payer: Aetna Medicare	$318.50
Rate for Payer: Aetna New Business (MI Preferred)	$414.05
Rate for Payer: BCBS Complete	$254.80
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cofinity Commercial	$445.90
Rate for Payer: Cofinity Commercial	$547.82
Rate for Payer: Cofinity Medicare Advantage	$445.90
Rate for Payer: Encore Health Key Benefits Commercial	$509.60
Rate for Payer: Healthscope Commercial	$573.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$541.45
Rate for Payer: PHP Commercial	$541.45
Rate for Payer: Priority Health Cigna Priority Health	$414.05
Rate for Payer: Priority Health SBD	$401.31

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$6.53

Service Code	NDC 00406051223
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$5.88
Rate for Payer: Aetna Commercial	$5.55
Rate for Payer: Aetna Medicare	$3.27
Rate for Payer: Aetna New Business (MI Preferred)	$4.24
Rate for Payer: BCBS Complete	$2.61
Rate for Payer: Cash Price	$5.22
Rate for Payer: Cofinity Commercial	$4.57
Rate for Payer: Cofinity Commercial	$5.62
Rate for Payer: Cofinity Medicare Advantage	$4.57
Rate for Payer: Encore Health Key Benefits Commercial	$5.22
Rate for Payer: Healthscope Commercial	$5.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.55
Rate for Payer: PHP Commercial	$5.55
Rate for Payer: Priority Health Cigna Priority Health	$4.24
Rate for Payer: Priority Health SBD	$4.11

OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET

Facility

$10.32

Service Code	NDC 00406052223
Hospital Charge Code	31863
Hospital Revenue Code	637
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$9.29
Rate for Payer: Aetna Commercial	$8.77
Rate for Payer: Aetna New Business (MI Preferred)	$6.71
Rate for Payer: Cash Price	$8.26
Rate for Payer: Cofinity Commercial	$7.22
Rate for Payer: Cofinity Commercial	$8.88
Rate for Payer: Cofinity Medicare Advantage	$7.22
Rate for Payer: Encore Health Key Benefits Commercial	$8.26
Rate for Payer: Healthscope Commercial	$9.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.77
Rate for Payer: PHP Commercial	$8.77
Rate for Payer: Priority Health Cigna Priority Health	$6.71
Rate for Payer: Priority Health SBD	$6.50

OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET

Facility

$246.75

Service Code	NDC 13107004501
Hospital Charge Code	31863
Hospital Revenue Code	637
Min. Negotiated Rate	$98.70
Max. Negotiated Rate	$222.07
Rate for Payer: Aetna Commercial	$209.74
Rate for Payer: Aetna Medicare	$123.38
Rate for Payer: Aetna New Business (MI Preferred)	$160.39
Rate for Payer: BCBS Complete	$98.70
Rate for Payer: Cash Price	$197.40
Rate for Payer: Cofinity Commercial	$172.72
Rate for Payer: Cofinity Commercial	$212.21
Rate for Payer: Cofinity Medicare Advantage	$172.72
Rate for Payer: Encore Health Key Benefits Commercial	$197.40
Rate for Payer: Healthscope Commercial	$222.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$209.74
Rate for Payer: PHP Commercial	$209.74
Rate for Payer: Priority Health Cigna Priority Health	$160.39
Rate for Payer: Priority Health SBD	$155.45

OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET

Facility

$1,031.10

Service Code	NDC 00406052262
Hospital Charge Code	31863
Hospital Revenue Code	637
Min. Negotiated Rate	$649.59
Max. Negotiated Rate	$927.99
Rate for Payer: Aetna Commercial	$876.43
Rate for Payer: Aetna New Business (MI Preferred)	$670.22
Rate for Payer: Cash Price	$824.88
Rate for Payer: Cofinity Commercial	$721.77
Rate for Payer: Cofinity Commercial	$886.75
Rate for Payer: Cofinity Medicare Advantage	$721.77
Rate for Payer: Encore Health Key Benefits Commercial	$824.88
Rate for Payer: Healthscope Commercial	$927.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$876.43
Rate for Payer: PHP Commercial	$876.43
Rate for Payer: Priority Health Cigna Priority Health	$670.22
Rate for Payer: Priority Health SBD	$649.59

OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET

Facility

$246.75

Service Code	NDC 13107004501
Hospital Charge Code	31863
Hospital Revenue Code	637
Min. Negotiated Rate	$155.45
Max. Negotiated Rate	$222.07
Rate for Payer: Aetna Commercial	$209.74
Rate for Payer: Aetna New Business (MI Preferred)	$160.39
Rate for Payer: Cash Price	$197.40
Rate for Payer: Cofinity Commercial	$172.72
Rate for Payer: Cofinity Commercial	$212.21
Rate for Payer: Cofinity Medicare Advantage	$172.72
Rate for Payer: Encore Health Key Benefits Commercial	$197.40
Rate for Payer: Healthscope Commercial	$222.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$209.74
Rate for Payer: PHP Commercial	$209.74
Rate for Payer: Priority Health Cigna Priority Health	$160.39
Rate for Payer: Priority Health SBD	$155.45

OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET

Facility

$1,031.10

Service Code	NDC 00406052262
Hospital Charge Code	31863
Hospital Revenue Code	637
Min. Negotiated Rate	$412.44
Max. Negotiated Rate	$927.99
Rate for Payer: Aetna Commercial	$876.43
Rate for Payer: Aetna Medicare	$515.55
Rate for Payer: Aetna New Business (MI Preferred)	$670.22
Rate for Payer: BCBS Complete	$412.44
Rate for Payer: Cash Price	$824.88
Rate for Payer: Cofinity Commercial	$721.77
Rate for Payer: Cofinity Commercial	$886.75
Rate for Payer: Cofinity Medicare Advantage	$721.77
Rate for Payer: Encore Health Key Benefits Commercial	$824.88
Rate for Payer: Healthscope Commercial	$927.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$876.43
Rate for Payer: PHP Commercial	$876.43
Rate for Payer: Priority Health Cigna Priority Health	$670.22
Rate for Payer: Priority Health SBD	$649.59

OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET

Facility

$10.32

Service Code	NDC 00406052223
Hospital Charge Code	31863
Hospital Revenue Code	637
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$9.29
Rate for Payer: Aetna Commercial	$8.77
Rate for Payer: Aetna Medicare	$5.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.71
Rate for Payer: BCBS Complete	$4.13
Rate for Payer: Cash Price	$8.26
Rate for Payer: Cofinity Commercial	$7.22
Rate for Payer: Cofinity Commercial	$8.88
Rate for Payer: Cofinity Medicare Advantage	$7.22
Rate for Payer: Encore Health Key Benefits Commercial	$8.26
Rate for Payer: Healthscope Commercial	$9.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.77
Rate for Payer: PHP Commercial	$8.77
Rate for Payer: Priority Health Cigna Priority Health	$6.71
Rate for Payer: Priority Health SBD	$6.50

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

Facility

$877.11

Service Code	NDC 00093573101
Hospital Charge Code	173651
Hospital Revenue Code	637
Min. Negotiated Rate	$552.58
Max. Negotiated Rate	$789.40
Rate for Payer: Aetna Commercial	$745.54
Rate for Payer: Aetna New Business (MI Preferred)	$570.12
Rate for Payer: Cash Price	$701.69
Rate for Payer: Cofinity Commercial	$613.98
Rate for Payer: Cofinity Commercial	$754.31
Rate for Payer: Cofinity Medicare Advantage	$613.98
Rate for Payer: Encore Health Key Benefits Commercial	$701.69
Rate for Payer: Healthscope Commercial	$789.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$745.54
Rate for Payer: PHP Commercial	$745.54
Rate for Payer: Priority Health Cigna Priority Health	$570.12
Rate for Payer: Priority Health SBD	$552.58

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

Facility

$325.65

Service Code	NDC 59011041020
Hospital Charge Code	173651
Hospital Revenue Code	637
Min. Negotiated Rate	$205.16
Max. Negotiated Rate	$293.08
Rate for Payer: Aetna Commercial	$276.80
Rate for Payer: Aetna New Business (MI Preferred)	$211.67
Rate for Payer: Cash Price	$260.52
Rate for Payer: Cofinity Commercial	$227.96
Rate for Payer: Cofinity Commercial	$280.06
Rate for Payer: Cofinity Medicare Advantage	$227.96
Rate for Payer: Encore Health Key Benefits Commercial	$260.52
Rate for Payer: Healthscope Commercial	$293.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$276.80
Rate for Payer: PHP Commercial	$276.80
Rate for Payer: Priority Health Cigna Priority Health	$211.67
Rate for Payer: Priority Health SBD	$205.16

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

Facility

$325.65

Service Code	NDC 59011041020
Hospital Charge Code	173651
Hospital Revenue Code	637
Min. Negotiated Rate	$130.26
Max. Negotiated Rate	$293.08
Rate for Payer: Aetna Commercial	$276.80
Rate for Payer: Aetna Medicare	$162.82
Rate for Payer: Aetna New Business (MI Preferred)	$211.67
Rate for Payer: BCBS Complete	$130.26
Rate for Payer: Cash Price	$260.52
Rate for Payer: Cofinity Commercial	$227.96
Rate for Payer: Cofinity Commercial	$280.06
Rate for Payer: Cofinity Medicare Advantage	$227.96
Rate for Payer: Encore Health Key Benefits Commercial	$260.52
Rate for Payer: Healthscope Commercial	$293.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$276.80
Rate for Payer: PHP Commercial	$276.80
Rate for Payer: Priority Health Cigna Priority Health	$211.67
Rate for Payer: Priority Health SBD	$205.16

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

Facility

$877.11

Service Code	NDC 00093573101
Hospital Charge Code	173651
Hospital Revenue Code	637
Min. Negotiated Rate	$350.84
Max. Negotiated Rate	$789.40
Rate for Payer: Aetna Commercial	$745.54
Rate for Payer: Aetna Medicare	$438.56
Rate for Payer: Aetna New Business (MI Preferred)	$570.12
Rate for Payer: BCBS Complete	$350.84
Rate for Payer: Cash Price	$701.69
Rate for Payer: Cofinity Commercial	$613.98
Rate for Payer: Cofinity Commercial	$754.31
Rate for Payer: Cofinity Medicare Advantage	$613.98
Rate for Payer: Encore Health Key Benefits Commercial	$701.69
Rate for Payer: Healthscope Commercial	$789.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$745.54
Rate for Payer: PHP Commercial	$745.54
Rate for Payer: Priority Health Cigna Priority Health	$570.12
Rate for Payer: Priority Health SBD	$552.58

OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

Facility

$513.35

Service Code	NDC 59011042020
Hospital Charge Code	173653
Hospital Revenue Code	637
Min. Negotiated Rate	$323.41
Max. Negotiated Rate	$462.01
Rate for Payer: Aetna Commercial	$436.35
Rate for Payer: Aetna New Business (MI Preferred)	$333.68
Rate for Payer: Cash Price	$410.68
Rate for Payer: Cofinity Commercial	$359.35
Rate for Payer: Cofinity Commercial	$441.48
Rate for Payer: Cofinity Medicare Advantage	$359.35
Rate for Payer: Encore Health Key Benefits Commercial	$410.68
Rate for Payer: Healthscope Commercial	$462.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$436.35
Rate for Payer: PHP Commercial	$436.35
Rate for Payer: Priority Health Cigna Priority Health	$333.68
Rate for Payer: Priority Health SBD	$323.41

OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

Facility

$513.35

Service Code	NDC 59011042020
Hospital Charge Code	173653
Hospital Revenue Code	637
Min. Negotiated Rate	$205.34
Max. Negotiated Rate	$462.01
Rate for Payer: Aetna Commercial	$436.35
Rate for Payer: Aetna Medicare	$256.68
Rate for Payer: Aetna New Business (MI Preferred)	$333.68
Rate for Payer: BCBS Complete	$205.34
Rate for Payer: Cash Price	$410.68
Rate for Payer: Cofinity Commercial	$359.35
Rate for Payer: Cofinity Commercial	$441.48
Rate for Payer: Cofinity Medicare Advantage	$359.35
Rate for Payer: Encore Health Key Benefits Commercial	$410.68
Rate for Payer: Healthscope Commercial	$462.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$436.35
Rate for Payer: PHP Commercial	$436.35
Rate for Payer: Priority Health Cigna Priority Health	$333.68
Rate for Payer: Priority Health SBD	$323.41

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$27.15

Service Code	NDC 41100081123
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$10.86
Max. Negotiated Rate	$24.43
Rate for Payer: Aetna Commercial	$23.08
Rate for Payer: Aetna Medicare	$13.57
Rate for Payer: Aetna New Business (MI Preferred)	$17.65
Rate for Payer: BCBS Complete	$10.86
Rate for Payer: Cash Price	$21.72
Rate for Payer: Cofinity Commercial	$19.00
Rate for Payer: Cofinity Commercial	$23.35
Rate for Payer: Cofinity Medicare Advantage	$19.00
Rate for Payer: Encore Health Key Benefits Commercial	$21.72
Rate for Payer: Healthscope Commercial	$24.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.08
Rate for Payer: PHP Commercial	$23.08
Rate for Payer: Priority Health Cigna Priority Health	$17.65
Rate for Payer: Priority Health SBD	$17.10

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$9.45

Service Code	NDC 00904676130
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$8.51
Rate for Payer: Aetna Commercial	$8.03
Rate for Payer: Aetna New Business (MI Preferred)	$6.14
Rate for Payer: Cash Price	$7.56
Rate for Payer: Cofinity Commercial	$6.62
Rate for Payer: Cofinity Commercial	$8.13
Rate for Payer: Cofinity Medicare Advantage	$6.62
Rate for Payer: Encore Health Key Benefits Commercial	$7.56
Rate for Payer: Healthscope Commercial	$8.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.03
Rate for Payer: PHP Commercial	$8.03
Rate for Payer: Priority Health Cigna Priority Health	$6.14
Rate for Payer: Priority Health SBD	$5.95

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$9.45

Service Code	NDC 00904676130
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$8.51
Rate for Payer: Aetna Commercial	$8.03
Rate for Payer: Aetna Medicare	$4.72
Rate for Payer: Aetna New Business (MI Preferred)	$6.14
Rate for Payer: BCBS Complete	$3.78
Rate for Payer: Cash Price	$7.56
Rate for Payer: Cofinity Commercial	$6.62
Rate for Payer: Cofinity Commercial	$8.13
Rate for Payer: Cofinity Medicare Advantage	$6.62
Rate for Payer: Encore Health Key Benefits Commercial	$7.56
Rate for Payer: Healthscope Commercial	$8.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.03
Rate for Payer: PHP Commercial	$8.03
Rate for Payer: Priority Health Cigna Priority Health	$6.14
Rate for Payer: Priority Health SBD	$5.95

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$10.53

Service Code	NDC 00904700635
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$9.48
Rate for Payer: Aetna Commercial	$8.95
Rate for Payer: Aetna New Business (MI Preferred)	$6.84
Rate for Payer: Cash Price	$8.42
Rate for Payer: Cofinity Commercial	$7.37
Rate for Payer: Cofinity Commercial	$9.06
Rate for Payer: Cofinity Medicare Advantage	$7.37
Rate for Payer: Encore Health Key Benefits Commercial	$8.42
Rate for Payer: Healthscope Commercial	$9.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.95
Rate for Payer: PHP Commercial	$8.95
Rate for Payer: Priority Health Cigna Priority Health	$6.84
Rate for Payer: Priority Health SBD	$6.63

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$10.53

Service Code	NDC 00904700635
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$9.48
Rate for Payer: Aetna Commercial	$8.95
Rate for Payer: Aetna Medicare	$5.26
Rate for Payer: Aetna New Business (MI Preferred)	$6.84
Rate for Payer: BCBS Complete	$4.21
Rate for Payer: Cash Price	$8.42
Rate for Payer: Cofinity Commercial	$7.37
Rate for Payer: Cofinity Commercial	$9.06
Rate for Payer: Cofinity Medicare Advantage	$7.37
Rate for Payer: Encore Health Key Benefits Commercial	$8.42
Rate for Payer: Healthscope Commercial	$9.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.95
Rate for Payer: PHP Commercial	$8.95
Rate for Payer: Priority Health Cigna Priority Health	$6.84
Rate for Payer: Priority Health SBD	$6.63

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$12.83

Service Code	NDC 00904742730
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$11.55
Rate for Payer: Aetna Commercial	$10.91
Rate for Payer: Aetna New Business (MI Preferred)	$8.34
Rate for Payer: Cash Price	$10.26
Rate for Payer: Cofinity Commercial	$11.03
Rate for Payer: Cofinity Commercial	$8.98
Rate for Payer: Cofinity Medicare Advantage	$8.98
Rate for Payer: Encore Health Key Benefits Commercial	$10.26
Rate for Payer: Healthscope Commercial	$11.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.91
Rate for Payer: PHP Commercial	$10.91
Rate for Payer: Priority Health Cigna Priority Health	$8.34
Rate for Payer: Priority Health SBD	$8.08

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$12.83

Service Code	NDC 00904742730
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$11.55
Rate for Payer: Aetna Commercial	$10.91
Rate for Payer: Aetna Medicare	$6.42
Rate for Payer: Aetna New Business (MI Preferred)	$8.34
Rate for Payer: BCBS Complete	$5.13
Rate for Payer: Cash Price	$10.26
Rate for Payer: Cofinity Commercial	$11.03
Rate for Payer: Cofinity Commercial	$8.98
Rate for Payer: Cofinity Medicare Advantage	$8.98
Rate for Payer: Encore Health Key Benefits Commercial	$10.26
Rate for Payer: Healthscope Commercial	$11.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.91
Rate for Payer: PHP Commercial	$10.91
Rate for Payer: Priority Health Cigna Priority Health	$8.34
Rate for Payer: Priority Health SBD	$8.08

Know your out-of-pocket cost for care.

All Charges