Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$5,887.07

Service Code	NDC 00904693761
Hospital Charge Code	78066
Hospital Revenue Code	637
Min. Negotiated Rate	$2,354.83
Max. Negotiated Rate	$5,298.36
Rate for Payer: Aetna Commercial	$5,004.01
Rate for Payer: Aetna Medicare	$2,943.54
Rate for Payer: Aetna New Business (MI Preferred)	$3,826.60
Rate for Payer: BCBS Complete	$2,354.83
Rate for Payer: Cash Price	$4,709.66
Rate for Payer: Cofinity Commercial	$4,120.95
Rate for Payer: Cofinity Commercial	$5,062.88
Rate for Payer: Cofinity Medicare Advantage	$4,120.95
Rate for Payer: Encore Health Key Benefits Commercial	$4,709.66
Rate for Payer: Healthscope Commercial	$5,298.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,004.01
Rate for Payer: PHP Commercial	$5,004.01
Rate for Payer: Priority Health Cigna Priority Health	$3,826.60
Rate for Payer: Priority Health SBD	$3,708.85

PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$379.07

Service Code	NDC 65162028303
Hospital Charge Code	78066
Hospital Revenue Code	637
Min. Negotiated Rate	$238.81
Max. Negotiated Rate	$341.16
Rate for Payer: Aetna Commercial	$322.21
Rate for Payer: Aetna New Business (MI Preferred)	$246.40
Rate for Payer: Cash Price	$303.26
Rate for Payer: Cofinity Commercial	$265.35
Rate for Payer: Cofinity Commercial	$326.00
Rate for Payer: Cofinity Medicare Advantage	$265.35
Rate for Payer: Encore Health Key Benefits Commercial	$303.26
Rate for Payer: Healthscope Commercial	$341.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$322.21
Rate for Payer: PHP Commercial	$322.21
Rate for Payer: Priority Health Cigna Priority Health	$246.40
Rate for Payer: Priority Health SBD	$238.81

PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$516.15

Service Code	NDC 47335076783
Hospital Charge Code	78066
Hospital Revenue Code	637
Min. Negotiated Rate	$206.46
Max. Negotiated Rate	$464.54
Rate for Payer: Aetna Commercial	$438.73
Rate for Payer: Aetna Medicare	$258.08
Rate for Payer: Aetna New Business (MI Preferred)	$335.50
Rate for Payer: BCBS Complete	$206.46
Rate for Payer: Cash Price	$412.92
Rate for Payer: Cofinity Commercial	$361.30
Rate for Payer: Cofinity Commercial	$443.89
Rate for Payer: Cofinity Medicare Advantage	$361.30
Rate for Payer: Encore Health Key Benefits Commercial	$412.92
Rate for Payer: Healthscope Commercial	$464.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$438.73
Rate for Payer: PHP Commercial	$438.73
Rate for Payer: Priority Health Cigna Priority Health	$335.50
Rate for Payer: Priority Health SBD	$325.17

PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$1,705.08

Service Code	NDC 10147095403
Hospital Charge Code	78066
Hospital Revenue Code	637
Min. Negotiated Rate	$1,074.20
Max. Negotiated Rate	$1,534.57
Rate for Payer: Aetna Commercial	$1,449.32
Rate for Payer: Aetna New Business (MI Preferred)	$1,108.30
Rate for Payer: Cash Price	$1,364.06
Rate for Payer: Cofinity Commercial	$1,193.56
Rate for Payer: Cofinity Commercial	$1,466.37
Rate for Payer: Cofinity Medicare Advantage	$1,193.56
Rate for Payer: Encore Health Key Benefits Commercial	$1,364.06
Rate for Payer: Healthscope Commercial	$1,534.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,449.32
Rate for Payer: PHP Commercial	$1,449.32
Rate for Payer: Priority Health Cigna Priority Health	$1,108.30
Rate for Payer: Priority Health SBD	$1,074.20

PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$5,887.07

Service Code	NDC 00904693761
Hospital Charge Code	78066
Hospital Revenue Code	637
Min. Negotiated Rate	$3,708.85
Max. Negotiated Rate	$5,298.36
Rate for Payer: Aetna Commercial	$5,004.01
Rate for Payer: Aetna New Business (MI Preferred)	$3,826.60
Rate for Payer: Cash Price	$4,709.66
Rate for Payer: Cofinity Commercial	$4,120.95
Rate for Payer: Cofinity Commercial	$5,062.88
Rate for Payer: Cofinity Medicare Advantage	$4,120.95
Rate for Payer: Encore Health Key Benefits Commercial	$4,709.66
Rate for Payer: Healthscope Commercial	$5,298.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,004.01
Rate for Payer: PHP Commercial	$5,004.01
Rate for Payer: Priority Health Cigna Priority Health	$3,826.60
Rate for Payer: Priority Health SBD	$3,708.85

PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$516.15

Service Code	NDC 47335076783
Hospital Charge Code	78066
Hospital Revenue Code	637
Min. Negotiated Rate	$325.17
Max. Negotiated Rate	$464.54
Rate for Payer: Aetna Commercial	$438.73
Rate for Payer: Aetna New Business (MI Preferred)	$335.50
Rate for Payer: Cash Price	$412.92
Rate for Payer: Cofinity Commercial	$361.30
Rate for Payer: Cofinity Commercial	$443.89
Rate for Payer: Cofinity Medicare Advantage	$361.30
Rate for Payer: Encore Health Key Benefits Commercial	$412.92
Rate for Payer: Healthscope Commercial	$464.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$438.73
Rate for Payer: PHP Commercial	$438.73
Rate for Payer: Priority Health Cigna Priority Health	$335.50
Rate for Payer: Priority Health SBD	$325.17

PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$1,705.08

Service Code	NDC 10147095403
Hospital Charge Code	78066
Hospital Revenue Code	637
Min. Negotiated Rate	$682.03
Max. Negotiated Rate	$1,534.57
Rate for Payer: Aetna Commercial	$1,449.32
Rate for Payer: Aetna Medicare	$852.54
Rate for Payer: Aetna New Business (MI Preferred)	$1,108.30
Rate for Payer: BCBS Complete	$682.03
Rate for Payer: Cash Price	$1,364.06
Rate for Payer: Cofinity Commercial	$1,193.56
Rate for Payer: Cofinity Commercial	$1,466.37
Rate for Payer: Cofinity Medicare Advantage	$1,193.56
Rate for Payer: Encore Health Key Benefits Commercial	$1,364.06
Rate for Payer: Healthscope Commercial	$1,534.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,449.32
Rate for Payer: PHP Commercial	$1,449.32
Rate for Payer: Priority Health Cigna Priority Health	$1,108.30
Rate for Payer: Priority Health SBD	$1,074.20

PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$379.07

Service Code	NDC 65162028303
Hospital Charge Code	78066
Hospital Revenue Code	637
Min. Negotiated Rate	$151.63
Max. Negotiated Rate	$341.16
Rate for Payer: Aetna Commercial	$322.21
Rate for Payer: Aetna Medicare	$189.54
Rate for Payer: Aetna New Business (MI Preferred)	$246.40
Rate for Payer: BCBS Complete	$151.63
Rate for Payer: Cash Price	$303.26
Rate for Payer: Cofinity Commercial	$265.35
Rate for Payer: Cofinity Commercial	$326.00
Rate for Payer: Cofinity Medicare Advantage	$265.35
Rate for Payer: Encore Health Key Benefits Commercial	$303.26
Rate for Payer: Healthscope Commercial	$341.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$322.21
Rate for Payer: PHP Commercial	$322.21
Rate for Payer: Priority Health Cigna Priority Health	$246.40
Rate for Payer: Priority Health SBD	$238.81

PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SYRINGE

Facility

$129.64

Service Code	HCPCS J2469
Hospital Charge Code	188040
Hospital Revenue Code	636
Min. Negotiated Rate	$81.67
Max. Negotiated Rate	$116.68
Rate for Payer: Aetna Commercial	$110.19
Rate for Payer: Aetna Commercial	$224.03
Rate for Payer: Aetna New Business (MI Preferred)	$84.27
Rate for Payer: Aetna New Business (MI Preferred)	$171.32
Rate for Payer: Cash Price	$103.71
Rate for Payer: Cash Price	$210.86
Rate for Payer: Cofinity Commercial	$111.49
Rate for Payer: Cofinity Commercial	$184.50
Rate for Payer: Cofinity Commercial	$226.67
Rate for Payer: Cofinity Commercial	$90.75
Rate for Payer: Cofinity Medicare Advantage	$184.50
Rate for Payer: Cofinity Medicare Advantage	$90.75
Rate for Payer: Encore Health Key Benefits Commercial	$103.71
Rate for Payer: Encore Health Key Benefits Commercial	$210.86
Rate for Payer: Healthscope Commercial	$116.68
Rate for Payer: Healthscope Commercial	$237.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$110.19
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$224.03
Rate for Payer: PHP Commercial	$110.19
Rate for Payer: PHP Commercial	$224.03
Rate for Payer: Priority Health Cigna Priority Health	$171.32
Rate for Payer: Priority Health Cigna Priority Health	$84.27
Rate for Payer: Priority Health SBD	$166.05
Rate for Payer: Priority Health SBD	$81.67

PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SYRINGE

Facility

$129.64

Service Code	HCPCS J2469
Hospital Charge Code	188040
Hospital Revenue Code	636
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$116.68
Rate for Payer: Aetna Commercial	$110.19
Rate for Payer: Aetna Commercial	$224.03
Rate for Payer: Aetna Medicare	$131.78
Rate for Payer: Aetna Medicare	$64.82
Rate for Payer: Aetna New Business (MI Preferred)	$84.27
Rate for Payer: Aetna New Business (MI Preferred)	$171.32
Rate for Payer: BCBS Complete	$105.43
Rate for Payer: BCBS Complete	$51.86
Rate for Payer: BCBS Trust/PPO	$1.72
Rate for Payer: BCBS Trust/PPO	$1.72
Rate for Payer: BCN Commercial	$1.72
Rate for Payer: BCN Commercial	$1.72
Rate for Payer: Cash Price	$210.86
Rate for Payer: Cash Price	$103.71
Rate for Payer: Cash Price	$103.71
Rate for Payer: Cash Price	$210.86
Rate for Payer: Cofinity Commercial	$90.75
Rate for Payer: Cofinity Commercial	$111.49
Rate for Payer: Cofinity Commercial	$184.50
Rate for Payer: Cofinity Commercial	$226.67
Rate for Payer: Cofinity Medicare Advantage	$90.75
Rate for Payer: Cofinity Medicare Advantage	$184.50
Rate for Payer: Encore Health Key Benefits Commercial	$103.71
Rate for Payer: Encore Health Key Benefits Commercial	$210.86
Rate for Payer: Healthscope Commercial	$237.21
Rate for Payer: Healthscope Commercial	$116.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$224.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$110.19
Rate for Payer: PHP Commercial	$224.03
Rate for Payer: PHP Commercial	$110.19
Rate for Payer: Priority Health Cigna Priority Health	$171.32
Rate for Payer: Priority Health Cigna Priority Health	$84.27
Rate for Payer: Priority Health SBD	$166.05
Rate for Payer: Priority Health SBD	$81.67

PALONOSETRON 250 MCG + DEXAMETHASONE 10 MG IVPB (PREMIX)

Facility

$298.74

Service Code	HCPCS J2469
Hospital Charge Code	301168
Hospital Revenue Code	636
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$268.87
Rate for Payer: Aetna Commercial	$253.93
Rate for Payer: Aetna Medicare	$149.37
Rate for Payer: Aetna New Business (MI Preferred)	$194.18
Rate for Payer: BCBS Complete	$119.50
Rate for Payer: BCBS Trust/PPO	$1.72
Rate for Payer: BCN Commercial	$1.72
Rate for Payer: Cash Price	$238.99
Rate for Payer: Cash Price	$238.99
Rate for Payer: Cofinity Commercial	$209.12
Rate for Payer: Cofinity Commercial	$256.92
Rate for Payer: Cofinity Medicare Advantage	$209.12
Rate for Payer: Encore Health Key Benefits Commercial	$238.99
Rate for Payer: Healthscope Commercial	$268.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$253.93
Rate for Payer: PHP Commercial	$253.93
Rate for Payer: Priority Health Cigna Priority Health	$194.18
Rate for Payer: Priority Health SBD	$188.21

PALONOSETRON 250 MCG + DEXAMETHASONE 10 MG IVPB (PREMIX)

Facility

$298.74

Service Code	HCPCS J2469
Hospital Charge Code	301168
Hospital Revenue Code	636
Min. Negotiated Rate	$188.21
Max. Negotiated Rate	$268.87
Rate for Payer: Aetna Commercial	$253.93
Rate for Payer: Aetna New Business (MI Preferred)	$194.18
Rate for Payer: Cash Price	$238.99
Rate for Payer: Cofinity Commercial	$209.12
Rate for Payer: Cofinity Commercial	$256.92
Rate for Payer: Cofinity Medicare Advantage	$209.12
Rate for Payer: Encore Health Key Benefits Commercial	$238.99
Rate for Payer: Healthscope Commercial	$268.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$253.93
Rate for Payer: PHP Commercial	$253.93
Rate for Payer: Priority Health Cigna Priority Health	$194.18
Rate for Payer: Priority Health SBD	$188.21

PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION

Facility

$38.14

Service Code	HCPCS J2430
Hospital Charge Code	32589
Hospital Revenue Code	250
Min. Negotiated Rate	$24.03
Max. Negotiated Rate	$34.33
Rate for Payer: Aetna Commercial	$32.42
Rate for Payer: Aetna Commercial	$50.62
Rate for Payer: Aetna New Business (MI Preferred)	$24.79
Rate for Payer: Aetna New Business (MI Preferred)	$38.71
Rate for Payer: Cash Price	$30.51
Rate for Payer: Cash Price	$47.64
Rate for Payer: Cofinity Commercial	$26.70
Rate for Payer: Cofinity Commercial	$41.68
Rate for Payer: Cofinity Commercial	$51.21
Rate for Payer: Cofinity Commercial	$32.80
Rate for Payer: Cofinity Medicare Advantage	$41.68
Rate for Payer: Cofinity Medicare Advantage	$26.70
Rate for Payer: Encore Health Key Benefits Commercial	$30.51
Rate for Payer: Encore Health Key Benefits Commercial	$47.64
Rate for Payer: Healthscope Commercial	$34.33
Rate for Payer: Healthscope Commercial	$53.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$32.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$50.62
Rate for Payer: PHP Commercial	$32.42
Rate for Payer: PHP Commercial	$50.62
Rate for Payer: Priority Health Cigna Priority Health	$38.71
Rate for Payer: Priority Health Cigna Priority Health	$24.79
Rate for Payer: Priority Health SBD	$37.52
Rate for Payer: Priority Health SBD	$24.03

PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION

Facility

$38.14

Service Code	HCPCS J2430
Hospital Charge Code	32589
Hospital Revenue Code	250
Min. Negotiated Rate	$15.26
Max. Negotiated Rate	$35.63
Rate for Payer: Aetna Commercial	$32.42
Rate for Payer: Aetna Commercial	$50.62
Rate for Payer: Aetna Medicare	$29.78
Rate for Payer: Aetna Medicare	$19.07
Rate for Payer: Aetna New Business (MI Preferred)	$24.79
Rate for Payer: Aetna New Business (MI Preferred)	$38.71
Rate for Payer: BCBS Complete	$23.82
Rate for Payer: BCBS Complete	$15.26
Rate for Payer: BCBS Trust/PPO	$35.63
Rate for Payer: BCBS Trust/PPO	$35.63
Rate for Payer: BCN Commercial	$35.63
Rate for Payer: BCN Commercial	$35.63
Rate for Payer: Cash Price	$47.64
Rate for Payer: Cash Price	$47.64
Rate for Payer: Cash Price	$30.51
Rate for Payer: Cash Price	$30.51
Rate for Payer: Cofinity Commercial	$26.70
Rate for Payer: Cofinity Commercial	$51.21
Rate for Payer: Cofinity Commercial	$41.68
Rate for Payer: Cofinity Commercial	$32.80
Rate for Payer: Cofinity Medicare Advantage	$41.68
Rate for Payer: Cofinity Medicare Advantage	$26.70
Rate for Payer: Encore Health Key Benefits Commercial	$30.51
Rate for Payer: Encore Health Key Benefits Commercial	$47.64
Rate for Payer: Healthscope Commercial	$34.33
Rate for Payer: Healthscope Commercial	$53.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$50.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$32.42
Rate for Payer: PHP Commercial	$50.62
Rate for Payer: PHP Commercial	$32.42
Rate for Payer: Priority Health Cigna Priority Health	$24.79
Rate for Payer: Priority Health Cigna Priority Health	$38.71
Rate for Payer: Priority Health SBD	$37.52
Rate for Payer: Priority Health SBD	$24.03

PAMIDRONATE 30 MG INTRAVENOUS SOLUTION

Facility

$64.05

Service Code	HCPCS J2430
Hospital Charge Code	10845
Hospital Revenue Code	636
Min. Negotiated Rate	$25.62
Max. Negotiated Rate	$57.64
Rate for Payer: Aetna Commercial	$54.44
Rate for Payer: Aetna Medicare	$32.02
Rate for Payer: Aetna New Business (MI Preferred)	$41.63
Rate for Payer: BCBS Complete	$25.62
Rate for Payer: BCBS Trust/PPO	$35.63
Rate for Payer: BCN Commercial	$35.63
Rate for Payer: Cash Price	$51.24
Rate for Payer: Cash Price	$51.24
Rate for Payer: Cofinity Commercial	$44.84
Rate for Payer: Cofinity Commercial	$55.08
Rate for Payer: Cofinity Medicare Advantage	$44.84
Rate for Payer: Encore Health Key Benefits Commercial	$51.24
Rate for Payer: Healthscope Commercial	$57.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.44
Rate for Payer: PHP Commercial	$54.44
Rate for Payer: Priority Health Cigna Priority Health	$41.63
Rate for Payer: Priority Health SBD	$40.35

PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION

Facility

$7,930.15

Service Code	HCPCS J9303
Hospital Charge Code	77484
Hospital Revenue Code	636
Min. Negotiated Rate	$4,995.99
Max. Negotiated Rate	$7,137.14
Rate for Payer: Aetna Commercial	$6,740.63
Rate for Payer: Aetna New Business (MI Preferred)	$5,154.60
Rate for Payer: Cash Price	$6,344.12
Rate for Payer: Cofinity Commercial	$5,551.10
Rate for Payer: Cofinity Commercial	$6,819.93
Rate for Payer: Cofinity Medicare Advantage	$5,551.10
Rate for Payer: Encore Health Key Benefits Commercial	$6,344.12
Rate for Payer: Healthscope Commercial	$7,137.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6,740.63
Rate for Payer: PHP Commercial	$6,740.63
Rate for Payer: Priority Health Cigna Priority Health	$5,154.60
Rate for Payer: Priority Health SBD	$4,995.99

PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION

Facility

$7,930.15

Service Code	HCPCS J9303
Hospital Charge Code	77484
Hospital Revenue Code	636
Min. Negotiated Rate	$88.82
Max. Negotiated Rate	$7,137.14
Rate for Payer: Aetna Commercial	$6,740.63
Rate for Payer: Aetna Medicare	$172.34
Rate for Payer: Aetna New Business (MI Preferred)	$5,154.60
Rate for Payer: Allen County Amish Medical Aid Commercial	$207.14
Rate for Payer: Amish Plain Church Group Commercial	$207.14
Rate for Payer: BCBS Complete	$93.26
Rate for Payer: BCBS MAPPO	$165.71
Rate for Payer: BCBS Trust/PPO	$441.71
Rate for Payer: BCN Commercial	$441.71
Rate for Payer: BCN Medicare Advantage	$165.71
Rate for Payer: Cash Price	$6,344.12
Rate for Payer: Cash Price	$6,344.12
Rate for Payer: Cofinity Commercial	$6,819.93
Rate for Payer: Cofinity Commercial	$5,551.10
Rate for Payer: Cofinity Medicare Advantage	$5,551.10
Rate for Payer: Encore Health Key Benefits Commercial	$6,344.12
Rate for Payer: Health Alliance Plan Medicare Advantage	$165.71
Rate for Payer: Healthscope Commercial	$7,137.14
Rate for Payer: Mclaren Medicaid	$88.82
Rate for Payer: Mclaren Medicare	$165.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$174.00
Rate for Payer: Meridian Medicaid	$93.26
Rate for Payer: MI Amish Medical Board Commercial	$190.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6,740.63
Rate for Payer: Nomi Health Commercial	$497.13
Rate for Payer: PACE Medicare	$157.42
Rate for Payer: PACE SWMI	$165.71
Rate for Payer: PHP Commercial	$6,740.63
Rate for Payer: PHP Medicare Advantage	$165.71
Rate for Payer: Priority Health Choice Medicaid	$88.82
Rate for Payer: Priority Health Cigna Priority Health	$5,154.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$458.55
Rate for Payer: Priority Health Medicare	$165.71
Rate for Payer: Priority Health Narrow Network	$366.84
Rate for Payer: Priority Health SBD	$4,995.99
Rate for Payer: Railroad Medicare Medicare	$165.71
Rate for Payer: UHC All Payor (Choice/PPO)	$466.46
Rate for Payer: UHC Dual Complete DSNP	$165.71
Rate for Payer: UHC Medicare Advantage	$165.71
Rate for Payer: UHCCP Medicaid	$93.29
Rate for Payer: VA VA	$165.71

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$2.18

Service Code	NDC 60687072511
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.96
Rate for Payer: Aetna Commercial	$1.85
Rate for Payer: Aetna New Business (MI Preferred)	$1.42
Rate for Payer: Cash Price	$1.74
Rate for Payer: Cofinity Commercial	$1.53
Rate for Payer: Cofinity Commercial	$1.87
Rate for Payer: Cofinity Medicare Advantage	$1.53
Rate for Payer: Encore Health Key Benefits Commercial	$1.74
Rate for Payer: Healthscope Commercial	$1.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.85
Rate for Payer: PHP Commercial	$1.85
Rate for Payer: Priority Health Cigna Priority Health	$1.42
Rate for Payer: Priority Health SBD	$1.37

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$1.98

Service Code	NDC 60687058511
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.78
Rate for Payer: Aetna Commercial	$1.68
Rate for Payer: Aetna Medicare	$0.99
Rate for Payer: Aetna New Business (MI Preferred)	$1.29
Rate for Payer: BCBS Complete	$0.79
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cofinity Commercial	$1.39
Rate for Payer: Cofinity Commercial	$1.70
Rate for Payer: Cofinity Medicare Advantage	$1.39
Rate for Payer: Encore Health Key Benefits Commercial	$1.58
Rate for Payer: Healthscope Commercial	$1.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.68
Rate for Payer: PHP Commercial	$1.68
Rate for Payer: Priority Health Cigna Priority Health	$1.29
Rate for Payer: Priority Health SBD	$1.25

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$1.98

Service Code	NDC 60687058511
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.78
Rate for Payer: Aetna Commercial	$1.68
Rate for Payer: Aetna New Business (MI Preferred)	$1.29
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cofinity Commercial	$1.39
Rate for Payer: Cofinity Commercial	$1.70
Rate for Payer: Cofinity Medicare Advantage	$1.39
Rate for Payer: Encore Health Key Benefits Commercial	$1.58
Rate for Payer: Healthscope Commercial	$1.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.68
Rate for Payer: PHP Commercial	$1.68
Rate for Payer: Priority Health Cigna Priority Health	$1.29
Rate for Payer: Priority Health SBD	$1.25

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$4,482.85

Service Code	NDC 00008084381
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$2,824.20
Max. Negotiated Rate	$4,034.56
Rate for Payer: Aetna Commercial	$3,810.42
Rate for Payer: Aetna New Business (MI Preferred)	$2,913.85
Rate for Payer: Cash Price	$3,586.28
Rate for Payer: Cofinity Commercial	$3,138.00
Rate for Payer: Cofinity Commercial	$3,855.25
Rate for Payer: Cofinity Medicare Advantage	$3,138.00
Rate for Payer: Encore Health Key Benefits Commercial	$3,586.28
Rate for Payer: Healthscope Commercial	$4,034.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,810.42
Rate for Payer: PHP Commercial	$3,810.42
Rate for Payer: Priority Health Cigna Priority Health	$2,913.85
Rate for Payer: Priority Health SBD	$2,824.20

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$197.60

Service Code	NDC 60687058501
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$79.04
Max. Negotiated Rate	$177.84
Rate for Payer: Aetna Commercial	$167.96
Rate for Payer: Aetna Medicare	$98.80
Rate for Payer: Aetna New Business (MI Preferred)	$128.44
Rate for Payer: BCBS Complete	$79.04
Rate for Payer: Cash Price	$158.08
Rate for Payer: Cofinity Commercial	$138.32
Rate for Payer: Cofinity Commercial	$169.94
Rate for Payer: Cofinity Medicare Advantage	$138.32
Rate for Payer: Encore Health Key Benefits Commercial	$158.08
Rate for Payer: Healthscope Commercial	$177.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.96
Rate for Payer: PHP Commercial	$167.96
Rate for Payer: Priority Health Cigna Priority Health	$128.44
Rate for Payer: Priority Health SBD	$124.49

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$4,482.85

Service Code	NDC 00008084381
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$1,793.14
Max. Negotiated Rate	$4,034.56
Rate for Payer: Aetna Commercial	$3,810.42
Rate for Payer: Aetna Medicare	$2,241.42
Rate for Payer: Aetna New Business (MI Preferred)	$2,913.85
Rate for Payer: BCBS Complete	$1,793.14
Rate for Payer: Cash Price	$3,586.28
Rate for Payer: Cofinity Commercial	$3,138.00
Rate for Payer: Cofinity Commercial	$3,855.25
Rate for Payer: Cofinity Medicare Advantage	$3,138.00
Rate for Payer: Encore Health Key Benefits Commercial	$3,586.28
Rate for Payer: Healthscope Commercial	$4,034.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,810.42
Rate for Payer: PHP Commercial	$3,810.42
Rate for Payer: Priority Health Cigna Priority Health	$2,913.85
Rate for Payer: Priority Health SBD	$2,824.20

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$2.16

Service Code	NDC 68084064311
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.94
Rate for Payer: Aetna Commercial	$1.84
Rate for Payer: Aetna Medicare	$1.08
Rate for Payer: Aetna New Business (MI Preferred)	$1.40
Rate for Payer: BCBS Complete	$0.86
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cofinity Commercial	$1.51
Rate for Payer: Cofinity Commercial	$1.86
Rate for Payer: Cofinity Medicare Advantage	$1.51
Rate for Payer: Encore Health Key Benefits Commercial	$1.73
Rate for Payer: Healthscope Commercial	$1.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.84
Rate for Payer: PHP Commercial	$1.84
Rate for Payer: Priority Health Cigna Priority Health	$1.40
Rate for Payer: Priority Health SBD	$1.36

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$215.65

Service Code	NDC 68084064301
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$135.86
Max. Negotiated Rate	$194.08
Rate for Payer: Aetna Commercial	$183.30
Rate for Payer: Aetna New Business (MI Preferred)	$140.17
Rate for Payer: Cash Price	$172.52
Rate for Payer: Cofinity Commercial	$150.96
Rate for Payer: Cofinity Commercial	$185.46
Rate for Payer: Cofinity Medicare Advantage	$150.96
Rate for Payer: Encore Health Key Benefits Commercial	$172.52
Rate for Payer: Healthscope Commercial	$194.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$183.30
Rate for Payer: PHP Commercial	$183.30
Rate for Payer: Priority Health Cigna Priority Health	$140.17
Rate for Payer: Priority Health SBD	$135.86

Know your out-of-pocket cost for care.

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