Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$153.93

Service Code	NDC 50268063915
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$96.98
Max. Negotiated Rate	$138.54
Rate for Payer: Aetna Commercial	$130.84
Rate for Payer: Aetna New Business (MI Preferred)	$100.05
Rate for Payer: Cash Price	$123.14
Rate for Payer: Cofinity Commercial	$107.75
Rate for Payer: Cofinity Commercial	$132.38
Rate for Payer: Cofinity Medicare Advantage	$107.75
Rate for Payer: Encore Health Key Benefits Commercial	$123.14
Rate for Payer: Healthscope Commercial	$138.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$130.84
Rate for Payer: PHP Commercial	$130.84
Rate for Payer: Priority Health Cigna Priority Health	$100.05
Rate for Payer: Priority Health SBD	$96.98

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$3.74

Service Code	NDC 60687073611
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$3.37
Rate for Payer: Aetna Commercial	$3.18
Rate for Payer: Aetna Medicare	$1.87
Rate for Payer: Aetna New Business (MI Preferred)	$2.43
Rate for Payer: BCBS Complete	$1.50
Rate for Payer: Cash Price	$2.99
Rate for Payer: Cofinity Commercial	$2.62
Rate for Payer: Cofinity Commercial	$3.22
Rate for Payer: Cofinity Medicare Advantage	$2.62
Rate for Payer: Encore Health Key Benefits Commercial	$2.99
Rate for Payer: Healthscope Commercial	$3.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.18
Rate for Payer: PHP Commercial	$3.18
Rate for Payer: Priority Health Cigna Priority Health	$2.43
Rate for Payer: Priority Health SBD	$2.36

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$3.74

Service Code	NDC 60687073611
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$3.37
Rate for Payer: Aetna Commercial	$3.18
Rate for Payer: Aetna New Business (MI Preferred)	$2.43
Rate for Payer: Cash Price	$2.99
Rate for Payer: Cofinity Commercial	$2.62
Rate for Payer: Cofinity Commercial	$3.22
Rate for Payer: Cofinity Medicare Advantage	$2.62
Rate for Payer: Encore Health Key Benefits Commercial	$2.99
Rate for Payer: Healthscope Commercial	$3.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.18
Rate for Payer: PHP Commercial	$3.18
Rate for Payer: Priority Health Cigna Priority Health	$2.43
Rate for Payer: Priority Health SBD	$2.36

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$272.84

Service Code	NDC 62175061746
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$109.14
Max. Negotiated Rate	$245.56
Rate for Payer: Aetna Commercial	$231.91
Rate for Payer: Aetna Medicare	$136.42
Rate for Payer: Aetna New Business (MI Preferred)	$177.35
Rate for Payer: BCBS Complete	$109.14
Rate for Payer: Cash Price	$218.27
Rate for Payer: Cofinity Commercial	$190.99
Rate for Payer: Cofinity Commercial	$234.64
Rate for Payer: Cofinity Medicare Advantage	$190.99
Rate for Payer: Encore Health Key Benefits Commercial	$218.27
Rate for Payer: Healthscope Commercial	$245.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.91
Rate for Payer: PHP Commercial	$231.91
Rate for Payer: Priority Health Cigna Priority Health	$177.35
Rate for Payer: Priority Health SBD	$171.89

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$169.20

Service Code	NDC 60687073665
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$106.60
Max. Negotiated Rate	$152.28
Rate for Payer: Aetna Commercial	$143.82
Rate for Payer: Aetna New Business (MI Preferred)	$109.98
Rate for Payer: Cash Price	$135.36
Rate for Payer: Cofinity Commercial	$118.44
Rate for Payer: Cofinity Commercial	$145.51
Rate for Payer: Cofinity Medicare Advantage	$118.44
Rate for Payer: Encore Health Key Benefits Commercial	$135.36
Rate for Payer: Healthscope Commercial	$152.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.82
Rate for Payer: PHP Commercial	$143.82
Rate for Payer: Priority Health Cigna Priority Health	$109.98
Rate for Payer: Priority Health SBD	$106.60

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$2.21

Service Code	NDC 35573042851
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$1.99
Rate for Payer: Aetna Commercial	$1.88
Rate for Payer: Aetna New Business (MI Preferred)	$1.44
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cofinity Commercial	$1.55
Rate for Payer: Cofinity Commercial	$1.90
Rate for Payer: Cofinity Medicare Advantage	$1.55
Rate for Payer: Encore Health Key Benefits Commercial	$1.77
Rate for Payer: Healthscope Commercial	$1.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.88
Rate for Payer: PHP Commercial	$1.88
Rate for Payer: Priority Health Cigna Priority Health	$1.44
Rate for Payer: Priority Health SBD	$1.39

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$4.00

Service Code	NDC 68084081311
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna Commercial	$3.40
Rate for Payer: Aetna New Business (MI Preferred)	$2.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cofinity Commercial	$2.80
Rate for Payer: Cofinity Commercial	$3.44
Rate for Payer: Cofinity Medicare Advantage	$2.80
Rate for Payer: Encore Health Key Benefits Commercial	$3.20
Rate for Payer: Healthscope Commercial	$3.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.40
Rate for Payer: PHP Commercial	$3.40
Rate for Payer: Priority Health Cigna Priority Health	$2.60
Rate for Payer: Priority Health SBD	$2.52

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$169.20

Service Code	NDC 60687073665
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$67.68
Max. Negotiated Rate	$152.28
Rate for Payer: Aetna Commercial	$143.82
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: Aetna New Business (MI Preferred)	$109.98
Rate for Payer: BCBS Complete	$67.68
Rate for Payer: Cash Price	$135.36
Rate for Payer: Cofinity Commercial	$118.44
Rate for Payer: Cofinity Commercial	$145.51
Rate for Payer: Cofinity Medicare Advantage	$118.44
Rate for Payer: Encore Health Key Benefits Commercial	$135.36
Rate for Payer: Healthscope Commercial	$152.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.82
Rate for Payer: PHP Commercial	$143.82
Rate for Payer: Priority Health Cigna Priority Health	$109.98
Rate for Payer: Priority Health SBD	$106.60

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$2.22

Service Code	NDC 51079005101
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.89
Rate for Payer: Aetna Medicare	$1.11
Rate for Payer: Aetna New Business (MI Preferred)	$1.44
Rate for Payer: BCBS Complete	$0.89
Rate for Payer: Cash Price	$1.78
Rate for Payer: Cofinity Commercial	$1.55
Rate for Payer: Cofinity Commercial	$1.91
Rate for Payer: Cofinity Medicare Advantage	$1.55
Rate for Payer: Encore Health Key Benefits Commercial	$1.78
Rate for Payer: Healthscope Commercial	$2.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.89
Rate for Payer: PHP Commercial	$1.89
Rate for Payer: Priority Health Cigna Priority Health	$1.44
Rate for Payer: Priority Health SBD	$1.40

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$2.21

Service Code	NDC 35573042851
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.99
Rate for Payer: Aetna Commercial	$1.88
Rate for Payer: Aetna Medicare	$1.10
Rate for Payer: Aetna New Business (MI Preferred)	$1.44
Rate for Payer: BCBS Complete	$0.88
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cofinity Commercial	$1.55
Rate for Payer: Cofinity Commercial	$1.90
Rate for Payer: Cofinity Medicare Advantage	$1.55
Rate for Payer: Encore Health Key Benefits Commercial	$1.77
Rate for Payer: Healthscope Commercial	$1.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.88
Rate for Payer: PHP Commercial	$1.88
Rate for Payer: Priority Health Cigna Priority Health	$1.44
Rate for Payer: Priority Health SBD	$1.39

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$4,482.85

Service Code	NDC 00008084181
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1,793.14
Max. Negotiated Rate	$4,034.57
Rate for Payer: Aetna Commercial	$3,810.42
Rate for Payer: Aetna Medicare	$2,241.43
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	$3,137.99
Rate for Payer: Cofinity Commercial	$3,855.25
Rate for Payer: Cofinity Medicare Advantage	$3,137.99
Rate for Payer: Encore Health Key Benefits Commercial	$3,586.28
Rate for Payer: Healthscope Commercial	$4,034.57
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 40 MG TABLET,DELAYED RELEASE

Facility

$180.41

Service Code	NDC 55111033390
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$113.66
Max. Negotiated Rate	$162.37
Rate for Payer: Aetna Commercial	$153.35
Rate for Payer: Aetna New Business (MI Preferred)	$117.27
Rate for Payer: Cash Price	$144.33
Rate for Payer: Cofinity Commercial	$126.29
Rate for Payer: Cofinity Commercial	$155.15
Rate for Payer: Cofinity Medicare Advantage	$126.29
Rate for Payer: Encore Health Key Benefits Commercial	$144.33
Rate for Payer: Healthscope Commercial	$162.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$153.35
Rate for Payer: PHP Commercial	$153.35
Rate for Payer: Priority Health Cigna Priority Health	$117.27
Rate for Payer: Priority Health SBD	$113.66

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$319.60

Service Code	NDC 68084081309
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$201.35
Max. Negotiated Rate	$287.64
Rate for Payer: Aetna Commercial	$271.66
Rate for Payer: Aetna New Business (MI Preferred)	$207.74
Rate for Payer: Cash Price	$255.68
Rate for Payer: Cofinity Commercial	$223.72
Rate for Payer: Cofinity Commercial	$274.86
Rate for Payer: Cofinity Medicare Advantage	$223.72
Rate for Payer: Encore Health Key Benefits Commercial	$255.68
Rate for Payer: Healthscope Commercial	$287.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$271.66
Rate for Payer: PHP Commercial	$271.66
Rate for Payer: Priority Health Cigna Priority Health	$207.74
Rate for Payer: Priority Health SBD	$201.35

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$2.22

Service Code	NDC 51079005101
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.89
Rate for Payer: Aetna New Business (MI Preferred)	$1.44
Rate for Payer: Cash Price	$1.78
Rate for Payer: Cofinity Commercial	$1.55
Rate for Payer: Cofinity Commercial	$1.91
Rate for Payer: Cofinity Medicare Advantage	$1.55
Rate for Payer: Encore Health Key Benefits Commercial	$1.78
Rate for Payer: Healthscope Commercial	$2.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.89
Rate for Payer: PHP Commercial	$1.89
Rate for Payer: Priority Health Cigna Priority Health	$1.44
Rate for Payer: Priority Health SBD	$1.40

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$319.60

Service Code	NDC 68084081309
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$127.84
Max. Negotiated Rate	$287.64
Rate for Payer: Aetna Commercial	$271.66
Rate for Payer: Aetna Medicare	$159.80
Rate for Payer: Aetna New Business (MI Preferred)	$207.74
Rate for Payer: BCBS Complete	$127.84
Rate for Payer: Cash Price	$255.68
Rate for Payer: Cofinity Commercial	$223.72
Rate for Payer: Cofinity Commercial	$274.86
Rate for Payer: Cofinity Medicare Advantage	$223.72
Rate for Payer: Encore Health Key Benefits Commercial	$255.68
Rate for Payer: Healthscope Commercial	$287.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$271.66
Rate for Payer: PHP Commercial	$271.66
Rate for Payer: Priority Health Cigna Priority Health	$207.74
Rate for Payer: Priority Health SBD	$201.35

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$220.40

Service Code	NDC 35573042880
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$138.85
Max. Negotiated Rate	$198.36
Rate for Payer: Aetna Commercial	$187.34
Rate for Payer: Aetna New Business (MI Preferred)	$143.26
Rate for Payer: Cash Price	$176.32
Rate for Payer: Cofinity Commercial	$154.28
Rate for Payer: Cofinity Commercial	$189.54
Rate for Payer: Cofinity Medicare Advantage	$154.28
Rate for Payer: Encore Health Key Benefits Commercial	$176.32
Rate for Payer: Healthscope Commercial	$198.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$187.34
Rate for Payer: PHP Commercial	$187.34
Rate for Payer: Priority Health Cigna Priority Health	$143.26
Rate for Payer: Priority Health SBD	$138.85

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$221.35

Service Code	NDC 51079005120
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$139.45
Max. Negotiated Rate	$199.22
Rate for Payer: Aetna Commercial	$188.15
Rate for Payer: Aetna New Business (MI Preferred)	$143.88
Rate for Payer: Cash Price	$177.08
Rate for Payer: Cofinity Commercial	$154.94
Rate for Payer: Cofinity Commercial	$190.36
Rate for Payer: Cofinity Medicare Advantage	$154.94
Rate for Payer: Encore Health Key Benefits Commercial	$177.08
Rate for Payer: Healthscope Commercial	$199.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.15
Rate for Payer: PHP Commercial	$188.15
Rate for Payer: Priority Health Cigna Priority Health	$143.88
Rate for Payer: Priority Health SBD	$139.45

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$4.00

Service Code	NDC 68084081311
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna Commercial	$3.40
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: Aetna New Business (MI Preferred)	$2.60
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cofinity Commercial	$2.80
Rate for Payer: Cofinity Commercial	$3.44
Rate for Payer: Cofinity Medicare Advantage	$2.80
Rate for Payer: Encore Health Key Benefits Commercial	$3.20
Rate for Payer: Healthscope Commercial	$3.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.40
Rate for Payer: PHP Commercial	$3.40
Rate for Payer: Priority Health Cigna Priority Health	$2.60
Rate for Payer: Priority Health SBD	$2.52

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$3.08

Service Code	NDC 50268063911
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1.94
Max. Negotiated Rate	$2.77
Rate for Payer: Aetna Commercial	$2.62
Rate for Payer: Aetna New Business (MI Preferred)	$2.00
Rate for Payer: Cash Price	$2.46
Rate for Payer: Cofinity Commercial	$2.16
Rate for Payer: Cofinity Commercial	$2.65
Rate for Payer: Cofinity Medicare Advantage	$2.16
Rate for Payer: Encore Health Key Benefits Commercial	$2.46
Rate for Payer: Healthscope Commercial	$2.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.62
Rate for Payer: PHP Commercial	$2.62
Rate for Payer: Priority Health Cigna Priority Health	$2.00
Rate for Payer: Priority Health SBD	$1.94

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$180.41

Service Code	NDC 55111033390
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$72.16
Max. Negotiated Rate	$162.37
Rate for Payer: Aetna Commercial	$153.35
Rate for Payer: Aetna Medicare	$90.20
Rate for Payer: Aetna New Business (MI Preferred)	$117.27
Rate for Payer: BCBS Complete	$72.16
Rate for Payer: Cash Price	$144.33
Rate for Payer: Cofinity Commercial	$126.29
Rate for Payer: Cofinity Commercial	$155.15
Rate for Payer: Cofinity Medicare Advantage	$126.29
Rate for Payer: Encore Health Key Benefits Commercial	$144.33
Rate for Payer: Healthscope Commercial	$162.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$153.35
Rate for Payer: PHP Commercial	$153.35
Rate for Payer: Priority Health Cigna Priority Health	$117.27
Rate for Payer: Priority Health SBD	$113.66

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$222.30

Service Code	NDC 63739056410
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$140.05
Max. Negotiated Rate	$200.07
Rate for Payer: Aetna Commercial	$188.96
Rate for Payer: Aetna New Business (MI Preferred)	$144.50
Rate for Payer: Cash Price	$177.84
Rate for Payer: Cofinity Commercial	$155.61
Rate for Payer: Cofinity Commercial	$191.18
Rate for Payer: Cofinity Medicare Advantage	$155.61
Rate for Payer: Encore Health Key Benefits Commercial	$177.84
Rate for Payer: Healthscope Commercial	$200.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.96
Rate for Payer: PHP Commercial	$188.96
Rate for Payer: Priority Health Cigna Priority Health	$144.50
Rate for Payer: Priority Health SBD	$140.05

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$120.56

Service Code	NDC 65862056090
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$48.22
Max. Negotiated Rate	$108.50
Rate for Payer: Aetna Commercial	$102.48
Rate for Payer: Aetna Medicare	$60.28
Rate for Payer: Aetna New Business (MI Preferred)	$78.36
Rate for Payer: BCBS Complete	$48.22
Rate for Payer: Cash Price	$96.45
Rate for Payer: Cofinity Commercial	$103.68
Rate for Payer: Cofinity Commercial	$84.39
Rate for Payer: Cofinity Medicare Advantage	$84.39
Rate for Payer: Encore Health Key Benefits Commercial	$96.45
Rate for Payer: Healthscope Commercial	$108.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$102.48
Rate for Payer: PHP Commercial	$102.48
Rate for Payer: Priority Health Cigna Priority Health	$78.36
Rate for Payer: Priority Health SBD	$75.95

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$222.30

Service Code	NDC 63739056410
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$88.92
Max. Negotiated Rate	$200.07
Rate for Payer: Aetna Commercial	$188.96
Rate for Payer: Aetna Medicare	$111.15
Rate for Payer: Aetna New Business (MI Preferred)	$144.50
Rate for Payer: BCBS Complete	$88.92
Rate for Payer: Cash Price	$177.84
Rate for Payer: Cofinity Commercial	$155.61
Rate for Payer: Cofinity Commercial	$191.18
Rate for Payer: Cofinity Medicare Advantage	$155.61
Rate for Payer: Encore Health Key Benefits Commercial	$177.84
Rate for Payer: Healthscope Commercial	$200.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.96
Rate for Payer: PHP Commercial	$188.96
Rate for Payer: Priority Health Cigna Priority Health	$144.50
Rate for Payer: Priority Health SBD	$140.05

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$153.93

Service Code	NDC 50268063915
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$61.57
Max. Negotiated Rate	$138.54
Rate for Payer: Aetna Commercial	$130.84
Rate for Payer: Aetna Medicare	$76.97
Rate for Payer: Aetna New Business (MI Preferred)	$100.05
Rate for Payer: BCBS Complete	$61.57
Rate for Payer: Cash Price	$123.14
Rate for Payer: Cofinity Commercial	$107.75
Rate for Payer: Cofinity Commercial	$132.38
Rate for Payer: Cofinity Medicare Advantage	$107.75
Rate for Payer: Encore Health Key Benefits Commercial	$123.14
Rate for Payer: Healthscope Commercial	$138.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$130.84
Rate for Payer: PHP Commercial	$130.84
Rate for Payer: Priority Health Cigna Priority Health	$100.05
Rate for Payer: Priority Health SBD	$96.98

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$3.08

Service Code	NDC 50268063911
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.77
Rate for Payer: Aetna Commercial	$2.62
Rate for Payer: Aetna Medicare	$1.54
Rate for Payer: Aetna New Business (MI Preferred)	$2.00
Rate for Payer: BCBS Complete	$1.23
Rate for Payer: Cash Price	$2.46
Rate for Payer: Cofinity Commercial	$2.16
Rate for Payer: Cofinity Commercial	$2.65
Rate for Payer: Cofinity Medicare Advantage	$2.16
Rate for Payer: Encore Health Key Benefits Commercial	$2.46
Rate for Payer: Healthscope Commercial	$2.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.62
Rate for Payer: PHP Commercial	$2.62
Rate for Payer: Priority Health Cigna Priority Health	$2.00
Rate for Payer: Priority Health SBD	$1.94

Know your out-of-pocket cost for care.

All Charges