Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$470.98

Service Code	NDC 59011-420-20
Hospital Charge Code	173653
Hospital Revenue Code	637
Min. Negotiated Rate	$287.25
Max. Negotiated Rate	$423.88
Rate for Payer: Aetna Commercial	$400.33
Rate for Payer: BCBS Trust/PPO	$363.97
Rate for Payer: BCN Commercial	$363.97
Rate for Payer: Cash Price	$376.78
Rate for Payer: Cofinity Commercial	$405.04
Rate for Payer: Encore Health Key Benefits Commercial	$376.78
Rate for Payer: Healthscope Commercial	$423.88
Rate for Payer: Lakeland Regional Health Systems Commercial	$353.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$400.33
Rate for Payer: PHP Commercial	$400.33
Rate for Payer: Priority Health Cigna Priority Health	$329.69
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$409.75
Rate for Payer: Priority Health Narrow/Tiered Network	$287.25
Rate for Payer: UHC All Payor (Choice/PPO)	$414.46
Rate for Payer: UHC Core	$393.27
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$353.24

OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

Facility

$806.26

Service Code	NDC 59011-440-20
Hospital Charge Code	173655
Hospital Revenue Code	637
Min. Negotiated Rate	$491.74
Max. Negotiated Rate	$725.63
Rate for Payer: Aetna Commercial	$685.32
Rate for Payer: BCBS Trust/PPO	$623.08
Rate for Payer: BCN Commercial	$623.08
Rate for Payer: Cash Price	$645.01
Rate for Payer: Cofinity Commercial	$693.38
Rate for Payer: Encore Health Key Benefits Commercial	$645.01
Rate for Payer: Healthscope Commercial	$725.63
Rate for Payer: Lakeland Regional Health Systems Commercial	$604.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$685.32
Rate for Payer: PHP Commercial	$685.32
Rate for Payer: Priority Health Cigna Priority Health	$564.38
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$701.45
Rate for Payer: Priority Health Narrow/Tiered Network	$491.74
Rate for Payer: UHC All Payor (Choice/PPO)	$709.51
Rate for Payer: UHC Core	$673.23
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$604.70

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$5.22

Service Code	NDC 0904-5711-30
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$4.70
Rate for Payer: Aetna Commercial	$4.44
Rate for Payer: BCBS Trust/PPO	$4.03
Rate for Payer: BCN Commercial	$4.03
Rate for Payer: Cash Price	$4.18
Rate for Payer: Cofinity Commercial	$4.49
Rate for Payer: Encore Health Key Benefits Commercial	$4.18
Rate for Payer: Healthscope Commercial	$4.70
Rate for Payer: Lakeland Regional Health Systems Commercial	$3.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.44
Rate for Payer: PHP Commercial	$4.44
Rate for Payer: Priority Health Cigna Priority Health	$3.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4.54
Rate for Payer: Priority Health Narrow/Tiered Network	$3.18
Rate for Payer: UHC All Payor (Choice/PPO)	$4.59
Rate for Payer: UHC Core	$4.36
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$3.92

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$16.20

Service Code	NDC 70000-0001-1
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$9.88
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: BCBS Trust/PPO	$12.52
Rate for Payer: BCN Commercial	$12.52
Rate for Payer: Cash Price	$12.96
Rate for Payer: Cofinity Commercial	$13.93
Rate for Payer: Encore Health Key Benefits Commercial	$12.96
Rate for Payer: Healthscope Commercial	$14.58
Rate for Payer: Lakeland Regional Health Systems Commercial	$12.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.77
Rate for Payer: PHP Commercial	$13.77
Rate for Payer: Priority Health Cigna Priority Health	$11.34
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14.09
Rate for Payer: Priority Health Narrow/Tiered Network	$9.88
Rate for Payer: UHC All Payor (Choice/PPO)	$14.26
Rate for Payer: UHC Core	$13.53
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$12.15

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$9.32

Service Code	NDC 0904-6761-30
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$8.39
Rate for Payer: Aetna Commercial	$7.92
Rate for Payer: BCBS Trust/PPO	$7.20
Rate for Payer: BCN Commercial	$7.20
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cofinity Commercial	$8.02
Rate for Payer: Encore Health Key Benefits Commercial	$7.46
Rate for Payer: Healthscope Commercial	$8.39
Rate for Payer: Lakeland Regional Health Systems Commercial	$6.99
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7.92
Rate for Payer: PHP Commercial	$7.92
Rate for Payer: Priority Health Cigna Priority Health	$6.52
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8.11
Rate for Payer: Priority Health Narrow/Tiered Network	$5.68
Rate for Payer: UHC All Payor (Choice/PPO)	$8.20
Rate for Payer: UHC Core	$7.78
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$6.99

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$41.06

Service Code	NDC 4110081125
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$25.04
Max. Negotiated Rate	$36.95
Rate for Payer: Aetna Commercial	$34.90
Rate for Payer: BCBS Trust/PPO	$31.73
Rate for Payer: BCN Commercial	$31.73
Rate for Payer: Cash Price	$32.85
Rate for Payer: Cofinity Commercial	$35.31
Rate for Payer: Encore Health Key Benefits Commercial	$32.85
Rate for Payer: Healthscope Commercial	$36.95
Rate for Payer: Lakeland Regional Health Systems Commercial	$30.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.90
Rate for Payer: PHP Commercial	$34.90
Rate for Payer: Priority Health Cigna Priority Health	$28.74
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$35.72
Rate for Payer: Priority Health Narrow/Tiered Network	$25.04
Rate for Payer: UHC All Payor (Choice/PPO)	$36.13
Rate for Payer: UHC Core	$34.29
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$30.80

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$13.23

Service Code	NDC 45802-410-59
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$8.07
Max. Negotiated Rate	$11.91
Rate for Payer: Aetna Commercial	$11.25
Rate for Payer: BCBS Trust/PPO	$10.22
Rate for Payer: BCN Commercial	$10.22
Rate for Payer: Cash Price	$10.58
Rate for Payer: Cofinity Commercial	$11.38
Rate for Payer: Encore Health Key Benefits Commercial	$10.58
Rate for Payer: Healthscope Commercial	$11.91
Rate for Payer: Lakeland Regional Health Systems Commercial	$9.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.25
Rate for Payer: PHP Commercial	$11.25
Rate for Payer: Priority Health Cigna Priority Health	$9.26
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11.51
Rate for Payer: Priority Health Narrow/Tiered Network	$8.07
Rate for Payer: UHC All Payor (Choice/PPO)	$11.64
Rate for Payer: UHC Core	$11.05
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$9.92

OXYTOCIN 10 UNIT/ML INJECTION SOLUTION

Facility

$13.08

Service Code	HCPCS J2590
Hospital Charge Code	5944
Hospital Revenue Code	636
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$11.77
Rate for Payer: Aetna Commercial	$11.12
Rate for Payer: BCBS Trust/PPO	$10.11
Rate for Payer: BCN Commercial	$10.11
Rate for Payer: Cash Price	$10.46
Rate for Payer: Cofinity Commercial	$11.25
Rate for Payer: Encore Health Key Benefits Commercial	$10.46
Rate for Payer: Healthscope Commercial	$11.77
Rate for Payer: Lakeland Regional Health Systems Commercial	$9.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.12
Rate for Payer: PHP Commercial	$11.12
Rate for Payer: Priority Health Cigna Priority Health	$9.16
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11.38
Rate for Payer: Priority Health Narrow/Tiered Network	$7.98
Rate for Payer: UHC All Payor (Choice/PPO)	$11.51
Rate for Payer: UHC Core	$10.92
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$9.81

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	$23.26
Max. Negotiated Rate	$34.33
Rate for Payer: Aetna Commercial	$32.42
Rate for Payer: BCBS Trust/PPO	$29.47
Rate for Payer: BCN Commercial	$29.47
Rate for Payer: Cash Price	$30.51
Rate for Payer: Cofinity Commercial	$32.80
Rate for Payer: Encore Health Key Benefits Commercial	$30.51
Rate for Payer: Healthscope Commercial	$34.33
Rate for Payer: Lakeland Regional Health Systems Commercial	$28.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$32.42
Rate for Payer: PHP Commercial	$32.42
Rate for Payer: Priority Health Cigna Priority Health	$26.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$33.18
Rate for Payer: Priority Health Narrow/Tiered Network	$23.26
Rate for Payer: UHC All Payor (Choice/PPO)	$33.56
Rate for Payer: UHC Core	$31.85
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$28.60

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$215.65

Service Code	NDC 68084-643-01
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$131.52
Max. Negotiated Rate	$194.08
Rate for Payer: Aetna Commercial	$183.30
Rate for Payer: BCBS Trust/PPO	$166.65
Rate for Payer: BCN Commercial	$166.65
Rate for Payer: Cash Price	$172.52
Rate for Payer: Cofinity Commercial	$185.46
Rate for Payer: Encore Health Key Benefits Commercial	$172.52
Rate for Payer: Healthscope Commercial	$194.08
Rate for Payer: Lakeland Regional Health Systems Commercial	$161.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$183.30
Rate for Payer: PHP Commercial	$183.30
Rate for Payer: Priority Health Cigna Priority Health	$150.96
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$187.62
Rate for Payer: Priority Health Narrow/Tiered Network	$131.52
Rate for Payer: UHC All Payor (Choice/PPO)	$189.77
Rate for Payer: UHC Core	$180.07
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$161.74

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$123.50

Service Code	NDC 50268-636-15
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$75.32
Max. Negotiated Rate	$111.15
Rate for Payer: Aetna Commercial	$104.98
Rate for Payer: BCBS Trust/PPO	$95.44
Rate for Payer: BCN Commercial	$95.44
Rate for Payer: Cash Price	$98.80
Rate for Payer: Cofinity Commercial	$106.21
Rate for Payer: Encore Health Key Benefits Commercial	$98.80
Rate for Payer: Healthscope Commercial	$111.15
Rate for Payer: Lakeland Regional Health Systems Commercial	$92.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$104.98
Rate for Payer: PHP Commercial	$104.98
Rate for Payer: Priority Health Cigna Priority Health	$86.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$107.44
Rate for Payer: Priority Health Narrow/Tiered Network	$75.32
Rate for Payer: UHC All Payor (Choice/PPO)	$108.68
Rate for Payer: UHC Core	$103.12
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$92.62

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$107.35

Service Code	NDC 50268-585-15
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$65.47
Max. Negotiated Rate	$96.62
Rate for Payer: Aetna Commercial	$91.25
Rate for Payer: BCBS Trust/PPO	$82.96
Rate for Payer: BCN Commercial	$82.96
Rate for Payer: Cash Price	$85.88
Rate for Payer: Cofinity Commercial	$92.32
Rate for Payer: Encore Health Key Benefits Commercial	$85.88
Rate for Payer: Healthscope Commercial	$96.62
Rate for Payer: Lakeland Regional Health Systems Commercial	$80.51
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$91.25
Rate for Payer: PHP Commercial	$91.25
Rate for Payer: Priority Health Cigna Priority Health	$75.14
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$93.39
Rate for Payer: Priority Health Narrow/Tiered Network	$65.47
Rate for Payer: UHC All Payor (Choice/PPO)	$94.47
Rate for Payer: UHC Core	$89.64
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$80.51

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$2.15

Service Code	NDC 50268-585-11
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.94
Rate for Payer: Aetna Commercial	$1.83
Rate for Payer: BCBS Trust/PPO	$1.66
Rate for Payer: BCN Commercial	$1.66
Rate for Payer: Cash Price	$1.72
Rate for Payer: Cofinity Commercial	$1.85
Rate for Payer: Encore Health Key Benefits Commercial	$1.72
Rate for Payer: Healthscope Commercial	$1.94
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.61
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.83
Rate for Payer: PHP Commercial	$1.83
Rate for Payer: Priority Health Cigna Priority Health	$1.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1.87
Rate for Payer: Priority Health Narrow/Tiered Network	$1.31
Rate for Payer: UHC All Payor (Choice/PPO)	$1.89
Rate for Payer: UHC Core	$1.80
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.61

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$2.47

Service Code	NDC 50268-636-11
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.22
Rate for Payer: Aetna Commercial	$2.10
Rate for Payer: BCBS Trust/PPO	$1.91
Rate for Payer: BCN Commercial	$1.91
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cofinity Commercial	$2.12
Rate for Payer: Encore Health Key Benefits Commercial	$1.98
Rate for Payer: Healthscope Commercial	$2.22
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.10
Rate for Payer: PHP Commercial	$2.10
Rate for Payer: Priority Health Cigna Priority Health	$1.73
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.15
Rate for Payer: Priority Health Narrow/Tiered Network	$1.51
Rate for Payer: UHC All Payor (Choice/PPO)	$2.17
Rate for Payer: UHC Core	$2.06
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.85

PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE

Facility

$2.16

Service Code	NDC 68084-643-11
Hospital Charge Code	26224
Hospital Revenue Code	637
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.94
Rate for Payer: Aetna Commercial	$1.84
Rate for Payer: BCBS Trust/PPO	$1.67
Rate for Payer: BCN Commercial	$1.67
Rate for Payer: Cash Price	$1.73
Rate for Payer: Cofinity Commercial	$1.86
Rate for Payer: Encore Health Key Benefits Commercial	$1.73
Rate for Payer: Healthscope Commercial	$1.94
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.84
Rate for Payer: PHP Commercial	$1.84
Rate for Payer: Priority Health Cigna Priority Health	$1.51
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1.88
Rate for Payer: Priority Health Narrow/Tiered Network	$1.32
Rate for Payer: UHC All Payor (Choice/PPO)	$1.90
Rate for Payer: UHC Core	$1.80
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.62

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$18.73

Service Code	NDC 0143-9284-01
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$11.42
Max. Negotiated Rate	$16.86
Rate for Payer: Aetna Commercial	$15.92
Rate for Payer: BCBS Trust/PPO	$14.47
Rate for Payer: BCN Commercial	$14.47
Rate for Payer: Cash Price	$14.98
Rate for Payer: Cofinity Commercial	$16.11
Rate for Payer: Encore Health Key Benefits Commercial	$14.98
Rate for Payer: Healthscope Commercial	$16.86
Rate for Payer: Lakeland Regional Health Systems Commercial	$14.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.92
Rate for Payer: PHP Commercial	$15.92
Rate for Payer: Priority Health Cigna Priority Health	$13.11
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.30
Rate for Payer: Priority Health Narrow/Tiered Network	$11.42
Rate for Payer: UHC All Payor (Choice/PPO)	$16.48
Rate for Payer: UHC Core	$15.64
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$14.05

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$26.31

Service Code	NDC 65219-433-01
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$16.05
Max. Negotiated Rate	$23.68
Rate for Payer: Aetna Commercial	$22.36
Rate for Payer: BCBS Trust/PPO	$20.33
Rate for Payer: BCN Commercial	$20.33
Rate for Payer: Cash Price	$21.05
Rate for Payer: Cofinity Commercial	$22.63
Rate for Payer: Encore Health Key Benefits Commercial	$21.05
Rate for Payer: Healthscope Commercial	$23.68
Rate for Payer: Lakeland Regional Health Systems Commercial	$19.73
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.36
Rate for Payer: PHP Commercial	$22.36
Rate for Payer: Priority Health Cigna Priority Health	$18.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.89
Rate for Payer: Priority Health Narrow/Tiered Network	$16.05
Rate for Payer: UHC All Payor (Choice/PPO)	$23.15
Rate for Payer: UHC Core	$21.97
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$19.73

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$22.47

Service Code	NDC 0781-3232-95
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$13.70
Max. Negotiated Rate	$20.22
Rate for Payer: Aetna Commercial	$19.10
Rate for Payer: BCBS Trust/PPO	$17.36
Rate for Payer: BCN Commercial	$17.36
Rate for Payer: Cash Price	$17.98
Rate for Payer: Cofinity Commercial	$19.32
Rate for Payer: Encore Health Key Benefits Commercial	$17.98
Rate for Payer: Healthscope Commercial	$20.22
Rate for Payer: Lakeland Regional Health Systems Commercial	$16.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.10
Rate for Payer: PHP Commercial	$19.10
Rate for Payer: Priority Health Cigna Priority Health	$15.73
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19.55
Rate for Payer: Priority Health Narrow/Tiered Network	$13.70
Rate for Payer: UHC All Payor (Choice/PPO)	$19.77
Rate for Payer: UHC Core	$18.76
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$16.85

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$18.73

Service Code	NDC 0143-9284-10
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$11.42
Max. Negotiated Rate	$16.86
Rate for Payer: Aetna Commercial	$15.92
Rate for Payer: BCBS Trust/PPO	$14.47
Rate for Payer: BCN Commercial	$14.47
Rate for Payer: Cash Price	$14.98
Rate for Payer: Cofinity Commercial	$16.11
Rate for Payer: Encore Health Key Benefits Commercial	$14.98
Rate for Payer: Healthscope Commercial	$16.86
Rate for Payer: Lakeland Regional Health Systems Commercial	$14.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.92
Rate for Payer: PHP Commercial	$15.92
Rate for Payer: Priority Health Cigna Priority Health	$13.11
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.30
Rate for Payer: Priority Health Narrow/Tiered Network	$11.42
Rate for Payer: UHC All Payor (Choice/PPO)	$16.48
Rate for Payer: UHC Core	$15.64
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$14.05

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$21.39

Service Code	NDC 55150-202-10
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$19.25
Rate for Payer: Aetna Commercial	$18.18
Rate for Payer: BCBS Trust/PPO	$16.53
Rate for Payer: BCN Commercial	$16.53
Rate for Payer: Cash Price	$17.11
Rate for Payer: Cofinity Commercial	$18.40
Rate for Payer: Encore Health Key Benefits Commercial	$17.11
Rate for Payer: Healthscope Commercial	$19.25
Rate for Payer: Lakeland Regional Health Systems Commercial	$16.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.18
Rate for Payer: PHP Commercial	$18.18
Rate for Payer: Priority Health Cigna Priority Health	$14.97
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$18.61
Rate for Payer: Priority Health Narrow/Tiered Network	$13.05
Rate for Payer: UHC All Payor (Choice/PPO)	$18.82
Rate for Payer: UHC Core	$17.86
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$16.04

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$21.91

Service Code	NDC 0008-0923-51
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$13.36
Max. Negotiated Rate	$19.72
Rate for Payer: Aetna Commercial	$18.62
Rate for Payer: BCBS Trust/PPO	$16.93
Rate for Payer: BCN Commercial	$16.93
Rate for Payer: Cash Price	$17.53
Rate for Payer: Cofinity Commercial	$18.84
Rate for Payer: Encore Health Key Benefits Commercial	$17.53
Rate for Payer: Healthscope Commercial	$19.72
Rate for Payer: Lakeland Regional Health Systems Commercial	$16.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.62
Rate for Payer: PHP Commercial	$18.62
Rate for Payer: Priority Health Cigna Priority Health	$15.34
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19.06
Rate for Payer: Priority Health Narrow/Tiered Network	$13.36
Rate for Payer: UHC All Payor (Choice/PPO)	$19.28
Rate for Payer: UHC Core	$18.29
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$16.43

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$21.39

Service Code	NDC 55150-202-00
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$19.25
Rate for Payer: Aetna Commercial	$18.18
Rate for Payer: BCBS Trust/PPO	$16.53
Rate for Payer: BCN Commercial	$16.53
Rate for Payer: Cash Price	$17.11
Rate for Payer: Cofinity Commercial	$18.40
Rate for Payer: Encore Health Key Benefits Commercial	$17.11
Rate for Payer: Healthscope Commercial	$19.25
Rate for Payer: Lakeland Regional Health Systems Commercial	$16.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.18
Rate for Payer: PHP Commercial	$18.18
Rate for Payer: Priority Health Cigna Priority Health	$14.97
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$18.61
Rate for Payer: Priority Health Narrow/Tiered Network	$13.05
Rate for Payer: UHC All Payor (Choice/PPO)	$18.82
Rate for Payer: UHC Core	$17.86
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$16.04

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$26.31

Service Code	NDC 65219-433-15
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$16.05
Max. Negotiated Rate	$23.68
Rate for Payer: Aetna Commercial	$22.36
Rate for Payer: BCBS Trust/PPO	$20.33
Rate for Payer: BCN Commercial	$20.33
Rate for Payer: Cash Price	$21.05
Rate for Payer: Cofinity Commercial	$22.63
Rate for Payer: Encore Health Key Benefits Commercial	$21.05
Rate for Payer: Healthscope Commercial	$23.68
Rate for Payer: Lakeland Regional Health Systems Commercial	$19.73
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.36
Rate for Payer: PHP Commercial	$22.36
Rate for Payer: Priority Health Cigna Priority Health	$18.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.89
Rate for Payer: Priority Health Narrow/Tiered Network	$16.05
Rate for Payer: UHC All Payor (Choice/PPO)	$23.15
Rate for Payer: UHC Core	$21.97
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$19.73

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION FOR DRIP

Facility

$22.47

Service Code	NDC 0781-3232-95
Hospital Charge Code	301183
Hospital Revenue Code	250
Min. Negotiated Rate	$13.70
Max. Negotiated Rate	$20.22
Rate for Payer: Aetna Commercial	$19.10
Rate for Payer: BCBS Trust/PPO	$17.36
Rate for Payer: BCN Commercial	$17.36
Rate for Payer: Cash Price	$17.98
Rate for Payer: Cofinity Commercial	$19.32
Rate for Payer: Encore Health Key Benefits Commercial	$17.98
Rate for Payer: Healthscope Commercial	$20.22
Rate for Payer: Lakeland Regional Health Systems Commercial	$16.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.10
Rate for Payer: PHP Commercial	$19.10
Rate for Payer: Priority Health Cigna Priority Health	$15.73
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19.55
Rate for Payer: Priority Health Narrow/Tiered Network	$13.70
Rate for Payer: UHC All Payor (Choice/PPO)	$19.77
Rate for Payer: UHC Core	$18.76
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$16.85

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$265.08

Service Code	NDC 0904-6870-45
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$161.67
Max. Negotiated Rate	$238.57
Rate for Payer: Aetna Commercial	$225.32
Rate for Payer: BCBS Trust/PPO	$204.85
Rate for Payer: BCN Commercial	$204.85
Rate for Payer: Cash Price	$212.06
Rate for Payer: Cofinity Commercial	$227.97
Rate for Payer: Encore Health Key Benefits Commercial	$212.06
Rate for Payer: Healthscope Commercial	$238.57
Rate for Payer: Lakeland Regional Health Systems Commercial	$198.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$225.32
Rate for Payer: PHP Commercial	$225.32
Rate for Payer: Priority Health Cigna Priority Health	$185.56
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$230.62
Rate for Payer: Priority Health Narrow/Tiered Network	$161.67
Rate for Payer: UHC All Payor (Choice/PPO)	$233.27
Rate for Payer: UHC Core	$221.34
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$198.81

Know your out-of-pocket cost for care.

All Charges