Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

OXYBUTYNIN CHLORIDE 5 MG TABLET

Facility

$3.23

Service Code	NDC 0832-0038-89
Hospital Charge Code	5938
Hospital Revenue Code	637
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$3.23
Rate for Payer: Aetna Commercial	$2.91
Rate for Payer: ASR ASR	$3.13
Rate for Payer: BCBS Trust/PPO	$2.50
Rate for Payer: BCN Commercial	$2.50
Rate for Payer: Cash Price	$2.58
Rate for Payer: Cofinity Commercial	$3.04
Rate for Payer: Encore Health Key Benefits Commercial	$2.58
Rate for Payer: Healthscope Commercial	$3.23
Rate for Payer: Healthscope Whirlpool	$3.13
Rate for Payer: Mclaren Commercial	$2.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.75
Rate for Payer: Priority Health Cigna Priority Health	$2.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.84

OXYBUTYNIN CHLORIDE 5 MG TABLET

Facility

$323.00

Service Code	NDC 0832-0038-01
Hospital Charge Code	5938
Hospital Revenue Code	637
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$323.00
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: ASR ASR	$313.31
Rate for Payer: BCBS Trust/PPO	$250.42
Rate for Payer: BCN Commercial	$250.42
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cofinity Commercial	$303.62
Rate for Payer: Encore Health Key Benefits Commercial	$258.40
Rate for Payer: Healthscope Commercial	$323.00
Rate for Payer: Healthscope Whirlpool	$313.31
Rate for Payer: Mclaren Commercial	$290.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$274.55
Rate for Payer: Priority Health Cigna Priority Health	$226.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$284.24

OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$157.45

Service Code	NDC 27241-155-04
Hospital Charge Code	24470
Hospital Revenue Code	637
Min. Negotiated Rate	$110.22
Max. Negotiated Rate	$157.45
Rate for Payer: Aetna Commercial	$141.70
Rate for Payer: ASR ASR	$152.73
Rate for Payer: BCBS Trust/PPO	$122.07
Rate for Payer: BCN Commercial	$122.07
Rate for Payer: Cash Price	$125.96
Rate for Payer: Cofinity Commercial	$148.00
Rate for Payer: Encore Health Key Benefits Commercial	$125.96
Rate for Payer: Healthscope Commercial	$157.45
Rate for Payer: Healthscope Whirlpool	$152.73
Rate for Payer: Mclaren Commercial	$141.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$133.83
Rate for Payer: Priority Health Cigna Priority Health	$110.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$138.56

OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$561.12

Service Code	NDC 0904-6570-61
Hospital Charge Code	24470
Hospital Revenue Code	637
Min. Negotiated Rate	$392.78
Max. Negotiated Rate	$561.12
Rate for Payer: Aetna Commercial	$505.01
Rate for Payer: ASR ASR	$544.29
Rate for Payer: BCBS Trust/PPO	$435.04
Rate for Payer: BCN Commercial	$435.04
Rate for Payer: Cash Price	$448.90
Rate for Payer: Cofinity Commercial	$527.45
Rate for Payer: Encore Health Key Benefits Commercial	$448.90
Rate for Payer: Healthscope Commercial	$561.12
Rate for Payer: Healthscope Whirlpool	$544.29
Rate for Payer: Mclaren Commercial	$505.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$476.95
Rate for Payer: Priority Health Cigna Priority Health	$392.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$493.79

OXYCODONE 10 MG TABLET

Facility

$10.03

Service Code	NDC 0406-8510-23
Hospital Charge Code	87795
Hospital Revenue Code	637
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$10.03
Rate for Payer: Aetna Commercial	$9.03
Rate for Payer: ASR ASR	$9.73
Rate for Payer: BCBS Trust/PPO	$7.78
Rate for Payer: BCN Commercial	$7.78
Rate for Payer: Cash Price	$8.02
Rate for Payer: Cofinity Commercial	$9.43
Rate for Payer: Encore Health Key Benefits Commercial	$8.02
Rate for Payer: Healthscope Commercial	$10.03
Rate for Payer: Healthscope Whirlpool	$9.73
Rate for Payer: Mclaren Commercial	$9.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8.53
Rate for Payer: Priority Health Cigna Priority Health	$7.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.83

OXYCODONE 10 MG TABLET

Facility

$1,002.75

Service Code	NDC 0406-8510-62
Hospital Charge Code	87795
Hospital Revenue Code	637
Min. Negotiated Rate	$701.92
Max. Negotiated Rate	$1,002.75
Rate for Payer: Aetna Commercial	$902.48
Rate for Payer: ASR ASR	$972.67
Rate for Payer: BCBS Trust/PPO	$777.43
Rate for Payer: BCN Commercial	$777.43
Rate for Payer: Cash Price	$802.20
Rate for Payer: Cofinity Commercial	$942.58
Rate for Payer: Encore Health Key Benefits Commercial	$802.20
Rate for Payer: Healthscope Commercial	$1,002.75
Rate for Payer: Healthscope Whirlpool	$972.67
Rate for Payer: Mclaren Commercial	$902.48
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$852.34
Rate for Payer: Priority Health Cigna Priority Health	$701.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$882.42

OXYCODONE 5 MG TABLET

Facility

$119.00

Service Code	NDC 42858-001-01
Hospital Charge Code	10814
Hospital Revenue Code	637
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$119.00
Rate for Payer: Aetna Commercial	$107.10
Rate for Payer: ASR ASR	$115.43
Rate for Payer: BCBS Trust/PPO	$92.26
Rate for Payer: BCN Commercial	$92.26
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cofinity Commercial	$111.86
Rate for Payer: Encore Health Key Benefits Commercial	$95.20
Rate for Payer: Healthscope Commercial	$119.00
Rate for Payer: Healthscope Whirlpool	$115.43
Rate for Payer: Mclaren Commercial	$107.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$101.15
Rate for Payer: Priority Health Cigna Priority Health	$83.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$104.72

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET

Facility

$232.05

Service Code	NDC 50268-646-15
Hospital Charge Code	31864
Hospital Revenue Code	637
Min. Negotiated Rate	$162.44
Max. Negotiated Rate	$232.05
Rate for Payer: Aetna Commercial	$208.84
Rate for Payer: ASR ASR	$225.09
Rate for Payer: BCBS Trust/PPO	$179.91
Rate for Payer: BCN Commercial	$179.91
Rate for Payer: Cash Price	$185.64
Rate for Payer: Cofinity Commercial	$218.13
Rate for Payer: Encore Health Key Benefits Commercial	$185.64
Rate for Payer: Healthscope Commercial	$232.05
Rate for Payer: Healthscope Whirlpool	$225.09
Rate for Payer: Mclaren Commercial	$208.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$197.24
Rate for Payer: Priority Health Cigna Priority Health	$162.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$204.20

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET

Facility

$10.26

Service Code	NDC 68084-710-11
Hospital Charge Code	31864
Hospital Revenue Code	637
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$10.26
Rate for Payer: Aetna Commercial	$9.23
Rate for Payer: ASR ASR	$9.95
Rate for Payer: BCBS Trust/PPO	$7.95
Rate for Payer: BCN Commercial	$7.95
Rate for Payer: Cash Price	$8.21
Rate for Payer: Cofinity Commercial	$9.64
Rate for Payer: Encore Health Key Benefits Commercial	$8.21
Rate for Payer: Healthscope Commercial	$10.26
Rate for Payer: Healthscope Whirlpool	$9.95
Rate for Payer: Mclaren Commercial	$9.23
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8.72
Rate for Payer: Priority Health Cigna Priority Health	$7.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.03

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET

Facility

$4.64

Service Code	NDC 50268-646-11
Hospital Charge Code	31864
Hospital Revenue Code	637
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$4.64
Rate for Payer: Aetna Commercial	$4.18
Rate for Payer: ASR ASR	$4.50
Rate for Payer: BCBS Trust/PPO	$3.60
Rate for Payer: BCN Commercial	$3.60
Rate for Payer: Cash Price	$3.71
Rate for Payer: Cofinity Commercial	$4.36
Rate for Payer: Encore Health Key Benefits Commercial	$3.71
Rate for Payer: Healthscope Commercial	$4.64
Rate for Payer: Healthscope Whirlpool	$4.50
Rate for Payer: Mclaren Commercial	$4.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.94
Rate for Payer: Priority Health Cigna Priority Health	$3.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.08

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET

Facility

$1,026.20

Service Code	NDC 68084-710-01
Hospital Charge Code	31864
Hospital Revenue Code	637
Min. Negotiated Rate	$718.34
Max. Negotiated Rate	$1,026.20
Rate for Payer: Aetna Commercial	$923.58
Rate for Payer: ASR ASR	$995.41
Rate for Payer: BCBS Trust/PPO	$795.61
Rate for Payer: BCN Commercial	$795.61
Rate for Payer: Cash Price	$820.96
Rate for Payer: Cofinity Commercial	$964.63
Rate for Payer: Encore Health Key Benefits Commercial	$820.96
Rate for Payer: Healthscope Commercial	$1,026.20
Rate for Payer: Healthscope Whirlpool	$995.41
Rate for Payer: Mclaren Commercial	$923.58
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$872.27
Rate for Payer: Priority Health Cigna Priority Health	$718.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$903.06

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$637.00

Service Code	NDC 68084-355-11
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$445.90
Max. Negotiated Rate	$637.00
Rate for Payer: Aetna Commercial	$573.30
Rate for Payer: ASR ASR	$617.89
Rate for Payer: BCBS Trust/PPO	$493.87
Rate for Payer: BCN Commercial	$493.87
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cofinity Commercial	$598.78
Rate for Payer: Encore Health Key Benefits Commercial	$509.60
Rate for Payer: Healthscope Commercial	$637.00
Rate for Payer: Healthscope Whirlpool	$617.89
Rate for Payer: Mclaren Commercial	$573.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$541.45
Rate for Payer: Priority Health Cigna Priority Health	$445.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$560.56

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$402.50

Service Code	NDC 0904-6437-61
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$281.75
Max. Negotiated Rate	$402.50
Rate for Payer: Aetna Commercial	$362.25
Rate for Payer: ASR ASR	$390.42
Rate for Payer: BCBS Trust/PPO	$312.06
Rate for Payer: BCN Commercial	$312.06
Rate for Payer: Cash Price	$322.00
Rate for Payer: Cofinity Commercial	$378.35
Rate for Payer: Encore Health Key Benefits Commercial	$322.00
Rate for Payer: Healthscope Commercial	$402.50
Rate for Payer: Healthscope Whirlpool	$390.42
Rate for Payer: Mclaren Commercial	$362.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$342.12
Rate for Payer: Priority Health Cigna Priority Health	$281.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$354.20

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$7.00

Service Code	NDC 0406-0512-23
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: ASR ASR	$6.79
Rate for Payer: BCBS Trust/PPO	$5.43
Rate for Payer: BCN Commercial	$5.43
Rate for Payer: Cash Price	$5.60
Rate for Payer: Cofinity Commercial	$6.58
Rate for Payer: Encore Health Key Benefits Commercial	$5.60
Rate for Payer: Healthscope Commercial	$7.00
Rate for Payer: Healthscope Whirlpool	$6.79
Rate for Payer: Mclaren Commercial	$6.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5.95
Rate for Payer: Priority Health Cigna Priority Health	$4.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$6.16

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$439.25

Service Code	NDC 0904-7093-61
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$307.48
Max. Negotiated Rate	$439.25
Rate for Payer: Aetna Commercial	$395.32
Rate for Payer: ASR ASR	$426.07
Rate for Payer: BCBS Trust/PPO	$340.55
Rate for Payer: BCN Commercial	$340.55
Rate for Payer: Cash Price	$351.40
Rate for Payer: Cofinity Commercial	$412.90
Rate for Payer: Encore Health Key Benefits Commercial	$351.40
Rate for Payer: Healthscope Commercial	$439.25
Rate for Payer: Healthscope Whirlpool	$426.07
Rate for Payer: Mclaren Commercial	$395.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$373.36
Rate for Payer: Priority Health Cigna Priority Health	$307.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$386.54

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$4.13

Service Code	NDC 9900-0008-90
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$4.13
Rate for Payer: Aetna Commercial	$3.72
Rate for Payer: ASR ASR	$4.01
Rate for Payer: BCBS Trust/PPO	$3.20
Rate for Payer: BCN Commercial	$3.20
Rate for Payer: Cash Price	$3.30
Rate for Payer: Cofinity Commercial	$3.88
Rate for Payer: Encore Health Key Benefits Commercial	$3.30
Rate for Payer: Healthscope Commercial	$4.13
Rate for Payer: Healthscope Whirlpool	$4.01
Rate for Payer: Mclaren Commercial	$3.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.51
Rate for Payer: Priority Health Cigna Priority Health	$2.89
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.63

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$637.00

Service Code	NDC 68084-355-01
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$445.90
Max. Negotiated Rate	$637.00
Rate for Payer: Aetna Commercial	$573.30
Rate for Payer: ASR ASR	$617.89
Rate for Payer: BCBS Trust/PPO	$493.87
Rate for Payer: BCN Commercial	$493.87
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cofinity Commercial	$598.78
Rate for Payer: Encore Health Key Benefits Commercial	$509.60
Rate for Payer: Healthscope Commercial	$637.00
Rate for Payer: Healthscope Whirlpool	$617.89
Rate for Payer: Mclaren Commercial	$573.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$541.45
Rate for Payer: Priority Health Cigna Priority Health	$445.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$560.56

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$70.00

Service Code	NDC 0406-0512-62
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: ASR ASR	$67.90
Rate for Payer: BCBS Trust/PPO	$54.27
Rate for Payer: BCN Commercial	$54.27
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$65.80
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$70.00
Rate for Payer: Healthscope Whirlpool	$67.90
Rate for Payer: Mclaren Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.60

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$290.50

Service Code	NDC 0406-0512-01
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$203.35
Max. Negotiated Rate	$290.50
Rate for Payer: Aetna Commercial	$261.45
Rate for Payer: ASR ASR	$281.78
Rate for Payer: BCBS Trust/PPO	$225.22
Rate for Payer: BCN Commercial	$225.22
Rate for Payer: Cash Price	$232.40
Rate for Payer: Cofinity Commercial	$273.07
Rate for Payer: Encore Health Key Benefits Commercial	$232.40
Rate for Payer: Healthscope Commercial	$290.50
Rate for Payer: Healthscope Whirlpool	$281.78
Rate for Payer: Mclaren Commercial	$261.45
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$246.92
Rate for Payer: Priority Health Cigna Priority Health	$203.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$255.64

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

Facility

$397.18

Service Code	NDC 59011-410-20
Hospital Charge Code	173651
Hospital Revenue Code	637
Min. Negotiated Rate	$278.03
Max. Negotiated Rate	$397.18
Rate for Payer: Aetna Commercial	$357.46
Rate for Payer: ASR ASR	$385.26
Rate for Payer: BCBS Trust/PPO	$307.93
Rate for Payer: BCN Commercial	$307.93
Rate for Payer: Cash Price	$317.74
Rate for Payer: Cofinity Commercial	$373.35
Rate for Payer: Encore Health Key Benefits Commercial	$317.74
Rate for Payer: Healthscope Commercial	$397.18
Rate for Payer: Healthscope Whirlpool	$385.26
Rate for Payer: Mclaren Commercial	$357.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$337.60
Rate for Payer: Priority Health Cigna Priority Health	$278.03
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$349.52

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

Facility

$626.01

Service Code	NDC 59011-420-20
Hospital Charge Code	173653
Hospital Revenue Code	637
Min. Negotiated Rate	$438.21
Max. Negotiated Rate	$626.01
Rate for Payer: Aetna Commercial	$563.41
Rate for Payer: ASR ASR	$607.23
Rate for Payer: BCBS Trust/PPO	$485.35
Rate for Payer: BCN Commercial	$485.35
Rate for Payer: Cash Price	$500.81
Rate for Payer: Cofinity Commercial	$588.45
Rate for Payer: Encore Health Key Benefits Commercial	$500.81
Rate for Payer: Healthscope Commercial	$626.01
Rate for Payer: Healthscope Whirlpool	$607.23
Rate for Payer: Mclaren Commercial	$563.41
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$532.11
Rate for Payer: Priority Health Cigna Priority Health	$438.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$550.89

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$24.84

Service Code	NDC 2390001252
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$17.39
Max. Negotiated Rate	$24.84
Rate for Payer: Aetna Commercial	$22.36
Rate for Payer: ASR ASR	$24.09
Rate for Payer: BCBS Trust/PPO	$19.26
Rate for Payer: BCN Commercial	$19.26
Rate for Payer: Cash Price	$19.87
Rate for Payer: Cofinity Commercial	$23.35
Rate for Payer: Encore Health Key Benefits Commercial	$19.87
Rate for Payer: Healthscope Commercial	$24.84
Rate for Payer: Healthscope Whirlpool	$24.09
Rate for Payer: Mclaren Commercial	$22.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.11
Rate for Payer: Priority Health Cigna Priority Health	$17.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.86

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$22.75

Service Code	NDC 5002443100
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$15.92
Max. Negotiated Rate	$22.75
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: ASR ASR	$22.07
Rate for Payer: BCBS Trust/PPO	$17.64
Rate for Payer: BCN Commercial	$17.64
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cofinity Commercial	$21.38
Rate for Payer: Encore Health Key Benefits Commercial	$18.20
Rate for Payer: Healthscope Commercial	$22.75
Rate for Payer: Healthscope Whirlpool	$22.07
Rate for Payer: Mclaren Commercial	$20.48
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.34
Rate for Payer: Priority Health Cigna Priority Health	$15.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.02

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$28.30

Service Code	NDC 4110081127
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$28.30
Rate for Payer: Aetna Commercial	$25.47
Rate for Payer: ASR ASR	$27.45
Rate for Payer: BCBS Trust/PPO	$21.94
Rate for Payer: BCN Commercial	$21.94
Rate for Payer: Cash Price	$22.64
Rate for Payer: Cofinity Commercial	$26.60
Rate for Payer: Encore Health Key Benefits Commercial	$22.64
Rate for Payer: Healthscope Commercial	$28.30
Rate for Payer: Healthscope Whirlpool	$27.45
Rate for Payer: Mclaren Commercial	$25.47
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$24.06
Rate for Payer: Priority Health Cigna Priority Health	$19.81
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$24.90

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$27.14

Service Code	NDC 4110081123
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$19.00
Max. Negotiated Rate	$27.14
Rate for Payer: Aetna Commercial	$24.43
Rate for Payer: ASR ASR	$26.33
Rate for Payer: BCBS Trust/PPO	$21.04
Rate for Payer: BCN Commercial	$21.04
Rate for Payer: Cash Price	$21.71
Rate for Payer: Cofinity Commercial	$25.51
Rate for Payer: Encore Health Key Benefits Commercial	$21.71
Rate for Payer: Healthscope Commercial	$27.14
Rate for Payer: Healthscope Whirlpool	$26.33
Rate for Payer: Mclaren Commercial	$24.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.07
Rate for Payer: Priority Health Cigna Priority Health	$19.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$23.88

Know your out-of-pocket cost for care.

All Charges