Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET

Facility

$5.69

Service Code	NDC 50268064611
Hospital Charge Code	31864
Hospital Revenue Code	637
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$5.69
Rate for Payer: Aetna Commercial	$5.12
Rate for Payer: Aetna Medicare	$2.11
Rate for Payer: ASR ASR	$5.52
Rate for Payer: BCBS Complete	$2.28
Rate for Payer: BCBS Trust/PPO	$4.69
Rate for Payer: BCN Commercial	$4.69
Rate for Payer: Cash Price	$4.55
Rate for Payer: Cofinity Commercial	$5.35
Rate for Payer: Encore Health Key Benefits Commercial	$4.55
Rate for Payer: Healthscope Commercial	$5.52
Rate for Payer: Healthscope Whirlpool	$5.69
Rate for Payer: Mclaren Commercial	$5.12
Rate for Payer: MI Amish Medical Board Commercial	$4.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.84
Rate for Payer: Nomi Health Commercial	$4.67
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.27
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.99
Rate for Payer: Priority Health Narrow Network	$3.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5.01

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET

Facility

$10.72

Service Code	NDC 68084071011
Hospital Charge Code	31864
Hospital Revenue Code	637
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$10.72
Rate for Payer: Aetna Commercial	$9.65
Rate for Payer: Aetna Medicare	$3.97
Rate for Payer: ASR ASR	$10.40
Rate for Payer: BCBS Complete	$4.29
Rate for Payer: BCBS Trust/PPO	$8.84
Rate for Payer: BCN Commercial	$8.84
Rate for Payer: Cash Price	$8.57
Rate for Payer: Cofinity Commercial	$10.07
Rate for Payer: Encore Health Key Benefits Commercial	$8.57
Rate for Payer: Healthscope Commercial	$10.40
Rate for Payer: Healthscope Whirlpool	$10.72
Rate for Payer: Mclaren Commercial	$9.65
Rate for Payer: MI Amish Medical Board Commercial	$8.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.11
Rate for Payer: Nomi Health Commercial	$8.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$8.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$9.39
Rate for Payer: Priority Health Narrow Network	$7.51
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.43

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET

Facility

$1,071.70

Service Code	NDC 68084071001
Hospital Charge Code	31864
Hospital Revenue Code	637
Min. Negotiated Rate	$803.77
Max. Negotiated Rate	$1,071.70
Rate for Payer: Aetna Commercial	$964.53
Rate for Payer: ASR ASR	$1,039.55
Rate for Payer: BCBS Trust/PPO	$880.08
Rate for Payer: BCN Commercial	$880.08
Rate for Payer: Cash Price	$857.36
Rate for Payer: Cofinity Commercial	$1,007.40
Rate for Payer: Encore Health Key Benefits Commercial	$857.36
Rate for Payer: Healthscope Commercial	$1,039.55
Rate for Payer: Healthscope Whirlpool	$1,071.70
Rate for Payer: Mclaren Commercial	$964.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$910.95
Rate for Payer: Nomi Health Commercial	$878.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$803.77
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$943.10

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$290.50

Service Code	NDC 406051201
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$107.48
Max. Negotiated Rate	$290.50
Rate for Payer: Aetna Commercial	$261.45
Rate for Payer: Aetna Medicare	$107.48
Rate for Payer: ASR ASR	$281.79
Rate for Payer: BCBS Complete	$116.20
Rate for Payer: BCBS Trust/PPO	$239.52
Rate for Payer: BCN Commercial	$239.52
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	$281.79
Rate for Payer: Healthscope Whirlpool	$290.50
Rate for Payer: Mclaren Commercial	$261.45
Rate for Payer: MI Amish Medical Board Commercial	$232.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$246.93
Rate for Payer: Nomi Health Commercial	$238.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$217.88
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$254.54
Rate for Payer: Priority Health Narrow Network	$203.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$255.64

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$4.13

Service Code	NDC 9900000890
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$3.10
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	$3.39
Rate for Payer: BCN Commercial	$3.39
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	$4.01
Rate for Payer: Healthscope Whirlpool	$4.13
Rate for Payer: Mclaren Commercial	$3.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.51
Rate for Payer: Nomi Health Commercial	$3.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.63

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$290.50

Service Code	NDC 406051201
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$217.88
Max. Negotiated Rate	$290.50
Rate for Payer: Aetna Commercial	$261.45
Rate for Payer: ASR ASR	$281.79
Rate for Payer: BCBS Trust/PPO	$238.56
Rate for Payer: BCN Commercial	$238.56
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	$281.79
Rate for Payer: Healthscope Whirlpool	$290.50
Rate for Payer: Mclaren Commercial	$261.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$246.93
Rate for Payer: Nomi Health Commercial	$238.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$217.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$255.64

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$82.25

Service Code	NDC 406051262
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$30.43
Max. Negotiated Rate	$82.25
Rate for Payer: Aetna Commercial	$74.03
Rate for Payer: Aetna Medicare	$30.43
Rate for Payer: ASR ASR	$79.78
Rate for Payer: BCBS Complete	$32.90
Rate for Payer: BCBS Trust/PPO	$67.82
Rate for Payer: BCN Commercial	$67.82
Rate for Payer: Cash Price	$65.80
Rate for Payer: Cofinity Commercial	$77.31
Rate for Payer: Encore Health Key Benefits Commercial	$65.80
Rate for Payer: Healthscope Commercial	$79.78
Rate for Payer: Healthscope Whirlpool	$82.25
Rate for Payer: Mclaren Commercial	$74.03
Rate for Payer: MI Amish Medical Board Commercial	$65.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.91
Rate for Payer: Nomi Health Commercial	$67.44
Rate for Payer: Opus (Opus Packaging Group) HMA	$61.69
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$72.07
Rate for Payer: Priority Health Narrow Network	$57.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$72.38

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$455.00

Service Code	NDC 904709361
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$341.25
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial	$409.50
Rate for Payer: ASR ASR	$441.35
Rate for Payer: BCBS Trust/PPO	$373.65
Rate for Payer: BCN Commercial	$373.65
Rate for Payer: Cash Price	$364.00
Rate for Payer: Cofinity Commercial	$427.70
Rate for Payer: Encore Health Key Benefits Commercial	$364.00
Rate for Payer: Healthscope Commercial	$441.35
Rate for Payer: Healthscope Whirlpool	$455.00
Rate for Payer: Mclaren Commercial	$409.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$386.75
Rate for Payer: Nomi Health Commercial	$373.10
Rate for Payer: Opus (Opus Packaging Group) HMA	$341.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$400.40

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$8.23

Service Code	NDC 406051223
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$8.22
Rate for Payer: Aetna Commercial	$7.40
Rate for Payer: Aetna Medicare	$3.04
Rate for Payer: ASR ASR	$7.98
Rate for Payer: BCBS Complete	$3.29
Rate for Payer: BCBS Trust/PPO	$6.78
Rate for Payer: BCN Commercial	$6.78
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cofinity Commercial	$7.73
Rate for Payer: Encore Health Key Benefits Commercial	$6.58
Rate for Payer: Healthscope Commercial	$7.98
Rate for Payer: Healthscope Whirlpool	$8.22
Rate for Payer: Mclaren Commercial	$7.40
Rate for Payer: MI Amish Medical Board Commercial	$6.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.99
Rate for Payer: Nomi Health Commercial	$6.74
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.17
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$7.21
Rate for Payer: Priority Health Narrow Network	$5.77
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7.24

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$455.00

Service Code	NDC 904709361
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$168.35
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial	$409.50
Rate for Payer: Aetna Medicare	$168.35
Rate for Payer: ASR ASR	$441.35
Rate for Payer: BCBS Complete	$182.00
Rate for Payer: BCBS Trust/PPO	$375.15
Rate for Payer: BCN Commercial	$375.15
Rate for Payer: Cash Price	$364.00
Rate for Payer: Cofinity Commercial	$427.70
Rate for Payer: Encore Health Key Benefits Commercial	$364.00
Rate for Payer: Healthscope Commercial	$441.35
Rate for Payer: Healthscope Whirlpool	$455.00
Rate for Payer: Mclaren Commercial	$409.50
Rate for Payer: MI Amish Medical Board Commercial	$364.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$386.75
Rate for Payer: Nomi Health Commercial	$373.10
Rate for Payer: Opus (Opus Packaging Group) HMA	$341.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$398.67
Rate for Payer: Priority Health Narrow Network	$318.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$400.40

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	$235.69
Max. Negotiated Rate	$637.00
Rate for Payer: Aetna Commercial	$573.30
Rate for Payer: Aetna Medicare	$235.69
Rate for Payer: ASR ASR	$617.89
Rate for Payer: BCBS Complete	$254.80
Rate for Payer: BCBS Trust/PPO	$525.21
Rate for Payer: BCN Commercial	$525.21
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	$617.89
Rate for Payer: Healthscope Whirlpool	$637.00
Rate for Payer: Mclaren Commercial	$573.30
Rate for Payer: MI Amish Medical Board Commercial	$509.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$541.45
Rate for Payer: Nomi Health Commercial	$522.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$477.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$558.14
Rate for Payer: Priority Health Narrow Network	$446.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$560.56

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	$235.69
Max. Negotiated Rate	$637.00
Rate for Payer: Aetna Commercial	$573.30
Rate for Payer: Aetna Medicare	$235.69
Rate for Payer: ASR ASR	$617.89
Rate for Payer: BCBS Complete	$254.80
Rate for Payer: BCBS Trust/PPO	$525.21
Rate for Payer: BCN Commercial	$525.21
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	$617.89
Rate for Payer: Healthscope Whirlpool	$637.00
Rate for Payer: Mclaren Commercial	$573.30
Rate for Payer: MI Amish Medical Board Commercial	$509.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$541.45
Rate for Payer: Nomi Health Commercial	$522.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$477.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$558.14
Rate for Payer: Priority Health Narrow Network	$446.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$560.56

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$82.25

Service Code	NDC 406051262
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$61.69
Max. Negotiated Rate	$82.25
Rate for Payer: Aetna Commercial	$74.03
Rate for Payer: ASR ASR	$79.78
Rate for Payer: BCBS Trust/PPO	$67.54
Rate for Payer: BCN Commercial	$67.54
Rate for Payer: Cash Price	$65.80
Rate for Payer: Cofinity Commercial	$77.31
Rate for Payer: Encore Health Key Benefits Commercial	$65.80
Rate for Payer: Healthscope Commercial	$79.78
Rate for Payer: Healthscope Whirlpool	$82.25
Rate for Payer: Mclaren Commercial	$74.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.91
Rate for Payer: Nomi Health Commercial	$67.44
Rate for Payer: Opus (Opus Packaging Group) HMA	$61.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$72.38

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$4.13

Service Code	NDC 9900000890
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$4.13
Rate for Payer: Aetna Commercial	$3.72
Rate for Payer: Aetna Medicare	$1.53
Rate for Payer: ASR ASR	$4.01
Rate for Payer: BCBS Complete	$1.65
Rate for Payer: BCBS Trust/PPO	$3.41
Rate for Payer: BCN Commercial	$3.41
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	$4.01
Rate for Payer: Healthscope Whirlpool	$4.13
Rate for Payer: Mclaren Commercial	$3.72
Rate for Payer: MI Amish Medical Board Commercial	$3.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.51
Rate for Payer: Nomi Health Commercial	$3.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.10
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$3.62
Rate for Payer: Priority Health Narrow Network	$2.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.63

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	$477.75
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	$523.10
Rate for Payer: BCN Commercial	$523.10
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	$617.89
Rate for Payer: Healthscope Whirlpool	$637.00
Rate for Payer: Mclaren Commercial	$573.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$541.45
Rate for Payer: Nomi Health Commercial	$522.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$477.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$560.56

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET

Facility

$8.23

Service Code	NDC 406051223
Hospital Charge Code	5940
Hospital Revenue Code	637
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$8.22
Rate for Payer: Aetna Commercial	$7.40
Rate for Payer: ASR ASR	$7.98
Rate for Payer: BCBS Trust/PPO	$6.75
Rate for Payer: BCN Commercial	$6.75
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cofinity Commercial	$7.73
Rate for Payer: Encore Health Key Benefits Commercial	$6.58
Rate for Payer: Healthscope Commercial	$7.98
Rate for Payer: Healthscope Whirlpool	$8.22
Rate for Payer: Mclaren Commercial	$7.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.99
Rate for Payer: Nomi Health Commercial	$6.74
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.17
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7.24

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	$477.75
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	$523.10
Rate for Payer: BCN Commercial	$523.10
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	$617.89
Rate for Payer: Healthscope Whirlpool	$637.00
Rate for Payer: Mclaren Commercial	$573.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$541.45
Rate for Payer: Nomi Health Commercial	$522.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$477.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$560.56

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

Facility

$457.78

Service Code	NDC 59011041020
Hospital Charge Code	173651
Hospital Revenue Code	637
Min. Negotiated Rate	$343.34
Max. Negotiated Rate	$457.78
Rate for Payer: Aetna Commercial	$412.00
Rate for Payer: ASR ASR	$444.05
Rate for Payer: BCBS Trust/PPO	$375.93
Rate for Payer: BCN Commercial	$375.93
Rate for Payer: Cash Price	$366.23
Rate for Payer: Cofinity Commercial	$430.32
Rate for Payer: Encore Health Key Benefits Commercial	$366.23
Rate for Payer: Healthscope Commercial	$444.05
Rate for Payer: Healthscope Whirlpool	$457.78
Rate for Payer: Mclaren Commercial	$412.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$389.11
Rate for Payer: Nomi Health Commercial	$375.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$343.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$402.85

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

Facility

$457.78

Service Code	NDC 59011041020
Hospital Charge Code	173651
Hospital Revenue Code	637
Min. Negotiated Rate	$169.38
Max. Negotiated Rate	$457.78
Rate for Payer: Aetna Commercial	$412.00
Rate for Payer: Aetna Medicare	$169.38
Rate for Payer: ASR ASR	$444.05
Rate for Payer: BCBS Complete	$183.11
Rate for Payer: BCBS Trust/PPO	$377.44
Rate for Payer: BCN Commercial	$377.44
Rate for Payer: Cash Price	$366.23
Rate for Payer: Cofinity Commercial	$430.32
Rate for Payer: Encore Health Key Benefits Commercial	$366.23
Rate for Payer: Healthscope Commercial	$444.05
Rate for Payer: Healthscope Whirlpool	$457.78
Rate for Payer: Mclaren Commercial	$412.00
Rate for Payer: MI Amish Medical Board Commercial	$366.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$389.11
Rate for Payer: Nomi Health Commercial	$375.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$343.34
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$401.11
Rate for Payer: Priority Health Narrow Network	$320.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$402.85

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

Facility

$721.71

Service Code	NDC 59011042020
Hospital Charge Code	173653
Hospital Revenue Code	637
Min. Negotiated Rate	$267.03
Max. Negotiated Rate	$721.71
Rate for Payer: Aetna Commercial	$649.54
Rate for Payer: Aetna Medicare	$267.03
Rate for Payer: ASR ASR	$700.06
Rate for Payer: BCBS Complete	$288.68
Rate for Payer: BCBS Trust/PPO	$595.05
Rate for Payer: BCN Commercial	$595.05
Rate for Payer: Cash Price	$577.37
Rate for Payer: Cofinity Commercial	$678.41
Rate for Payer: Encore Health Key Benefits Commercial	$577.37
Rate for Payer: Healthscope Commercial	$700.06
Rate for Payer: Healthscope Whirlpool	$721.71
Rate for Payer: Mclaren Commercial	$649.54
Rate for Payer: MI Amish Medical Board Commercial	$577.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$613.45
Rate for Payer: Nomi Health Commercial	$591.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$541.28
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$632.36
Rate for Payer: Priority Health Narrow Network	$505.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$635.10

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

Facility

$721.71

Service Code	NDC 59011042020
Hospital Charge Code	173653
Hospital Revenue Code	637
Min. Negotiated Rate	$541.28
Max. Negotiated Rate	$721.71
Rate for Payer: Aetna Commercial	$649.54
Rate for Payer: ASR ASR	$700.06
Rate for Payer: BCBS Trust/PPO	$592.67
Rate for Payer: BCN Commercial	$592.67
Rate for Payer: Cash Price	$577.37
Rate for Payer: Cofinity Commercial	$678.41
Rate for Payer: Encore Health Key Benefits Commercial	$577.37
Rate for Payer: Healthscope Commercial	$700.06
Rate for Payer: Healthscope Whirlpool	$721.71
Rate for Payer: Mclaren Commercial	$649.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$613.45
Rate for Payer: Nomi Health Commercial	$591.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$541.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$635.10

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$10.53

Service Code	NDC 904700635
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$10.53
Rate for Payer: Aetna Commercial	$9.48
Rate for Payer: ASR ASR	$10.21
Rate for Payer: BCBS Trust/PPO	$8.65
Rate for Payer: BCN Commercial	$8.65
Rate for Payer: Cash Price	$8.42
Rate for Payer: Cofinity Commercial	$9.90
Rate for Payer: Encore Health Key Benefits Commercial	$8.42
Rate for Payer: Healthscope Commercial	$10.21
Rate for Payer: Healthscope Whirlpool	$10.53
Rate for Payer: Mclaren Commercial	$9.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.95
Rate for Payer: Nomi Health Commercial	$8.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.27

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$10.53

Service Code	NDC 904700635
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$10.53
Rate for Payer: Aetna Commercial	$9.48
Rate for Payer: Aetna Medicare	$3.90
Rate for Payer: ASR ASR	$10.21
Rate for Payer: BCBS Complete	$4.21
Rate for Payer: BCBS Trust/PPO	$8.68
Rate for Payer: BCN Commercial	$8.68
Rate for Payer: Cash Price	$8.42
Rate for Payer: Cofinity Commercial	$9.90
Rate for Payer: Encore Health Key Benefits Commercial	$8.42
Rate for Payer: Healthscope Commercial	$10.21
Rate for Payer: Healthscope Whirlpool	$10.53
Rate for Payer: Mclaren Commercial	$9.48
Rate for Payer: MI Amish Medical Board Commercial	$8.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.95
Rate for Payer: Nomi Health Commercial	$8.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.90
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$9.23
Rate for Payer: Priority Health Narrow Network	$7.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.27

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$28.30

Service Code	NDC 41100081127
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$21.22
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	$23.24
Rate for Payer: BCN Commercial	$23.24
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	$27.45
Rate for Payer: Healthscope Whirlpool	$28.30
Rate for Payer: Mclaren Commercial	$25.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$24.05
Rate for Payer: Nomi Health Commercial	$23.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$21.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$24.90

OXYMETAZOLINE 0.05 % NASAL SPRAY

Facility

$9.45

Service Code	NDC 904676130
Hospital Charge Code	5943
Hospital Revenue Code	637
Min. Negotiated Rate	$7.09
Max. Negotiated Rate	$9.45
Rate for Payer: Aetna Commercial	$8.51
Rate for Payer: ASR ASR	$9.17
Rate for Payer: BCBS Trust/PPO	$7.76
Rate for Payer: BCN Commercial	$7.76
Rate for Payer: Cash Price	$7.56
Rate for Payer: Cofinity Commercial	$8.88
Rate for Payer: Encore Health Key Benefits Commercial	$7.56
Rate for Payer: Healthscope Commercial	$9.17
Rate for Payer: Healthscope Whirlpool	$9.45
Rate for Payer: Mclaren Commercial	$8.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.03
Rate for Payer: Nomi Health Commercial	$7.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.09
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.32

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