Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE

Facility

$686.00

Service Code	NDC 64850051101
Hospital Charge Code	31587
Hospital Revenue Code	637
Min. Negotiated Rate	$432.18
Max. Negotiated Rate	$617.40
Rate for Payer: Aetna Commercial	$583.10
Rate for Payer: Aetna New Business (MI Preferred)	$445.90
Rate for Payer: Cash Price	$548.80
Rate for Payer: Cofinity Advantage	$480.20
Rate for Payer: Cofinity Commercial	$589.96
Rate for Payer: Encore Health Key Benefits Commercial	$548.80
Rate for Payer: Healthscope Commercial	$617.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$583.10
Rate for Payer: Opus (Opus Packaging Group) HMA	$514.50
Rate for Payer: PHP Commercial	$583.10
Rate for Payer: Priority Health SBD	$432.18

DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE

Facility

$985.25

Service Code	NDC 70010003001
Hospital Charge Code	31587
Hospital Revenue Code	637
Min. Negotiated Rate	$620.71
Max. Negotiated Rate	$886.73
Rate for Payer: Aetna Commercial	$837.46
Rate for Payer: Aetna New Business (MI Preferred)	$640.41
Rate for Payer: Cash Price	$788.20
Rate for Payer: Cofinity Advantage	$689.67
Rate for Payer: Cofinity Commercial	$847.32
Rate for Payer: Encore Health Key Benefits Commercial	$788.20
Rate for Payer: Healthscope Commercial	$886.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$837.46
Rate for Payer: Opus (Opus Packaging Group) HMA	$738.94
Rate for Payer: PHP Commercial	$837.46
Rate for Payer: Priority Health SBD	$620.71

DEXTROAMPHETAMINE-AMPHETAMINE ER 10 MG 24HR CAPSULE,EXTEND RELEASE

Facility

$716.10

Service Code	NDC 66993059502
Hospital Charge Code	31587
Hospital Revenue Code	637
Min. Negotiated Rate	$451.14
Max. Negotiated Rate	$644.49
Rate for Payer: Aetna Commercial	$608.68
Rate for Payer: Aetna New Business (MI Preferred)	$465.46
Rate for Payer: Cash Price	$572.88
Rate for Payer: Cofinity Advantage	$501.27
Rate for Payer: Cofinity Commercial	$615.85
Rate for Payer: Encore Health Key Benefits Commercial	$572.88
Rate for Payer: Healthscope Commercial	$644.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$608.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$537.08
Rate for Payer: PHP Commercial	$608.68
Rate for Payer: Priority Health SBD	$451.14

DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE

Facility

$491.04

Service Code	NDC 66993059402
Hospital Charge Code	33005
Hospital Revenue Code	637
Min. Negotiated Rate	$309.36
Max. Negotiated Rate	$441.94
Rate for Payer: Aetna Commercial	$417.38
Rate for Payer: Aetna New Business (MI Preferred)	$319.18
Rate for Payer: Cash Price	$392.83
Rate for Payer: Cofinity Advantage	$343.73
Rate for Payer: Cofinity Commercial	$422.29
Rate for Payer: Encore Health Key Benefits Commercial	$392.83
Rate for Payer: Healthscope Commercial	$441.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$417.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$368.28
Rate for Payer: PHP Commercial	$417.38
Rate for Payer: Priority Health SBD	$309.36

DEXTROAMPHETAMINE-AMPHETAMINE ER 5 MG 24HR CAPSULE,EXTEND RELEASE

Facility

$491.04

Service Code	NDC 66993059402
Hospital Charge Code	33005
Hospital Revenue Code	637
Min. Negotiated Rate	$192.98
Max. Negotiated Rate	$441.94
Rate for Payer: Aetna Commercial	$417.38
Rate for Payer: Aetna Medicare	$245.52
Rate for Payer: Aetna New Business (MI Preferred)	$319.18
Rate for Payer: BCBS Complete	$196.42
Rate for Payer: Cash Price	$392.83
Rate for Payer: Cofinity Advantage	$343.73
Rate for Payer: Cofinity Commercial	$422.29
Rate for Payer: Encore Health Key Benefits Commercial	$392.83
Rate for Payer: Healthscope Commercial	$441.94
Rate for Payer: MI Amish Medical Board Commercial	$392.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$417.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$368.28
Rate for Payer: PHP Commercial	$417.38
Rate for Payer: Priority Health SBD	$309.36
Rate for Payer: UHC All Payor (Choice/PPO)	$319.18
Rate for Payer: UHC Core	$255.83
Rate for Payer: UHC Exchange	$192.98

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL LIQUID

Facility

$84.70

Service Code	NDC 61787006204
Hospital Charge Code	108397
Hospital Revenue Code	637
Min. Negotiated Rate	$53.36
Max. Negotiated Rate	$76.23
Rate for Payer: Aetna Commercial	$72.00
Rate for Payer: Aetna New Business (MI Preferred)	$55.05
Rate for Payer: Cash Price	$67.76
Rate for Payer: Cofinity Advantage	$59.29
Rate for Payer: Cofinity Commercial	$72.84
Rate for Payer: Encore Health Key Benefits Commercial	$67.76
Rate for Payer: Healthscope Commercial	$76.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$72.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.52
Rate for Payer: PHP Commercial	$72.00
Rate for Payer: Priority Health SBD	$53.36

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL LIQUID

Facility

$80.94

Service Code	NDC 60569006204
Hospital Charge Code	108397
Hospital Revenue Code	637
Min. Negotiated Rate	$50.99
Max. Negotiated Rate	$72.85
Rate for Payer: Aetna Commercial	$68.80
Rate for Payer: Aetna New Business (MI Preferred)	$52.61
Rate for Payer: Cash Price	$64.75
Rate for Payer: Cofinity Advantage	$56.66
Rate for Payer: Cofinity Commercial	$69.61
Rate for Payer: Encore Health Key Benefits Commercial	$64.75
Rate for Payer: Healthscope Commercial	$72.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$68.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$60.70
Rate for Payer: PHP Commercial	$68.80
Rate for Payer: Priority Health SBD	$50.99

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL LIQUID

Facility

$80.94

Service Code	NDC 60569006204
Hospital Charge Code	108397
Hospital Revenue Code	637
Min. Negotiated Rate	$31.81
Max. Negotiated Rate	$72.85
Rate for Payer: Aetna Commercial	$68.80
Rate for Payer: Aetna Medicare	$40.47
Rate for Payer: Aetna New Business (MI Preferred)	$52.61
Rate for Payer: BCBS Complete	$32.38
Rate for Payer: Cash Price	$64.75
Rate for Payer: Cofinity Advantage	$56.66
Rate for Payer: Cofinity Commercial	$69.61
Rate for Payer: Encore Health Key Benefits Commercial	$64.75
Rate for Payer: Healthscope Commercial	$72.85
Rate for Payer: MI Amish Medical Board Commercial	$64.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$68.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$60.70
Rate for Payer: PHP Commercial	$68.80
Rate for Payer: Priority Health SBD	$50.99
Rate for Payer: UHC All Payor (Choice/PPO)	$52.61
Rate for Payer: UHC Core	$42.17
Rate for Payer: UHC Exchange	$31.81

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL LIQUID

Facility

$84.70

Service Code	NDC 61787006204
Hospital Charge Code	108397
Hospital Revenue Code	637
Min. Negotiated Rate	$33.29
Max. Negotiated Rate	$76.23
Rate for Payer: Aetna Commercial	$72.00
Rate for Payer: Aetna Medicare	$42.35
Rate for Payer: Aetna New Business (MI Preferred)	$55.05
Rate for Payer: BCBS Complete	$33.88
Rate for Payer: Cash Price	$67.76
Rate for Payer: Cofinity Advantage	$59.29
Rate for Payer: Cofinity Commercial	$72.84
Rate for Payer: Encore Health Key Benefits Commercial	$67.76
Rate for Payer: Healthscope Commercial	$76.23
Rate for Payer: MI Amish Medical Board Commercial	$67.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$72.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.52
Rate for Payer: PHP Commercial	$72.00
Rate for Payer: Priority Health SBD	$53.36
Rate for Payer: UHC All Payor (Choice/PPO)	$55.05
Rate for Payer: UHC Core	$44.13
Rate for Payer: UHC Exchange	$33.29

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP

Facility

$9.32

Service Code	NDC 00121127600
Hospital Charge Code	9774
Hospital Revenue Code	637
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$8.39
Rate for Payer: Aetna Commercial	$7.92
Rate for Payer: Aetna New Business (MI Preferred)	$6.06
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cofinity Advantage	$6.52
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: Multiplan/Beech St/PHCS Commercial	$7.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.99
Rate for Payer: PHP Commercial	$7.92
Rate for Payer: Priority Health SBD	$5.87

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP

Facility

$9.32

Service Code	NDC 00121127600
Hospital Charge Code	9774
Hospital Revenue Code	637
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$8.39
Rate for Payer: Aetna Commercial	$7.92
Rate for Payer: Aetna Medicare	$4.66
Rate for Payer: Aetna New Business (MI Preferred)	$6.06
Rate for Payer: BCBS Complete	$3.73
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cofinity Advantage	$6.52
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: MI Amish Medical Board Commercial	$7.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.99
Rate for Payer: PHP Commercial	$7.92
Rate for Payer: Priority Health SBD	$5.87
Rate for Payer: UHC All Payor (Choice/PPO)	$6.06
Rate for Payer: UHC Core	$4.86
Rate for Payer: UHC Exchange	$3.66

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP

Facility

$9.32

Service Code	NDC 00121127610
Hospital Charge Code	9774
Hospital Revenue Code	637
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$8.39
Rate for Payer: Aetna Commercial	$7.92
Rate for Payer: Aetna Medicare	$4.66
Rate for Payer: Aetna New Business (MI Preferred)	$6.06
Rate for Payer: BCBS Complete	$3.73
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cofinity Advantage	$6.52
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: MI Amish Medical Board Commercial	$7.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.99
Rate for Payer: PHP Commercial	$7.92
Rate for Payer: Priority Health SBD	$5.87
Rate for Payer: UHC All Payor (Choice/PPO)	$6.06
Rate for Payer: UHC Core	$4.86
Rate for Payer: UHC Exchange	$3.66

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP

Facility

$9.32

Service Code	NDC 00121127610
Hospital Charge Code	9774
Hospital Revenue Code	637
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$8.39
Rate for Payer: Aetna Commercial	$7.92
Rate for Payer: Aetna New Business (MI Preferred)	$6.06
Rate for Payer: Cash Price	$7.46
Rate for Payer: Cofinity Advantage	$6.52
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: Multiplan/Beech St/PHCS Commercial	$7.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.99
Rate for Payer: PHP Commercial	$7.92
Rate for Payer: Priority Health SBD	$5.87

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION

Facility

$69.92

Service Code	NDC 00338002304
Hospital Charge Code	2357
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$45.45
Rate for Payer: UHC Core	$36.43
Rate for Payer: UHC Exchange	$27.48

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION

Facility

$61.18

Service Code	NDC 00338002302
Hospital Charge Code	2357
Hospital Revenue Code	250
Min. Negotiated Rate	$24.04
Max. Negotiated Rate	$55.06
Rate for Payer: Aetna Commercial	$52.00
Rate for Payer: Aetna Medicare	$30.59
Rate for Payer: Aetna New Business (MI Preferred)	$39.77
Rate for Payer: BCBS Complete	$24.47
Rate for Payer: Cash Price	$48.94
Rate for Payer: Cofinity Advantage	$42.83
Rate for Payer: Cofinity Commercial	$52.61
Rate for Payer: Encore Health Key Benefits Commercial	$48.94
Rate for Payer: Healthscope Commercial	$55.06
Rate for Payer: MI Amish Medical Board Commercial	$48.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$52.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$45.88
Rate for Payer: PHP Commercial	$52.00
Rate for Payer: Priority Health SBD	$38.54
Rate for Payer: UHC All Payor (Choice/PPO)	$39.77
Rate for Payer: UHC Core	$31.87
Rate for Payer: UHC Exchange	$24.04

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION

Facility

$69.92

Service Code	NDC 00338002303
Hospital Charge Code	2357
Hospital Revenue Code	250
Min. Negotiated Rate	$44.05
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION

Facility

$79.75

Service Code	NDC 00990793002
Hospital Charge Code	2357
Hospital Revenue Code	250
Min. Negotiated Rate	$50.24
Max. Negotiated Rate	$71.78
Rate for Payer: Aetna Commercial	$67.79
Rate for Payer: Aetna New Business (MI Preferred)	$51.84
Rate for Payer: Cash Price	$63.80
Rate for Payer: Cofinity Advantage	$55.83
Rate for Payer: Cofinity Commercial	$68.58
Rate for Payer: Encore Health Key Benefits Commercial	$63.80
Rate for Payer: Healthscope Commercial	$71.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$67.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$59.81
Rate for Payer: PHP Commercial	$67.79
Rate for Payer: Priority Health SBD	$50.24

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION

Facility

$79.75

Service Code	NDC 00990793002
Hospital Charge Code	2357
Hospital Revenue Code	250
Min. Negotiated Rate	$31.34
Max. Negotiated Rate	$71.78
Rate for Payer: Aetna Commercial	$67.79
Rate for Payer: Aetna Medicare	$39.88
Rate for Payer: Aetna New Business (MI Preferred)	$51.84
Rate for Payer: BCBS Complete	$31.90
Rate for Payer: Cash Price	$63.80
Rate for Payer: Cofinity Advantage	$55.83
Rate for Payer: Cofinity Commercial	$68.58
Rate for Payer: Encore Health Key Benefits Commercial	$63.80
Rate for Payer: Healthscope Commercial	$71.78
Rate for Payer: MI Amish Medical Board Commercial	$63.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$67.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$59.81
Rate for Payer: PHP Commercial	$67.79
Rate for Payer: Priority Health SBD	$50.24
Rate for Payer: UHC All Payor (Choice/PPO)	$51.84
Rate for Payer: UHC Core	$41.55
Rate for Payer: UHC Exchange	$31.34

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION

Facility

$69.92

Service Code	NDC 00338002303
Hospital Charge Code	2357
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$45.45
Rate for Payer: UHC Core	$36.43
Rate for Payer: UHC Exchange	$27.48

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION

Facility

$61.18

Service Code	NDC 00338002302
Hospital Charge Code	2357
Hospital Revenue Code	250
Min. Negotiated Rate	$38.54
Max. Negotiated Rate	$55.06
Rate for Payer: Aetna Commercial	$52.00
Rate for Payer: Aetna New Business (MI Preferred)	$39.77
Rate for Payer: Cash Price	$48.94
Rate for Payer: Cofinity Advantage	$42.83
Rate for Payer: Cofinity Commercial	$52.61
Rate for Payer: Encore Health Key Benefits Commercial	$48.94
Rate for Payer: Healthscope Commercial	$55.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$52.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$45.88
Rate for Payer: PHP Commercial	$52.00
Rate for Payer: Priority Health SBD	$38.54

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION

Facility

$69.92

Service Code	NDC 00338002304
Hospital Charge Code	2357
Hospital Revenue Code	250
Min. Negotiated Rate	$44.05
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)

Facility

$69.92

Service Code	NDC 00338002303
Hospital Charge Code	300135
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$45.45
Rate for Payer: UHC Core	$36.43
Rate for Payer: UHC Exchange	$27.48

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)

Facility

$69.92

Service Code	NDC 00338002304
Hospital Charge Code	300135
Hospital Revenue Code	250
Min. Negotiated Rate	$44.05
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)

Facility

$61.18

Service Code	NDC 00338002302
Hospital Charge Code	300135
Hospital Revenue Code	250
Min. Negotiated Rate	$24.04
Max. Negotiated Rate	$55.06
Rate for Payer: Aetna Commercial	$52.00
Rate for Payer: Aetna Medicare	$30.59
Rate for Payer: Aetna New Business (MI Preferred)	$39.77
Rate for Payer: BCBS Complete	$24.47
Rate for Payer: Cash Price	$48.94
Rate for Payer: Cofinity Advantage	$42.83
Rate for Payer: Cofinity Commercial	$52.61
Rate for Payer: Encore Health Key Benefits Commercial	$48.94
Rate for Payer: Healthscope Commercial	$55.06
Rate for Payer: MI Amish Medical Board Commercial	$48.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$52.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$45.88
Rate for Payer: PHP Commercial	$52.00
Rate for Payer: Priority Health SBD	$38.54
Rate for Payer: UHC All Payor (Choice/PPO)	$39.77
Rate for Payer: UHC Core	$31.87
Rate for Payer: UHC Exchange	$24.04

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)

Facility

$69.92

Service Code	NDC 00338002303
Hospital Charge Code	300135
Hospital Revenue Code	250
Min. Negotiated Rate	$44.05
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05

Know your out-of-pocket cost for care.

All Charges