Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DOFETILIDE 125 MCG CAPSULE

Facility

$163.01

Service Code	NDC 69452013117
Hospital Charge Code	26965
Hospital Revenue Code	637
Min. Negotiated Rate	$64.06
Max. Negotiated Rate	$146.71
Rate for Payer: Aetna Commercial	$138.56
Rate for Payer: Aetna Medicare	$81.50
Rate for Payer: Aetna New Business (MI Preferred)	$105.96
Rate for Payer: BCBS Complete	$65.20
Rate for Payer: Cash Price	$130.41
Rate for Payer: Cofinity Advantage	$114.11
Rate for Payer: Cofinity Commercial	$140.19
Rate for Payer: Encore Health Key Benefits Commercial	$130.41
Rate for Payer: Healthscope Commercial	$146.71
Rate for Payer: MI Amish Medical Board Commercial	$130.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$138.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$122.26
Rate for Payer: PHP Commercial	$138.56
Rate for Payer: Priority Health SBD	$102.70
Rate for Payer: UHC All Payor (Choice/PPO)	$105.96
Rate for Payer: UHC Core	$84.93
Rate for Payer: UHC Exchange	$64.06

DOFETILIDE 125 MCG CAPSULE

Facility

$627.08

Service Code	NDC 00904668108
Hospital Charge Code	26965
Hospital Revenue Code	637
Min. Negotiated Rate	$395.06
Max. Negotiated Rate	$564.37
Rate for Payer: Aetna Commercial	$533.02
Rate for Payer: Aetna New Business (MI Preferred)	$407.60
Rate for Payer: Cash Price	$501.66
Rate for Payer: Cofinity Advantage	$438.96
Rate for Payer: Cofinity Commercial	$539.29
Rate for Payer: Encore Health Key Benefits Commercial	$501.66
Rate for Payer: Healthscope Commercial	$564.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$533.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$470.31
Rate for Payer: PHP Commercial	$533.02
Rate for Payer: Priority Health SBD	$395.06

DOFETILIDE 125 MCG CAPSULE

Facility

$396.35

Service Code	NDC 00904752208
Hospital Charge Code	26965
Hospital Revenue Code	637
Min. Negotiated Rate	$155.77
Max. Negotiated Rate	$356.71
Rate for Payer: Aetna Commercial	$336.90
Rate for Payer: Aetna Medicare	$198.18
Rate for Payer: Aetna New Business (MI Preferred)	$257.63
Rate for Payer: BCBS Complete	$158.54
Rate for Payer: Cash Price	$317.08
Rate for Payer: Cofinity Advantage	$277.44
Rate for Payer: Cofinity Commercial	$340.86
Rate for Payer: Encore Health Key Benefits Commercial	$317.08
Rate for Payer: Healthscope Commercial	$356.71
Rate for Payer: MI Amish Medical Board Commercial	$317.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$336.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$297.26
Rate for Payer: PHP Commercial	$336.90
Rate for Payer: Priority Health SBD	$249.70
Rate for Payer: UHC All Payor (Choice/PPO)	$257.63
Rate for Payer: UHC Core	$206.50
Rate for Payer: UHC Exchange	$155.77

DOFETILIDE 125 MCG CAPSULE

Facility

$627.08

Service Code	NDC 00904668108
Hospital Charge Code	26965
Hospital Revenue Code	637
Min. Negotiated Rate	$246.44
Max. Negotiated Rate	$564.37
Rate for Payer: Aetna Commercial	$533.02
Rate for Payer: Aetna Medicare	$313.54
Rate for Payer: Aetna New Business (MI Preferred)	$407.60
Rate for Payer: BCBS Complete	$250.83
Rate for Payer: Cash Price	$501.66
Rate for Payer: Cofinity Advantage	$438.96
Rate for Payer: Cofinity Commercial	$539.29
Rate for Payer: Encore Health Key Benefits Commercial	$501.66
Rate for Payer: Healthscope Commercial	$564.37
Rate for Payer: MI Amish Medical Board Commercial	$501.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$533.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$470.31
Rate for Payer: PHP Commercial	$533.02
Rate for Payer: Priority Health SBD	$395.06
Rate for Payer: UHC All Payor (Choice/PPO)	$407.60
Rate for Payer: UHC Core	$326.71
Rate for Payer: UHC Exchange	$246.44

DOFETILIDE 125 MCG CAPSULE

Facility

$2,310.80

Service Code	NDC 00069580060
Hospital Charge Code	26965
Hospital Revenue Code	637
Min. Negotiated Rate	$908.14
Max. Negotiated Rate	$2,079.72
Rate for Payer: Aetna Commercial	$1,964.18
Rate for Payer: Aetna Medicare	$1,155.40
Rate for Payer: Aetna New Business (MI Preferred)	$1,502.02
Rate for Payer: BCBS Complete	$924.32
Rate for Payer: Cash Price	$1,848.64
Rate for Payer: Cofinity Advantage	$1,617.56
Rate for Payer: Cofinity Commercial	$1,987.29
Rate for Payer: Encore Health Key Benefits Commercial	$1,848.64
Rate for Payer: Healthscope Commercial	$2,079.72
Rate for Payer: MI Amish Medical Board Commercial	$1,848.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,964.18
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,733.10
Rate for Payer: PHP Commercial	$1,964.18
Rate for Payer: Priority Health SBD	$1,455.80
Rate for Payer: UHC All Payor (Choice/PPO)	$1,502.02
Rate for Payer: UHC Core	$1,203.93
Rate for Payer: UHC Exchange	$908.14

DOFETILIDE 250 MCG CAPSULE

Facility

$634.92

Service Code	NDC 00904668208
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$400.00
Max. Negotiated Rate	$571.43
Rate for Payer: Aetna Commercial	$539.68
Rate for Payer: Aetna New Business (MI Preferred)	$412.70
Rate for Payer: Cash Price	$507.94
Rate for Payer: Cofinity Advantage	$444.44
Rate for Payer: Cofinity Commercial	$546.03
Rate for Payer: Encore Health Key Benefits Commercial	$507.94
Rate for Payer: Healthscope Commercial	$571.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$539.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$476.19
Rate for Payer: PHP Commercial	$539.68
Rate for Payer: Priority Health SBD	$400.00

DOFETILIDE 250 MCG CAPSULE

Facility

$2,310.80

Service Code	NDC 00069581060
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$1,455.80
Max. Negotiated Rate	$2,079.72
Rate for Payer: Aetna Commercial	$1,964.18
Rate for Payer: Aetna New Business (MI Preferred)	$1,502.02
Rate for Payer: Cash Price	$1,848.64
Rate for Payer: Cofinity Advantage	$1,617.56
Rate for Payer: Cofinity Commercial	$1,987.29
Rate for Payer: Encore Health Key Benefits Commercial	$1,848.64
Rate for Payer: Healthscope Commercial	$2,079.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,964.18
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,733.10
Rate for Payer: PHP Commercial	$1,964.18
Rate for Payer: Priority Health SBD	$1,455.80

DOFETILIDE 250 MCG CAPSULE

Facility

$0.94

Service Code	NDC 00069581043
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna Commercial	$0.80
Rate for Payer: Aetna Medicare	$0.47
Rate for Payer: Aetna New Business (MI Preferred)	$0.61
Rate for Payer: BCBS Complete	$0.38
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cofinity Advantage	$0.66
Rate for Payer: Cofinity Commercial	$0.81
Rate for Payer: Encore Health Key Benefits Commercial	$0.75
Rate for Payer: Healthscope Commercial	$0.85
Rate for Payer: MI Amish Medical Board Commercial	$0.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$0.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$0.71
Rate for Payer: PHP Commercial	$0.80
Rate for Payer: Priority Health SBD	$0.59
Rate for Payer: UHC All Payor (Choice/PPO)	$0.61
Rate for Payer: UHC Core	$0.49
Rate for Payer: UHC Exchange	$0.37

DOFETILIDE 250 MCG CAPSULE

Facility

$0.94

Service Code	NDC 00069581043
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna Commercial	$0.80
Rate for Payer: Aetna New Business (MI Preferred)	$0.61
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cofinity Advantage	$0.66
Rate for Payer: Cofinity Commercial	$0.81
Rate for Payer: Encore Health Key Benefits Commercial	$0.75
Rate for Payer: Healthscope Commercial	$0.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$0.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$0.71
Rate for Payer: PHP Commercial	$0.80
Rate for Payer: Priority Health SBD	$0.59

DOFETILIDE 250 MCG CAPSULE

Facility

$2,310.80

Service Code	NDC 00069581060
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$908.14
Max. Negotiated Rate	$2,079.72
Rate for Payer: Aetna Commercial	$1,964.18
Rate for Payer: Aetna Medicare	$1,155.40
Rate for Payer: Aetna New Business (MI Preferred)	$1,502.02
Rate for Payer: BCBS Complete	$924.32
Rate for Payer: Cash Price	$1,848.64
Rate for Payer: Cofinity Advantage	$1,617.56
Rate for Payer: Cofinity Commercial	$1,987.29
Rate for Payer: Encore Health Key Benefits Commercial	$1,848.64
Rate for Payer: Healthscope Commercial	$2,079.72
Rate for Payer: MI Amish Medical Board Commercial	$1,848.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,964.18
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,733.10
Rate for Payer: PHP Commercial	$1,964.18
Rate for Payer: Priority Health SBD	$1,455.80
Rate for Payer: UHC All Payor (Choice/PPO)	$1,502.02
Rate for Payer: UHC Core	$1,203.93
Rate for Payer: UHC Exchange	$908.14

DOFETILIDE 250 MCG CAPSULE

Facility

$163.01

Service Code	NDC 69452013217
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$64.06
Max. Negotiated Rate	$146.71
Rate for Payer: Aetna Commercial	$138.56
Rate for Payer: Aetna Medicare	$81.50
Rate for Payer: Aetna New Business (MI Preferred)	$105.96
Rate for Payer: BCBS Complete	$65.20
Rate for Payer: Cash Price	$130.41
Rate for Payer: Cofinity Advantage	$114.11
Rate for Payer: Cofinity Commercial	$140.19
Rate for Payer: Encore Health Key Benefits Commercial	$130.41
Rate for Payer: Healthscope Commercial	$146.71
Rate for Payer: MI Amish Medical Board Commercial	$130.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$138.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$122.26
Rate for Payer: PHP Commercial	$138.56
Rate for Payer: Priority Health SBD	$102.70
Rate for Payer: UHC All Payor (Choice/PPO)	$105.96
Rate for Payer: UHC Core	$84.93
Rate for Payer: UHC Exchange	$64.06

DOFETILIDE 250 MCG CAPSULE

Facility

$532.66

Service Code	NDC 00904752308
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$335.58
Max. Negotiated Rate	$479.39
Rate for Payer: Aetna Commercial	$452.76
Rate for Payer: Aetna New Business (MI Preferred)	$346.23
Rate for Payer: Cash Price	$426.13
Rate for Payer: Cofinity Advantage	$372.86
Rate for Payer: Cofinity Commercial	$458.09
Rate for Payer: Encore Health Key Benefits Commercial	$426.13
Rate for Payer: Healthscope Commercial	$479.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$452.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$399.50
Rate for Payer: PHP Commercial	$452.76
Rate for Payer: Priority Health SBD	$335.58

DOFETILIDE 250 MCG CAPSULE

Facility

$634.92

Service Code	NDC 00904668208
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$249.52
Max. Negotiated Rate	$571.43
Rate for Payer: Aetna Commercial	$539.68
Rate for Payer: Aetna Medicare	$317.46
Rate for Payer: Aetna New Business (MI Preferred)	$412.70
Rate for Payer: BCBS Complete	$253.97
Rate for Payer: Cash Price	$507.94
Rate for Payer: Cofinity Advantage	$444.44
Rate for Payer: Cofinity Commercial	$546.03
Rate for Payer: Encore Health Key Benefits Commercial	$507.94
Rate for Payer: Healthscope Commercial	$571.43
Rate for Payer: MI Amish Medical Board Commercial	$507.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$539.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$476.19
Rate for Payer: PHP Commercial	$539.68
Rate for Payer: Priority Health SBD	$400.00
Rate for Payer: UHC All Payor (Choice/PPO)	$412.70
Rate for Payer: UHC Core	$330.79
Rate for Payer: UHC Exchange	$249.52

DOFETILIDE 250 MCG CAPSULE

Facility

$532.66

Service Code	NDC 00904752308
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$209.34
Max. Negotiated Rate	$479.39
Rate for Payer: Aetna Commercial	$452.76
Rate for Payer: Aetna Medicare	$266.33
Rate for Payer: Aetna New Business (MI Preferred)	$346.23
Rate for Payer: BCBS Complete	$213.06
Rate for Payer: Cash Price	$426.13
Rate for Payer: Cofinity Advantage	$372.86
Rate for Payer: Cofinity Commercial	$458.09
Rate for Payer: Encore Health Key Benefits Commercial	$426.13
Rate for Payer: Healthscope Commercial	$479.39
Rate for Payer: MI Amish Medical Board Commercial	$426.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$452.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$399.50
Rate for Payer: PHP Commercial	$452.76
Rate for Payer: Priority Health SBD	$335.58
Rate for Payer: UHC All Payor (Choice/PPO)	$346.23
Rate for Payer: UHC Core	$277.52
Rate for Payer: UHC Exchange	$209.34

DOFETILIDE 250 MCG CAPSULE

Facility

$163.01

Service Code	NDC 69452013217
Hospital Charge Code	26966
Hospital Revenue Code	637
Min. Negotiated Rate	$102.70
Max. Negotiated Rate	$146.71
Rate for Payer: Aetna Commercial	$138.56
Rate for Payer: Aetna New Business (MI Preferred)	$105.96
Rate for Payer: Cash Price	$130.41
Rate for Payer: Cofinity Advantage	$114.11
Rate for Payer: Cofinity Commercial	$140.19
Rate for Payer: Encore Health Key Benefits Commercial	$130.41
Rate for Payer: Healthscope Commercial	$146.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$138.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$122.26
Rate for Payer: PHP Commercial	$138.56
Rate for Payer: Priority Health SBD	$102.70

DOLUTEGRAVIR 50 MG TABLET

Facility

$8,639.69

Service Code	NDC 49702022813
Hospital Charge Code	167672
Hospital Revenue Code	637
Min. Negotiated Rate	$5,443.00
Max. Negotiated Rate	$7,775.72
Rate for Payer: Aetna Commercial	$7,343.74
Rate for Payer: Aetna New Business (MI Preferred)	$5,615.80
Rate for Payer: Cash Price	$6,911.75
Rate for Payer: Cofinity Advantage	$6,047.78
Rate for Payer: Cofinity Commercial	$7,430.13
Rate for Payer: Encore Health Key Benefits Commercial	$6,911.75
Rate for Payer: Healthscope Commercial	$7,775.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,343.74
Rate for Payer: Opus (Opus Packaging Group) HMA	$6,479.77
Rate for Payer: PHP Commercial	$7,343.74
Rate for Payer: Priority Health SBD	$5,443.00

DOLUTEGRAVIR 50 MG TABLET

Facility

$8,639.69

Service Code	NDC 49702022813
Hospital Charge Code	167672
Hospital Revenue Code	637
Min. Negotiated Rate	$3,395.40
Max. Negotiated Rate	$7,775.72
Rate for Payer: Aetna Commercial	$7,343.74
Rate for Payer: Aetna Medicare	$4,319.85
Rate for Payer: Aetna New Business (MI Preferred)	$5,615.80
Rate for Payer: BCBS Complete	$3,455.88
Rate for Payer: Cash Price	$6,911.75
Rate for Payer: Cofinity Advantage	$6,047.78
Rate for Payer: Cofinity Commercial	$7,430.13
Rate for Payer: Encore Health Key Benefits Commercial	$6,911.75
Rate for Payer: Healthscope Commercial	$7,775.72
Rate for Payer: MI Amish Medical Board Commercial	$6,911.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,343.74
Rate for Payer: Opus (Opus Packaging Group) HMA	$6,479.77
Rate for Payer: PHP Commercial	$7,343.74
Rate for Payer: Priority Health SBD	$5,443.00
Rate for Payer: UHC All Payor (Choice/PPO)	$5,615.80
Rate for Payer: UHC Core	$4,501.28
Rate for Payer: UHC Exchange	$3,395.40

DONEPEZIL 10 MG TABLET

Facility

$2.92

Service Code	NDC 60687030311
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: Aetna Medicare	$1.46
Rate for Payer: Aetna New Business (MI Preferred)	$1.90
Rate for Payer: BCBS Complete	$1.17
Rate for Payer: Cash Price	$2.34
Rate for Payer: Cofinity Advantage	$2.04
Rate for Payer: Cofinity Commercial	$2.51
Rate for Payer: Encore Health Key Benefits Commercial	$2.34
Rate for Payer: Healthscope Commercial	$2.63
Rate for Payer: MI Amish Medical Board Commercial	$2.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.19
Rate for Payer: PHP Commercial	$2.48
Rate for Payer: Priority Health SBD	$1.84
Rate for Payer: UHC All Payor (Choice/PPO)	$1.90
Rate for Payer: UHC Core	$1.52
Rate for Payer: UHC Exchange	$1.15

DONEPEZIL 10 MG TABLET

Facility

$291.40

Service Code	NDC 60687030301
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$114.52
Max. Negotiated Rate	$262.26
Rate for Payer: Aetna Commercial	$247.69
Rate for Payer: Aetna Medicare	$145.70
Rate for Payer: Aetna New Business (MI Preferred)	$189.41
Rate for Payer: BCBS Complete	$116.56
Rate for Payer: Cash Price	$233.12
Rate for Payer: Cofinity Advantage	$203.98
Rate for Payer: Cofinity Commercial	$250.60
Rate for Payer: Encore Health Key Benefits Commercial	$233.12
Rate for Payer: Healthscope Commercial	$262.26
Rate for Payer: MI Amish Medical Board Commercial	$233.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$247.69
Rate for Payer: Opus (Opus Packaging Group) HMA	$218.55
Rate for Payer: PHP Commercial	$247.69
Rate for Payer: Priority Health SBD	$183.58
Rate for Payer: UHC All Payor (Choice/PPO)	$189.41
Rate for Payer: UHC Core	$151.82
Rate for Payer: UHC Exchange	$114.52

DONEPEZIL 10 MG TABLET

Facility

$291.40

Service Code	NDC 60687030301
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$183.58
Max. Negotiated Rate	$262.26
Rate for Payer: Aetna Commercial	$247.69
Rate for Payer: Aetna New Business (MI Preferred)	$189.41
Rate for Payer: Cash Price	$233.12
Rate for Payer: Cofinity Advantage	$203.98
Rate for Payer: Cofinity Commercial	$250.60
Rate for Payer: Encore Health Key Benefits Commercial	$233.12
Rate for Payer: Healthscope Commercial	$262.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$247.69
Rate for Payer: Opus (Opus Packaging Group) HMA	$218.55
Rate for Payer: PHP Commercial	$247.69
Rate for Payer: Priority Health SBD	$183.58

DONEPEZIL 10 MG TABLET

Facility

$265.55

Service Code	NDC 00904647861
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$225.72
Rate for Payer: Aetna New Business (MI Preferred)	$172.61
Rate for Payer: Cash Price	$212.44
Rate for Payer: Cofinity Advantage	$185.88
Rate for Payer: Cofinity Commercial	$228.37
Rate for Payer: Encore Health Key Benefits Commercial	$212.44
Rate for Payer: Healthscope Commercial	$239.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$225.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$199.16
Rate for Payer: PHP Commercial	$225.72
Rate for Payer: Priority Health SBD	$167.30

DONEPEZIL 10 MG TABLET

Facility

$2.92

Service Code	NDC 60687030311
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: Aetna New Business (MI Preferred)	$1.90
Rate for Payer: Cash Price	$2.34
Rate for Payer: Cofinity Advantage	$2.04
Rate for Payer: Cofinity Commercial	$2.51
Rate for Payer: Encore Health Key Benefits Commercial	$2.34
Rate for Payer: Healthscope Commercial	$2.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.19
Rate for Payer: PHP Commercial	$2.48
Rate for Payer: Priority Health SBD	$1.84

DONEPEZIL 10 MG TABLET

Facility

$265.55

Service Code	NDC 00904647861
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$104.36
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$225.72
Rate for Payer: Aetna Medicare	$132.78
Rate for Payer: Aetna New Business (MI Preferred)	$172.61
Rate for Payer: BCBS Complete	$106.22
Rate for Payer: Cash Price	$212.44
Rate for Payer: Cofinity Advantage	$185.88
Rate for Payer: Cofinity Commercial	$228.37
Rate for Payer: Encore Health Key Benefits Commercial	$212.44
Rate for Payer: Healthscope Commercial	$239.00
Rate for Payer: MI Amish Medical Board Commercial	$212.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$225.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$199.16
Rate for Payer: PHP Commercial	$225.72
Rate for Payer: Priority Health SBD	$167.30
Rate for Payer: UHC All Payor (Choice/PPO)	$172.61
Rate for Payer: UHC Core	$138.35
Rate for Payer: UHC Exchange	$104.36

DONEPEZIL 5 MG TABLET

Facility

$260.85

Service Code	NDC 00904647761
Hospital Charge Code	18786
Hospital Revenue Code	637
Min. Negotiated Rate	$164.34
Max. Negotiated Rate	$234.76
Rate for Payer: Aetna Commercial	$221.72
Rate for Payer: Aetna New Business (MI Preferred)	$169.55
Rate for Payer: Cash Price	$208.68
Rate for Payer: Cofinity Advantage	$182.59
Rate for Payer: Cofinity Commercial	$224.33
Rate for Payer: Encore Health Key Benefits Commercial	$208.68
Rate for Payer: Healthscope Commercial	$234.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$195.64
Rate for Payer: PHP Commercial	$221.72
Rate for Payer: Priority Health SBD	$164.34

DONEPEZIL 5 MG TABLET

Facility

$260.85

Service Code	NDC 00904647761
Hospital Charge Code	18786
Hospital Revenue Code	637
Min. Negotiated Rate	$102.51
Max. Negotiated Rate	$234.76
Rate for Payer: Aetna Commercial	$221.72
Rate for Payer: Aetna Medicare	$130.43
Rate for Payer: Aetna New Business (MI Preferred)	$169.55
Rate for Payer: BCBS Complete	$104.34
Rate for Payer: Cash Price	$208.68
Rate for Payer: Cofinity Advantage	$182.59
Rate for Payer: Cofinity Commercial	$224.33
Rate for Payer: Encore Health Key Benefits Commercial	$208.68
Rate for Payer: Healthscope Commercial	$234.76
Rate for Payer: MI Amish Medical Board Commercial	$208.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$195.64
Rate for Payer: PHP Commercial	$221.72
Rate for Payer: Priority Health SBD	$164.34
Rate for Payer: UHC All Payor (Choice/PPO)	$169.55
Rate for Payer: UHC Core	$135.90
Rate for Payer: UHC Exchange	$102.51

Know your out-of-pocket cost for care.

All Charges