Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DRONABINOL 2.5 MG CAPSULE

Facility

$1,498.77

Service Code	NDC 60687037501
Hospital Charge Code	9904
Hospital Revenue Code	637
Min. Negotiated Rate	$944.23
Max. Negotiated Rate	$1,348.89
Rate for Payer: Aetna Commercial	$1,273.95
Rate for Payer: Aetna New Business (MI Preferred)	$974.20
Rate for Payer: Cash Price	$1,199.02
Rate for Payer: Cofinity Advantage	$1,049.14
Rate for Payer: Cofinity Commercial	$1,288.94
Rate for Payer: Encore Health Key Benefits Commercial	$1,199.02
Rate for Payer: Healthscope Commercial	$1,348.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,273.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,124.08
Rate for Payer: PHP Commercial	$1,273.95
Rate for Payer: Priority Health SBD	$944.23

DRONABINOL 2.5 MG CAPSULE

Facility

$697.20

Service Code	NDC 67877075360
Hospital Charge Code	9904
Hospital Revenue Code	637
Min. Negotiated Rate	$274.00
Max. Negotiated Rate	$627.48
Rate for Payer: Aetna Commercial	$592.62
Rate for Payer: Aetna Medicare	$348.60
Rate for Payer: Aetna New Business (MI Preferred)	$453.18
Rate for Payer: BCBS Complete	$278.88
Rate for Payer: Cash Price	$557.76
Rate for Payer: Cofinity Advantage	$488.04
Rate for Payer: Cofinity Commercial	$599.59
Rate for Payer: Encore Health Key Benefits Commercial	$557.76
Rate for Payer: Healthscope Commercial	$627.48
Rate for Payer: MI Amish Medical Board Commercial	$557.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$592.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$522.90
Rate for Payer: PHP Commercial	$592.62
Rate for Payer: Priority Health SBD	$439.24
Rate for Payer: UHC All Payor (Choice/PPO)	$453.18
Rate for Payer: UHC Core	$363.24
Rate for Payer: UHC Exchange	$274.00

DRONABINOL 2.5 MG CAPSULE

Facility

$697.20

Service Code	NDC 67877075360
Hospital Charge Code	9904
Hospital Revenue Code	637
Min. Negotiated Rate	$439.24
Max. Negotiated Rate	$627.48
Rate for Payer: Aetna Commercial	$592.62
Rate for Payer: Aetna New Business (MI Preferred)	$453.18
Rate for Payer: Cash Price	$557.76
Rate for Payer: Cofinity Advantage	$488.04
Rate for Payer: Cofinity Commercial	$599.59
Rate for Payer: Encore Health Key Benefits Commercial	$557.76
Rate for Payer: Healthscope Commercial	$627.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$592.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$522.90
Rate for Payer: PHP Commercial	$592.62
Rate for Payer: Priority Health SBD	$439.24

DRONABINOL 2.5 MG CAPSULE

Facility

$1,498.77

Service Code	NDC 60687037501
Hospital Charge Code	9904
Hospital Revenue Code	637
Min. Negotiated Rate	$589.02
Max. Negotiated Rate	$1,348.89
Rate for Payer: Aetna Commercial	$1,273.95
Rate for Payer: Aetna Medicare	$749.38
Rate for Payer: Aetna New Business (MI Preferred)	$974.20
Rate for Payer: BCBS Complete	$599.51
Rate for Payer: Cash Price	$1,199.02
Rate for Payer: Cofinity Advantage	$1,049.14
Rate for Payer: Cofinity Commercial	$1,288.94
Rate for Payer: Encore Health Key Benefits Commercial	$1,199.02
Rate for Payer: Healthscope Commercial	$1,348.89
Rate for Payer: MI Amish Medical Board Commercial	$1,199.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,273.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,124.08
Rate for Payer: PHP Commercial	$1,273.95
Rate for Payer: Priority Health SBD	$944.23
Rate for Payer: UHC All Payor (Choice/PPO)	$974.20
Rate for Payer: UHC Core	$780.86
Rate for Payer: UHC Exchange	$589.02

DRONABINOL 2.5 MG CAPSULE

Facility

$21.72

Service Code	NDC 60687037511
Hospital Charge Code	9904
Hospital Revenue Code	637
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$19.55
Rate for Payer: Aetna Commercial	$18.46
Rate for Payer: Aetna New Business (MI Preferred)	$14.12
Rate for Payer: Cash Price	$17.38
Rate for Payer: Cofinity Advantage	$15.20
Rate for Payer: Cofinity Commercial	$18.68
Rate for Payer: Encore Health Key Benefits Commercial	$17.38
Rate for Payer: Healthscope Commercial	$19.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.46
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.29
Rate for Payer: PHP Commercial	$18.46
Rate for Payer: Priority Health SBD	$13.68

DRONABINOL 2.5 MG CAPSULE

Facility

$21.72

Service Code	NDC 60687037511
Hospital Charge Code	9904
Hospital Revenue Code	637
Min. Negotiated Rate	$8.54
Max. Negotiated Rate	$19.55
Rate for Payer: Aetna Commercial	$18.46
Rate for Payer: Aetna Medicare	$10.86
Rate for Payer: Aetna New Business (MI Preferred)	$14.12
Rate for Payer: BCBS Complete	$8.69
Rate for Payer: Cash Price	$17.38
Rate for Payer: Cofinity Advantage	$15.20
Rate for Payer: Cofinity Commercial	$18.68
Rate for Payer: Encore Health Key Benefits Commercial	$17.38
Rate for Payer: Healthscope Commercial	$19.55
Rate for Payer: MI Amish Medical Board Commercial	$17.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.46
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.29
Rate for Payer: PHP Commercial	$18.46
Rate for Payer: Priority Health SBD	$13.68
Rate for Payer: UHC All Payor (Choice/PPO)	$14.12
Rate for Payer: UHC Core	$11.32
Rate for Payer: UHC Exchange	$8.54

DRONEDARONE 400 MG TABLET

Facility

$2,786.10

Service Code	NDC 00024414260
Hospital Charge Code	98329
Hospital Revenue Code	637
Min. Negotiated Rate	$1,094.94
Max. Negotiated Rate	$2,507.49
Rate for Payer: Aetna Commercial	$2,368.18
Rate for Payer: Aetna Medicare	$1,393.05
Rate for Payer: Aetna New Business (MI Preferred)	$1,810.96
Rate for Payer: BCBS Complete	$1,114.44
Rate for Payer: Cash Price	$2,228.88
Rate for Payer: Cofinity Advantage	$1,950.27
Rate for Payer: Cofinity Commercial	$2,396.05
Rate for Payer: Encore Health Key Benefits Commercial	$2,228.88
Rate for Payer: Healthscope Commercial	$2,507.49
Rate for Payer: MI Amish Medical Board Commercial	$2,228.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,368.18
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,089.57
Rate for Payer: PHP Commercial	$2,368.18
Rate for Payer: Priority Health SBD	$1,755.24
Rate for Payer: UHC All Payor (Choice/PPO)	$1,810.96
Rate for Payer: UHC Core	$1,451.56
Rate for Payer: UHC Exchange	$1,094.94

DRONEDARONE 400 MG TABLET

Facility

$2,786.10

Service Code	NDC 00024414260
Hospital Charge Code	98329
Hospital Revenue Code	637
Min. Negotiated Rate	$1,755.24
Max. Negotiated Rate	$2,507.49
Rate for Payer: Aetna Commercial	$2,368.18
Rate for Payer: Aetna New Business (MI Preferred)	$1,810.96
Rate for Payer: Cash Price	$2,228.88
Rate for Payer: Cofinity Advantage	$1,950.27
Rate for Payer: Cofinity Commercial	$2,396.05
Rate for Payer: Encore Health Key Benefits Commercial	$2,228.88
Rate for Payer: Healthscope Commercial	$2,507.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,368.18
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,089.57
Rate for Payer: PHP Commercial	$2,368.18
Rate for Payer: Priority Health SBD	$1,755.24

DROPERIDOL 2.5 MG/ML INJECTION SOLUTION

Facility

$54.51

Service Code	HCPCS J1790
Hospital Charge Code	2654
Hospital Revenue Code	636
Min. Negotiated Rate	$34.34
Max. Negotiated Rate	$49.06
Rate for Payer: Aetna Commercial	$46.33
Rate for Payer: Aetna Commercial	$41.19
Rate for Payer: Aetna New Business (MI Preferred)	$35.43
Rate for Payer: Aetna New Business (MI Preferred)	$31.50
Rate for Payer: Cash Price	$38.77
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cofinity Advantage	$38.16
Rate for Payer: Cofinity Advantage	$33.92
Rate for Payer: Cofinity Commercial	$41.68
Rate for Payer: Cofinity Commercial	$46.88
Rate for Payer: Encore Health Key Benefits Commercial	$43.61
Rate for Payer: Encore Health Key Benefits Commercial	$38.77
Rate for Payer: Healthscope Commercial	$49.06
Rate for Payer: Healthscope Commercial	$43.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$46.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$41.19
Rate for Payer: Opus (Opus Packaging Group) HMA	$36.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$40.88
Rate for Payer: PHP Commercial	$41.19
Rate for Payer: PHP Commercial	$46.33
Rate for Payer: Priority Health SBD	$34.34
Rate for Payer: Priority Health SBD	$30.53

DROPERIDOL 2.5 MG/ML INJECTION SOLUTION

Facility

$54.51

Service Code	HCPCS J1790
Hospital Charge Code	2654
Hospital Revenue Code	636
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$49.06
Rate for Payer: Aetna Commercial	$46.33
Rate for Payer: Aetna Commercial	$41.19
Rate for Payer: Aetna Medicare	$24.23
Rate for Payer: Aetna Medicare	$27.25
Rate for Payer: Aetna New Business (MI Preferred)	$35.43
Rate for Payer: Aetna New Business (MI Preferred)	$31.50
Rate for Payer: BCBS Complete	$19.38
Rate for Payer: BCBS Complete	$21.80
Rate for Payer: BCBS Trust/PPO	$18.00
Rate for Payer: BCBS Trust/PPO	$18.00
Rate for Payer: BCN Commercial	$18.00
Rate for Payer: BCN Commercial	$18.00
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$38.77
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$38.77
Rate for Payer: Cofinity Advantage	$38.16
Rate for Payer: Cofinity Advantage	$33.92
Rate for Payer: Cofinity Commercial	$46.88
Rate for Payer: Cofinity Commercial	$41.68
Rate for Payer: Encore Health Key Benefits Commercial	$38.77
Rate for Payer: Encore Health Key Benefits Commercial	$43.61
Rate for Payer: Healthscope Commercial	$43.61
Rate for Payer: Healthscope Commercial	$49.06
Rate for Payer: MI Amish Medical Board Commercial	$38.77
Rate for Payer: MI Amish Medical Board Commercial	$43.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$46.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$41.19
Rate for Payer: Opus (Opus Packaging Group) HMA	$40.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$36.34
Rate for Payer: PHP Commercial	$46.33
Rate for Payer: PHP Commercial	$41.19
Rate for Payer: Priority Health SBD	$34.34
Rate for Payer: Priority Health SBD	$30.53
Rate for Payer: UHC All Payor (Choice/PPO)	$11.85
Rate for Payer: UHC All Payor (Choice/PPO)	$11.85
Rate for Payer: UHC Core	$11.85
Rate for Payer: UHC Core	$11.85
Rate for Payer: UHC Exchange	$11.85
Rate for Payer: UHC Exchange	$11.85

DROXIDOPA 200 MG CAPSULE

Facility

$688.32

Service Code	NDC 31722001590
Hospital Charge Code	171896
Hospital Revenue Code	637
Min. Negotiated Rate	$433.64
Max. Negotiated Rate	$619.49
Rate for Payer: Aetna Commercial	$585.07
Rate for Payer: Aetna New Business (MI Preferred)	$447.41
Rate for Payer: Cash Price	$550.66
Rate for Payer: Cofinity Advantage	$481.82
Rate for Payer: Cofinity Commercial	$591.96
Rate for Payer: Encore Health Key Benefits Commercial	$550.66
Rate for Payer: Healthscope Commercial	$619.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$585.07
Rate for Payer: Opus (Opus Packaging Group) HMA	$516.24
Rate for Payer: PHP Commercial	$585.07
Rate for Payer: Priority Health SBD	$433.64

DROXIDOPA 200 MG CAPSULE

Facility

$688.32

Service Code	NDC 31722001590
Hospital Charge Code	171896
Hospital Revenue Code	637
Min. Negotiated Rate	$270.51
Max. Negotiated Rate	$619.49
Rate for Payer: Aetna Commercial	$585.07
Rate for Payer: Aetna Medicare	$344.16
Rate for Payer: Aetna New Business (MI Preferred)	$447.41
Rate for Payer: BCBS Complete	$275.33
Rate for Payer: Cash Price	$550.66
Rate for Payer: Cofinity Advantage	$481.82
Rate for Payer: Cofinity Commercial	$591.96
Rate for Payer: Encore Health Key Benefits Commercial	$550.66
Rate for Payer: Healthscope Commercial	$619.49
Rate for Payer: MI Amish Medical Board Commercial	$550.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$585.07
Rate for Payer: Opus (Opus Packaging Group) HMA	$516.24
Rate for Payer: PHP Commercial	$585.07
Rate for Payer: Priority Health SBD	$433.64
Rate for Payer: UHC All Payor (Choice/PPO)	$447.41
Rate for Payer: UHC Core	$358.61
Rate for Payer: UHC Exchange	$270.51

DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE

Facility

$2,358.56

Service Code	APR-DRG 7702
Min. Negotiated Rate	$2,246.24
Max. Negotiated Rate	$2,358.56
Rate for Payer: BCBS Complete	$2,358.56
Rate for Payer: Mclaren Medicaid	$2,246.24
Rate for Payer: Meridian Medicaid	$2,358.56
Rate for Payer: Priority Health Choice Medicaid	$2,246.24
Rate for Payer: UHC Medicaid	$2,246.24
Rate for Payer: UHCCP Medicaid	$2,246.24

DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE

Facility

$10,794.09

Service Code	APR-DRG 7704
Min. Negotiated Rate	$10,280.09
Max. Negotiated Rate	$10,794.09
Rate for Payer: BCBS Complete	$10,794.09
Rate for Payer: Mclaren Medicaid	$10,280.09
Rate for Payer: Meridian Medicaid	$10,794.09
Rate for Payer: Priority Health Choice Medicaid	$10,280.09
Rate for Payer: UHC Medicaid	$10,280.09
Rate for Payer: UHCCP Medicaid	$10,280.09

DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE

Facility

$1,843.16

Service Code	APR-DRG 7701
Min. Negotiated Rate	$1,755.39
Max. Negotiated Rate	$1,843.16
Rate for Payer: BCBS Complete	$1,843.16
Rate for Payer: Mclaren Medicaid	$1,755.39
Rate for Payer: Meridian Medicaid	$1,843.16
Rate for Payer: Priority Health Choice Medicaid	$1,755.39
Rate for Payer: UHC Medicaid	$1,755.39
Rate for Payer: UHCCP Medicaid	$1,755.39

DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE

Facility

$3,197.29

Service Code	APR-DRG 7703
Min. Negotiated Rate	$3,045.04
Max. Negotiated Rate	$3,197.29
Rate for Payer: BCBS Complete	$3,197.29
Rate for Payer: Mclaren Medicaid	$3,045.04
Rate for Payer: Meridian Medicaid	$3,197.29
Rate for Payer: Priority Health Choice Medicaid	$3,045.04
Rate for Payer: UHC Medicaid	$3,045.04
Rate for Payer: UHCCP Medicaid	$3,045.04

DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC

Facility

$5,735.32

Service Code	CPT 42975
Hospital Revenue Code	360
Min. Negotiated Rate	$75.30
Max. Negotiated Rate	$5,735.32
Rate for Payer: Aetna Medicare	$1,844.44
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,216.88
Rate for Payer: Amish Plain Church Group Commercial	$2,216.88
Rate for Payer: BCBS Complete	$974.01
Rate for Payer: BCBS MAPPO	$1,773.50
Rate for Payer: BCBS Trust/PPO	$75.30
Rate for Payer: BCN Commercial	$75.30
Rate for Payer: BCN Medicare Advantage	$1,773.50
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,773.50
Rate for Payer: Mclaren Medicaid	$927.54
Rate for Payer: Mclaren Medicare	$1,773.50
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,862.17
Rate for Payer: Meridian Medicaid	$1,862.17
Rate for Payer: MI Amish Medical Board Commercial	$2,039.53
Rate for Payer: Molina Medicare/Medicaid	$1,950.85
Rate for Payer: Nomi Health Commercial	$5,320.50
Rate for Payer: PACE Medicare	$1,684.83
Rate for Payer: PACE SWMI	$1,773.50
Rate for Payer: PHP Medicare Advantage	$1,773.50
Rate for Payer: Priority Health Choice Medicaid	$927.54
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$5,735.32
Rate for Payer: Priority Health Medicare	$1,773.50
Rate for Payer: Priority Health Tiered Network	$4,588.26
Rate for Payer: Railroad Medicare Medicare	$1,773.50
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$1,773.50
Rate for Payer: UHC Medicaid	$927.54
Rate for Payer: UHCCP Medicaid	$927.54
Rate for Payer: VA VA	$1,773.50

DRUG TEST PRESUMPTIVE READ BY INSTR ASSISTED DIRECT OPTICAL OBS

Professional

Both

$16.00

Service Code	HCPCS G0478
Min. Negotiated Rate	$6.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Medicare	$8.00
Rate for Payer: BCBS Complete	$6.40
Rate for Payer: Cash Price	$12.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.00

DRUG TEST PRESUMPTIVE USING IMMUNOASSAY

Professional

Both

$84.00

Service Code	HCPCS G0479
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Medicare	$42.00
Rate for Payer: BCBS Complete	$33.60
Rate for Payer: Cash Price	$67.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.00

DRUG TEST(S), PRESUMPTIVE READ BY DIRECT OPTICAL OBSERVATION

Professional

Both

$12.00

Service Code	HCPCS G0477
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Medicare	$6.00
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: Cash Price	$9.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$9.00

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$4.24

Service Code	NDC 60687072311
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$3.82
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Aetna Medicare	$2.12
Rate for Payer: Aetna New Business (MI Preferred)	$2.76
Rate for Payer: BCBS Complete	$1.70
Rate for Payer: Cash Price	$3.39
Rate for Payer: Cofinity Advantage	$2.97
Rate for Payer: Cofinity Commercial	$3.65
Rate for Payer: Encore Health Key Benefits Commercial	$3.39
Rate for Payer: Healthscope Commercial	$3.82
Rate for Payer: MI Amish Medical Board Commercial	$3.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.18
Rate for Payer: PHP Commercial	$3.60
Rate for Payer: Priority Health SBD	$2.67
Rate for Payer: UHC All Payor (Choice/PPO)	$2.76
Rate for Payer: UHC Core	$2.21
Rate for Payer: UHC Exchange	$1.67

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$4.24

Service Code	NDC 60687072311
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.82
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Aetna New Business (MI Preferred)	$2.76
Rate for Payer: Cash Price	$3.39
Rate for Payer: Cofinity Advantage	$2.97
Rate for Payer: Cofinity Commercial	$3.65
Rate for Payer: Encore Health Key Benefits Commercial	$3.39
Rate for Payer: Healthscope Commercial	$3.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.18
Rate for Payer: PHP Commercial	$3.60
Rate for Payer: Priority Health SBD	$2.67

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$115.35

Service Code	NDC 00904704304
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$72.67
Max. Negotiated Rate	$103.81
Rate for Payer: Aetna Commercial	$98.05
Rate for Payer: Aetna New Business (MI Preferred)	$74.98
Rate for Payer: Cash Price	$92.28
Rate for Payer: Cofinity Advantage	$80.75
Rate for Payer: Cofinity Commercial	$99.20
Rate for Payer: Encore Health Key Benefits Commercial	$92.28
Rate for Payer: Healthscope Commercial	$103.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$98.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$86.51
Rate for Payer: PHP Commercial	$98.05
Rate for Payer: Priority Health SBD	$72.67

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$159.03

Service Code	NDC 27241009706
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$100.19
Max. Negotiated Rate	$143.13
Rate for Payer: Aetna Commercial	$135.18
Rate for Payer: Aetna New Business (MI Preferred)	$103.37
Rate for Payer: Cash Price	$127.22
Rate for Payer: Cofinity Advantage	$111.32
Rate for Payer: Cofinity Commercial	$136.77
Rate for Payer: Encore Health Key Benefits Commercial	$127.22
Rate for Payer: Healthscope Commercial	$143.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.18
Rate for Payer: Opus (Opus Packaging Group) HMA	$119.27
Rate for Payer: PHP Commercial	$135.18
Rate for Payer: Priority Health SBD	$100.19

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$1,721.84

Service Code	NDC 00002323560
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$676.68
Max. Negotiated Rate	$1,549.66
Rate for Payer: Aetna Commercial	$1,463.56
Rate for Payer: Aetna Medicare	$860.92
Rate for Payer: Aetna New Business (MI Preferred)	$1,119.20
Rate for Payer: BCBS Complete	$688.74
Rate for Payer: Cash Price	$1,377.47
Rate for Payer: Cofinity Advantage	$1,205.29
Rate for Payer: Cofinity Commercial	$1,480.78
Rate for Payer: Encore Health Key Benefits Commercial	$1,377.47
Rate for Payer: Healthscope Commercial	$1,549.66
Rate for Payer: MI Amish Medical Board Commercial	$1,377.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,463.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,291.38
Rate for Payer: PHP Commercial	$1,463.56
Rate for Payer: Priority Health SBD	$1,084.76
Rate for Payer: UHC All Payor (Choice/PPO)	$1,119.20
Rate for Payer: UHC Core	$897.08
Rate for Payer: UHC Exchange	$676.68

Know your out-of-pocket cost for care.

All Charges