Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$113.23

Service Code	NDC 00409166010
Hospital Charge Code	166083
Hospital Revenue Code	250
Min. Negotiated Rate	$45.29
Max. Negotiated Rate	$101.91
Rate for Payer: Aetna Commercial	$96.25
Rate for Payer: Aetna Medicare	$56.62
Rate for Payer: Aetna New Business (MI Preferred)	$73.60
Rate for Payer: BCBS Complete	$45.29
Rate for Payer: Cash Price	$90.58
Rate for Payer: Cofinity Commercial	$79.26
Rate for Payer: Cofinity Commercial	$97.38
Rate for Payer: Cofinity Medicare Advantage	$79.26
Rate for Payer: Encore Health Key Benefits Commercial	$90.58
Rate for Payer: Healthscope Commercial	$101.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$96.25
Rate for Payer: PHP Commercial	$96.25
Rate for Payer: Priority Health Cigna Priority Health	$73.60
Rate for Payer: Priority Health SBD	$71.33

DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$97.64

Service Code	NDC 55150029701
Hospital Charge Code	166083
Hospital Revenue Code	250
Min. Negotiated Rate	$61.51
Max. Negotiated Rate	$87.88
Rate for Payer: Aetna Commercial	$82.99
Rate for Payer: Aetna New Business (MI Preferred)	$63.47
Rate for Payer: Cash Price	$78.11
Rate for Payer: Cofinity Commercial	$68.35
Rate for Payer: Cofinity Commercial	$83.97
Rate for Payer: Cofinity Medicare Advantage	$68.35
Rate for Payer: Encore Health Key Benefits Commercial	$78.11
Rate for Payer: Healthscope Commercial	$87.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$82.99
Rate for Payer: PHP Commercial	$82.99
Rate for Payer: Priority Health Cigna Priority Health	$63.47
Rate for Payer: Priority Health SBD	$61.51

DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$102.38

Service Code	NDC 70121138907
Hospital Charge Code	166083
Hospital Revenue Code	250
Min. Negotiated Rate	$40.95
Max. Negotiated Rate	$92.14
Rate for Payer: Aetna Commercial	$87.02
Rate for Payer: Aetna Medicare	$51.19
Rate for Payer: Aetna New Business (MI Preferred)	$66.55
Rate for Payer: BCBS Complete	$40.95
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cofinity Commercial	$71.67
Rate for Payer: Cofinity Commercial	$88.05
Rate for Payer: Cofinity Medicare Advantage	$71.67
Rate for Payer: Encore Health Key Benefits Commercial	$81.90
Rate for Payer: Healthscope Commercial	$92.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$87.02
Rate for Payer: PHP Commercial	$87.02
Rate for Payer: Priority Health Cigna Priority Health	$66.55
Rate for Payer: Priority Health SBD	$64.50

DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$89.32

Service Code	NDC 09900001136
Hospital Charge Code	166083
Hospital Revenue Code	250
Min. Negotiated Rate	$56.27
Max. Negotiated Rate	$80.39
Rate for Payer: Aetna Commercial	$75.92
Rate for Payer: Aetna New Business (MI Preferred)	$58.06
Rate for Payer: Cash Price	$71.46
Rate for Payer: Cofinity Commercial	$62.52
Rate for Payer: Cofinity Commercial	$76.82
Rate for Payer: Cofinity Medicare Advantage	$62.52
Rate for Payer: Encore Health Key Benefits Commercial	$71.46
Rate for Payer: Healthscope Commercial	$80.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$75.92
Rate for Payer: PHP Commercial	$75.92
Rate for Payer: Priority Health Cigna Priority Health	$58.06
Rate for Payer: Priority Health SBD	$56.27

DEXMEDETOMIDINE 4 MCG/ML IV PUSH SOLUTION

Facility

$191.17

Service Code	NDC 09900001120
Hospital Charge Code	300091
Hospital Revenue Code	250
Min. Negotiated Rate	$120.44
Max. Negotiated Rate	$172.05
Rate for Payer: Aetna Commercial	$162.49
Rate for Payer: Aetna New Business (MI Preferred)	$124.26
Rate for Payer: Cash Price	$152.94
Rate for Payer: Cofinity Commercial	$133.82
Rate for Payer: Cofinity Commercial	$164.41
Rate for Payer: Cofinity Medicare Advantage	$133.82
Rate for Payer: Encore Health Key Benefits Commercial	$152.94
Rate for Payer: Healthscope Commercial	$172.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$162.49
Rate for Payer: PHP Commercial	$162.49
Rate for Payer: Priority Health Cigna Priority Health	$124.26
Rate for Payer: Priority Health SBD	$120.44

DEXMEDETOMIDINE 4 MCG/ML IV PUSH SOLUTION

Facility

$191.17

Service Code	NDC 09900001120
Hospital Charge Code	300091
Hospital Revenue Code	250
Min. Negotiated Rate	$76.47
Max. Negotiated Rate	$172.05
Rate for Payer: Aetna Commercial	$162.49
Rate for Payer: Aetna Medicare	$95.58
Rate for Payer: Aetna New Business (MI Preferred)	$124.26
Rate for Payer: BCBS Complete	$76.47
Rate for Payer: Cash Price	$152.94
Rate for Payer: Cofinity Commercial	$133.82
Rate for Payer: Cofinity Commercial	$164.41
Rate for Payer: Cofinity Medicare Advantage	$133.82
Rate for Payer: Encore Health Key Benefits Commercial	$152.94
Rate for Payer: Healthscope Commercial	$172.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$162.49
Rate for Payer: PHP Commercial	$162.49
Rate for Payer: Priority Health Cigna Priority Health	$124.26
Rate for Payer: Priority Health SBD	$120.44

DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$58.14

Service Code	NDC 00781349395
Hospital Charge Code	173991
Hospital Revenue Code	250
Min. Negotiated Rate	$36.63
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Cofinity Medicare Advantage	$40.70
Rate for Payer: Encore Health Key Benefits Commercial	$46.51
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$37.79
Rate for Payer: Priority Health SBD	$36.63

DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$91.39

Service Code	NDC 00409166022
Hospital Charge Code	173991
Hospital Revenue Code	250
Min. Negotiated Rate	$36.56
Max. Negotiated Rate	$82.25
Rate for Payer: Aetna Commercial	$77.68
Rate for Payer: Aetna Medicare	$45.70
Rate for Payer: Aetna New Business (MI Preferred)	$59.40
Rate for Payer: BCBS Complete	$36.56
Rate for Payer: Cash Price	$73.11
Rate for Payer: Cofinity Commercial	$63.97
Rate for Payer: Cofinity Commercial	$78.60
Rate for Payer: Cofinity Medicare Advantage	$63.97
Rate for Payer: Encore Health Key Benefits Commercial	$73.11
Rate for Payer: Healthscope Commercial	$82.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$77.68
Rate for Payer: PHP Commercial	$77.68
Rate for Payer: Priority Health Cigna Priority Health	$59.40
Rate for Payer: Priority Health SBD	$57.58

DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$91.39

Service Code	NDC 00409166022
Hospital Charge Code	173991
Hospital Revenue Code	250
Min. Negotiated Rate	$57.58
Max. Negotiated Rate	$82.25
Rate for Payer: Aetna Commercial	$77.68
Rate for Payer: Aetna New Business (MI Preferred)	$59.40
Rate for Payer: Cash Price	$73.11
Rate for Payer: Cofinity Commercial	$63.97
Rate for Payer: Cofinity Commercial	$78.60
Rate for Payer: Cofinity Medicare Advantage	$63.97
Rate for Payer: Encore Health Key Benefits Commercial	$73.11
Rate for Payer: Healthscope Commercial	$82.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$77.68
Rate for Payer: PHP Commercial	$77.68
Rate for Payer: Priority Health Cigna Priority Health	$59.40
Rate for Payer: Priority Health SBD	$57.58

DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$58.14

Service Code	NDC 00781349380
Hospital Charge Code	173991
Hospital Revenue Code	250
Min. Negotiated Rate	$23.26
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna Medicare	$29.07
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: BCBS Complete	$23.26
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Cofinity Medicare Advantage	$40.70
Rate for Payer: Encore Health Key Benefits Commercial	$46.51
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$37.79
Rate for Payer: Priority Health SBD	$36.63

DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$58.14

Service Code	NDC 00781349395
Hospital Charge Code	173991
Hospital Revenue Code	250
Min. Negotiated Rate	$23.26
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna Medicare	$29.07
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: BCBS Complete	$23.26
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Cofinity Medicare Advantage	$40.70
Rate for Payer: Encore Health Key Benefits Commercial	$46.51
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$37.79
Rate for Payer: Priority Health SBD	$36.63

DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$58.14

Service Code	NDC 00781349380
Hospital Charge Code	173991
Hospital Revenue Code	250
Min. Negotiated Rate	$36.63
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Cofinity Medicare Advantage	$40.70
Rate for Payer: Encore Health Key Benefits Commercial	$46.51
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$37.79
Rate for Payer: Priority Health SBD	$36.63

DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$91.39

Service Code	NDC 00409166020
Hospital Charge Code	173991
Hospital Revenue Code	250
Min. Negotiated Rate	$57.58
Max. Negotiated Rate	$82.25
Rate for Payer: Aetna Commercial	$77.68
Rate for Payer: Aetna New Business (MI Preferred)	$59.40
Rate for Payer: Cash Price	$73.11
Rate for Payer: Cofinity Commercial	$63.97
Rate for Payer: Cofinity Commercial	$78.60
Rate for Payer: Cofinity Medicare Advantage	$63.97
Rate for Payer: Encore Health Key Benefits Commercial	$73.11
Rate for Payer: Healthscope Commercial	$82.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$77.68
Rate for Payer: PHP Commercial	$77.68
Rate for Payer: Priority Health Cigna Priority Health	$59.40
Rate for Payer: Priority Health SBD	$57.58

DEXMEDETOMIDINE 80 MCG/20 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV

Facility

$91.39

Service Code	NDC 00409166020
Hospital Charge Code	173991
Hospital Revenue Code	250
Min. Negotiated Rate	$36.56
Max. Negotiated Rate	$82.25
Rate for Payer: Aetna Commercial	$77.68
Rate for Payer: Aetna Medicare	$45.70
Rate for Payer: Aetna New Business (MI Preferred)	$59.40
Rate for Payer: BCBS Complete	$36.56
Rate for Payer: Cash Price	$73.11
Rate for Payer: Cofinity Commercial	$63.97
Rate for Payer: Cofinity Commercial	$78.60
Rate for Payer: Cofinity Medicare Advantage	$63.97
Rate for Payer: Encore Health Key Benefits Commercial	$73.11
Rate for Payer: Healthscope Commercial	$82.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$77.68
Rate for Payer: PHP Commercial	$77.68
Rate for Payer: Priority Health Cigna Priority Health	$59.40
Rate for Payer: Priority Health SBD	$57.58

DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION

Facility

$485.33

Service Code	HCPCS J1190
Hospital Charge Code	15156
Hospital Revenue Code	636
Min. Negotiated Rate	$305.76
Max. Negotiated Rate	$436.80
Rate for Payer: Aetna Commercial	$412.53
Rate for Payer: Aetna New Business (MI Preferred)	$315.46
Rate for Payer: Cash Price	$388.26
Rate for Payer: Cofinity Commercial	$339.73
Rate for Payer: Cofinity Commercial	$417.38
Rate for Payer: Cofinity Medicare Advantage	$339.73
Rate for Payer: Encore Health Key Benefits Commercial	$388.26
Rate for Payer: Healthscope Commercial	$436.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$412.53
Rate for Payer: PHP Commercial	$412.53
Rate for Payer: Priority Health Cigna Priority Health	$315.46
Rate for Payer: Priority Health SBD	$305.76

DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION

Facility

$485.33

Service Code	HCPCS J1190
Hospital Charge Code	15156
Hospital Revenue Code	636
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$436.80
Rate for Payer: Aetna Commercial	$412.53
Rate for Payer: Aetna Medicare	$84.12
Rate for Payer: Aetna New Business (MI Preferred)	$315.46
Rate for Payer: Allen County Amish Medical Aid Commercial	$101.10
Rate for Payer: Amish Plain Church Group Commercial	$101.10
Rate for Payer: BCBS Complete	$45.52
Rate for Payer: BCBS MAPPO	$80.88
Rate for Payer: BCBS Trust/PPO	$247.14
Rate for Payer: BCN Commercial	$247.14
Rate for Payer: BCN Medicare Advantage	$80.88
Rate for Payer: Cash Price	$388.26
Rate for Payer: Cash Price	$388.26
Rate for Payer: Cofinity Commercial	$417.38
Rate for Payer: Cofinity Commercial	$339.73
Rate for Payer: Cofinity Medicare Advantage	$339.73
Rate for Payer: Encore Health Key Benefits Commercial	$388.26
Rate for Payer: Health Alliance Plan Medicare Advantage	$80.88
Rate for Payer: Healthscope Commercial	$436.80
Rate for Payer: Mclaren Medicaid	$43.35
Rate for Payer: Mclaren Medicare	$80.88
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$84.92
Rate for Payer: Meridian Medicaid	$45.52
Rate for Payer: MI Amish Medical Board Commercial	$93.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$412.53
Rate for Payer: Nomi Health Commercial	$242.64
Rate for Payer: PACE Medicare	$76.84
Rate for Payer: PACE SWMI	$80.88
Rate for Payer: PHP Commercial	$412.53
Rate for Payer: PHP Medicare Advantage	$80.88
Rate for Payer: Priority Health Choice Medicaid	$43.35
Rate for Payer: Priority Health Cigna Priority Health	$315.46
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$251.81
Rate for Payer: Priority Health Medicare	$80.88
Rate for Payer: Priority Health Narrow Network	$201.45
Rate for Payer: Priority Health SBD	$305.76
Rate for Payer: Railroad Medicare Medicare	$80.88
Rate for Payer: UHC All Payor (Choice/PPO)	$227.67
Rate for Payer: UHC Dual Complete DSNP	$80.88
Rate for Payer: UHC Medicare Advantage	$80.88
Rate for Payer: UHCCP Medicaid	$45.54
Rate for Payer: VA VA	$80.88

DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION

Facility

$983.57

Service Code	HCPCS J1190
Hospital Charge Code	15157
Hospital Revenue Code	636
Min. Negotiated Rate	$619.65
Max. Negotiated Rate	$885.21
Rate for Payer: Aetna Commercial	$836.03
Rate for Payer: Aetna New Business (MI Preferred)	$639.32
Rate for Payer: Cash Price	$786.86
Rate for Payer: Cofinity Commercial	$688.50
Rate for Payer: Cofinity Commercial	$845.87
Rate for Payer: Cofinity Medicare Advantage	$688.50
Rate for Payer: Encore Health Key Benefits Commercial	$786.86
Rate for Payer: Healthscope Commercial	$885.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$836.03
Rate for Payer: PHP Commercial	$836.03
Rate for Payer: Priority Health Cigna Priority Health	$639.32
Rate for Payer: Priority Health SBD	$619.65

DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION

Facility

$983.57

Service Code	HCPCS J1190
Hospital Charge Code	15157
Hospital Revenue Code	636
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$885.21
Rate for Payer: Aetna Commercial	$836.03
Rate for Payer: Aetna Medicare	$84.12
Rate for Payer: Aetna New Business (MI Preferred)	$639.32
Rate for Payer: Allen County Amish Medical Aid Commercial	$101.10
Rate for Payer: Amish Plain Church Group Commercial	$101.10
Rate for Payer: BCBS Complete	$45.52
Rate for Payer: BCBS MAPPO	$80.88
Rate for Payer: BCBS Trust/PPO	$247.14
Rate for Payer: BCN Commercial	$247.14
Rate for Payer: BCN Medicare Advantage	$80.88
Rate for Payer: Cash Price	$786.86
Rate for Payer: Cash Price	$786.86
Rate for Payer: Cofinity Commercial	$845.87
Rate for Payer: Cofinity Commercial	$688.50
Rate for Payer: Cofinity Medicare Advantage	$688.50
Rate for Payer: Encore Health Key Benefits Commercial	$786.86
Rate for Payer: Health Alliance Plan Medicare Advantage	$80.88
Rate for Payer: Healthscope Commercial	$885.21
Rate for Payer: Mclaren Medicaid	$43.35
Rate for Payer: Mclaren Medicare	$80.88
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$84.92
Rate for Payer: Meridian Medicaid	$45.52
Rate for Payer: MI Amish Medical Board Commercial	$93.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$836.03
Rate for Payer: Nomi Health Commercial	$242.64
Rate for Payer: PACE Medicare	$76.84
Rate for Payer: PACE SWMI	$80.88
Rate for Payer: PHP Commercial	$836.03
Rate for Payer: PHP Medicare Advantage	$80.88
Rate for Payer: Priority Health Choice Medicaid	$43.35
Rate for Payer: Priority Health Cigna Priority Health	$639.32
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$251.81
Rate for Payer: Priority Health Medicare	$80.88
Rate for Payer: Priority Health Narrow Network	$201.45
Rate for Payer: Priority Health SBD	$619.65
Rate for Payer: Railroad Medicare Medicare	$80.88
Rate for Payer: UHC All Payor (Choice/PPO)	$227.67
Rate for Payer: UHC Dual Complete DSNP	$80.88
Rate for Payer: UHC Medicare Advantage	$80.88
Rate for Payer: UHCCP Medicaid	$45.54
Rate for Payer: VA VA	$80.88

DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS

Facility

$148.48

Service Code	HCPCS J7100
Hospital Charge Code	9759
Hospital Revenue Code	250
Min. Negotiated Rate	$59.39
Max. Negotiated Rate	$133.63
Rate for Payer: Aetna Commercial	$126.21
Rate for Payer: Aetna Medicare	$74.24
Rate for Payer: Aetna New Business (MI Preferred)	$96.51
Rate for Payer: BCBS Complete	$59.39
Rate for Payer: BCBS Trust/PPO	$111.01
Rate for Payer: BCN Commercial	$111.01
Rate for Payer: Cash Price	$118.78
Rate for Payer: Cash Price	$118.78
Rate for Payer: Cofinity Commercial	$103.94
Rate for Payer: Cofinity Commercial	$127.69
Rate for Payer: Cofinity Medicare Advantage	$103.94
Rate for Payer: Encore Health Key Benefits Commercial	$118.78
Rate for Payer: Healthscope Commercial	$133.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$126.21
Rate for Payer: PHP Commercial	$126.21
Rate for Payer: Priority Health Cigna Priority Health	$96.51
Rate for Payer: Priority Health SBD	$93.54

DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS

Facility

$148.48

Service Code	HCPCS J7100
Hospital Charge Code	9759
Hospital Revenue Code	250
Min. Negotiated Rate	$93.54
Max. Negotiated Rate	$133.63
Rate for Payer: Aetna Commercial	$126.21
Rate for Payer: Aetna New Business (MI Preferred)	$96.51
Rate for Payer: Cash Price	$118.78
Rate for Payer: Cofinity Commercial	$103.94
Rate for Payer: Cofinity Commercial	$127.69
Rate for Payer: Cofinity Medicare Advantage	$103.94
Rate for Payer: Encore Health Key Benefits Commercial	$118.78
Rate for Payer: Healthscope Commercial	$133.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$126.21
Rate for Payer: PHP Commercial	$126.21
Rate for Payer: Priority Health Cigna Priority Health	$96.51
Rate for Payer: Priority Health SBD	$93.54

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET

Facility

$822.50

Service Code	NDC 00527150237
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$518.18
Max. Negotiated Rate	$740.25
Rate for Payer: Aetna Commercial	$699.12
Rate for Payer: Aetna New Business (MI Preferred)	$534.62
Rate for Payer: Cash Price	$658.00
Rate for Payer: Cofinity Commercial	$575.75
Rate for Payer: Cofinity Commercial	$707.35
Rate for Payer: Cofinity Medicare Advantage	$575.75
Rate for Payer: Encore Health Key Benefits Commercial	$658.00
Rate for Payer: Healthscope Commercial	$740.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$699.12
Rate for Payer: PHP Commercial	$699.12
Rate for Payer: Priority Health Cigna Priority Health	$534.62
Rate for Payer: Priority Health SBD	$518.18

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET

Facility

$3,600.30

Service Code	NDC 57844011001
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$1,440.12
Max. Negotiated Rate	$3,240.27
Rate for Payer: Aetna Commercial	$3,060.26
Rate for Payer: Aetna Medicare	$1,800.15
Rate for Payer: Aetna New Business (MI Preferred)	$2,340.20
Rate for Payer: BCBS Complete	$1,440.12
Rate for Payer: Cash Price	$2,880.24
Rate for Payer: Cofinity Commercial	$2,520.21
Rate for Payer: Cofinity Commercial	$3,096.26
Rate for Payer: Cofinity Medicare Advantage	$2,520.21
Rate for Payer: Encore Health Key Benefits Commercial	$2,880.24
Rate for Payer: Healthscope Commercial	$3,240.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,060.26
Rate for Payer: PHP Commercial	$3,060.26
Rate for Payer: Priority Health Cigna Priority Health	$2,340.20
Rate for Payer: Priority Health SBD	$2,268.19

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET

Facility

$822.50

Service Code	NDC 00527150237
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$329.00
Max. Negotiated Rate	$740.25
Rate for Payer: Aetna Commercial	$699.12
Rate for Payer: Aetna Medicare	$411.25
Rate for Payer: Aetna New Business (MI Preferred)	$534.62
Rate for Payer: BCBS Complete	$329.00
Rate for Payer: Cash Price	$658.00
Rate for Payer: Cofinity Commercial	$575.75
Rate for Payer: Cofinity Commercial	$707.35
Rate for Payer: Cofinity Medicare Advantage	$575.75
Rate for Payer: Encore Health Key Benefits Commercial	$658.00
Rate for Payer: Healthscope Commercial	$740.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$699.12
Rate for Payer: PHP Commercial	$699.12
Rate for Payer: Priority Health Cigna Priority Health	$534.62
Rate for Payer: Priority Health SBD	$518.18

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET

Facility

$563.50

Service Code	NDC 00555097202
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$355.00
Max. Negotiated Rate	$507.15
Rate for Payer: Aetna Commercial	$478.98
Rate for Payer: Aetna New Business (MI Preferred)	$366.28
Rate for Payer: Cash Price	$450.80
Rate for Payer: Cofinity Commercial	$394.45
Rate for Payer: Cofinity Commercial	$484.61
Rate for Payer: Cofinity Medicare Advantage	$394.45
Rate for Payer: Encore Health Key Benefits Commercial	$450.80
Rate for Payer: Healthscope Commercial	$507.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$478.98
Rate for Payer: PHP Commercial	$478.98
Rate for Payer: Priority Health Cigna Priority Health	$366.28
Rate for Payer: Priority Health SBD	$355.00

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET

Facility

$610.75

Service Code	NDC 13107007001
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$244.30
Max. Negotiated Rate	$549.68
Rate for Payer: Aetna Commercial	$519.14
Rate for Payer: Aetna Medicare	$305.38
Rate for Payer: Aetna New Business (MI Preferred)	$396.99
Rate for Payer: BCBS Complete	$244.30
Rate for Payer: Cash Price	$488.60
Rate for Payer: Cofinity Commercial	$427.52
Rate for Payer: Cofinity Commercial	$525.24
Rate for Payer: Cofinity Medicare Advantage	$427.52
Rate for Payer: Encore Health Key Benefits Commercial	$488.60
Rate for Payer: Healthscope Commercial	$549.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$519.14
Rate for Payer: PHP Commercial	$519.14
Rate for Payer: Priority Health Cigna Priority Health	$396.99
Rate for Payer: Priority Health SBD	$384.77

Know your out-of-pocket cost for care.

All Charges