Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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

$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

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 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

$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 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

$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

$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

$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

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	$33.80
Max. Negotiated Rate	$436.80
Rate for Payer: Aetna Commercial	$412.53
Rate for Payer: Aetna Medicare	$65.58
Rate for Payer: Aetna New Business (MI Preferred)	$315.46
Rate for Payer: Allen County Amish Medical Aid Commercial	$78.83
Rate for Payer: Amish Plain Church Group Commercial	$78.83
Rate for Payer: BCBS Complete	$35.49
Rate for Payer: BCBS MAPPO	$63.06
Rate for Payer: BCN Medicare Advantage	$63.06
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	$63.06
Rate for Payer: Healthscope Commercial	$436.80
Rate for Payer: Mclaren Medicaid	$33.80
Rate for Payer: Mclaren Medicare	$63.06
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$66.21
Rate for Payer: Meridian Medicaid	$35.49
Rate for Payer: MI Amish Medical Board Commercial	$72.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$412.53
Rate for Payer: PACE Medicare	$59.91
Rate for Payer: PACE SWMI	$63.06
Rate for Payer: PHP Commercial	$412.53
Rate for Payer: PHP Medicare Advantage	$63.06
Rate for Payer: Priority Health Choice Medicaid	$33.80
Rate for Payer: Priority Health Cigna Priority Health	$315.46
Rate for Payer: Priority Health Medicare	$63.06
Rate for Payer: Priority Health SBD	$305.76
Rate for Payer: Railroad Medicare Medicare	$63.06
Rate for Payer: UHC All Payor (Choice/PPO)	$177.51
Rate for Payer: UHC Dual Complete DSNP	$63.06
Rate for Payer: UHC Medicare Advantage	$63.06
Rate for Payer: UHCCP Medicaid	$35.50
Rate for Payer: VA VA	$63.06

DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION

Facility

$983.57

Service Code	HCPCS J1190
Hospital Charge Code	15157
Hospital Revenue Code	636
Min. Negotiated Rate	$33.80
Max. Negotiated Rate	$885.21
Rate for Payer: Aetna Commercial	$836.03
Rate for Payer: Aetna Medicare	$65.58
Rate for Payer: Aetna New Business (MI Preferred)	$639.32
Rate for Payer: Allen County Amish Medical Aid Commercial	$78.83
Rate for Payer: Amish Plain Church Group Commercial	$78.83
Rate for Payer: BCBS Complete	$35.49
Rate for Payer: BCBS MAPPO	$63.06
Rate for Payer: BCN Medicare Advantage	$63.06
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	$63.06
Rate for Payer: Healthscope Commercial	$885.21
Rate for Payer: Mclaren Medicaid	$33.80
Rate for Payer: Mclaren Medicare	$63.06
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$66.21
Rate for Payer: Meridian Medicaid	$35.49
Rate for Payer: MI Amish Medical Board Commercial	$72.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$836.03
Rate for Payer: PACE Medicare	$59.91
Rate for Payer: PACE SWMI	$63.06
Rate for Payer: PHP Commercial	$836.03
Rate for Payer: PHP Medicare Advantage	$63.06
Rate for Payer: Priority Health Choice Medicaid	$33.80
Rate for Payer: Priority Health Cigna Priority Health	$639.32
Rate for Payer: Priority Health Medicare	$63.06
Rate for Payer: Priority Health SBD	$619.65
Rate for Payer: Railroad Medicare Medicare	$63.06
Rate for Payer: UHC All Payor (Choice/PPO)	$177.51
Rate for Payer: UHC Dual Complete DSNP	$63.06
Rate for Payer: UHC Medicare Advantage	$63.06
Rate for Payer: UHCCP Medicaid	$35.50
Rate for Payer: VA VA	$63.06

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

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: 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

$610.75

Service Code	NDC 13107007001
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$244.30
Max. Negotiated Rate	$549.67
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	$525.25
Rate for Payer: Cofinity Medicare Advantage	$427.52
Rate for Payer: Encore Health Key Benefits Commercial	$488.60
Rate for Payer: Healthscope Commercial	$549.67
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

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)	$366.27
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	$366.27
Rate for Payer: Priority Health SBD	$355.00

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET

Facility

$3,600.30

Service Code	NDC 57844011001
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$2,268.19
Max. Negotiated Rate	$3,240.27
Rate for Payer: Aetna Commercial	$3,060.26
Rate for Payer: Aetna New Business (MI Preferred)	$2,340.20
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	$518.17
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	$518.17

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET

Facility

$563.50

Service Code	NDC 00555097202
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$225.40
Max. Negotiated Rate	$507.15
Rate for Payer: Aetna Commercial	$478.98
Rate for Payer: Aetna Medicare	$281.75
Rate for Payer: Aetna New Business (MI Preferred)	$366.27
Rate for Payer: BCBS Complete	$225.40
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	$366.27
Rate for Payer: Priority Health SBD	$355.00

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	$518.17

DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET

Facility

$610.75

Service Code	NDC 13107007001
Hospital Charge Code	108419
Hospital Revenue Code	637
Min. Negotiated Rate	$384.77
Max. Negotiated Rate	$549.67
Rate for Payer: Aetna Commercial	$519.14
Rate for Payer: Aetna New Business (MI Preferred)	$396.99
Rate for Payer: Cash Price	$488.60
Rate for Payer: Cofinity Commercial	$427.52
Rate for Payer: Cofinity Commercial	$525.25
Rate for Payer: Cofinity Medicare Advantage	$427.52
Rate for Payer: Encore Health Key Benefits Commercial	$488.60
Rate for Payer: Healthscope Commercial	$549.67
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

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	$3,096.26
Rate for Payer: Cofinity Commercial	$2,520.21
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 ER 10 MG 24HR CAPSULE,EXTEND RELEASE

Facility

$976.50

Service Code	NDC 70010003001
Hospital Charge Code	31587
Hospital Revenue Code	637
Min. Negotiated Rate	$390.60
Max. Negotiated Rate	$878.85
Rate for Payer: Aetna Commercial	$830.02
Rate for Payer: Aetna Medicare	$488.25
Rate for Payer: Aetna New Business (MI Preferred)	$634.73
Rate for Payer: BCBS Complete	$390.60
Rate for Payer: Cash Price	$781.20
Rate for Payer: Cofinity Commercial	$683.55
Rate for Payer: Cofinity Commercial	$839.79
Rate for Payer: Cofinity Medicare Advantage	$683.55
Rate for Payer: Encore Health Key Benefits Commercial	$781.20
Rate for Payer: Healthscope Commercial	$878.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$830.02
Rate for Payer: PHP Commercial	$830.02
Rate for Payer: Priority Health Cigna Priority Health	$634.73
Rate for Payer: Priority Health SBD	$615.20

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	$286.44
Max. Negotiated Rate	$644.49
Rate for Payer: Aetna Commercial	$608.68
Rate for Payer: Aetna Medicare	$358.05
Rate for Payer: Aetna New Business (MI Preferred)	$465.46
Rate for Payer: BCBS Complete	$286.44
Rate for Payer: Cash Price	$572.88
Rate for Payer: Cofinity Commercial	$501.27
Rate for Payer: Cofinity Commercial	$615.85
Rate for Payer: Cofinity Medicare Advantage	$501.27
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: PHP Commercial	$608.68
Rate for Payer: Priority Health Cigna Priority Health	$465.46
Rate for Payer: Priority Health SBD	$451.14

Know your out-of-pocket cost for care.

All Charges