Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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

$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)	$366.28
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	$366.28
Rate for Payer: Priority Health SBD	$355.00

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 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)	$634.72
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	$634.72
Rate for Payer: Priority Health SBD	$615.20

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	$615.20
Max. Negotiated Rate	$878.85
Rate for Payer: Aetna Commercial	$830.02
Rate for Payer: Aetna New Business (MI Preferred)	$634.72
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	$634.72
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	$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 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

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

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 Commercial	$343.73
Rate for Payer: Cofinity Commercial	$422.29
Rate for Payer: Cofinity Medicare Advantage	$343.73
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: PHP Commercial	$417.38
Rate for Payer: Priority Health Cigna Priority Health	$319.18
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	$196.42
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 Commercial	$343.73
Rate for Payer: Cofinity Commercial	$422.29
Rate for Payer: Cofinity Medicare Advantage	$343.73
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: PHP Commercial	$417.38
Rate for Payer: Priority Health Cigna Priority Health	$319.18
Rate for Payer: Priority Health SBD	$309.36

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

Facility

$53.63

Service Code	NDC 00904675920
Hospital Charge Code	108397
Hospital Revenue Code	637
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$48.27
Rate for Payer: Aetna Commercial	$45.59
Rate for Payer: Aetna Medicare	$26.82
Rate for Payer: Aetna New Business (MI Preferred)	$34.86
Rate for Payer: BCBS Complete	$21.45
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cofinity Commercial	$37.54
Rate for Payer: Cofinity Commercial	$46.12
Rate for Payer: Cofinity Medicare Advantage	$37.54
Rate for Payer: Encore Health Key Benefits Commercial	$42.90
Rate for Payer: Healthscope Commercial	$48.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.59
Rate for Payer: PHP Commercial	$45.59
Rate for Payer: Priority Health Cigna Priority Health	$34.86
Rate for Payer: Priority Health SBD	$33.79

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	$32.38
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 Commercial	$56.66
Rate for Payer: Cofinity Commercial	$69.61
Rate for Payer: Cofinity Medicare Advantage	$56.66
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: PHP Commercial	$68.80
Rate for Payer: Priority Health Cigna Priority Health	$52.61
Rate for Payer: Priority Health SBD	$50.99

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

Facility

$53.63

Service Code	NDC 00904675920
Hospital Charge Code	108397
Hospital Revenue Code	637
Min. Negotiated Rate	$33.79
Max. Negotiated Rate	$48.27
Rate for Payer: Aetna Commercial	$45.59
Rate for Payer: Aetna New Business (MI Preferred)	$34.86
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cofinity Commercial	$37.54
Rate for Payer: Cofinity Commercial	$46.12
Rate for Payer: Cofinity Medicare Advantage	$37.54
Rate for Payer: Encore Health Key Benefits Commercial	$42.90
Rate for Payer: Healthscope Commercial	$48.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.59
Rate for Payer: PHP Commercial	$45.59
Rate for Payer: Priority Health Cigna Priority Health	$34.86
Rate for Payer: Priority Health SBD	$33.79

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 Commercial	$56.66
Rate for Payer: Cofinity Commercial	$69.61
Rate for Payer: Cofinity Medicare Advantage	$56.66
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: PHP Commercial	$68.80
Rate for Payer: Priority Health Cigna Priority Health	$52.61
Rate for Payer: Priority Health SBD	$50.99

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)	$55.06
Rate for Payer: Cash Price	$67.76
Rate for Payer: Cofinity Commercial	$59.29
Rate for Payer: Cofinity Commercial	$72.84
Rate for Payer: Cofinity Medicare Advantage	$59.29
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: PHP Commercial	$72.00
Rate for Payer: Priority Health Cigna Priority Health	$55.06
Rate for Payer: Priority Health SBD	$53.36

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	$33.88
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)	$55.06
Rate for Payer: BCBS Complete	$33.88
Rate for Payer: Cash Price	$67.76
Rate for Payer: Cofinity Commercial	$59.29
Rate for Payer: Cofinity Commercial	$72.84
Rate for Payer: Cofinity Medicare Advantage	$59.29
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: PHP Commercial	$72.00
Rate for Payer: Priority Health Cigna Priority Health	$55.06
Rate for Payer: Priority Health SBD	$53.36

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

Facility

$7.54

Service Code	NDC 00121127600
Hospital Charge Code	9774
Hospital Revenue Code	637
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna Commercial	$6.41
Rate for Payer: Aetna Medicare	$3.77
Rate for Payer: Aetna New Business (MI Preferred)	$4.90
Rate for Payer: BCBS Complete	$3.02
Rate for Payer: Cash Price	$6.03
Rate for Payer: Cofinity Commercial	$5.28
Rate for Payer: Cofinity Commercial	$6.48
Rate for Payer: Cofinity Medicare Advantage	$5.28
Rate for Payer: Encore Health Key Benefits Commercial	$6.03
Rate for Payer: Healthscope Commercial	$6.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.41
Rate for Payer: PHP Commercial	$6.41
Rate for Payer: Priority Health Cigna Priority Health	$4.90
Rate for Payer: Priority Health SBD	$4.75

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

Facility

$7.54

Service Code	NDC 00121127610
Hospital Charge Code	9774
Hospital Revenue Code	637
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna Commercial	$6.41
Rate for Payer: Aetna Medicare	$3.77
Rate for Payer: Aetna New Business (MI Preferred)	$4.90
Rate for Payer: BCBS Complete	$3.02
Rate for Payer: Cash Price	$6.03
Rate for Payer: Cofinity Commercial	$5.28
Rate for Payer: Cofinity Commercial	$6.48
Rate for Payer: Cofinity Medicare Advantage	$5.28
Rate for Payer: Encore Health Key Benefits Commercial	$6.03
Rate for Payer: Healthscope Commercial	$6.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.41
Rate for Payer: PHP Commercial	$6.41
Rate for Payer: Priority Health Cigna Priority Health	$4.90
Rate for Payer: Priority Health SBD	$4.75

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

Facility

$7.54

Service Code	NDC 00121127610
Hospital Charge Code	9774
Hospital Revenue Code	637
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna Commercial	$6.41
Rate for Payer: Aetna New Business (MI Preferred)	$4.90
Rate for Payer: Cash Price	$6.03
Rate for Payer: Cofinity Commercial	$5.28
Rate for Payer: Cofinity Commercial	$6.48
Rate for Payer: Cofinity Medicare Advantage	$5.28
Rate for Payer: Encore Health Key Benefits Commercial	$6.03
Rate for Payer: Healthscope Commercial	$6.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.41
Rate for Payer: PHP Commercial	$6.41
Rate for Payer: Priority Health Cigna Priority Health	$4.90
Rate for Payer: Priority Health SBD	$4.75

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

Facility

$7.54

Service Code	NDC 00121127600
Hospital Charge Code	9774
Hospital Revenue Code	637
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna Commercial	$6.41
Rate for Payer: Aetna New Business (MI Preferred)	$4.90
Rate for Payer: Cash Price	$6.03
Rate for Payer: Cofinity Commercial	$5.28
Rate for Payer: Cofinity Commercial	$6.48
Rate for Payer: Cofinity Medicare Advantage	$5.28
Rate for Payer: Encore Health Key Benefits Commercial	$6.03
Rate for Payer: Healthscope Commercial	$6.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.41
Rate for Payer: PHP Commercial	$6.41
Rate for Payer: Priority Health Cigna Priority Health	$4.90
Rate for Payer: Priority Health SBD	$4.75

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 Commercial	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Cofinity Medicare Advantage	$48.94
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: PHP Commercial	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$45.45
Rate for Payer: Priority Health SBD	$44.05

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 Commercial	$42.83
Rate for Payer: Cofinity Commercial	$52.61
Rate for Payer: Cofinity Medicare Advantage	$42.83
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: PHP Commercial	$52.00
Rate for Payer: Priority Health Cigna Priority Health	$39.77
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 Commercial	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Cofinity Medicare Advantage	$48.94
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: PHP Commercial	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$45.45
Rate for Payer: Priority Health SBD	$44.05

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	$27.97
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 Commercial	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Cofinity Medicare Advantage	$48.94
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: PHP Commercial	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$45.45
Rate for Payer: Priority Health SBD	$44.05

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	$27.97
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 Commercial	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Cofinity Medicare Advantage	$48.94
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: PHP Commercial	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$45.45
Rate for Payer: Priority Health SBD	$44.05

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	$24.47
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 Commercial	$42.83
Rate for Payer: Cofinity Commercial	$52.61
Rate for Payer: Cofinity Medicare Advantage	$42.83
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: PHP Commercial	$52.00
Rate for Payer: Priority Health Cigna Priority Health	$39.77
Rate for Payer: Priority Health SBD	$38.54

Know your out-of-pocket cost for care.

All Charges