Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DRAINAGE OF SCROTAL WALL ABSCESS

Facility

$4,989.41

Service Code	CPT 55100
Hospital Revenue Code	360
Min. Negotiated Rate	$177.62
Max. Negotiated Rate	$4,989.41
Rate for Payer: Aetna Medicare	$1,650.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,984.35
Rate for Payer: Amish Plain Church Group Commercial	$1,984.35
Rate for Payer: BCBS Complete	$893.43
Rate for Payer: BCBS MAPPO	$1,587.48
Rate for Payer: BCBS Trust/PPO	$466.03
Rate for Payer: BCN Commercial	$466.03
Rate for Payer: BCN Medicare Advantage	$1,587.48
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,587.48
Rate for Payer: Mclaren Medicaid	$850.89
Rate for Payer: Mclaren Medicare	$1,587.48
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,666.85
Rate for Payer: Meridian Medicaid	$893.43
Rate for Payer: MI Amish Medical Board Commercial	$1,825.60
Rate for Payer: Nomi Health Commercial	$3,333.71
Rate for Payer: PACE Medicare	$1,508.11
Rate for Payer: PACE SWMI	$1,587.48
Rate for Payer: PHP Medicare Advantage	$1,587.48
Rate for Payer: Priority Health Choice Medicaid	$850.89
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,989.41
Rate for Payer: Priority Health Medicare	$1,587.48
Rate for Payer: Priority Health Narrow Network	$3,991.53
Rate for Payer: Railroad Medicare Medicare	$1,587.48
Rate for Payer: UHC All Payor (Choice/PPO)	$177.62
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,587.48
Rate for Payer: UHC Exchange	$3,362.00
Rate for Payer: UHC Medicare Advantage	$1,587.48
Rate for Payer: UHCCP Medicaid	$893.75
Rate for Payer: VA VA	$1,587.48

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 Commercial	$15.20
Rate for Payer: Cofinity Commercial	$18.68
Rate for Payer: Cofinity Medicare Advantage	$15.20
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: PHP Commercial	$18.46
Rate for Payer: Priority Health Cigna Priority Health	$14.12
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	$8.69
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 Commercial	$15.20
Rate for Payer: Cofinity Commercial	$18.68
Rate for Payer: Cofinity Medicare Advantage	$15.20
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: PHP Commercial	$18.46
Rate for Payer: Priority Health Cigna Priority Health	$14.12
Rate for Payer: Priority Health SBD	$13.68

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 Commercial	$1,049.14
Rate for Payer: Cofinity Commercial	$1,288.94
Rate for Payer: Cofinity Medicare Advantage	$1,049.14
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: PHP Commercial	$1,273.95
Rate for Payer: Priority Health Cigna Priority Health	$974.20
Rate for Payer: Priority Health SBD	$944.23

DRONABINOL 2.5 MG CAPSULE

Facility

$1,498.77

Service Code	NDC 60687037501
Hospital Charge Code	9904
Hospital Revenue Code	637
Min. Negotiated Rate	$599.51
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 Commercial	$1,049.14
Rate for Payer: Cofinity Commercial	$1,288.94
Rate for Payer: Cofinity Medicare Advantage	$1,049.14
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: PHP Commercial	$1,273.95
Rate for Payer: Priority Health Cigna Priority Health	$974.20
Rate for Payer: Priority Health SBD	$944.23

DRONEDARONE 400 MG TABLET

Facility

$2,731.49

Service Code	NDC 00024414260
Hospital Charge Code	98329
Hospital Revenue Code	637
Min. Negotiated Rate	$1,092.60
Max. Negotiated Rate	$2,458.34
Rate for Payer: Aetna Commercial	$2,321.77
Rate for Payer: Aetna Medicare	$1,365.74
Rate for Payer: Aetna New Business (MI Preferred)	$1,775.47
Rate for Payer: BCBS Complete	$1,092.60
Rate for Payer: Cash Price	$2,185.19
Rate for Payer: Cofinity Commercial	$1,912.04
Rate for Payer: Cofinity Commercial	$2,349.08
Rate for Payer: Cofinity Medicare Advantage	$1,912.04
Rate for Payer: Encore Health Key Benefits Commercial	$2,185.19
Rate for Payer: Healthscope Commercial	$2,458.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,321.77
Rate for Payer: PHP Commercial	$2,321.77
Rate for Payer: Priority Health Cigna Priority Health	$1,775.47
Rate for Payer: Priority Health SBD	$1,720.84

DRONEDARONE 400 MG TABLET

Facility

$2,731.49

Service Code	NDC 00024414260
Hospital Charge Code	98329
Hospital Revenue Code	637
Min. Negotiated Rate	$1,720.84
Max. Negotiated Rate	$2,458.34
Rate for Payer: Aetna Commercial	$2,321.77
Rate for Payer: Aetna New Business (MI Preferred)	$1,775.47
Rate for Payer: Cash Price	$2,185.19
Rate for Payer: Cofinity Commercial	$1,912.04
Rate for Payer: Cofinity Commercial	$2,349.08
Rate for Payer: Cofinity Medicare Advantage	$1,912.04
Rate for Payer: Encore Health Key Benefits Commercial	$2,185.19
Rate for Payer: Healthscope Commercial	$2,458.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,321.77
Rate for Payer: PHP Commercial	$2,321.77
Rate for Payer: Priority Health Cigna Priority Health	$1,775.47
Rate for Payer: Priority Health SBD	$1,720.84

DROPERIDOL 2.5 MG/ML INJECTION SOLUTION

Facility

$38.86

Service Code	HCPCS J1790
Hospital Charge Code	2654
Hospital Revenue Code	636
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$34.97
Rate for Payer: Aetna Commercial	$33.03
Rate for Payer: Aetna Commercial	$46.33
Rate for Payer: Aetna Medicare	$27.26
Rate for Payer: Aetna Medicare	$19.43
Rate for Payer: Aetna New Business (MI Preferred)	$25.26
Rate for Payer: Aetna New Business (MI Preferred)	$35.43
Rate for Payer: BCBS Complete	$21.80
Rate for Payer: BCBS Complete	$15.54
Rate for Payer: BCBS Trust/PPO	$27.12
Rate for Payer: BCBS Trust/PPO	$27.12
Rate for Payer: BCN Commercial	$27.12
Rate for Payer: BCN Commercial	$27.12
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cash Price	$31.09
Rate for Payer: Cash Price	$31.09
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cofinity Commercial	$33.42
Rate for Payer: Cofinity Commercial	$27.20
Rate for Payer: Cofinity Commercial	$38.16
Rate for Payer: Cofinity Commercial	$46.88
Rate for Payer: Cofinity Medicare Advantage	$27.20
Rate for Payer: Cofinity Medicare Advantage	$38.16
Rate for Payer: Encore Health Key Benefits Commercial	$31.09
Rate for Payer: Encore Health Key Benefits Commercial	$43.61
Rate for Payer: Healthscope Commercial	$49.06
Rate for Payer: Healthscope Commercial	$34.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$46.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.03
Rate for Payer: PHP Commercial	$46.33
Rate for Payer: PHP Commercial	$33.03
Rate for Payer: Priority Health Cigna Priority Health	$35.43
Rate for Payer: Priority Health Cigna Priority Health	$25.26
Rate for Payer: Priority Health SBD	$34.34
Rate for Payer: Priority Health SBD	$24.48

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	$33.03
Rate for Payer: Aetna New Business (MI Preferred)	$25.26
Rate for Payer: Aetna New Business (MI Preferred)	$35.43
Rate for Payer: Cash Price	$31.09
Rate for Payer: Cash Price	$43.61
Rate for Payer: Cofinity Commercial	$46.88
Rate for Payer: Cofinity Commercial	$38.16
Rate for Payer: Cofinity Commercial	$27.20
Rate for Payer: Cofinity Commercial	$33.42
Rate for Payer: Cofinity Medicare Advantage	$27.20
Rate for Payer: Cofinity Medicare Advantage	$38.16
Rate for Payer: Encore Health Key Benefits Commercial	$31.09
Rate for Payer: Encore Health Key Benefits Commercial	$43.61
Rate for Payer: Healthscope Commercial	$49.06
Rate for Payer: Healthscope Commercial	$34.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$46.33
Rate for Payer: PHP Commercial	$46.33
Rate for Payer: PHP Commercial	$33.03
Rate for Payer: Priority Health Cigna Priority Health	$25.26
Rate for Payer: Priority Health Cigna Priority Health	$35.43
Rate for Payer: Priority Health SBD	$24.48
Rate for Payer: Priority Health SBD	$34.34

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

Facility

$5,310.41

Service Code	CPT 42975
Hospital Revenue Code	360
Min. Negotiated Rate	$58.79
Max. Negotiated Rate	$5,310.41
Rate for Payer: Aetna Medicare	$1,757.18
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,112.00
Rate for Payer: Amish Plain Church Group Commercial	$2,112.00
Rate for Payer: BCBS Complete	$950.91
Rate for Payer: BCBS MAPPO	$1,689.60
Rate for Payer: BCBS Trust/PPO	$58.79
Rate for Payer: BCN Commercial	$58.79
Rate for Payer: BCN Medicare Advantage	$1,689.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,689.60
Rate for Payer: Mclaren Medicaid	$905.63
Rate for Payer: Mclaren Medicare	$1,689.60
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,774.08
Rate for Payer: Meridian Medicaid	$950.91
Rate for Payer: MI Amish Medical Board Commercial	$1,943.04
Rate for Payer: Nomi Health Commercial	$3,548.16
Rate for Payer: PACE Medicare	$1,605.12
Rate for Payer: PACE SWMI	$1,689.60
Rate for Payer: PHP Medicare Advantage	$1,689.60
Rate for Payer: Priority Health Choice Medicaid	$905.63
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,310.41
Rate for Payer: Priority Health Medicare	$1,689.60
Rate for Payer: Priority Health Narrow Network	$4,248.33
Rate for Payer: Railroad Medicare Medicare	$1,689.60
Rate for Payer: UHC All Payor (Choice/PPO)	$102.72
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Dual Complete DSNP	$1,689.60
Rate for Payer: UHC Exchange	$940.00
Rate for Payer: UHC Medicare Advantage	$1,689.60
Rate for Payer: UHCCP Medicaid	$951.24
Rate for Payer: VA VA	$1,689.60

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	$16.78
Rate for Payer: Aetna Medicare	$8.00
Rate for Payer: BCBS Complete	$6.40
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cash Price	$12.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$10.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.78
Rate for Payer: Priority Health Narrow Network	$16.78
Rate for Payer: Priority Health SBD	$16.78

DRUG TEST PRESUMPTIVE USING IMMUNOASSAY

Professional

Both

$82.00

Service Code	HCPCS G0479
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$67.44
Rate for Payer: Aetna Medicare	$41.00
Rate for Payer: BCBS Complete	$32.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.30
Rate for Payer: Priority Health Cigna Priority Health	$53.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$67.44
Rate for Payer: Priority Health Narrow Network	$67.44
Rate for Payer: Priority Health SBD	$67.44

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	$12.82
Rate for Payer: Aetna Medicare	$6.00
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.80
Rate for Payer: Priority Health Cigna Priority Health	$7.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12.82
Rate for Payer: Priority Health Narrow Network	$12.82
Rate for Payer: Priority Health SBD	$12.82

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 Commercial	$2.97
Rate for Payer: Cofinity Commercial	$3.65
Rate for Payer: Cofinity Medicare Advantage	$2.97
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: PHP Commercial	$3.60
Rate for Payer: Priority Health Cigna Priority Health	$2.76
Rate for Payer: Priority Health SBD	$2.67

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	$1,084.76
Max. Negotiated Rate	$1,549.66
Rate for Payer: Aetna Commercial	$1,463.56
Rate for Payer: Aetna New Business (MI Preferred)	$1,119.20
Rate for Payer: Cash Price	$1,377.47
Rate for Payer: Cofinity Commercial	$1,205.29
Rate for Payer: Cofinity Commercial	$1,480.78
Rate for Payer: Cofinity Medicare Advantage	$1,205.29
Rate for Payer: Encore Health Key Benefits Commercial	$1,377.47
Rate for Payer: Healthscope Commercial	$1,549.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,463.56
Rate for Payer: PHP Commercial	$1,463.56
Rate for Payer: Priority Health Cigna Priority Health	$1,119.20
Rate for Payer: Priority Health SBD	$1,084.76

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	$103.82
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 Commercial	$80.74
Rate for Payer: Cofinity Commercial	$99.20
Rate for Payer: Cofinity Medicare Advantage	$80.74
Rate for Payer: Encore Health Key Benefits Commercial	$92.28
Rate for Payer: Healthscope Commercial	$103.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$98.05
Rate for Payer: PHP Commercial	$98.05
Rate for Payer: Priority Health Cigna Priority Health	$74.98
Rate for Payer: Priority Health SBD	$72.67

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	$688.74
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 Commercial	$1,205.29
Rate for Payer: Cofinity Commercial	$1,480.78
Rate for Payer: Cofinity Medicare Advantage	$1,205.29
Rate for Payer: Encore Health Key Benefits Commercial	$1,377.47
Rate for Payer: Healthscope Commercial	$1,549.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,463.56
Rate for Payer: PHP Commercial	$1,463.56
Rate for Payer: Priority Health Cigna Priority Health	$1,119.20
Rate for Payer: Priority Health SBD	$1,084.76

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$127.01

Service Code	NDC 60687072321
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$80.02
Max. Negotiated Rate	$114.31
Rate for Payer: Aetna Commercial	$107.96
Rate for Payer: Aetna New Business (MI Preferred)	$82.56
Rate for Payer: Cash Price	$101.61
Rate for Payer: Cofinity Commercial	$109.23
Rate for Payer: Cofinity Commercial	$88.91
Rate for Payer: Cofinity Medicare Advantage	$88.91
Rate for Payer: Encore Health Key Benefits Commercial	$101.61
Rate for Payer: Healthscope Commercial	$114.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$107.96
Rate for Payer: PHP Commercial	$107.96
Rate for Payer: Priority Health Cigna Priority Health	$82.56
Rate for Payer: Priority Health SBD	$80.02

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$115.35

Service Code	NDC 00904704304
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$46.14
Max. Negotiated Rate	$103.82
Rate for Payer: Aetna Commercial	$98.05
Rate for Payer: Aetna Medicare	$57.68
Rate for Payer: Aetna New Business (MI Preferred)	$74.98
Rate for Payer: BCBS Complete	$46.14
Rate for Payer: Cash Price	$92.28
Rate for Payer: Cofinity Commercial	$80.74
Rate for Payer: Cofinity Commercial	$99.20
Rate for Payer: Cofinity Medicare Advantage	$80.74
Rate for Payer: Encore Health Key Benefits Commercial	$92.28
Rate for Payer: Healthscope Commercial	$103.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$98.05
Rate for Payer: PHP Commercial	$98.05
Rate for Payer: Priority Health Cigna Priority Health	$74.98
Rate for Payer: Priority Health SBD	$72.67

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$127.01

Service Code	NDC 60687072321
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$50.80
Max. Negotiated Rate	$114.31
Rate for Payer: Aetna Commercial	$107.96
Rate for Payer: Aetna Medicare	$63.50
Rate for Payer: Aetna New Business (MI Preferred)	$82.56
Rate for Payer: BCBS Complete	$50.80
Rate for Payer: Cash Price	$101.61
Rate for Payer: Cofinity Commercial	$109.23
Rate for Payer: Cofinity Commercial	$88.91
Rate for Payer: Cofinity Medicare Advantage	$88.91
Rate for Payer: Encore Health Key Benefits Commercial	$101.61
Rate for Payer: Healthscope Commercial	$114.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$107.96
Rate for Payer: PHP Commercial	$107.96
Rate for Payer: Priority Health Cigna Priority Health	$82.56
Rate for Payer: Priority Health SBD	$80.02

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$4.24

Service Code	NDC 60687072311
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$1.70
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 Commercial	$2.97
Rate for Payer: Cofinity Commercial	$3.65
Rate for Payer: Cofinity Medicare Advantage	$2.97
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: PHP Commercial	$3.60
Rate for Payer: Priority Health Cigna Priority Health	$2.76
Rate for Payer: Priority Health SBD	$2.67

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$714.24

Service Code	NDC 68084068301
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$449.97
Max. Negotiated Rate	$642.82
Rate for Payer: Aetna Commercial	$607.10
Rate for Payer: Aetna New Business (MI Preferred)	$464.26
Rate for Payer: Cash Price	$571.39
Rate for Payer: Cofinity Commercial	$499.97
Rate for Payer: Cofinity Commercial	$614.25
Rate for Payer: Cofinity Medicare Advantage	$499.97
Rate for Payer: Encore Health Key Benefits Commercial	$571.39
Rate for Payer: Healthscope Commercial	$642.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$607.10
Rate for Payer: PHP Commercial	$607.10
Rate for Payer: Priority Health Cigna Priority Health	$464.26
Rate for Payer: Priority Health SBD	$449.97

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$714.24

Service Code	NDC 68084068301
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$285.70
Max. Negotiated Rate	$642.82
Rate for Payer: Aetna Commercial	$607.10
Rate for Payer: Aetna Medicare	$357.12
Rate for Payer: Aetna New Business (MI Preferred)	$464.26
Rate for Payer: BCBS Complete	$285.70
Rate for Payer: Cash Price	$571.39
Rate for Payer: Cofinity Commercial	$499.97
Rate for Payer: Cofinity Commercial	$614.25
Rate for Payer: Cofinity Medicare Advantage	$499.97
Rate for Payer: Encore Health Key Benefits Commercial	$571.39
Rate for Payer: Healthscope Commercial	$642.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$607.10
Rate for Payer: PHP Commercial	$607.10
Rate for Payer: Priority Health Cigna Priority Health	$464.26
Rate for Payer: Priority Health SBD	$449.97

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$445.44

Service Code	NDC 00904704461
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$178.18
Max. Negotiated Rate	$400.90
Rate for Payer: Aetna Commercial	$378.62
Rate for Payer: Aetna Medicare	$222.72
Rate for Payer: Aetna New Business (MI Preferred)	$289.54
Rate for Payer: BCBS Complete	$178.18
Rate for Payer: Cash Price	$356.35
Rate for Payer: Cofinity Commercial	$311.81
Rate for Payer: Cofinity Commercial	$383.08
Rate for Payer: Cofinity Medicare Advantage	$311.81
Rate for Payer: Encore Health Key Benefits Commercial	$356.35
Rate for Payer: Healthscope Commercial	$400.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$378.62
Rate for Payer: PHP Commercial	$378.62
Rate for Payer: Priority Health Cigna Priority Health	$289.54
Rate for Payer: Priority Health SBD	$280.63

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$445.44

Service Code	NDC 00904704461
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$280.63
Max. Negotiated Rate	$400.90
Rate for Payer: Aetna Commercial	$378.62
Rate for Payer: Aetna New Business (MI Preferred)	$289.54
Rate for Payer: Cash Price	$356.35
Rate for Payer: Cofinity Commercial	$311.81
Rate for Payer: Cofinity Commercial	$383.08
Rate for Payer: Cofinity Medicare Advantage	$311.81
Rate for Payer: Encore Health Key Benefits Commercial	$356.35
Rate for Payer: Healthscope Commercial	$400.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$378.62
Rate for Payer: PHP Commercial	$378.62
Rate for Payer: Priority Health Cigna Priority Health	$289.54
Rate for Payer: Priority Health SBD	$280.63

Know your out-of-pocket cost for care.

All Charges