Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$211.85

Service Code	NDC 65162-755-10
Hospital Charge Code	34418
Hospital Revenue Code	637
Min. Negotiated Rate	$129.21
Max. Negotiated Rate	$190.66
Rate for Payer: Aetna Commercial	$180.07
Rate for Payer: BCBS Trust/PPO	$163.72
Rate for Payer: BCN Commercial	$163.72
Rate for Payer: Cash Price	$169.48
Rate for Payer: Cofinity Commercial	$182.19
Rate for Payer: Encore Health Key Benefits Commercial	$169.48
Rate for Payer: Healthscope Commercial	$190.66
Rate for Payer: Lakeland Regional Health Systems Commercial	$158.89
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$180.07
Rate for Payer: PHP Commercial	$180.07
Rate for Payer: Priority Health Cigna Priority Health	$148.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$184.31
Rate for Payer: Priority Health Narrow/Tiered Network	$129.21
Rate for Payer: UHC All Payor (Choice/PPO)	$186.43
Rate for Payer: UHC Core	$176.89
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$158.89

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$1,149.96

Service Code	NDC 0074-3826-11
Hospital Charge Code	34418
Hospital Revenue Code	637
Min. Negotiated Rate	$701.36
Max. Negotiated Rate	$1,034.96
Rate for Payer: Aetna Commercial	$977.47
Rate for Payer: BCBS Trust/PPO	$888.69
Rate for Payer: BCN Commercial	$888.69
Rate for Payer: Cash Price	$919.97
Rate for Payer: Cofinity Commercial	$988.97
Rate for Payer: Encore Health Key Benefits Commercial	$919.97
Rate for Payer: Healthscope Commercial	$1,034.96
Rate for Payer: Lakeland Regional Health Systems Commercial	$862.47
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$977.47
Rate for Payer: PHP Commercial	$977.47
Rate for Payer: Priority Health Cigna Priority Health	$804.97
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,000.47
Rate for Payer: Priority Health Narrow/Tiered Network	$701.36
Rate for Payer: UHC All Payor (Choice/PPO)	$1,011.96
Rate for Payer: UHC Core	$960.22
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$862.47

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$380.00

Service Code	NDC 55111-533-01
Hospital Charge Code	34418
Hospital Revenue Code	637
Min. Negotiated Rate	$231.76
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$323.00
Rate for Payer: BCBS Trust/PPO	$293.66
Rate for Payer: BCN Commercial	$293.66
Rate for Payer: Cash Price	$304.00
Rate for Payer: Cofinity Commercial	$326.80
Rate for Payer: Encore Health Key Benefits Commercial	$304.00
Rate for Payer: Healthscope Commercial	$342.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$285.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$323.00
Rate for Payer: PHP Commercial	$323.00
Rate for Payer: Priority Health Cigna Priority Health	$266.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$330.60
Rate for Payer: Priority Health Narrow/Tiered Network	$231.76
Rate for Payer: UHC All Payor (Choice/PPO)	$334.40
Rate for Payer: UHC Core	$317.30
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$285.00

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$601.44

Service Code	NDC 0904-7182-61
Hospital Charge Code	81426
Hospital Revenue Code	637
Min. Negotiated Rate	$366.82
Max. Negotiated Rate	$541.30
Rate for Payer: Aetna Commercial	$511.22
Rate for Payer: BCBS Trust/PPO	$464.79
Rate for Payer: BCN Commercial	$464.79
Rate for Payer: Cash Price	$481.15
Rate for Payer: Cofinity Commercial	$517.24
Rate for Payer: Encore Health Key Benefits Commercial	$481.15
Rate for Payer: Healthscope Commercial	$541.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$451.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$511.22
Rate for Payer: PHP Commercial	$511.22
Rate for Payer: Priority Health Cigna Priority Health	$421.01
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$523.25
Rate for Payer: Priority Health Narrow/Tiered Network	$366.82
Rate for Payer: UHC All Payor (Choice/PPO)	$529.27
Rate for Payer: UHC Core	$502.20
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$451.08

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$797.28

Service Code	NDC 68084-415-01
Hospital Charge Code	81426
Hospital Revenue Code	637
Min. Negotiated Rate	$486.26
Max. Negotiated Rate	$717.55
Rate for Payer: Aetna Commercial	$677.69
Rate for Payer: BCBS Trust/PPO	$616.14
Rate for Payer: BCN Commercial	$616.14
Rate for Payer: Cash Price	$637.82
Rate for Payer: Cofinity Commercial	$685.66
Rate for Payer: Encore Health Key Benefits Commercial	$637.82
Rate for Payer: Healthscope Commercial	$717.55
Rate for Payer: Lakeland Regional Health Systems Commercial	$597.96
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$677.69
Rate for Payer: PHP Commercial	$677.69
Rate for Payer: Priority Health Cigna Priority Health	$558.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$693.63
Rate for Payer: Priority Health Narrow/Tiered Network	$486.26
Rate for Payer: UHC All Payor (Choice/PPO)	$701.61
Rate for Payer: UHC Core	$665.73
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$597.96

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$258.40

Service Code	NDC 65162-757-10
Hospital Charge Code	81426
Hospital Revenue Code	637
Min. Negotiated Rate	$157.60
Max. Negotiated Rate	$232.56
Rate for Payer: Aetna Commercial	$219.64
Rate for Payer: BCBS Trust/PPO	$199.69
Rate for Payer: BCN Commercial	$199.69
Rate for Payer: Cash Price	$206.72
Rate for Payer: Cofinity Commercial	$222.22
Rate for Payer: Encore Health Key Benefits Commercial	$206.72
Rate for Payer: Healthscope Commercial	$232.56
Rate for Payer: Lakeland Regional Health Systems Commercial	$193.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$219.64
Rate for Payer: PHP Commercial	$219.64
Rate for Payer: Priority Health Cigna Priority Health	$180.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$224.81
Rate for Payer: Priority Health Narrow/Tiered Network	$157.60
Rate for Payer: UHC All Payor (Choice/PPO)	$227.39
Rate for Payer: UHC Core	$215.76
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$193.80

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$604.80

Service Code	NDC 0904-6364-61
Hospital Charge Code	81426
Hospital Revenue Code	637
Min. Negotiated Rate	$368.87
Max. Negotiated Rate	$544.32
Rate for Payer: Aetna Commercial	$514.08
Rate for Payer: BCBS Trust/PPO	$467.39
Rate for Payer: BCN Commercial	$467.39
Rate for Payer: Cash Price	$483.84
Rate for Payer: Cofinity Commercial	$520.13
Rate for Payer: Encore Health Key Benefits Commercial	$483.84
Rate for Payer: Healthscope Commercial	$544.32
Rate for Payer: Lakeland Regional Health Systems Commercial	$453.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$514.08
Rate for Payer: PHP Commercial	$514.08
Rate for Payer: Priority Health Cigna Priority Health	$423.36
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$526.18
Rate for Payer: Priority Health Narrow/Tiered Network	$368.87
Rate for Payer: UHC All Payor (Choice/PPO)	$532.22
Rate for Payer: UHC Core	$505.01
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$453.60

DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$7.98

Service Code	NDC 68084-415-11
Hospital Charge Code	81426
Hospital Revenue Code	637
Min. Negotiated Rate	$4.87
Max. Negotiated Rate	$7.18
Rate for Payer: Aetna Commercial	$6.78
Rate for Payer: BCBS Trust/PPO	$6.17
Rate for Payer: BCN Commercial	$6.17
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cofinity Commercial	$6.86
Rate for Payer: Encore Health Key Benefits Commercial	$6.38
Rate for Payer: Healthscope Commercial	$7.18
Rate for Payer: Lakeland Regional Health Systems Commercial	$5.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.78
Rate for Payer: PHP Commercial	$6.78
Rate for Payer: Priority Health Cigna Priority Health	$5.59
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$6.94
Rate for Payer: Priority Health Narrow/Tiered Network	$4.87
Rate for Payer: UHC All Payor (Choice/PPO)	$7.02
Rate for Payer: UHC Core	$6.66
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$5.98

DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS

Facility

$87.73

Service Code	HCPCS J1250
Hospital Charge Code	15981
Hospital Revenue Code	636
Min. Negotiated Rate	$53.51
Max. Negotiated Rate	$78.96
Rate for Payer: Aetna Commercial	$74.57
Rate for Payer: BCBS Trust/PPO	$67.80
Rate for Payer: BCN Commercial	$67.80
Rate for Payer: Cash Price	$70.18
Rate for Payer: Cofinity Commercial	$75.45
Rate for Payer: Encore Health Key Benefits Commercial	$70.18
Rate for Payer: Healthscope Commercial	$78.96
Rate for Payer: Lakeland Regional Health Systems Commercial	$65.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$74.57
Rate for Payer: PHP Commercial	$74.57
Rate for Payer: Priority Health Cigna Priority Health	$61.41
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$76.33
Rate for Payer: Priority Health Narrow/Tiered Network	$53.51
Rate for Payer: UHC All Payor (Choice/PPO)	$77.20
Rate for Payer: UHC Core	$73.25
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$65.80

DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV

Facility

$89.51

Service Code	HCPCS J1250
Hospital Charge Code	18315
Hospital Revenue Code	636
Min. Negotiated Rate	$54.59
Max. Negotiated Rate	$80.56
Rate for Payer: Aetna Commercial	$76.08
Rate for Payer: BCBS Trust/PPO	$69.17
Rate for Payer: BCN Commercial	$69.17
Rate for Payer: Cash Price	$71.61
Rate for Payer: Cofinity Commercial	$76.98
Rate for Payer: Encore Health Key Benefits Commercial	$71.61
Rate for Payer: Healthscope Commercial	$80.56
Rate for Payer: Lakeland Regional Health Systems Commercial	$67.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$76.08
Rate for Payer: PHP Commercial	$76.08
Rate for Payer: Priority Health Cigna Priority Health	$62.66
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$77.87
Rate for Payer: Priority Health Narrow/Tiered Network	$54.59
Rate for Payer: UHC All Payor (Choice/PPO)	$78.77
Rate for Payer: UHC Core	$74.74
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$67.13

DOCUSATE SODIUM 100 MG CAPSULE

Facility

$119.70

Service Code	NDC 0904-6457-60
Hospital Charge Code	2566
Hospital Revenue Code	637
Min. Negotiated Rate	$73.01
Max. Negotiated Rate	$107.73
Rate for Payer: Aetna Commercial	$101.74
Rate for Payer: BCBS Trust/PPO	$92.50
Rate for Payer: BCN Commercial	$92.50
Rate for Payer: Cash Price	$95.76
Rate for Payer: Cofinity Commercial	$102.94
Rate for Payer: Encore Health Key Benefits Commercial	$95.76
Rate for Payer: Healthscope Commercial	$107.73
Rate for Payer: Lakeland Regional Health Systems Commercial	$89.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$101.74
Rate for Payer: PHP Commercial	$101.74
Rate for Payer: Priority Health Cigna Priority Health	$83.79
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$104.14
Rate for Payer: Priority Health Narrow/Tiered Network	$73.01
Rate for Payer: UHC All Payor (Choice/PPO)	$105.34
Rate for Payer: UHC Core	$99.95
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$89.78

DOCUSATE SODIUM 100 MG CAPSULE

Facility

$100.80

Service Code	NDC 0904-6998-60
Hospital Charge Code	2566
Hospital Revenue Code	637
Min. Negotiated Rate	$61.48
Max. Negotiated Rate	$90.72
Rate for Payer: Aetna Commercial	$85.68
Rate for Payer: BCBS Trust/PPO	$77.90
Rate for Payer: BCN Commercial	$77.90
Rate for Payer: Cash Price	$80.64
Rate for Payer: Cofinity Commercial	$86.69
Rate for Payer: Encore Health Key Benefits Commercial	$80.64
Rate for Payer: Healthscope Commercial	$90.72
Rate for Payer: Lakeland Regional Health Systems Commercial	$75.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$85.68
Rate for Payer: PHP Commercial	$85.68
Rate for Payer: Priority Health Cigna Priority Health	$70.56
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$87.70
Rate for Payer: Priority Health Narrow/Tiered Network	$61.48
Rate for Payer: UHC All Payor (Choice/PPO)	$88.70
Rate for Payer: UHC Core	$84.17
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$75.60

DOCUSATE SODIUM 100 MG CAPSULE

Facility

$1.84

Service Code	NDC 60687-129-11
Hospital Charge Code	2566
Hospital Revenue Code	637
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna Commercial	$1.56
Rate for Payer: BCBS Trust/PPO	$1.42
Rate for Payer: BCN Commercial	$1.42
Rate for Payer: Cash Price	$1.47
Rate for Payer: Cofinity Commercial	$1.58
Rate for Payer: Encore Health Key Benefits Commercial	$1.47
Rate for Payer: Healthscope Commercial	$1.66
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.56
Rate for Payer: PHP Commercial	$1.56
Rate for Payer: Priority Health Cigna Priority Health	$1.29
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1.60
Rate for Payer: Priority Health Narrow/Tiered Network	$1.12
Rate for Payer: UHC All Payor (Choice/PPO)	$1.62
Rate for Payer: UHC Core	$1.54
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.38

DOCUSATE SODIUM 100 MG CAPSULE

Facility

$157.50

Service Code	NDC 0904-6455-61
Hospital Charge Code	2566
Hospital Revenue Code	637
Min. Negotiated Rate	$96.06
Max. Negotiated Rate	$141.75
Rate for Payer: Aetna Commercial	$133.88
Rate for Payer: BCBS Trust/PPO	$121.72
Rate for Payer: BCN Commercial	$121.72
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cofinity Commercial	$135.45
Rate for Payer: Encore Health Key Benefits Commercial	$126.00
Rate for Payer: Healthscope Commercial	$141.75
Rate for Payer: Lakeland Regional Health Systems Commercial	$118.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$133.88
Rate for Payer: PHP Commercial	$133.88
Rate for Payer: Priority Health Cigna Priority Health	$110.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$137.02
Rate for Payer: Priority Health Narrow/Tiered Network	$96.06
Rate for Payer: UHC All Payor (Choice/PPO)	$138.60
Rate for Payer: UHC Core	$131.51
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$118.12

DOCUSATE SODIUM 100 MG CAPSULE

Facility

$183.70

Service Code	NDC 60687-129-01
Hospital Charge Code	2566
Hospital Revenue Code	637
Min. Negotiated Rate	$112.04
Max. Negotiated Rate	$165.33
Rate for Payer: Aetna Commercial	$156.14
Rate for Payer: BCBS Trust/PPO	$141.96
Rate for Payer: BCN Commercial	$141.96
Rate for Payer: Cash Price	$146.96
Rate for Payer: Cofinity Commercial	$157.98
Rate for Payer: Encore Health Key Benefits Commercial	$146.96
Rate for Payer: Healthscope Commercial	$165.33
Rate for Payer: Lakeland Regional Health Systems Commercial	$137.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$156.14
Rate for Payer: PHP Commercial	$156.14
Rate for Payer: Priority Health Cigna Priority Health	$128.59
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$159.82
Rate for Payer: Priority Health Narrow/Tiered Network	$112.04
Rate for Payer: UHC All Payor (Choice/PPO)	$161.66
Rate for Payer: UHC Core	$153.39
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$137.78

DOCUSATE SODIUM 100 MG CAPSULE

Facility

$176.40

Service Code	NDC 0536-1062-29
Hospital Charge Code	2566
Hospital Revenue Code	637
Min. Negotiated Rate	$107.59
Max. Negotiated Rate	$158.76
Rate for Payer: Aetna Commercial	$149.94
Rate for Payer: BCBS Trust/PPO	$136.32
Rate for Payer: BCN Commercial	$136.32
Rate for Payer: Cash Price	$141.12
Rate for Payer: Cofinity Commercial	$151.70
Rate for Payer: Encore Health Key Benefits Commercial	$141.12
Rate for Payer: Healthscope Commercial	$158.76
Rate for Payer: Lakeland Regional Health Systems Commercial	$132.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$149.94
Rate for Payer: PHP Commercial	$149.94
Rate for Payer: Priority Health Cigna Priority Health	$123.48
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$153.47
Rate for Payer: Priority Health Narrow/Tiered Network	$107.59
Rate for Payer: UHC All Payor (Choice/PPO)	$155.23
Rate for Payer: UHC Core	$147.29
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$132.30

DOCUSATE SODIUM 100 MG CAPSULE

Facility

$189.00

Service Code	NDC 63739-478-10
Hospital Charge Code	2566
Hospital Revenue Code	637
Min. Negotiated Rate	$115.27
Max. Negotiated Rate	$170.10
Rate for Payer: Aetna Commercial	$160.65
Rate for Payer: BCBS Trust/PPO	$146.06
Rate for Payer: BCN Commercial	$146.06
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cofinity Commercial	$162.54
Rate for Payer: Encore Health Key Benefits Commercial	$151.20
Rate for Payer: Healthscope Commercial	$170.10
Rate for Payer: Lakeland Regional Health Systems Commercial	$141.75
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$160.65
Rate for Payer: PHP Commercial	$160.65
Rate for Payer: Priority Health Cigna Priority Health	$132.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$164.43
Rate for Payer: Priority Health Narrow/Tiered Network	$115.27
Rate for Payer: UHC All Payor (Choice/PPO)	$166.32
Rate for Payer: UHC Core	$157.82
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$141.75

DOCUSATE SODIUM 100 MG CAPSULE

Facility

$176.00

Service Code	NDC 0904-7183-61
Hospital Charge Code	2566
Hospital Revenue Code	637
Min. Negotiated Rate	$107.34
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna Commercial	$149.60
Rate for Payer: BCBS Trust/PPO	$136.01
Rate for Payer: BCN Commercial	$136.01
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cofinity Commercial	$151.36
Rate for Payer: Encore Health Key Benefits Commercial	$140.80
Rate for Payer: Healthscope Commercial	$158.40
Rate for Payer: Lakeland Regional Health Systems Commercial	$132.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$149.60
Rate for Payer: PHP Commercial	$149.60
Rate for Payer: Priority Health Cigna Priority Health	$123.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$153.12
Rate for Payer: Priority Health Narrow/Tiered Network	$107.34
Rate for Payer: UHC All Payor (Choice/PPO)	$154.88
Rate for Payer: UHC Core	$146.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$132.00

DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID

Facility

$3.90

Service Code	NDC 0121-0544-10
Hospital Charge Code	36962
Hospital Revenue Code	637
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna Commercial	$3.32
Rate for Payer: BCBS Trust/PPO	$3.01
Rate for Payer: BCN Commercial	$3.01
Rate for Payer: Cash Price	$3.12
Rate for Payer: Cofinity Commercial	$3.35
Rate for Payer: Encore Health Key Benefits Commercial	$3.12
Rate for Payer: Healthscope Commercial	$3.51
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.32
Rate for Payer: PHP Commercial	$3.32
Rate for Payer: Priority Health Cigna Priority Health	$2.73
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.39
Rate for Payer: Priority Health Narrow/Tiered Network	$2.38
Rate for Payer: UHC All Payor (Choice/PPO)	$3.43
Rate for Payer: UHC Core	$3.26
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.92

DONEPEZIL 10 MG TABLET

Facility

$67.68

Service Code	NDC 43547-276-09
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$41.28
Max. Negotiated Rate	$60.91
Rate for Payer: Aetna Commercial	$57.53
Rate for Payer: BCBS Trust/PPO	$52.30
Rate for Payer: BCN Commercial	$52.30
Rate for Payer: Cash Price	$54.14
Rate for Payer: Cofinity Commercial	$58.20
Rate for Payer: Encore Health Key Benefits Commercial	$54.14
Rate for Payer: Healthscope Commercial	$60.91
Rate for Payer: Lakeland Regional Health Systems Commercial	$50.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.53
Rate for Payer: PHP Commercial	$57.53
Rate for Payer: Priority Health Cigna Priority Health	$47.38
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$58.88
Rate for Payer: Priority Health Narrow/Tiered Network	$41.28
Rate for Payer: UHC All Payor (Choice/PPO)	$59.56
Rate for Payer: UHC Core	$56.51
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$50.76

DONEPEZIL 10 MG TABLET

Facility

$220.90

Service Code	NDC 0904-6478-61
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$134.73
Max. Negotiated Rate	$198.81
Rate for Payer: Aetna Commercial	$187.76
Rate for Payer: BCBS Trust/PPO	$170.71
Rate for Payer: BCN Commercial	$170.71
Rate for Payer: Cash Price	$176.72
Rate for Payer: Cofinity Commercial	$189.97
Rate for Payer: Encore Health Key Benefits Commercial	$176.72
Rate for Payer: Healthscope Commercial	$198.81
Rate for Payer: Lakeland Regional Health Systems Commercial	$165.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$187.76
Rate for Payer: PHP Commercial	$187.76
Rate for Payer: Priority Health Cigna Priority Health	$154.63
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$192.18
Rate for Payer: Priority Health Narrow/Tiered Network	$134.73
Rate for Payer: UHC All Payor (Choice/PPO)	$194.39
Rate for Payer: UHC Core	$184.45
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$165.68

DONEPEZIL 10 MG TABLET

Facility

$296.10

Service Code	NDC 60687-303-01
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$180.59
Max. Negotiated Rate	$266.49
Rate for Payer: Aetna Commercial	$251.68
Rate for Payer: BCBS Trust/PPO	$228.83
Rate for Payer: BCN Commercial	$228.83
Rate for Payer: Cash Price	$236.88
Rate for Payer: Cofinity Commercial	$254.65
Rate for Payer: Encore Health Key Benefits Commercial	$236.88
Rate for Payer: Healthscope Commercial	$266.49
Rate for Payer: Lakeland Regional Health Systems Commercial	$222.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$251.68
Rate for Payer: PHP Commercial	$251.68
Rate for Payer: Priority Health Cigna Priority Health	$207.27
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$257.61
Rate for Payer: Priority Health Narrow/Tiered Network	$180.59
Rate for Payer: UHC All Payor (Choice/PPO)	$260.57
Rate for Payer: UHC Core	$247.24
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$222.08

DONEPEZIL 10 MG TABLET

Facility

$2.97

Service Code	NDC 60687-303-11
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.67
Rate for Payer: Aetna Commercial	$2.52
Rate for Payer: BCBS Trust/PPO	$2.30
Rate for Payer: BCN Commercial	$2.30
Rate for Payer: Cash Price	$2.38
Rate for Payer: Cofinity Commercial	$2.55
Rate for Payer: Encore Health Key Benefits Commercial	$2.38
Rate for Payer: Healthscope Commercial	$2.67
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.23
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.52
Rate for Payer: PHP Commercial	$2.52
Rate for Payer: Priority Health Cigna Priority Health	$2.08
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.58
Rate for Payer: Priority Health Narrow/Tiered Network	$1.81
Rate for Payer: UHC All Payor (Choice/PPO)	$2.61
Rate for Payer: UHC Core	$2.48
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.23

DONEPEZIL 5 MG TABLET

Facility

$42.30

Service Code	NDC 43547-275-03
Hospital Charge Code	18786
Hospital Revenue Code	637
Min. Negotiated Rate	$25.80
Max. Negotiated Rate	$38.07
Rate for Payer: Aetna Commercial	$35.96
Rate for Payer: BCBS Trust/PPO	$32.69
Rate for Payer: BCN Commercial	$32.69
Rate for Payer: Cash Price	$33.84
Rate for Payer: Cofinity Commercial	$36.38
Rate for Payer: Encore Health Key Benefits Commercial	$33.84
Rate for Payer: Healthscope Commercial	$38.07
Rate for Payer: Lakeland Regional Health Systems Commercial	$31.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$35.96
Rate for Payer: PHP Commercial	$35.96
Rate for Payer: Priority Health Cigna Priority Health	$29.61
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.80
Rate for Payer: Priority Health Narrow/Tiered Network	$25.80
Rate for Payer: UHC All Payor (Choice/PPO)	$37.22
Rate for Payer: UHC Core	$35.32
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$31.72

DONEPEZIL 5 MG TABLET

Facility

$59.22

Service Code	NDC 43547-275-09
Hospital Charge Code	18786
Hospital Revenue Code	637
Min. Negotiated Rate	$36.12
Max. Negotiated Rate	$53.30
Rate for Payer: Aetna Commercial	$50.34
Rate for Payer: BCBS Trust/PPO	$45.77
Rate for Payer: BCN Commercial	$45.77
Rate for Payer: Cash Price	$47.38
Rate for Payer: Cofinity Commercial	$50.93
Rate for Payer: Encore Health Key Benefits Commercial	$47.38
Rate for Payer: Healthscope Commercial	$53.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$44.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$50.34
Rate for Payer: PHP Commercial	$50.34
Rate for Payer: Priority Health Cigna Priority Health	$41.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$51.52
Rate for Payer: Priority Health Narrow/Tiered Network	$36.12
Rate for Payer: UHC All Payor (Choice/PPO)	$52.11
Rate for Payer: UHC Core	$49.45
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$44.42

Know your out-of-pocket cost for care.

All Charges