Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET

Facility

$2,343.88

Service Code	NDC 00078065920
Hospital Charge Code	174639
Hospital Revenue Code	637
Min. Negotiated Rate	$937.55
Max. Negotiated Rate	$2,109.49
Rate for Payer: Aetna Commercial	$1,992.30
Rate for Payer: Aetna Medicare	$1,171.94
Rate for Payer: Aetna New Business (MI Preferred)	$1,523.52
Rate for Payer: BCBS Complete	$937.55
Rate for Payer: Cash Price	$1,875.10
Rate for Payer: Cofinity Commercial	$1,640.72
Rate for Payer: Cofinity Commercial	$2,015.74
Rate for Payer: Cofinity Medicare Advantage	$1,640.72
Rate for Payer: Encore Health Key Benefits Commercial	$1,875.10
Rate for Payer: Healthscope Commercial	$2,109.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,992.30
Rate for Payer: PHP Commercial	$1,992.30
Rate for Payer: Priority Health Cigna Priority Health	$1,523.52
Rate for Payer: Priority Health SBD	$1,476.64

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET

Facility

$2,343.88

Service Code	NDC 00078065920
Hospital Charge Code	174639
Hospital Revenue Code	637
Min. Negotiated Rate	$1,476.64
Max. Negotiated Rate	$2,109.49
Rate for Payer: Aetna Commercial	$1,992.30
Rate for Payer: Aetna New Business (MI Preferred)	$1,523.52
Rate for Payer: Cash Price	$1,875.10
Rate for Payer: Cofinity Commercial	$1,640.72
Rate for Payer: Cofinity Commercial	$2,015.74
Rate for Payer: Cofinity Medicare Advantage	$1,640.72
Rate for Payer: Encore Health Key Benefits Commercial	$1,875.10
Rate for Payer: Healthscope Commercial	$2,109.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,992.30
Rate for Payer: PHP Commercial	$1,992.30
Rate for Payer: Priority Health Cigna Priority Health	$1,523.52
Rate for Payer: Priority Health SBD	$1,476.64

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET

Facility

$2,343.88

Service Code	NDC 00078077720
Hospital Charge Code	174640
Hospital Revenue Code	637
Min. Negotiated Rate	$937.55
Max. Negotiated Rate	$2,109.49
Rate for Payer: Aetna Commercial	$1,992.30
Rate for Payer: Aetna Medicare	$1,171.94
Rate for Payer: Aetna New Business (MI Preferred)	$1,523.52
Rate for Payer: BCBS Complete	$937.55
Rate for Payer: Cash Price	$1,875.10
Rate for Payer: Cofinity Commercial	$1,640.72
Rate for Payer: Cofinity Commercial	$2,015.74
Rate for Payer: Cofinity Medicare Advantage	$1,640.72
Rate for Payer: Encore Health Key Benefits Commercial	$1,875.10
Rate for Payer: Healthscope Commercial	$2,109.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,992.30
Rate for Payer: PHP Commercial	$1,992.30
Rate for Payer: Priority Health Cigna Priority Health	$1,523.52
Rate for Payer: Priority Health SBD	$1,476.64

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET

Facility

$2,343.88

Service Code	NDC 00078077720
Hospital Charge Code	174640
Hospital Revenue Code	637
Min. Negotiated Rate	$1,476.64
Max. Negotiated Rate	$2,109.49
Rate for Payer: Aetna Commercial	$1,992.30
Rate for Payer: Aetna New Business (MI Preferred)	$1,523.52
Rate for Payer: Cash Price	$1,875.10
Rate for Payer: Cofinity Commercial	$1,640.72
Rate for Payer: Cofinity Commercial	$2,015.74
Rate for Payer: Cofinity Medicare Advantage	$1,640.72
Rate for Payer: Encore Health Key Benefits Commercial	$1,875.10
Rate for Payer: Healthscope Commercial	$2,109.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,992.30
Rate for Payer: PHP Commercial	$1,992.30
Rate for Payer: Priority Health Cigna Priority Health	$1,523.52
Rate for Payer: Priority Health SBD	$1,476.64

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET

Facility

$2,343.88

Service Code	NDC 00078069620
Hospital Charge Code	174641
Hospital Revenue Code	637
Min. Negotiated Rate	$937.55
Max. Negotiated Rate	$2,109.49
Rate for Payer: Aetna Commercial	$1,992.30
Rate for Payer: Aetna Medicare	$1,171.94
Rate for Payer: Aetna New Business (MI Preferred)	$1,523.52
Rate for Payer: BCBS Complete	$937.55
Rate for Payer: Cash Price	$1,875.10
Rate for Payer: Cofinity Commercial	$1,640.72
Rate for Payer: Cofinity Commercial	$2,015.74
Rate for Payer: Cofinity Medicare Advantage	$1,640.72
Rate for Payer: Encore Health Key Benefits Commercial	$1,875.10
Rate for Payer: Healthscope Commercial	$2,109.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,992.30
Rate for Payer: PHP Commercial	$1,992.30
Rate for Payer: Priority Health Cigna Priority Health	$1,523.52
Rate for Payer: Priority Health SBD	$1,476.64

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET

Facility

$2,343.88

Service Code	NDC 00078069620
Hospital Charge Code	174641
Hospital Revenue Code	637
Min. Negotiated Rate	$1,476.64
Max. Negotiated Rate	$2,109.49
Rate for Payer: Aetna Commercial	$1,992.30
Rate for Payer: Aetna New Business (MI Preferred)	$1,523.52
Rate for Payer: Cash Price	$1,875.10
Rate for Payer: Cofinity Commercial	$1,640.72
Rate for Payer: Cofinity Commercial	$2,015.74
Rate for Payer: Cofinity Medicare Advantage	$1,640.72
Rate for Payer: Encore Health Key Benefits Commercial	$1,875.10
Rate for Payer: Healthscope Commercial	$2,109.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,992.30
Rate for Payer: PHP Commercial	$1,992.30
Rate for Payer: Priority Health Cigna Priority Health	$1,523.52
Rate for Payer: Priority Health SBD	$1,476.64

SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY

Facility

$24.97

Service Code	NDC 48582000155
Hospital Charge Code	118454
Hospital Revenue Code	637
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$22.47
Rate for Payer: Aetna Commercial	$21.22
Rate for Payer: Aetna Medicare	$12.48
Rate for Payer: Aetna New Business (MI Preferred)	$16.23
Rate for Payer: BCBS Complete	$9.99
Rate for Payer: Cash Price	$19.98
Rate for Payer: Cofinity Commercial	$17.48
Rate for Payer: Cofinity Commercial	$21.47
Rate for Payer: Cofinity Medicare Advantage	$17.48
Rate for Payer: Encore Health Key Benefits Commercial	$19.98
Rate for Payer: Healthscope Commercial	$22.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.22
Rate for Payer: PHP Commercial	$21.22
Rate for Payer: Priority Health Cigna Priority Health	$16.23
Rate for Payer: Priority Health SBD	$15.73

SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY

Facility

$24.97

Service Code	NDC 48582000155
Hospital Charge Code	118454
Hospital Revenue Code	637
Min. Negotiated Rate	$15.73
Max. Negotiated Rate	$22.47
Rate for Payer: Aetna Commercial	$21.22
Rate for Payer: Aetna New Business (MI Preferred)	$16.23
Rate for Payer: Cash Price	$19.98
Rate for Payer: Cofinity Commercial	$17.48
Rate for Payer: Cofinity Commercial	$21.47
Rate for Payer: Cofinity Medicare Advantage	$17.48
Rate for Payer: Encore Health Key Benefits Commercial	$19.98
Rate for Payer: Healthscope Commercial	$22.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.22
Rate for Payer: PHP Commercial	$21.22
Rate for Payer: Priority Health Cigna Priority Health	$16.23
Rate for Payer: Priority Health SBD	$15.73

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$586.71

Service Code	NDC 50742050524
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$369.63
Max. Negotiated Rate	$528.04
Rate for Payer: Aetna Commercial	$498.70
Rate for Payer: Aetna New Business (MI Preferred)	$381.36
Rate for Payer: Cash Price	$469.37
Rate for Payer: Cofinity Commercial	$410.70
Rate for Payer: Cofinity Commercial	$504.57
Rate for Payer: Cofinity Medicare Advantage	$410.70
Rate for Payer: Encore Health Key Benefits Commercial	$469.37
Rate for Payer: Healthscope Commercial	$528.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$498.70
Rate for Payer: PHP Commercial	$498.70
Rate for Payer: Priority Health Cigna Priority Health	$381.36
Rate for Payer: Priority Health SBD	$369.63

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$1,051.31

Service Code	NDC 10019055304
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$662.33
Max. Negotiated Rate	$946.18
Rate for Payer: Aetna Commercial	$893.61
Rate for Payer: Aetna New Business (MI Preferred)	$683.35
Rate for Payer: Cash Price	$841.05
Rate for Payer: Cofinity Commercial	$735.92
Rate for Payer: Cofinity Commercial	$904.13
Rate for Payer: Cofinity Medicare Advantage	$735.92
Rate for Payer: Encore Health Key Benefits Commercial	$841.05
Rate for Payer: Healthscope Commercial	$946.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$893.61
Rate for Payer: PHP Commercial	$893.61
Rate for Payer: Priority Health Cigna Priority Health	$683.35
Rate for Payer: Priority Health SBD	$662.33

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$245.35

Service Code	NDC 50742050510
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$154.57
Max. Negotiated Rate	$220.81
Rate for Payer: Aetna Commercial	$208.55
Rate for Payer: Aetna New Business (MI Preferred)	$159.48
Rate for Payer: Cash Price	$196.28
Rate for Payer: Cofinity Commercial	$171.75
Rate for Payer: Cofinity Commercial	$211.00
Rate for Payer: Cofinity Medicare Advantage	$171.75
Rate for Payer: Encore Health Key Benefits Commercial	$196.28
Rate for Payer: Healthscope Commercial	$220.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$208.55
Rate for Payer: PHP Commercial	$208.55
Rate for Payer: Priority Health Cigna Priority Health	$159.48
Rate for Payer: Priority Health SBD	$154.57

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$632.41

Service Code	NDC 00378647097
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$252.96
Max. Negotiated Rate	$569.17
Rate for Payer: Aetna Commercial	$537.55
Rate for Payer: Aetna Medicare	$316.20
Rate for Payer: Aetna New Business (MI Preferred)	$411.07
Rate for Payer: BCBS Complete	$252.96
Rate for Payer: Cash Price	$505.93
Rate for Payer: Cofinity Commercial	$442.69
Rate for Payer: Cofinity Commercial	$543.87
Rate for Payer: Cofinity Medicare Advantage	$442.69
Rate for Payer: Encore Health Key Benefits Commercial	$505.93
Rate for Payer: Healthscope Commercial	$569.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$537.55
Rate for Payer: PHP Commercial	$537.55
Rate for Payer: Priority Health Cigna Priority Health	$411.07
Rate for Payer: Priority Health SBD	$398.42

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$32.69

Service Code	NDC 45802058001
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$13.08
Max. Negotiated Rate	$29.42
Rate for Payer: Aetna Commercial	$27.79
Rate for Payer: Aetna Medicare	$16.34
Rate for Payer: Aetna New Business (MI Preferred)	$21.25
Rate for Payer: BCBS Complete	$13.08
Rate for Payer: Cash Price	$26.15
Rate for Payer: Cofinity Commercial	$22.88
Rate for Payer: Cofinity Commercial	$28.11
Rate for Payer: Cofinity Medicare Advantage	$22.88
Rate for Payer: Encore Health Key Benefits Commercial	$26.15
Rate for Payer: Healthscope Commercial	$29.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$27.79
Rate for Payer: PHP Commercial	$27.79
Rate for Payer: Priority Health Cigna Priority Health	$21.25
Rate for Payer: Priority Health SBD	$20.59

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$63.25

Service Code	NDC 00378647016
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$39.85
Max. Negotiated Rate	$56.92
Rate for Payer: Aetna Commercial	$53.76
Rate for Payer: Aetna New Business (MI Preferred)	$41.11
Rate for Payer: Cash Price	$50.60
Rate for Payer: Cofinity Commercial	$44.27
Rate for Payer: Cofinity Commercial	$54.40
Rate for Payer: Cofinity Medicare Advantage	$44.27
Rate for Payer: Encore Health Key Benefits Commercial	$50.60
Rate for Payer: Healthscope Commercial	$56.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.76
Rate for Payer: PHP Commercial	$53.76
Rate for Payer: Priority Health Cigna Priority Health	$41.11
Rate for Payer: Priority Health SBD	$39.85

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$326.90

Service Code	NDC 45802058046
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$205.95
Max. Negotiated Rate	$294.21
Rate for Payer: Aetna Commercial	$277.87
Rate for Payer: Aetna New Business (MI Preferred)	$212.49
Rate for Payer: Cash Price	$261.52
Rate for Payer: Cofinity Commercial	$228.83
Rate for Payer: Cofinity Commercial	$281.13
Rate for Payer: Cofinity Medicare Advantage	$228.83
Rate for Payer: Encore Health Key Benefits Commercial	$261.52
Rate for Payer: Healthscope Commercial	$294.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$277.87
Rate for Payer: PHP Commercial	$277.87
Rate for Payer: Priority Health Cigna Priority Health	$212.49
Rate for Payer: Priority Health SBD	$205.95

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$326.90

Service Code	NDC 45802058046
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$130.76
Max. Negotiated Rate	$294.21
Rate for Payer: Aetna Commercial	$277.87
Rate for Payer: Aetna Medicare	$163.45
Rate for Payer: Aetna New Business (MI Preferred)	$212.49
Rate for Payer: BCBS Complete	$130.76
Rate for Payer: Cash Price	$261.52
Rate for Payer: Cofinity Commercial	$228.83
Rate for Payer: Cofinity Commercial	$281.13
Rate for Payer: Cofinity Medicare Advantage	$228.83
Rate for Payer: Encore Health Key Benefits Commercial	$261.52
Rate for Payer: Healthscope Commercial	$294.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$277.87
Rate for Payer: PHP Commercial	$277.87
Rate for Payer: Priority Health Cigna Priority Health	$212.49
Rate for Payer: Priority Health SBD	$205.95

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$245.35

Service Code	NDC 50742050510
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$98.14
Max. Negotiated Rate	$220.81
Rate for Payer: Aetna Commercial	$208.55
Rate for Payer: Aetna Medicare	$122.67
Rate for Payer: Aetna New Business (MI Preferred)	$159.48
Rate for Payer: BCBS Complete	$98.14
Rate for Payer: Cash Price	$196.28
Rate for Payer: Cofinity Commercial	$171.75
Rate for Payer: Cofinity Commercial	$211.00
Rate for Payer: Cofinity Medicare Advantage	$171.75
Rate for Payer: Encore Health Key Benefits Commercial	$196.28
Rate for Payer: Healthscope Commercial	$220.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$208.55
Rate for Payer: PHP Commercial	$208.55
Rate for Payer: Priority Health Cigna Priority Health	$159.48
Rate for Payer: Priority Health SBD	$154.57

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$586.71

Service Code	NDC 50742050524
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$234.68
Max. Negotiated Rate	$528.04
Rate for Payer: Aetna Commercial	$498.70
Rate for Payer: Aetna Medicare	$293.36
Rate for Payer: Aetna New Business (MI Preferred)	$381.36
Rate for Payer: BCBS Complete	$234.68
Rate for Payer: Cash Price	$469.37
Rate for Payer: Cofinity Commercial	$410.70
Rate for Payer: Cofinity Commercial	$504.57
Rate for Payer: Cofinity Medicare Advantage	$410.70
Rate for Payer: Encore Health Key Benefits Commercial	$469.37
Rate for Payer: Healthscope Commercial	$528.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$498.70
Rate for Payer: PHP Commercial	$498.70
Rate for Payer: Priority Health Cigna Priority Health	$381.36
Rate for Payer: Priority Health SBD	$369.63

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$632.41

Service Code	NDC 00378647097
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$398.42
Max. Negotiated Rate	$569.17
Rate for Payer: Aetna Commercial	$537.55
Rate for Payer: Aetna New Business (MI Preferred)	$411.07
Rate for Payer: Cash Price	$505.93
Rate for Payer: Cofinity Commercial	$442.69
Rate for Payer: Cofinity Commercial	$543.87
Rate for Payer: Cofinity Medicare Advantage	$442.69
Rate for Payer: Encore Health Key Benefits Commercial	$505.93
Rate for Payer: Healthscope Commercial	$569.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$537.55
Rate for Payer: PHP Commercial	$537.55
Rate for Payer: Priority Health Cigna Priority Health	$411.07
Rate for Payer: Priority Health SBD	$398.42

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$1,051.31

Service Code	NDC 10019055304
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$420.52
Max. Negotiated Rate	$946.18
Rate for Payer: Aetna Commercial	$893.61
Rate for Payer: Aetna Medicare	$525.65
Rate for Payer: Aetna New Business (MI Preferred)	$683.35
Rate for Payer: BCBS Complete	$420.52
Rate for Payer: Cash Price	$841.05
Rate for Payer: Cofinity Commercial	$735.92
Rate for Payer: Cofinity Commercial	$904.13
Rate for Payer: Cofinity Medicare Advantage	$735.92
Rate for Payer: Encore Health Key Benefits Commercial	$841.05
Rate for Payer: Healthscope Commercial	$946.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$893.61
Rate for Payer: PHP Commercial	$893.61
Rate for Payer: Priority Health Cigna Priority Health	$683.35
Rate for Payer: Priority Health SBD	$662.33

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$63.25

Service Code	NDC 00378647016
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$25.30
Max. Negotiated Rate	$56.92
Rate for Payer: Aetna Commercial	$53.76
Rate for Payer: Aetna Medicare	$31.62
Rate for Payer: Aetna New Business (MI Preferred)	$41.11
Rate for Payer: BCBS Complete	$25.30
Rate for Payer: Cash Price	$50.60
Rate for Payer: Cofinity Commercial	$44.27
Rate for Payer: Cofinity Commercial	$54.40
Rate for Payer: Cofinity Medicare Advantage	$44.27
Rate for Payer: Encore Health Key Benefits Commercial	$50.60
Rate for Payer: Healthscope Commercial	$56.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.76
Rate for Payer: PHP Commercial	$53.76
Rate for Payer: Priority Health Cigna Priority Health	$41.11
Rate for Payer: Priority Health SBD	$39.85

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$43.81

Service Code	NDC 10019055390
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$27.60
Max. Negotiated Rate	$39.43
Rate for Payer: Aetna Commercial	$37.24
Rate for Payer: Aetna New Business (MI Preferred)	$28.48
Rate for Payer: Cash Price	$35.05
Rate for Payer: Cofinity Commercial	$30.67
Rate for Payer: Cofinity Commercial	$37.68
Rate for Payer: Cofinity Medicare Advantage	$30.67
Rate for Payer: Encore Health Key Benefits Commercial	$35.05
Rate for Payer: Healthscope Commercial	$39.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$37.24
Rate for Payer: PHP Commercial	$37.24
Rate for Payer: Priority Health Cigna Priority Health	$28.48
Rate for Payer: Priority Health SBD	$27.60

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$438.05

Service Code	NDC 10019055303
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$175.22
Max. Negotiated Rate	$394.25
Rate for Payer: Aetna Commercial	$372.34
Rate for Payer: Aetna Medicare	$219.03
Rate for Payer: Aetna New Business (MI Preferred)	$284.73
Rate for Payer: BCBS Complete	$175.22
Rate for Payer: Cash Price	$350.44
Rate for Payer: Cofinity Commercial	$306.63
Rate for Payer: Cofinity Commercial	$376.72
Rate for Payer: Cofinity Medicare Advantage	$306.63
Rate for Payer: Encore Health Key Benefits Commercial	$350.44
Rate for Payer: Healthscope Commercial	$394.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$372.34
Rate for Payer: PHP Commercial	$372.34
Rate for Payer: Priority Health Cigna Priority Health	$284.73
Rate for Payer: Priority Health SBD	$275.97

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$438.05

Service Code	NDC 10019055303
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$275.97
Max. Negotiated Rate	$394.25
Rate for Payer: Aetna Commercial	$372.34
Rate for Payer: Aetna New Business (MI Preferred)	$284.73
Rate for Payer: Cash Price	$350.44
Rate for Payer: Cofinity Commercial	$306.63
Rate for Payer: Cofinity Commercial	$376.72
Rate for Payer: Cofinity Medicare Advantage	$306.63
Rate for Payer: Encore Health Key Benefits Commercial	$350.44
Rate for Payer: Healthscope Commercial	$394.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$372.34
Rate for Payer: PHP Commercial	$372.34
Rate for Payer: Priority Health Cigna Priority Health	$284.73
Rate for Payer: Priority Health SBD	$275.97

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH

Facility

$24.23

Service Code	NDC 50742050501
Hospital Charge Code	27696
Hospital Revenue Code	637
Min. Negotiated Rate	$15.26
Max. Negotiated Rate	$21.81
Rate for Payer: Aetna Commercial	$20.60
Rate for Payer: Aetna New Business (MI Preferred)	$15.75
Rate for Payer: Cash Price	$19.38
Rate for Payer: Cofinity Commercial	$16.96
Rate for Payer: Cofinity Commercial	$20.84
Rate for Payer: Cofinity Medicare Advantage	$16.96
Rate for Payer: Encore Health Key Benefits Commercial	$19.38
Rate for Payer: Healthscope Commercial	$21.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.60
Rate for Payer: PHP Commercial	$20.60
Rate for Payer: Priority Health Cigna Priority Health	$15.75
Rate for Payer: Priority Health SBD	$15.26

Know your out-of-pocket cost for care.

All Charges