Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CLONIDINE HCL 0.2 MG TABLET

Facility

$126.90

Service Code	NDC 52817018110
Hospital Charge Code	1756
Hospital Revenue Code	637
Min. Negotiated Rate	$50.76
Max. Negotiated Rate	$114.21
Rate for Payer: Aetna Commercial	$107.86
Rate for Payer: Aetna Medicare	$63.45
Rate for Payer: Aetna New Business (MI Preferred)	$82.48
Rate for Payer: BCBS Complete	$50.76
Rate for Payer: Cash Price	$101.52
Rate for Payer: Cofinity Commercial	$109.13
Rate for Payer: Cofinity Commercial	$88.83
Rate for Payer: Cofinity Medicare Advantage	$88.83
Rate for Payer: Encore Health Key Benefits Commercial	$101.52
Rate for Payer: Healthscope Commercial	$114.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$107.86
Rate for Payer: PHP Commercial	$107.86
Rate for Payer: Priority Health Cigna Priority Health	$82.48
Rate for Payer: Priority Health SBD	$79.95

CLONIDINE HCL 0.3 MG TABLET

Facility

$223.25

Service Code	NDC 51079030120
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$89.30
Max. Negotiated Rate	$200.93
Rate for Payer: Aetna Commercial	$189.76
Rate for Payer: Aetna Medicare	$111.62
Rate for Payer: Aetna New Business (MI Preferred)	$145.11
Rate for Payer: BCBS Complete	$89.30
Rate for Payer: Cash Price	$178.60
Rate for Payer: Cofinity Commercial	$156.28
Rate for Payer: Cofinity Commercial	$192.00
Rate for Payer: Cofinity Medicare Advantage	$156.28
Rate for Payer: Encore Health Key Benefits Commercial	$178.60
Rate for Payer: Healthscope Commercial	$200.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$189.76
Rate for Payer: PHP Commercial	$189.76
Rate for Payer: Priority Health Cigna Priority Health	$145.11
Rate for Payer: Priority Health SBD	$140.65

CLONIDINE HCL 0.3 MG TABLET

Facility

$2.24

Service Code	NDC 51079030101
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna Commercial	$1.90
Rate for Payer: Aetna New Business (MI Preferred)	$1.46
Rate for Payer: Cash Price	$1.79
Rate for Payer: Cofinity Commercial	$1.57
Rate for Payer: Cofinity Commercial	$1.93
Rate for Payer: Cofinity Medicare Advantage	$1.57
Rate for Payer: Encore Health Key Benefits Commercial	$1.79
Rate for Payer: Healthscope Commercial	$2.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.90
Rate for Payer: PHP Commercial	$1.90
Rate for Payer: Priority Health Cigna Priority Health	$1.46
Rate for Payer: Priority Health SBD	$1.41

CLONIDINE HCL 0.3 MG TABLET

Facility

$159.60

Service Code	NDC 50268019415
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$100.55
Max. Negotiated Rate	$143.64
Rate for Payer: Aetna Commercial	$135.66
Rate for Payer: Aetna New Business (MI Preferred)	$103.74
Rate for Payer: Cash Price	$127.68
Rate for Payer: Cofinity Commercial	$111.72
Rate for Payer: Cofinity Commercial	$137.26
Rate for Payer: Cofinity Medicare Advantage	$111.72
Rate for Payer: Encore Health Key Benefits Commercial	$127.68
Rate for Payer: Healthscope Commercial	$143.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.66
Rate for Payer: PHP Commercial	$135.66
Rate for Payer: Priority Health Cigna Priority Health	$103.74
Rate for Payer: Priority Health SBD	$100.55

CLONIDINE HCL 0.3 MG TABLET

Facility

$133.95

Service Code	NDC 00228212910
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$53.58
Max. Negotiated Rate	$120.56
Rate for Payer: Aetna Commercial	$113.86
Rate for Payer: Aetna Medicare	$66.97
Rate for Payer: Aetna New Business (MI Preferred)	$87.07
Rate for Payer: BCBS Complete	$53.58
Rate for Payer: Cash Price	$107.16
Rate for Payer: Cofinity Commercial	$115.20
Rate for Payer: Cofinity Commercial	$93.77
Rate for Payer: Cofinity Medicare Advantage	$93.77
Rate for Payer: Encore Health Key Benefits Commercial	$107.16
Rate for Payer: Healthscope Commercial	$120.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$113.86
Rate for Payer: PHP Commercial	$113.86
Rate for Payer: Priority Health Cigna Priority Health	$87.07
Rate for Payer: Priority Health SBD	$84.39

CLONIDINE HCL 0.3 MG TABLET

Facility

$3.20

Service Code	NDC 50268019411
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna Medicare	$1.60
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: BCBS Complete	$1.28
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Commercial	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Cofinity Medicare Advantage	$2.24
Rate for Payer: Encore Health Key Benefits Commercial	$2.56
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.72
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health Cigna Priority Health	$2.08
Rate for Payer: Priority Health SBD	$2.02

CLONIDINE HCL 0.3 MG TABLET

Facility

$244.40

Service Code	NDC 29300013701
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$97.76
Max. Negotiated Rate	$219.96
Rate for Payer: Aetna Commercial	$207.74
Rate for Payer: Aetna Medicare	$122.20
Rate for Payer: Aetna New Business (MI Preferred)	$158.86
Rate for Payer: BCBS Complete	$97.76
Rate for Payer: Cash Price	$195.52
Rate for Payer: Cofinity Commercial	$171.08
Rate for Payer: Cofinity Commercial	$210.18
Rate for Payer: Cofinity Medicare Advantage	$171.08
Rate for Payer: Encore Health Key Benefits Commercial	$195.52
Rate for Payer: Healthscope Commercial	$219.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$207.74
Rate for Payer: PHP Commercial	$207.74
Rate for Payer: Priority Health Cigna Priority Health	$158.86
Rate for Payer: Priority Health SBD	$153.97

CLONIDINE HCL 0.3 MG TABLET

Facility

$3.20

Service Code	NDC 50268019411
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Commercial	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Cofinity Medicare Advantage	$2.24
Rate for Payer: Encore Health Key Benefits Commercial	$2.56
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.72
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health Cigna Priority Health	$2.08
Rate for Payer: Priority Health SBD	$2.02

CLONIDINE HCL 0.3 MG TABLET

Facility

$162.15

Service Code	NDC 52817018210
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$64.86
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$137.83
Rate for Payer: Aetna Medicare	$81.08
Rate for Payer: Aetna New Business (MI Preferred)	$105.40
Rate for Payer: BCBS Complete	$64.86
Rate for Payer: Cash Price	$129.72
Rate for Payer: Cofinity Commercial	$113.50
Rate for Payer: Cofinity Commercial	$139.45
Rate for Payer: Cofinity Medicare Advantage	$113.50
Rate for Payer: Encore Health Key Benefits Commercial	$129.72
Rate for Payer: Healthscope Commercial	$145.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$137.83
Rate for Payer: PHP Commercial	$137.83
Rate for Payer: Priority Health Cigna Priority Health	$105.40
Rate for Payer: Priority Health SBD	$102.15

CLONIDINE HCL 0.3 MG TABLET

Facility

$162.15

Service Code	NDC 52817018210
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$102.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$137.83
Rate for Payer: Aetna New Business (MI Preferred)	$105.40
Rate for Payer: Cash Price	$129.72
Rate for Payer: Cofinity Commercial	$113.50
Rate for Payer: Cofinity Commercial	$139.45
Rate for Payer: Cofinity Medicare Advantage	$113.50
Rate for Payer: Encore Health Key Benefits Commercial	$129.72
Rate for Payer: Healthscope Commercial	$145.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$137.83
Rate for Payer: PHP Commercial	$137.83
Rate for Payer: Priority Health Cigna Priority Health	$105.40
Rate for Payer: Priority Health SBD	$102.15

CLONIDINE HCL 0.3 MG TABLET

Facility

$159.60

Service Code	NDC 50268019415
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$63.84
Max. Negotiated Rate	$143.64
Rate for Payer: Aetna Commercial	$135.66
Rate for Payer: Aetna Medicare	$79.80
Rate for Payer: Aetna New Business (MI Preferred)	$103.74
Rate for Payer: BCBS Complete	$63.84
Rate for Payer: Cash Price	$127.68
Rate for Payer: Cofinity Commercial	$111.72
Rate for Payer: Cofinity Commercial	$137.26
Rate for Payer: Cofinity Medicare Advantage	$111.72
Rate for Payer: Encore Health Key Benefits Commercial	$127.68
Rate for Payer: Healthscope Commercial	$143.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.66
Rate for Payer: PHP Commercial	$135.66
Rate for Payer: Priority Health Cigna Priority Health	$103.74
Rate for Payer: Priority Health SBD	$100.55

CLONIDINE HCL 0.3 MG TABLET

Facility

$2.24

Service Code	NDC 51079030101
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna Commercial	$1.90
Rate for Payer: Aetna Medicare	$1.12
Rate for Payer: Aetna New Business (MI Preferred)	$1.46
Rate for Payer: BCBS Complete	$0.90
Rate for Payer: Cash Price	$1.79
Rate for Payer: Cofinity Commercial	$1.57
Rate for Payer: Cofinity Commercial	$1.93
Rate for Payer: Cofinity Medicare Advantage	$1.57
Rate for Payer: Encore Health Key Benefits Commercial	$1.79
Rate for Payer: Healthscope Commercial	$2.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.90
Rate for Payer: PHP Commercial	$1.90
Rate for Payer: Priority Health Cigna Priority Health	$1.46
Rate for Payer: Priority Health SBD	$1.41

CLONIDINE HCL 0.3 MG TABLET

Facility

$223.25

Service Code	NDC 51079030120
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$140.65
Max. Negotiated Rate	$200.93
Rate for Payer: Aetna Commercial	$189.76
Rate for Payer: Aetna New Business (MI Preferred)	$145.11
Rate for Payer: Cash Price	$178.60
Rate for Payer: Cofinity Commercial	$156.28
Rate for Payer: Cofinity Commercial	$192.00
Rate for Payer: Cofinity Medicare Advantage	$156.28
Rate for Payer: Encore Health Key Benefits Commercial	$178.60
Rate for Payer: Healthscope Commercial	$200.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$189.76
Rate for Payer: PHP Commercial	$189.76
Rate for Payer: Priority Health Cigna Priority Health	$145.11
Rate for Payer: Priority Health SBD	$140.65

CLONIDINE HCL 0.3 MG TABLET

Facility

$133.95

Service Code	NDC 00228212910
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$84.39
Max. Negotiated Rate	$120.56
Rate for Payer: Aetna Commercial	$113.86
Rate for Payer: Aetna New Business (MI Preferred)	$87.07
Rate for Payer: Cash Price	$107.16
Rate for Payer: Cofinity Commercial	$115.20
Rate for Payer: Cofinity Commercial	$93.77
Rate for Payer: Cofinity Medicare Advantage	$93.77
Rate for Payer: Encore Health Key Benefits Commercial	$107.16
Rate for Payer: Healthscope Commercial	$120.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$113.86
Rate for Payer: PHP Commercial	$113.86
Rate for Payer: Priority Health Cigna Priority Health	$87.07
Rate for Payer: Priority Health SBD	$84.39

CLONIDINE HCL 0.3 MG TABLET

Facility

$244.40

Service Code	NDC 29300013701
Hospital Charge Code	1757
Hospital Revenue Code	637
Min. Negotiated Rate	$153.97
Max. Negotiated Rate	$219.96
Rate for Payer: Aetna Commercial	$207.74
Rate for Payer: Aetna New Business (MI Preferred)	$158.86
Rate for Payer: Cash Price	$195.52
Rate for Payer: Cofinity Commercial	$171.08
Rate for Payer: Cofinity Commercial	$210.18
Rate for Payer: Cofinity Medicare Advantage	$171.08
Rate for Payer: Encore Health Key Benefits Commercial	$195.52
Rate for Payer: Healthscope Commercial	$219.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$207.74
Rate for Payer: PHP Commercial	$207.74
Rate for Payer: Priority Health Cigna Priority Health	$158.86
Rate for Payer: Priority Health SBD	$153.97

CLOPIDOGREL 75 MG TABLET

Facility

$446.50

Service Code	NDC 68084053601
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$281.30
Max. Negotiated Rate	$401.85
Rate for Payer: Aetna Commercial	$379.52
Rate for Payer: Aetna New Business (MI Preferred)	$290.23
Rate for Payer: Cash Price	$357.20
Rate for Payer: Cofinity Commercial	$312.55
Rate for Payer: Cofinity Commercial	$383.99
Rate for Payer: Cofinity Medicare Advantage	$312.55
Rate for Payer: Encore Health Key Benefits Commercial	$357.20
Rate for Payer: Healthscope Commercial	$401.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$379.52
Rate for Payer: PHP Commercial	$379.52
Rate for Payer: Priority Health Cigna Priority Health	$290.23
Rate for Payer: Priority Health SBD	$281.30

CLOPIDOGREL 75 MG TABLET

Facility

$404.20

Service Code	NDC 00904629461
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$161.68
Max. Negotiated Rate	$363.78
Rate for Payer: Aetna Commercial	$343.57
Rate for Payer: Aetna Medicare	$202.10
Rate for Payer: Aetna New Business (MI Preferred)	$262.73
Rate for Payer: BCBS Complete	$161.68
Rate for Payer: Cash Price	$323.36
Rate for Payer: Cofinity Commercial	$282.94
Rate for Payer: Cofinity Commercial	$347.61
Rate for Payer: Cofinity Medicare Advantage	$282.94
Rate for Payer: Encore Health Key Benefits Commercial	$323.36
Rate for Payer: Healthscope Commercial	$363.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$343.57
Rate for Payer: PHP Commercial	$343.57
Rate for Payer: Priority Health Cigna Priority Health	$262.73
Rate for Payer: Priority Health SBD	$254.65

CLOPIDOGREL 75 MG TABLET

Facility

$446.50

Service Code	NDC 68084053601
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$178.60
Max. Negotiated Rate	$401.85
Rate for Payer: Aetna Commercial	$379.52
Rate for Payer: Aetna Medicare	$223.25
Rate for Payer: Aetna New Business (MI Preferred)	$290.23
Rate for Payer: BCBS Complete	$178.60
Rate for Payer: Cash Price	$357.20
Rate for Payer: Cofinity Commercial	$312.55
Rate for Payer: Cofinity Commercial	$383.99
Rate for Payer: Cofinity Medicare Advantage	$312.55
Rate for Payer: Encore Health Key Benefits Commercial	$357.20
Rate for Payer: Healthscope Commercial	$401.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$379.52
Rate for Payer: PHP Commercial	$379.52
Rate for Payer: Priority Health Cigna Priority Health	$290.23
Rate for Payer: Priority Health SBD	$281.30

CLOPIDOGREL 75 MG TABLET

Facility

$97.29

Service Code	NDC 16729021815
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$61.29
Max. Negotiated Rate	$87.56
Rate for Payer: Aetna Commercial	$82.70
Rate for Payer: Aetna New Business (MI Preferred)	$63.24
Rate for Payer: Cash Price	$77.83
Rate for Payer: Cofinity Commercial	$68.10
Rate for Payer: Cofinity Commercial	$83.67
Rate for Payer: Cofinity Medicare Advantage	$68.10
Rate for Payer: Encore Health Key Benefits Commercial	$77.83
Rate for Payer: Healthscope Commercial	$87.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$82.70
Rate for Payer: PHP Commercial	$82.70
Rate for Payer: Priority Health Cigna Priority Health	$63.24
Rate for Payer: Priority Health SBD	$61.29

CLOPIDOGREL 75 MG TABLET

Facility

$4.47

Service Code	NDC 68084053611
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna New Business (MI Preferred)	$2.91
Rate for Payer: Cash Price	$3.58
Rate for Payer: Cofinity Commercial	$3.13
Rate for Payer: Cofinity Commercial	$3.84
Rate for Payer: Cofinity Medicare Advantage	$3.13
Rate for Payer: Encore Health Key Benefits Commercial	$3.58
Rate for Payer: Healthscope Commercial	$4.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.80
Rate for Payer: PHP Commercial	$3.80
Rate for Payer: Priority Health Cigna Priority Health	$2.91
Rate for Payer: Priority Health SBD	$2.82

CLOPIDOGREL 75 MG TABLET

Facility

$404.20

Service Code	NDC 00904629461
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$254.65
Max. Negotiated Rate	$363.78
Rate for Payer: Aetna Commercial	$343.57
Rate for Payer: Aetna New Business (MI Preferred)	$262.73
Rate for Payer: Cash Price	$323.36
Rate for Payer: Cofinity Commercial	$282.94
Rate for Payer: Cofinity Commercial	$347.61
Rate for Payer: Cofinity Medicare Advantage	$282.94
Rate for Payer: Encore Health Key Benefits Commercial	$323.36
Rate for Payer: Healthscope Commercial	$363.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$343.57
Rate for Payer: PHP Commercial	$343.57
Rate for Payer: Priority Health Cigna Priority Health	$262.73
Rate for Payer: Priority Health SBD	$254.65

CLOPIDOGREL 75 MG TABLET

Facility

$97.29

Service Code	NDC 16729021815
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$38.92
Max. Negotiated Rate	$87.56
Rate for Payer: Aetna Commercial	$82.70
Rate for Payer: Aetna Medicare	$48.65
Rate for Payer: Aetna New Business (MI Preferred)	$63.24
Rate for Payer: BCBS Complete	$38.92
Rate for Payer: Cash Price	$77.83
Rate for Payer: Cofinity Commercial	$68.10
Rate for Payer: Cofinity Commercial	$83.67
Rate for Payer: Cofinity Medicare Advantage	$68.10
Rate for Payer: Encore Health Key Benefits Commercial	$77.83
Rate for Payer: Healthscope Commercial	$87.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$82.70
Rate for Payer: PHP Commercial	$82.70
Rate for Payer: Priority Health Cigna Priority Health	$63.24
Rate for Payer: Priority Health SBD	$61.29

CLOPIDOGREL 75 MG TABLET

Facility

$4.47

Service Code	NDC 68084053611
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$2.23
Rate for Payer: Aetna New Business (MI Preferred)	$2.91
Rate for Payer: BCBS Complete	$1.79
Rate for Payer: Cash Price	$3.58
Rate for Payer: Cofinity Commercial	$3.13
Rate for Payer: Cofinity Commercial	$3.84
Rate for Payer: Cofinity Medicare Advantage	$3.13
Rate for Payer: Encore Health Key Benefits Commercial	$3.58
Rate for Payer: Healthscope Commercial	$4.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.80
Rate for Payer: PHP Commercial	$3.80
Rate for Payer: Priority Health Cigna Priority Health	$2.91
Rate for Payer: Priority Health SBD	$2.82

CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET

Facility

$444.00

Service Code	NDC 51672404201
Hospital Charge Code	1759
Hospital Revenue Code	637
Min. Negotiated Rate	$177.60
Max. Negotiated Rate	$399.60
Rate for Payer: Aetna Commercial	$377.40
Rate for Payer: Aetna Medicare	$222.00
Rate for Payer: Aetna New Business (MI Preferred)	$288.60
Rate for Payer: BCBS Complete	$177.60
Rate for Payer: Cash Price	$355.20
Rate for Payer: Cofinity Commercial	$310.80
Rate for Payer: Cofinity Commercial	$381.84
Rate for Payer: Cofinity Medicare Advantage	$310.80
Rate for Payer: Encore Health Key Benefits Commercial	$355.20
Rate for Payer: Healthscope Commercial	$399.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$377.40
Rate for Payer: PHP Commercial	$377.40
Rate for Payer: Priority Health Cigna Priority Health	$288.60
Rate for Payer: Priority Health SBD	$279.72

CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET

Facility

$444.00

Service Code	NDC 51672404201
Hospital Charge Code	1759
Hospital Revenue Code	637
Min. Negotiated Rate	$279.72
Max. Negotiated Rate	$399.60
Rate for Payer: Aetna Commercial	$377.40
Rate for Payer: Aetna New Business (MI Preferred)	$288.60
Rate for Payer: Cash Price	$355.20
Rate for Payer: Cofinity Commercial	$310.80
Rate for Payer: Cofinity Commercial	$381.84
Rate for Payer: Cofinity Medicare Advantage	$310.80
Rate for Payer: Encore Health Key Benefits Commercial	$355.20
Rate for Payer: Healthscope Commercial	$399.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$377.40
Rate for Payer: PHP Commercial	$377.40
Rate for Payer: Priority Health Cigna Priority Health	$288.60
Rate for Payer: Priority Health SBD	$279.72

Know your out-of-pocket cost for care.

All Charges