Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DICLOFENAC 1 % TOPICAL GEL

Facility

$49.00

Service Code	NDC 65162083366
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$44.10
Rate for Payer: Aetna Commercial	$41.65
Rate for Payer: Aetna Medicare	$24.50
Rate for Payer: Aetna New Business (MI Preferred)	$31.85
Rate for Payer: BCBS Complete	$19.60
Rate for Payer: Cash Price	$39.20
Rate for Payer: Cofinity Commercial	$34.30
Rate for Payer: Cofinity Commercial	$42.14
Rate for Payer: Cofinity Medicare Advantage	$34.30
Rate for Payer: Encore Health Key Benefits Commercial	$39.20
Rate for Payer: Healthscope Commercial	$44.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$41.65
Rate for Payer: PHP Commercial	$41.65
Rate for Payer: Priority Health Cigna Priority Health	$31.85
Rate for Payer: Priority Health SBD	$30.87

DICLOFENAC 1 % TOPICAL GEL

Facility

$39.90

Service Code	NDC 45802095301
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$25.14
Max. Negotiated Rate	$35.91
Rate for Payer: Aetna Commercial	$33.91
Rate for Payer: Aetna New Business (MI Preferred)	$25.93
Rate for Payer: Cash Price	$31.92
Rate for Payer: Cofinity Commercial	$27.93
Rate for Payer: Cofinity Commercial	$34.31
Rate for Payer: Cofinity Medicare Advantage	$27.93
Rate for Payer: Encore Health Key Benefits Commercial	$31.92
Rate for Payer: Healthscope Commercial	$35.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.91
Rate for Payer: PHP Commercial	$33.91
Rate for Payer: Priority Health Cigna Priority Health	$25.93
Rate for Payer: Priority Health SBD	$25.14

DICLOFENAC 1 % TOPICAL GEL

Facility

$39.90

Service Code	NDC 45802095301
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$15.96
Max. Negotiated Rate	$35.91
Rate for Payer: Aetna Commercial	$33.91
Rate for Payer: Aetna Medicare	$19.95
Rate for Payer: Aetna New Business (MI Preferred)	$25.93
Rate for Payer: BCBS Complete	$15.96
Rate for Payer: Cash Price	$31.92
Rate for Payer: Cofinity Commercial	$27.93
Rate for Payer: Cofinity Commercial	$34.31
Rate for Payer: Cofinity Medicare Advantage	$27.93
Rate for Payer: Encore Health Key Benefits Commercial	$31.92
Rate for Payer: Healthscope Commercial	$35.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.91
Rate for Payer: PHP Commercial	$33.91
Rate for Payer: Priority Health Cigna Priority Health	$25.93
Rate for Payer: Priority Health SBD	$25.14

DICLOFENAC 1 % TOPICAL GEL

Facility

$56.00

Service Code	NDC 25866059361
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$35.28
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna Commercial	$47.60
Rate for Payer: Aetna New Business (MI Preferred)	$36.40
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cofinity Commercial	$39.20
Rate for Payer: Cofinity Commercial	$48.16
Rate for Payer: Cofinity Medicare Advantage	$39.20
Rate for Payer: Encore Health Key Benefits Commercial	$44.80
Rate for Payer: Healthscope Commercial	$50.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.60
Rate for Payer: PHP Commercial	$47.60
Rate for Payer: Priority Health Cigna Priority Health	$36.40
Rate for Payer: Priority Health SBD	$35.28

DICLOFENAC 1 % TOPICAL GEL

Facility

$63.35

Service Code	NDC 00067815203
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$39.91
Max. Negotiated Rate	$57.02
Rate for Payer: Aetna Commercial	$53.85
Rate for Payer: Aetna New Business (MI Preferred)	$41.18
Rate for Payer: Cash Price	$50.68
Rate for Payer: Cofinity Commercial	$44.34
Rate for Payer: Cofinity Commercial	$54.48
Rate for Payer: Cofinity Medicare Advantage	$44.34
Rate for Payer: Encore Health Key Benefits Commercial	$50.68
Rate for Payer: Healthscope Commercial	$57.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.85
Rate for Payer: PHP Commercial	$53.85
Rate for Payer: Priority Health Cigna Priority Health	$41.18
Rate for Payer: Priority Health SBD	$39.91

DICLOFENAC 1 % TOPICAL GEL

Facility

$36.75

Service Code	NDC 57896014001
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$23.15
Max. Negotiated Rate	$33.08
Rate for Payer: Aetna Commercial	$31.24
Rate for Payer: Aetna New Business (MI Preferred)	$23.89
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cofinity Commercial	$25.73
Rate for Payer: Cofinity Commercial	$31.61
Rate for Payer: Cofinity Medicare Advantage	$25.73
Rate for Payer: Encore Health Key Benefits Commercial	$29.40
Rate for Payer: Healthscope Commercial	$33.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$31.24
Rate for Payer: PHP Commercial	$31.24
Rate for Payer: Priority Health Cigna Priority Health	$23.89
Rate for Payer: Priority Health SBD	$23.15

DICLOFENAC 1 % TOPICAL GEL

Facility

$49.00

Service Code	NDC 65162083366
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$30.87
Max. Negotiated Rate	$44.10
Rate for Payer: Aetna Commercial	$41.65
Rate for Payer: Aetna New Business (MI Preferred)	$31.85
Rate for Payer: Cash Price	$39.20
Rate for Payer: Cofinity Commercial	$34.30
Rate for Payer: Cofinity Commercial	$42.14
Rate for Payer: Cofinity Medicare Advantage	$34.30
Rate for Payer: Encore Health Key Benefits Commercial	$39.20
Rate for Payer: Healthscope Commercial	$44.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$41.65
Rate for Payer: PHP Commercial	$41.65
Rate for Payer: Priority Health Cigna Priority Health	$31.85
Rate for Payer: Priority Health SBD	$30.87

DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE

Facility

$361.44

Service Code	NDC 16571020310
Hospital Charge Code	15339
Hospital Revenue Code	637
Min. Negotiated Rate	$227.71
Max. Negotiated Rate	$325.30
Rate for Payer: Aetna Commercial	$307.22
Rate for Payer: Aetna New Business (MI Preferred)	$234.94
Rate for Payer: Cash Price	$289.15
Rate for Payer: Cofinity Commercial	$253.01
Rate for Payer: Cofinity Commercial	$310.84
Rate for Payer: Cofinity Medicare Advantage	$253.01
Rate for Payer: Encore Health Key Benefits Commercial	$289.15
Rate for Payer: Healthscope Commercial	$325.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$307.22
Rate for Payer: PHP Commercial	$307.22
Rate for Payer: Priority Health Cigna Priority Health	$234.94
Rate for Payer: Priority Health SBD	$227.71

DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE

Facility

$361.44

Service Code	NDC 16571020310
Hospital Charge Code	15339
Hospital Revenue Code	637
Min. Negotiated Rate	$144.58
Max. Negotiated Rate	$325.30
Rate for Payer: Aetna Commercial	$307.22
Rate for Payer: Aetna Medicare	$180.72
Rate for Payer: Aetna New Business (MI Preferred)	$234.94
Rate for Payer: BCBS Complete	$144.58
Rate for Payer: Cash Price	$289.15
Rate for Payer: Cofinity Commercial	$253.01
Rate for Payer: Cofinity Commercial	$310.84
Rate for Payer: Cofinity Medicare Advantage	$253.01
Rate for Payer: Encore Health Key Benefits Commercial	$289.15
Rate for Payer: Healthscope Commercial	$325.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$307.22
Rate for Payer: PHP Commercial	$307.22
Rate for Payer: Priority Health Cigna Priority Health	$234.94
Rate for Payer: Priority Health SBD	$227.71

DICYCLOMINE 10 MG CAPSULE

Facility

$3.82

Service Code	NDC 51079011801
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$2.41
Max. Negotiated Rate	$3.44
Rate for Payer: Aetna Commercial	$3.25
Rate for Payer: Aetna New Business (MI Preferred)	$2.48
Rate for Payer: Cash Price	$3.06
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Cofinity Commercial	$3.29
Rate for Payer: Cofinity Medicare Advantage	$2.67
Rate for Payer: Encore Health Key Benefits Commercial	$3.06
Rate for Payer: Healthscope Commercial	$3.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.25
Rate for Payer: PHP Commercial	$3.25
Rate for Payer: Priority Health Cigna Priority Health	$2.48
Rate for Payer: Priority Health SBD	$2.41

DICYCLOMINE 10 MG CAPSULE

Facility

$437.95

Service Code	NDC 60687036901
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$175.18
Max. Negotiated Rate	$394.15
Rate for Payer: Aetna Commercial	$372.26
Rate for Payer: Aetna Medicare	$218.97
Rate for Payer: Aetna New Business (MI Preferred)	$284.67
Rate for Payer: BCBS Complete	$175.18
Rate for Payer: Cash Price	$350.36
Rate for Payer: Cofinity Commercial	$306.56
Rate for Payer: Cofinity Commercial	$376.64
Rate for Payer: Cofinity Medicare Advantage	$306.56
Rate for Payer: Encore Health Key Benefits Commercial	$350.36
Rate for Payer: Healthscope Commercial	$394.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$372.26
Rate for Payer: PHP Commercial	$372.26
Rate for Payer: Priority Health Cigna Priority Health	$284.67
Rate for Payer: Priority Health SBD	$275.91

DICYCLOMINE 10 MG CAPSULE

Facility

$4.38

Service Code	NDC 60687036911
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$3.94
Rate for Payer: Aetna Commercial	$3.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.85
Rate for Payer: Cash Price	$3.50
Rate for Payer: Cofinity Commercial	$3.77
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Cofinity Medicare Advantage	$3.07
Rate for Payer: Encore Health Key Benefits Commercial	$3.50
Rate for Payer: Healthscope Commercial	$3.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.72
Rate for Payer: PHP Commercial	$3.72
Rate for Payer: Priority Health Cigna Priority Health	$2.85
Rate for Payer: Priority Health SBD	$2.76

DICYCLOMINE 10 MG CAPSULE

Facility

$437.10

Service Code	NDC 00591079401
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$275.37
Max. Negotiated Rate	$393.39
Rate for Payer: Aetna Commercial	$371.54
Rate for Payer: Aetna New Business (MI Preferred)	$284.12
Rate for Payer: Cash Price	$349.68
Rate for Payer: Cofinity Commercial	$305.97
Rate for Payer: Cofinity Commercial	$375.91
Rate for Payer: Cofinity Medicare Advantage	$305.97
Rate for Payer: Encore Health Key Benefits Commercial	$349.68
Rate for Payer: Healthscope Commercial	$393.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$371.54
Rate for Payer: PHP Commercial	$371.54
Rate for Payer: Priority Health Cigna Priority Health	$284.12
Rate for Payer: Priority Health SBD	$275.37

DICYCLOMINE 10 MG CAPSULE

Facility

$381.90

Service Code	NDC 51079011820
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$152.76
Max. Negotiated Rate	$343.71
Rate for Payer: Aetna Commercial	$324.62
Rate for Payer: Aetna Medicare	$190.95
Rate for Payer: Aetna New Business (MI Preferred)	$248.24
Rate for Payer: BCBS Complete	$152.76
Rate for Payer: Cash Price	$305.52
Rate for Payer: Cofinity Commercial	$267.33
Rate for Payer: Cofinity Commercial	$328.43
Rate for Payer: Cofinity Medicare Advantage	$267.33
Rate for Payer: Encore Health Key Benefits Commercial	$305.52
Rate for Payer: Healthscope Commercial	$343.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$324.62
Rate for Payer: PHP Commercial	$324.62
Rate for Payer: Priority Health Cigna Priority Health	$248.24
Rate for Payer: Priority Health SBD	$240.60

DICYCLOMINE 10 MG CAPSULE

Facility

$4.38

Service Code	NDC 60687036911
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$3.94
Rate for Payer: Aetna Commercial	$3.72
Rate for Payer: Aetna Medicare	$2.19
Rate for Payer: Aetna New Business (MI Preferred)	$2.85
Rate for Payer: BCBS Complete	$1.75
Rate for Payer: Cash Price	$3.50
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Cofinity Commercial	$3.77
Rate for Payer: Cofinity Medicare Advantage	$3.07
Rate for Payer: Encore Health Key Benefits Commercial	$3.50
Rate for Payer: Healthscope Commercial	$3.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.72
Rate for Payer: PHP Commercial	$3.72
Rate for Payer: Priority Health Cigna Priority Health	$2.85
Rate for Payer: Priority Health SBD	$2.76

DICYCLOMINE 10 MG CAPSULE

Facility

$437.10

Service Code	NDC 00591079401
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$174.84
Max. Negotiated Rate	$393.39
Rate for Payer: Aetna Commercial	$371.54
Rate for Payer: Aetna Medicare	$218.55
Rate for Payer: Aetna New Business (MI Preferred)	$284.12
Rate for Payer: BCBS Complete	$174.84
Rate for Payer: Cash Price	$349.68
Rate for Payer: Cofinity Commercial	$305.97
Rate for Payer: Cofinity Commercial	$375.91
Rate for Payer: Cofinity Medicare Advantage	$305.97
Rate for Payer: Encore Health Key Benefits Commercial	$349.68
Rate for Payer: Healthscope Commercial	$393.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$371.54
Rate for Payer: PHP Commercial	$371.54
Rate for Payer: Priority Health Cigna Priority Health	$284.12
Rate for Payer: Priority Health SBD	$275.37

DICYCLOMINE 10 MG CAPSULE

Facility

$3.82

Service Code	NDC 51079011801
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$3.44
Rate for Payer: Aetna Commercial	$3.25
Rate for Payer: Aetna Medicare	$1.91
Rate for Payer: Aetna New Business (MI Preferred)	$2.48
Rate for Payer: BCBS Complete	$1.53
Rate for Payer: Cash Price	$3.06
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Cofinity Commercial	$3.29
Rate for Payer: Cofinity Medicare Advantage	$2.67
Rate for Payer: Encore Health Key Benefits Commercial	$3.06
Rate for Payer: Healthscope Commercial	$3.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.25
Rate for Payer: PHP Commercial	$3.25
Rate for Payer: Priority Health Cigna Priority Health	$2.48
Rate for Payer: Priority Health SBD	$2.41

DICYCLOMINE 10 MG CAPSULE

Facility

$381.90

Service Code	NDC 51079011820
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$240.60
Max. Negotiated Rate	$343.71
Rate for Payer: Aetna Commercial	$324.62
Rate for Payer: Aetna New Business (MI Preferred)	$248.24
Rate for Payer: Cash Price	$305.52
Rate for Payer: Cofinity Commercial	$267.33
Rate for Payer: Cofinity Commercial	$328.43
Rate for Payer: Cofinity Medicare Advantage	$267.33
Rate for Payer: Encore Health Key Benefits Commercial	$305.52
Rate for Payer: Healthscope Commercial	$343.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$324.62
Rate for Payer: PHP Commercial	$324.62
Rate for Payer: Priority Health Cigna Priority Health	$248.24
Rate for Payer: Priority Health SBD	$240.60

DICYCLOMINE 10 MG CAPSULE

Facility

$437.95

Service Code	NDC 60687036901
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$275.91
Max. Negotiated Rate	$394.15
Rate for Payer: Aetna Commercial	$372.26
Rate for Payer: Aetna New Business (MI Preferred)	$284.67
Rate for Payer: Cash Price	$350.36
Rate for Payer: Cofinity Commercial	$306.56
Rate for Payer: Cofinity Commercial	$376.64
Rate for Payer: Cofinity Medicare Advantage	$306.56
Rate for Payer: Encore Health Key Benefits Commercial	$350.36
Rate for Payer: Healthscope Commercial	$394.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$372.26
Rate for Payer: PHP Commercial	$372.26
Rate for Payer: Priority Health Cigna Priority Health	$284.67
Rate for Payer: Priority Health SBD	$275.91

DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION

Facility

$41.39

Service Code	HCPCS J0500
Hospital Charge Code	2417
Hospital Revenue Code	636
Min. Negotiated Rate	$16.56
Max. Negotiated Rate	$37.25
Rate for Payer: Aetna Commercial	$35.18
Rate for Payer: Aetna Commercial	$235.89
Rate for Payer: Aetna Commercial	$76.75
Rate for Payer: Aetna Commercial	$23.39
Rate for Payer: Aetna Medicare	$45.15
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Aetna Medicare	$138.76
Rate for Payer: Aetna Medicare	$13.76
Rate for Payer: Aetna New Business (MI Preferred)	$26.90
Rate for Payer: Aetna New Business (MI Preferred)	$17.89
Rate for Payer: Aetna New Business (MI Preferred)	$180.39
Rate for Payer: Aetna New Business (MI Preferred)	$58.69
Rate for Payer: BCBS Complete	$11.01
Rate for Payer: BCBS Complete	$36.12
Rate for Payer: BCBS Complete	$111.01
Rate for Payer: BCBS Complete	$16.56
Rate for Payer: Cash Price	$72.23
Rate for Payer: Cash Price	$222.02
Rate for Payer: Cash Price	$33.11
Rate for Payer: Cash Price	$22.02
Rate for Payer: Cofinity Commercial	$238.67
Rate for Payer: Cofinity Commercial	$77.65
Rate for Payer: Cofinity Commercial	$28.97
Rate for Payer: Cofinity Commercial	$63.20
Rate for Payer: Cofinity Commercial	$35.60
Rate for Payer: Cofinity Commercial	$19.26
Rate for Payer: Cofinity Commercial	$23.67
Rate for Payer: Cofinity Commercial	$194.26
Rate for Payer: Cofinity Medicare Advantage	$28.97
Rate for Payer: Cofinity Medicare Advantage	$19.26
Rate for Payer: Cofinity Medicare Advantage	$194.26
Rate for Payer: Cofinity Medicare Advantage	$63.20
Rate for Payer: Encore Health Key Benefits Commercial	$33.11
Rate for Payer: Encore Health Key Benefits Commercial	$72.23
Rate for Payer: Encore Health Key Benefits Commercial	$22.02
Rate for Payer: Encore Health Key Benefits Commercial	$222.02
Rate for Payer: Healthscope Commercial	$24.77
Rate for Payer: Healthscope Commercial	$81.26
Rate for Payer: Healthscope Commercial	$249.77
Rate for Payer: Healthscope Commercial	$37.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$76.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.39
Rate for Payer: PHP Commercial	$235.89
Rate for Payer: PHP Commercial	$76.75
Rate for Payer: PHP Commercial	$35.18
Rate for Payer: PHP Commercial	$23.39
Rate for Payer: Priority Health Cigna Priority Health	$180.39
Rate for Payer: Priority Health Cigna Priority Health	$26.90
Rate for Payer: Priority Health Cigna Priority Health	$17.89
Rate for Payer: Priority Health Cigna Priority Health	$58.69
Rate for Payer: Priority Health SBD	$17.34
Rate for Payer: Priority Health SBD	$26.08
Rate for Payer: Priority Health SBD	$174.84
Rate for Payer: Priority Health SBD	$56.88

DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION

Facility

$90.29

Service Code	HCPCS J0500
Hospital Charge Code	2417
Hospital Revenue Code	636
Min. Negotiated Rate	$56.88
Max. Negotiated Rate	$81.26
Rate for Payer: Aetna Commercial	$76.75
Rate for Payer: Aetna Commercial	$23.39
Rate for Payer: Aetna Commercial	$35.18
Rate for Payer: Aetna Commercial	$235.89
Rate for Payer: Aetna New Business (MI Preferred)	$180.39
Rate for Payer: Aetna New Business (MI Preferred)	$17.89
Rate for Payer: Aetna New Business (MI Preferred)	$58.69
Rate for Payer: Aetna New Business (MI Preferred)	$26.90
Rate for Payer: Cash Price	$72.23
Rate for Payer: Cash Price	$22.02
Rate for Payer: Cash Price	$33.11
Rate for Payer: Cash Price	$222.02
Rate for Payer: Cofinity Commercial	$77.65
Rate for Payer: Cofinity Commercial	$23.67
Rate for Payer: Cofinity Commercial	$28.97
Rate for Payer: Cofinity Commercial	$194.26
Rate for Payer: Cofinity Commercial	$238.67
Rate for Payer: Cofinity Commercial	$19.26
Rate for Payer: Cofinity Commercial	$35.60
Rate for Payer: Cofinity Commercial	$63.20
Rate for Payer: Cofinity Medicare Advantage	$63.20
Rate for Payer: Cofinity Medicare Advantage	$19.26
Rate for Payer: Cofinity Medicare Advantage	$194.26
Rate for Payer: Cofinity Medicare Advantage	$28.97
Rate for Payer: Encore Health Key Benefits Commercial	$33.11
Rate for Payer: Encore Health Key Benefits Commercial	$222.02
Rate for Payer: Encore Health Key Benefits Commercial	$22.02
Rate for Payer: Encore Health Key Benefits Commercial	$72.23
Rate for Payer: Healthscope Commercial	$249.77
Rate for Payer: Healthscope Commercial	$37.25
Rate for Payer: Healthscope Commercial	$81.26
Rate for Payer: Healthscope Commercial	$24.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$76.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.39
Rate for Payer: PHP Commercial	$235.89
Rate for Payer: PHP Commercial	$35.18
Rate for Payer: PHP Commercial	$76.75
Rate for Payer: PHP Commercial	$23.39
Rate for Payer: Priority Health Cigna Priority Health	$180.39
Rate for Payer: Priority Health Cigna Priority Health	$26.90
Rate for Payer: Priority Health Cigna Priority Health	$17.89
Rate for Payer: Priority Health Cigna Priority Health	$58.69
Rate for Payer: Priority Health SBD	$56.88
Rate for Payer: Priority Health SBD	$174.84
Rate for Payer: Priority Health SBD	$26.08
Rate for Payer: Priority Health SBD	$17.34

DICYCLOMINE 20 MG TABLET

Facility

$425.60

Service Code	HCPCS J0500
Hospital Charge Code	2420
Hospital Revenue Code	636
Min. Negotiated Rate	$268.13
Max. Negotiated Rate	$383.04
Rate for Payer: Aetna Commercial	$361.76
Rate for Payer: Aetna Commercial	$3.62
Rate for Payer: Aetna Commercial	$289.64
Rate for Payer: Aetna Commercial	$329.46
Rate for Payer: Aetna New Business (MI Preferred)	$221.49
Rate for Payer: Aetna New Business (MI Preferred)	$276.64
Rate for Payer: Aetna New Business (MI Preferred)	$251.94
Rate for Payer: Aetna New Business (MI Preferred)	$2.77
Rate for Payer: Cash Price	$310.08
Rate for Payer: Cash Price	$272.60
Rate for Payer: Cash Price	$340.48
Rate for Payer: Cash Price	$3.41
Rate for Payer: Cofinity Commercial	$238.53
Rate for Payer: Cofinity Commercial	$293.05
Rate for Payer: Cofinity Commercial	$366.02
Rate for Payer: Cofinity Commercial	$271.32
Rate for Payer: Cofinity Commercial	$333.34
Rate for Payer: Cofinity Commercial	$297.92
Rate for Payer: Cofinity Commercial	$3.66
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Cofinity Medicare Advantage	$2.98
Rate for Payer: Cofinity Medicare Advantage	$297.92
Rate for Payer: Cofinity Medicare Advantage	$238.53
Rate for Payer: Cofinity Medicare Advantage	$271.32
Rate for Payer: Encore Health Key Benefits Commercial	$272.60
Rate for Payer: Encore Health Key Benefits Commercial	$310.08
Rate for Payer: Encore Health Key Benefits Commercial	$340.48
Rate for Payer: Encore Health Key Benefits Commercial	$3.41
Rate for Payer: Healthscope Commercial	$383.04
Rate for Payer: Healthscope Commercial	$348.84
Rate for Payer: Healthscope Commercial	$306.68
Rate for Payer: Healthscope Commercial	$3.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$361.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$289.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$329.46
Rate for Payer: PHP Commercial	$329.46
Rate for Payer: PHP Commercial	$289.64
Rate for Payer: PHP Commercial	$3.62
Rate for Payer: PHP Commercial	$361.76
Rate for Payer: Priority Health Cigna Priority Health	$2.77
Rate for Payer: Priority Health Cigna Priority Health	$221.49
Rate for Payer: Priority Health Cigna Priority Health	$251.94
Rate for Payer: Priority Health Cigna Priority Health	$276.64
Rate for Payer: Priority Health SBD	$214.67
Rate for Payer: Priority Health SBD	$268.13
Rate for Payer: Priority Health SBD	$244.19
Rate for Payer: Priority Health SBD	$2.68

DICYCLOMINE 20 MG TABLET

Facility

$425.60

Service Code	HCPCS J0500
Hospital Charge Code	2420
Hospital Revenue Code	636
Min. Negotiated Rate	$170.24
Max. Negotiated Rate	$383.04
Rate for Payer: Aetna Commercial	$361.76
Rate for Payer: Aetna Commercial	$329.46
Rate for Payer: Aetna Commercial	$3.62
Rate for Payer: Aetna Commercial	$289.64
Rate for Payer: Aetna Medicare	$2.13
Rate for Payer: Aetna Medicare	$212.80
Rate for Payer: Aetna Medicare	$193.80
Rate for Payer: Aetna Medicare	$170.38
Rate for Payer: Aetna New Business (MI Preferred)	$276.64
Rate for Payer: Aetna New Business (MI Preferred)	$221.49
Rate for Payer: Aetna New Business (MI Preferred)	$251.94
Rate for Payer: Aetna New Business (MI Preferred)	$2.77
Rate for Payer: BCBS Complete	$136.30
Rate for Payer: BCBS Complete	$1.70
Rate for Payer: BCBS Complete	$155.04
Rate for Payer: BCBS Complete	$170.24
Rate for Payer: Cash Price	$3.41
Rate for Payer: Cash Price	$310.08
Rate for Payer: Cash Price	$340.48
Rate for Payer: Cash Price	$272.60
Rate for Payer: Cofinity Commercial	$333.34
Rate for Payer: Cofinity Commercial	$3.66
Rate for Payer: Cofinity Commercial	$297.92
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Cofinity Commercial	$366.02
Rate for Payer: Cofinity Commercial	$238.53
Rate for Payer: Cofinity Commercial	$293.05
Rate for Payer: Cofinity Commercial	$271.32
Rate for Payer: Cofinity Medicare Advantage	$297.92
Rate for Payer: Cofinity Medicare Advantage	$238.53
Rate for Payer: Cofinity Medicare Advantage	$271.32
Rate for Payer: Cofinity Medicare Advantage	$2.98
Rate for Payer: Encore Health Key Benefits Commercial	$340.48
Rate for Payer: Encore Health Key Benefits Commercial	$3.41
Rate for Payer: Encore Health Key Benefits Commercial	$272.60
Rate for Payer: Encore Health Key Benefits Commercial	$310.08
Rate for Payer: Healthscope Commercial	$306.68
Rate for Payer: Healthscope Commercial	$3.83
Rate for Payer: Healthscope Commercial	$348.84
Rate for Payer: Healthscope Commercial	$383.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$361.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$329.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$289.64
Rate for Payer: PHP Commercial	$329.46
Rate for Payer: PHP Commercial	$3.62
Rate for Payer: PHP Commercial	$361.76
Rate for Payer: PHP Commercial	$289.64
Rate for Payer: Priority Health Cigna Priority Health	$251.94
Rate for Payer: Priority Health Cigna Priority Health	$276.64
Rate for Payer: Priority Health Cigna Priority Health	$221.49
Rate for Payer: Priority Health Cigna Priority Health	$2.77
Rate for Payer: Priority Health SBD	$214.67
Rate for Payer: Priority Health SBD	$268.13
Rate for Payer: Priority Health SBD	$244.19
Rate for Payer: Priority Health SBD	$2.68

DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION

Facility

$454.72

Service Code	HCPCS J1160
Hospital Charge Code	9853
Hospital Revenue Code	636
Min. Negotiated Rate	$181.89
Max. Negotiated Rate	$409.25
Rate for Payer: Aetna Commercial	$386.51
Rate for Payer: Aetna Medicare	$227.36
Rate for Payer: Aetna New Business (MI Preferred)	$295.57
Rate for Payer: BCBS Complete	$181.89
Rate for Payer: Cash Price	$363.78
Rate for Payer: Cofinity Commercial	$318.30
Rate for Payer: Cofinity Commercial	$391.06
Rate for Payer: Cofinity Medicare Advantage	$318.30
Rate for Payer: Encore Health Key Benefits Commercial	$363.78
Rate for Payer: Healthscope Commercial	$409.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$386.51
Rate for Payer: PHP Commercial	$386.51
Rate for Payer: Priority Health Cigna Priority Health	$295.57
Rate for Payer: Priority Health SBD	$286.47

DIGOXIN 100 MCG/ML (0.1 MG/ML) INJECTION SOLUTION

Facility

$454.72

Service Code	HCPCS J1160
Hospital Charge Code	9853
Hospital Revenue Code	636
Min. Negotiated Rate	$286.47
Max. Negotiated Rate	$409.25
Rate for Payer: Aetna Commercial	$386.51
Rate for Payer: Aetna New Business (MI Preferred)	$295.57
Rate for Payer: Cash Price	$363.78
Rate for Payer: Cofinity Commercial	$318.30
Rate for Payer: Cofinity Commercial	$391.06
Rate for Payer: Cofinity Medicare Advantage	$318.30
Rate for Payer: Encore Health Key Benefits Commercial	$363.78
Rate for Payer: Healthscope Commercial	$409.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$386.51
Rate for Payer: PHP Commercial	$386.51
Rate for Payer: Priority Health Cigna Priority Health	$295.57
Rate for Payer: Priority Health SBD	$286.47

Know your out-of-pocket cost for care.

All Charges