Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DICLOFENAC 1 % TOPICAL GEL

Facility

$38.85

Service Code	NDC 43598097710
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$34.96
Rate for Payer: Aetna Commercial	$33.02
Rate for Payer: Aetna Medicare	$19.42
Rate for Payer: Aetna New Business (MI Preferred)	$25.25
Rate for Payer: BCBS Complete	$15.54
Rate for Payer: Cash Price	$31.08
Rate for Payer: Cofinity Commercial	$27.20
Rate for Payer: Cofinity Commercial	$33.41
Rate for Payer: Cofinity Medicare Advantage	$27.20
Rate for Payer: Encore Health Key Benefits Commercial	$31.08
Rate for Payer: Healthscope Commercial	$34.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.02
Rate for Payer: PHP Commercial	$33.02
Rate for Payer: Priority Health Cigna Priority Health	$25.25
Rate for Payer: Priority Health SBD	$24.48

DICLOFENAC 1 % TOPICAL GEL

Facility

$14.85

Service Code	NDC 76282066339
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$13.36
Rate for Payer: Aetna Commercial	$12.62
Rate for Payer: Aetna Medicare	$7.42
Rate for Payer: Aetna New Business (MI Preferred)	$9.65
Rate for Payer: BCBS Complete	$5.94
Rate for Payer: Cash Price	$11.88
Rate for Payer: Cofinity Commercial	$10.40
Rate for Payer: Cofinity Commercial	$12.77
Rate for Payer: Cofinity Medicare Advantage	$10.40
Rate for Payer: Encore Health Key Benefits Commercial	$11.88
Rate for Payer: Healthscope Commercial	$13.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.62
Rate for Payer: PHP Commercial	$12.62
Rate for Payer: Priority Health Cigna Priority Health	$9.65
Rate for Payer: Priority Health SBD	$9.36

DICLOFENAC 1 % TOPICAL GEL

Facility

$54.25

Service Code	NDC 41167057403
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$48.82
Rate for Payer: Aetna Commercial	$46.11
Rate for Payer: Aetna Medicare	$27.12
Rate for Payer: Aetna New Business (MI Preferred)	$35.26
Rate for Payer: BCBS Complete	$21.70
Rate for Payer: Cash Price	$43.40
Rate for Payer: Cofinity Commercial	$37.98
Rate for Payer: Cofinity Commercial	$46.66
Rate for Payer: Cofinity Medicare Advantage	$37.98
Rate for Payer: Encore Health Key Benefits Commercial	$43.40
Rate for Payer: Healthscope Commercial	$48.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$46.11
Rate for Payer: PHP Commercial	$46.11
Rate for Payer: Priority Health Cigna Priority Health	$35.26
Rate for Payer: Priority Health SBD	$34.18

DICLOFENAC 1 % TOPICAL GEL

Facility

$49.00

Service Code	NDC 45802016000
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 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	$33.92
Rate for Payer: Aetna Medicare	$19.95
Rate for Payer: Aetna New Business (MI Preferred)	$25.94
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	$33.92
Rate for Payer: PHP Commercial	$33.92
Rate for Payer: Priority Health Cigna Priority Health	$25.94
Rate for Payer: Priority Health SBD	$25.14

DICLOFENAC 1 % TOPICAL GEL

Facility

$49.00

Service Code	NDC 69097052444
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 1 % TOPICAL GEL

Facility

$49.00

Service Code	NDC 45802016000
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

$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	$25.72
Rate for Payer: Cofinity Commercial	$31.60
Rate for Payer: Cofinity Medicare Advantage	$25.72
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

$63.35

Service Code	NDC 00067815203
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$57.02
Rate for Payer: Aetna Commercial	$53.85
Rate for Payer: Aetna Medicare	$31.68
Rate for Payer: Aetna New Business (MI Preferred)	$41.18
Rate for Payer: BCBS Complete	$25.34
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

$26.95

Service Code	NDC 70000055502
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$16.98
Max. Negotiated Rate	$24.26
Rate for Payer: Aetna Commercial	$22.91
Rate for Payer: Aetna New Business (MI Preferred)	$17.52
Rate for Payer: Cash Price	$21.56
Rate for Payer: Cofinity Commercial	$18.86
Rate for Payer: Cofinity Commercial	$23.18
Rate for Payer: Cofinity Medicare Advantage	$18.86
Rate for Payer: Encore Health Key Benefits Commercial	$21.56
Rate for Payer: Healthscope Commercial	$24.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.91
Rate for Payer: PHP Commercial	$22.91
Rate for Payer: Priority Health Cigna Priority Health	$17.52
Rate for Payer: Priority Health SBD	$16.98

DICLOFENAC 1 % TOPICAL GEL

Facility

$14.85

Service Code	NDC 76282066339
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$13.36
Rate for Payer: Aetna Commercial	$12.62
Rate for Payer: Aetna New Business (MI Preferred)	$9.65
Rate for Payer: Cash Price	$11.88
Rate for Payer: Cofinity Commercial	$10.40
Rate for Payer: Cofinity Commercial	$12.77
Rate for Payer: Cofinity Medicare Advantage	$10.40
Rate for Payer: Encore Health Key Benefits Commercial	$11.88
Rate for Payer: Healthscope Commercial	$13.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.62
Rate for Payer: PHP Commercial	$12.62
Rate for Payer: Priority Health Cigna Priority Health	$9.65
Rate for Payer: Priority Health SBD	$9.36

DICLOFENAC 1 % TOPICAL GEL

Facility

$49.00

Service Code	NDC 69097052444
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

$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	$14.70
Max. Negotiated Rate	$33.08
Rate for Payer: Aetna Commercial	$31.24
Rate for Payer: Aetna Medicare	$18.38
Rate for Payer: Aetna New Business (MI Preferred)	$23.89
Rate for Payer: BCBS Complete	$14.70
Rate for Payer: Cash Price	$29.40
Rate for Payer: Cofinity Commercial	$25.72
Rate for Payer: Cofinity Commercial	$31.60
Rate for Payer: Cofinity Medicare Advantage	$25.72
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 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

$437.95

Service Code	NDC 60687036901
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$175.18
Max. Negotiated Rate	$394.16
Rate for Payer: Aetna Commercial	$372.26
Rate for Payer: Aetna Medicare	$218.98
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	$394.16
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	$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	$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

$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

$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	$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

$437.95

Service Code	NDC 60687036901
Hospital Charge Code	2418
Hospital Revenue Code	637
Min. Negotiated Rate	$275.91
Max. Negotiated Rate	$394.16
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	$394.16
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

$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

Know your out-of-pocket cost for care.

All Charges