Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$172.71

Service Code	NDC 50742024990
Hospital Charge Code	29272
Hospital Revenue Code	637
Min. Negotiated Rate	$108.81
Max. Negotiated Rate	$155.44
Rate for Payer: Aetna Commercial	$146.80
Rate for Payer: Aetna New Business (MI Preferred)	$112.26
Rate for Payer: Cash Price	$138.17
Rate for Payer: Cofinity Commercial	$120.90
Rate for Payer: Cofinity Commercial	$148.53
Rate for Payer: Cofinity Medicare Advantage	$120.90
Rate for Payer: Encore Health Key Benefits Commercial	$138.17
Rate for Payer: Healthscope Commercial	$155.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$146.80
Rate for Payer: PHP Commercial	$146.80
Rate for Payer: Priority Health Cigna Priority Health	$112.26
Rate for Payer: Priority Health SBD	$108.81

DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$304.00

Service Code	NDC 60687020601
Hospital Charge Code	29272
Hospital Revenue Code	637
Min. Negotiated Rate	$121.60
Max. Negotiated Rate	$273.60
Rate for Payer: Aetna Commercial	$258.40
Rate for Payer: Aetna Medicare	$152.00
Rate for Payer: Aetna New Business (MI Preferred)	$197.60
Rate for Payer: BCBS Complete	$121.60
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cofinity Commercial	$212.80
Rate for Payer: Cofinity Commercial	$261.44
Rate for Payer: Cofinity Medicare Advantage	$212.80
Rate for Payer: Encore Health Key Benefits Commercial	$243.20
Rate for Payer: Healthscope Commercial	$273.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$258.40
Rate for Payer: PHP Commercial	$258.40
Rate for Payer: Priority Health Cigna Priority Health	$197.60
Rate for Payer: Priority Health SBD	$191.52

DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$3.04

Service Code	NDC 60687020611
Hospital Charge Code	29272
Hospital Revenue Code	637
Min. Negotiated Rate	$1.92
Max. Negotiated Rate	$2.74
Rate for Payer: Aetna Commercial	$2.58
Rate for Payer: Aetna New Business (MI Preferred)	$1.98
Rate for Payer: Cash Price	$2.43
Rate for Payer: Cofinity Commercial	$2.13
Rate for Payer: Cofinity Commercial	$2.61
Rate for Payer: Cofinity Medicare Advantage	$2.13
Rate for Payer: Encore Health Key Benefits Commercial	$2.43
Rate for Payer: Healthscope Commercial	$2.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.58
Rate for Payer: PHP Commercial	$2.58
Rate for Payer: Priority Health Cigna Priority Health	$1.98
Rate for Payer: Priority Health SBD	$1.92

DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$129.03

Service Code	NDC 10370083011
Hospital Charge Code	29272
Hospital Revenue Code	637
Min. Negotiated Rate	$51.61
Max. Negotiated Rate	$116.13
Rate for Payer: Aetna Commercial	$109.68
Rate for Payer: Aetna Medicare	$64.52
Rate for Payer: Aetna New Business (MI Preferred)	$83.87
Rate for Payer: BCBS Complete	$51.61
Rate for Payer: Cash Price	$103.22
Rate for Payer: Cofinity Commercial	$110.97
Rate for Payer: Cofinity Commercial	$90.32
Rate for Payer: Cofinity Medicare Advantage	$90.32
Rate for Payer: Encore Health Key Benefits Commercial	$103.22
Rate for Payer: Healthscope Commercial	$116.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$109.68
Rate for Payer: PHP Commercial	$109.68
Rate for Payer: Priority Health Cigna Priority Health	$83.87
Rate for Payer: Priority Health SBD	$81.29

DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$304.00

Service Code	NDC 60687020601
Hospital Charge Code	29272
Hospital Revenue Code	637
Min. Negotiated Rate	$191.52
Max. Negotiated Rate	$273.60
Rate for Payer: Aetna Commercial	$258.40
Rate for Payer: Aetna New Business (MI Preferred)	$197.60
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cofinity Commercial	$212.80
Rate for Payer: Cofinity Commercial	$261.44
Rate for Payer: Cofinity Medicare Advantage	$212.80
Rate for Payer: Encore Health Key Benefits Commercial	$243.20
Rate for Payer: Healthscope Commercial	$273.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$258.40
Rate for Payer: PHP Commercial	$258.40
Rate for Payer: Priority Health Cigna Priority Health	$197.60
Rate for Payer: Priority Health SBD	$191.52

DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$3.04

Service Code	NDC 60687020611
Hospital Charge Code	29272
Hospital Revenue Code	637
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$2.74
Rate for Payer: Aetna Commercial	$2.58
Rate for Payer: Aetna Medicare	$1.52
Rate for Payer: Aetna New Business (MI Preferred)	$1.98
Rate for Payer: BCBS Complete	$1.22
Rate for Payer: Cash Price	$2.43
Rate for Payer: Cofinity Commercial	$2.13
Rate for Payer: Cofinity Commercial	$2.61
Rate for Payer: Cofinity Medicare Advantage	$2.13
Rate for Payer: Encore Health Key Benefits Commercial	$2.43
Rate for Payer: Healthscope Commercial	$2.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.58
Rate for Payer: PHP Commercial	$2.58
Rate for Payer: Priority Health Cigna Priority Health	$1.98
Rate for Payer: Priority Health SBD	$1.92

DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$342.00

Service Code	NDC 00904721961
Hospital Charge Code	29274
Hospital Revenue Code	637
Min. Negotiated Rate	$136.80
Max. Negotiated Rate	$307.80
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: Aetna New Business (MI Preferred)	$222.30
Rate for Payer: BCBS Complete	$136.80
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cofinity Commercial	$239.40
Rate for Payer: Cofinity Commercial	$294.12
Rate for Payer: Cofinity Medicare Advantage	$239.40
Rate for Payer: Encore Health Key Benefits Commercial	$273.60
Rate for Payer: Healthscope Commercial	$307.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$290.70
Rate for Payer: PHP Commercial	$290.70
Rate for Payer: Priority Health Cigna Priority Health	$222.30
Rate for Payer: Priority Health SBD	$215.46

DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$342.00

Service Code	NDC 00904721961
Hospital Charge Code	29274
Hospital Revenue Code	637
Min. Negotiated Rate	$215.46
Max. Negotiated Rate	$307.80
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna New Business (MI Preferred)	$222.30
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cofinity Commercial	$239.40
Rate for Payer: Cofinity Commercial	$294.12
Rate for Payer: Cofinity Medicare Advantage	$239.40
Rate for Payer: Encore Health Key Benefits Commercial	$273.60
Rate for Payer: Healthscope Commercial	$307.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$290.70
Rate for Payer: PHP Commercial	$290.70
Rate for Payer: Priority Health Cigna Priority Health	$222.30
Rate for Payer: Priority Health SBD	$215.46

DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$2.54

Service Code	NDC 60687021711
Hospital Charge Code	29274
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna Commercial	$2.16
Rate for Payer: Aetna Medicare	$1.27
Rate for Payer: Aetna New Business (MI Preferred)	$1.65
Rate for Payer: BCBS Complete	$1.02
Rate for Payer: Cash Price	$2.03
Rate for Payer: Cofinity Commercial	$1.78
Rate for Payer: Cofinity Commercial	$2.18
Rate for Payer: Cofinity Medicare Advantage	$1.78
Rate for Payer: Encore Health Key Benefits Commercial	$2.03
Rate for Payer: Healthscope Commercial	$2.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.16
Rate for Payer: PHP Commercial	$2.16
Rate for Payer: Priority Health Cigna Priority Health	$1.65
Rate for Payer: Priority Health SBD	$1.60

DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$253.92

Service Code	NDC 60687021701
Hospital Charge Code	29274
Hospital Revenue Code	637
Min. Negotiated Rate	$159.97
Max. Negotiated Rate	$228.53
Rate for Payer: Aetna Commercial	$215.83
Rate for Payer: Aetna New Business (MI Preferred)	$165.05
Rate for Payer: Cash Price	$203.14
Rate for Payer: Cofinity Commercial	$177.74
Rate for Payer: Cofinity Commercial	$218.37
Rate for Payer: Cofinity Medicare Advantage	$177.74
Rate for Payer: Encore Health Key Benefits Commercial	$203.14
Rate for Payer: Healthscope Commercial	$228.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.83
Rate for Payer: PHP Commercial	$215.83
Rate for Payer: Priority Health Cigna Priority Health	$165.05
Rate for Payer: Priority Health SBD	$159.97

DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$527.04

Service Code	NDC 68682099798
Hospital Charge Code	29274
Hospital Revenue Code	637
Min. Negotiated Rate	$332.04
Max. Negotiated Rate	$474.34
Rate for Payer: Aetna Commercial	$447.98
Rate for Payer: Aetna New Business (MI Preferred)	$342.58
Rate for Payer: Cash Price	$421.63
Rate for Payer: Cofinity Commercial	$368.93
Rate for Payer: Cofinity Commercial	$453.25
Rate for Payer: Cofinity Medicare Advantage	$368.93
Rate for Payer: Encore Health Key Benefits Commercial	$421.63
Rate for Payer: Healthscope Commercial	$474.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$447.98
Rate for Payer: PHP Commercial	$447.98
Rate for Payer: Priority Health Cigna Priority Health	$342.58
Rate for Payer: Priority Health SBD	$332.04

DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$253.92

Service Code	NDC 60687021701
Hospital Charge Code	29274
Hospital Revenue Code	637
Min. Negotiated Rate	$101.57
Max. Negotiated Rate	$228.53
Rate for Payer: Aetna Commercial	$215.83
Rate for Payer: Aetna Medicare	$126.96
Rate for Payer: Aetna New Business (MI Preferred)	$165.05
Rate for Payer: BCBS Complete	$101.57
Rate for Payer: Cash Price	$203.14
Rate for Payer: Cofinity Commercial	$177.74
Rate for Payer: Cofinity Commercial	$218.37
Rate for Payer: Cofinity Medicare Advantage	$177.74
Rate for Payer: Encore Health Key Benefits Commercial	$203.14
Rate for Payer: Healthscope Commercial	$228.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.83
Rate for Payer: PHP Commercial	$215.83
Rate for Payer: Priority Health Cigna Priority Health	$165.05
Rate for Payer: Priority Health SBD	$159.97

DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$527.04

Service Code	NDC 68682099798
Hospital Charge Code	29274
Hospital Revenue Code	637
Min. Negotiated Rate	$210.82
Max. Negotiated Rate	$474.34
Rate for Payer: Aetna Commercial	$447.98
Rate for Payer: Aetna Medicare	$263.52
Rate for Payer: Aetna New Business (MI Preferred)	$342.58
Rate for Payer: BCBS Complete	$210.82
Rate for Payer: Cash Price	$421.63
Rate for Payer: Cofinity Commercial	$368.93
Rate for Payer: Cofinity Commercial	$453.25
Rate for Payer: Cofinity Medicare Advantage	$368.93
Rate for Payer: Encore Health Key Benefits Commercial	$421.63
Rate for Payer: Healthscope Commercial	$474.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$447.98
Rate for Payer: PHP Commercial	$447.98
Rate for Payer: Priority Health Cigna Priority Health	$342.58
Rate for Payer: Priority Health SBD	$332.04

DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR

Facility

$2.54

Service Code	NDC 60687021711
Hospital Charge Code	29274
Hospital Revenue Code	637
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna Commercial	$2.16
Rate for Payer: Aetna New Business (MI Preferred)	$1.65
Rate for Payer: Cash Price	$2.03
Rate for Payer: Cofinity Commercial	$1.78
Rate for Payer: Cofinity Commercial	$2.18
Rate for Payer: Cofinity Medicare Advantage	$1.78
Rate for Payer: Encore Health Key Benefits Commercial	$2.03
Rate for Payer: Healthscope Commercial	$2.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.16
Rate for Payer: PHP Commercial	$2.16
Rate for Payer: Priority Health Cigna Priority Health	$1.65
Rate for Payer: Priority Health SBD	$1.60

DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION

Facility

$24.01

Service Code	HCPCS J1240
Hospital Charge Code	2483
Hospital Revenue Code	636
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$24.48
Rate for Payer: Aetna Commercial	$20.41
Rate for Payer: Aetna Medicare	$12.00
Rate for Payer: Aetna New Business (MI Preferred)	$15.61
Rate for Payer: BCBS Complete	$9.60
Rate for Payer: BCBS Trust/PPO	$24.48
Rate for Payer: BCN Commercial	$24.48
Rate for Payer: Cash Price	$19.21
Rate for Payer: Cash Price	$19.21
Rate for Payer: Cofinity Commercial	$16.81
Rate for Payer: Cofinity Commercial	$20.65
Rate for Payer: Cofinity Medicare Advantage	$16.81
Rate for Payer: Encore Health Key Benefits Commercial	$19.21
Rate for Payer: Healthscope Commercial	$21.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.41
Rate for Payer: PHP Commercial	$20.41
Rate for Payer: Priority Health Cigna Priority Health	$15.61
Rate for Payer: Priority Health SBD	$15.13

DIMENHYDRINATE 50 MG/ML INJECTION SOLUTION

Facility

$24.01

Service Code	HCPCS J1240
Hospital Charge Code	2483
Hospital Revenue Code	636
Min. Negotiated Rate	$15.13
Max. Negotiated Rate	$21.61
Rate for Payer: Aetna Commercial	$20.41
Rate for Payer: Aetna New Business (MI Preferred)	$15.61
Rate for Payer: Cash Price	$19.21
Rate for Payer: Cofinity Commercial	$16.81
Rate for Payer: Cofinity Commercial	$20.65
Rate for Payer: Cofinity Medicare Advantage	$16.81
Rate for Payer: Encore Health Key Benefits Commercial	$19.21
Rate for Payer: Healthscope Commercial	$21.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.41
Rate for Payer: PHP Commercial	$20.41
Rate for Payer: Priority Health Cigna Priority Health	$15.61
Rate for Payer: Priority Health SBD	$15.13

DIMENHYDRINATE 50 MG TABLET

Facility

$88.20

Service Code	NDC 00904205159
Hospital Charge Code	2485
Hospital Revenue Code	637
Min. Negotiated Rate	$55.57
Max. Negotiated Rate	$79.38
Rate for Payer: Aetna Commercial	$74.97
Rate for Payer: Aetna New Business (MI Preferred)	$57.33
Rate for Payer: Cash Price	$70.56
Rate for Payer: Cofinity Commercial	$61.74
Rate for Payer: Cofinity Commercial	$75.85
Rate for Payer: Cofinity Medicare Advantage	$61.74
Rate for Payer: Encore Health Key Benefits Commercial	$70.56
Rate for Payer: Healthscope Commercial	$79.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$74.97
Rate for Payer: PHP Commercial	$74.97
Rate for Payer: Priority Health Cigna Priority Health	$57.33
Rate for Payer: Priority Health SBD	$55.57

DIMENHYDRINATE 50 MG TABLET

Facility

$88.20

Service Code	NDC 00904205159
Hospital Charge Code	2485
Hospital Revenue Code	637
Min. Negotiated Rate	$35.28
Max. Negotiated Rate	$79.38
Rate for Payer: Aetna Commercial	$74.97
Rate for Payer: Aetna Medicare	$44.10
Rate for Payer: Aetna New Business (MI Preferred)	$57.33
Rate for Payer: BCBS Complete	$35.28
Rate for Payer: Cash Price	$70.56
Rate for Payer: Cofinity Commercial	$61.74
Rate for Payer: Cofinity Commercial	$75.85
Rate for Payer: Cofinity Medicare Advantage	$61.74
Rate for Payer: Encore Health Key Benefits Commercial	$70.56
Rate for Payer: Healthscope Commercial	$79.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$74.97
Rate for Payer: PHP Commercial	$74.97
Rate for Payer: Priority Health Cigna Priority Health	$57.33
Rate for Payer: Priority Health SBD	$55.57

DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE

Facility

$1,803.01

Service Code	NDC 55566280001
Hospital Charge Code	27467
Hospital Revenue Code	637
Min. Negotiated Rate	$1,135.90
Max. Negotiated Rate	$1,622.71
Rate for Payer: Aetna Commercial	$1,532.56
Rate for Payer: Aetna New Business (MI Preferred)	$1,171.96
Rate for Payer: Cash Price	$1,442.41
Rate for Payer: Cofinity Commercial	$1,262.11
Rate for Payer: Cofinity Commercial	$1,550.59
Rate for Payer: Cofinity Medicare Advantage	$1,262.11
Rate for Payer: Encore Health Key Benefits Commercial	$1,442.41
Rate for Payer: Healthscope Commercial	$1,622.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,532.56
Rate for Payer: PHP Commercial	$1,532.56
Rate for Payer: Priority Health Cigna Priority Health	$1,171.96
Rate for Payer: Priority Health SBD	$1,135.90

DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE

Facility

$1,803.01

Service Code	NDC 55566280001
Hospital Charge Code	27467
Hospital Revenue Code	637
Min. Negotiated Rate	$721.20
Max. Negotiated Rate	$1,622.71
Rate for Payer: Aetna Commercial	$1,532.56
Rate for Payer: Aetna Medicare	$901.50
Rate for Payer: Aetna New Business (MI Preferred)	$1,171.96
Rate for Payer: BCBS Complete	$721.20
Rate for Payer: Cash Price	$1,442.41
Rate for Payer: Cofinity Commercial	$1,262.11
Rate for Payer: Cofinity Commercial	$1,550.59
Rate for Payer: Cofinity Medicare Advantage	$1,262.11
Rate for Payer: Encore Health Key Benefits Commercial	$1,442.41
Rate for Payer: Healthscope Commercial	$1,622.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,532.56
Rate for Payer: PHP Commercial	$1,532.56
Rate for Payer: Priority Health Cigna Priority Health	$1,171.96
Rate for Payer: Priority Health SBD	$1,135.90

DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE

Facility

$1,803.01

Service Code	NDC 55566280000
Hospital Charge Code	27467
Hospital Revenue Code	637
Min. Negotiated Rate	$721.20
Max. Negotiated Rate	$1,622.71
Rate for Payer: Aetna Commercial	$1,532.56
Rate for Payer: Aetna Medicare	$901.50
Rate for Payer: Aetna New Business (MI Preferred)	$1,171.96
Rate for Payer: BCBS Complete	$721.20
Rate for Payer: Cash Price	$1,442.41
Rate for Payer: Cofinity Commercial	$1,262.11
Rate for Payer: Cofinity Commercial	$1,550.59
Rate for Payer: Cofinity Medicare Advantage	$1,262.11
Rate for Payer: Encore Health Key Benefits Commercial	$1,442.41
Rate for Payer: Healthscope Commercial	$1,622.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,532.56
Rate for Payer: PHP Commercial	$1,532.56
Rate for Payer: Priority Health Cigna Priority Health	$1,171.96
Rate for Payer: Priority Health SBD	$1,135.90

DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE

Facility

$1,803.01

Service Code	NDC 55566280000
Hospital Charge Code	27467
Hospital Revenue Code	637
Min. Negotiated Rate	$1,135.90
Max. Negotiated Rate	$1,622.71
Rate for Payer: Aetna Commercial	$1,532.56
Rate for Payer: Aetna New Business (MI Preferred)	$1,171.96
Rate for Payer: Cash Price	$1,442.41
Rate for Payer: Cofinity Commercial	$1,262.11
Rate for Payer: Cofinity Commercial	$1,550.59
Rate for Payer: Cofinity Medicare Advantage	$1,262.11
Rate for Payer: Encore Health Key Benefits Commercial	$1,442.41
Rate for Payer: Healthscope Commercial	$1,622.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,532.56
Rate for Payer: PHP Commercial	$1,532.56
Rate for Payer: Priority Health Cigna Priority Health	$1,171.96
Rate for Payer: Priority Health SBD	$1,135.90

DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH

Facility

$6.54

Service Code	NDC 09900000847
Hospital Charge Code	39984
Hospital Revenue Code	637
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$5.89
Rate for Payer: Aetna Commercial	$5.56
Rate for Payer: Aetna New Business (MI Preferred)	$4.25
Rate for Payer: Cash Price	$5.23
Rate for Payer: Cofinity Commercial	$4.58
Rate for Payer: Cofinity Commercial	$5.62
Rate for Payer: Cofinity Medicare Advantage	$4.58
Rate for Payer: Encore Health Key Benefits Commercial	$5.23
Rate for Payer: Healthscope Commercial	$5.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.56
Rate for Payer: PHP Commercial	$5.56
Rate for Payer: Priority Health Cigna Priority Health	$4.25
Rate for Payer: Priority Health SBD	$4.12

DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH

Facility

$6.54

Service Code	NDC 09900000847
Hospital Charge Code	39984
Hospital Revenue Code	637
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$5.89
Rate for Payer: Aetna Commercial	$5.56
Rate for Payer: Aetna Medicare	$3.27
Rate for Payer: Aetna New Business (MI Preferred)	$4.25
Rate for Payer: BCBS Complete	$2.62
Rate for Payer: Cash Price	$5.23
Rate for Payer: Cofinity Commercial	$4.58
Rate for Payer: Cofinity Commercial	$5.62
Rate for Payer: Cofinity Medicare Advantage	$4.58
Rate for Payer: Encore Health Key Benefits Commercial	$5.23
Rate for Payer: Healthscope Commercial	$5.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.56
Rate for Payer: PHP Commercial	$5.56
Rate for Payer: Priority Health Cigna Priority Health	$4.25
Rate for Payer: Priority Health SBD	$4.12

DIPHENHYD 25 MG-LIDO 200 MG-MAG,AL 400 MG-SIMETH 40 MG/30 ML MOUTHWASH

Facility

$306.97

Service Code	NDC 65628005004
Hospital Charge Code	39984
Hospital Revenue Code	637
Min. Negotiated Rate	$193.39
Max. Negotiated Rate	$276.27
Rate for Payer: Aetna Commercial	$260.92
Rate for Payer: Aetna New Business (MI Preferred)	$199.53
Rate for Payer: Cash Price	$245.58
Rate for Payer: Cofinity Commercial	$214.88
Rate for Payer: Cofinity Commercial	$263.99
Rate for Payer: Cofinity Medicare Advantage	$214.88
Rate for Payer: Encore Health Key Benefits Commercial	$245.58
Rate for Payer: Healthscope Commercial	$276.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$260.92
Rate for Payer: PHP Commercial	$260.92
Rate for Payer: Priority Health Cigna Priority Health	$199.53
Rate for Payer: Priority Health SBD	$193.39

Know your out-of-pocket cost for care.

All Charges