Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

diclofenac sodium 75 mg Oral EC Tab [HMC]

Facility

IP

$8.43

Service Code	NDC 00591033960
Hospital Charge Code	3800745
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$7.59
Rate for Payer: UnitedHealthcare Commercial	$8.01
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diclofenac sodium 75 mg Oral EC Tab [HMC]

Facility

OP

$9.33

Service Code	NDC 61442010301
Hospital Charge Code	3800745
Hospital Revenue Code	250
Min. Negotiated Rate	$3.73
Max. Negotiated Rate	$8.86
Rate for Payer: Aetna Commercial	$8.40
Rate for Payer: Humana Medicare Advantage	$3.92
Rate for Payer: UnitedHealthcare Commercial	$8.86
Rate for Payer: UnitedHealthcare Medicaid	$3.73
Rate for Payer: WPPA Medicare Advantage	$5.60

diclofenac sodium 75 mg Oral EC Tab [HMC]

Facility

IP

$7.41

Service Code	NDC 68084033301
Hospital Charge Code	3800745
Hospital Revenue Code	250
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.67
Rate for Payer: UnitedHealthcare Commercial	$7.04
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diclofenac sodium 75 mg Oral EC Tab [HMC]

Facility

OP

$8.43

Service Code	NDC 00591033960
Hospital Charge Code	3800745
Hospital Revenue Code	250
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$8.01
Rate for Payer: Aetna Commercial	$7.59
Rate for Payer: Humana Medicare Advantage	$3.54
Rate for Payer: UnitedHealthcare Commercial	$8.01
Rate for Payer: UnitedHealthcare Medicaid	$3.37
Rate for Payer: WPPA Medicare Advantage	$5.06

diclofenac sodium 75 mg Oral EC Tab [HMC]

Facility

IP

$9.33

Service Code	NDC 61442010301
Hospital Charge Code	3800745
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.40
Rate for Payer: UnitedHealthcare Commercial	$8.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diclofenac Top 1% gel [HMC]

Facility

IP

$42.05

Service Code	NDC 45802095301
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$37.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$37.84
Rate for Payer: UnitedHealthcare Commercial	$39.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diclofenac Top 1% gel [HMC]

Facility

OP

$42.05

Service Code	NDC 45802095301
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$16.82
Max. Negotiated Rate	$39.95
Rate for Payer: Aetna Commercial	$37.84
Rate for Payer: Humana Medicare Advantage	$17.66
Rate for Payer: UnitedHealthcare Commercial	$39.95
Rate for Payer: UnitedHealthcare Medicaid	$16.82
Rate for Payer: WPPA Medicare Advantage	$25.23

diclofenac Top 1% gel [HMC]

Facility

OP

$107.51

Service Code	NDC 63481068447
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$43.00
Max. Negotiated Rate	$102.13
Rate for Payer: Aetna Commercial	$96.76
Rate for Payer: Humana Medicare Advantage	$45.15
Rate for Payer: UnitedHealthcare Commercial	$102.13
Rate for Payer: UnitedHealthcare Medicaid	$43.00
Rate for Payer: WPPA Medicare Advantage	$64.51

diclofenac Top 1% gel [HMC]

Facility

IP

$107.51

Service Code	NDC 63481068447
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$96.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$96.76
Rate for Payer: UnitedHealthcare Commercial	$102.13
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diclofenac Top 1% gel [HMC]

Facility

OP

$91.04

Service Code	NDC 69097052444
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$36.42
Max. Negotiated Rate	$86.49
Rate for Payer: Aetna Commercial	$81.94
Rate for Payer: Humana Medicare Advantage	$38.24
Rate for Payer: UnitedHealthcare Commercial	$86.49
Rate for Payer: UnitedHealthcare Medicaid	$36.42
Rate for Payer: WPPA Medicare Advantage	$54.62

diclofenac Top 1% gel [HMC]

Facility

IP

$47.00

Service Code	NDC 69097072044
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diclofenac Top 1% gel [HMC]

Facility

OP

$53.71

Service Code	NDC 00067815203
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$21.48
Max. Negotiated Rate	$51.02
Rate for Payer: Aetna Commercial	$48.34
Rate for Payer: Humana Medicare Advantage	$22.56
Rate for Payer: UnitedHealthcare Commercial	$51.02
Rate for Payer: UnitedHealthcare Medicaid	$21.48
Rate for Payer: WPPA Medicare Advantage	$32.23

diclofenac Top 1% gel [HMC]

Facility

IP

$91.04

Service Code	NDC 69097052444
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$81.94
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.94
Rate for Payer: UnitedHealthcare Commercial	$86.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diclofenac Top 1% gel [HMC]

Facility

IP

$53.71

Service Code	NDC 00067815203
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$48.34
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.34
Rate for Payer: UnitedHealthcare Commercial	$51.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

diclofenac Top 1% gel [HMC]

Facility

OP

$47.00

Service Code	NDC 69097072044
Hospital Charge Code	3800065
Hospital Revenue Code	250
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$44.65
Rate for Payer: Aetna Commercial	$42.30
Rate for Payer: Humana Medicare Advantage	$19.74
Rate for Payer: UnitedHealthcare Commercial	$44.65
Rate for Payer: UnitedHealthcare Medicaid	$18.80
Rate for Payer: WPPA Medicare Advantage	$28.20

dicyclomine 10 mg/mL Inj Sol [HMC]

Facility

OP

$90.20

Service Code	HCPCS J0500
Hospital Charge Code	3800372
Hospital Revenue Code	250
Min. Negotiated Rate	$11.33
Max. Negotiated Rate	$85.69
Rate for Payer: Aetna Commercial	$81.18
Rate for Payer: Aetna Commercial	$83.81
Rate for Payer: Aetna Commercial	$154.17
Rate for Payer: Aetna Commercial	$57.85
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.12
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.12
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.12
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$32.12
Rate for Payer: Humana Medicare Advantage	$27.00
Rate for Payer: Humana Medicare Advantage	$37.88
Rate for Payer: Humana Medicare Advantage	$71.95
Rate for Payer: Humana Medicare Advantage	$39.11
Rate for Payer: UnitedHealthcare Commercial	$162.74
Rate for Payer: UnitedHealthcare Commercial	$61.07
Rate for Payer: UnitedHealthcare Commercial	$88.46
Rate for Payer: UnitedHealthcare Commercial	$85.69
Rate for Payer: UnitedHealthcare Medicaid	$11.33
Rate for Payer: UnitedHealthcare Medicaid	$11.33
Rate for Payer: UnitedHealthcare Medicaid	$11.33
Rate for Payer: UnitedHealthcare Medicaid	$11.33
Rate for Payer: WPPA Medicare Advantage	$102.78
Rate for Payer: WPPA Medicare Advantage	$54.12
Rate for Payer: WPPA Medicare Advantage	$55.87
Rate for Payer: WPPA Medicare Advantage	$38.57

dicyclomine 10 mg/mL Inj Sol [HMC]

Facility

OP

$90.20

Service Code	NDC 63323084202
Hospital Charge Code	3800372
Hospital Revenue Code	250
Min. Negotiated Rate	$36.08
Max. Negotiated Rate	$85.69
Rate for Payer: Aetna Commercial	$81.18
Rate for Payer: Humana Medicare Advantage	$37.88
Rate for Payer: UnitedHealthcare Commercial	$85.69
Rate for Payer: UnitedHealthcare Medicaid	$36.08
Rate for Payer: WPPA Medicare Advantage	$54.12

dicyclomine 10 mg/mL Inj Sol [HMC]

Facility

IP

$90.20

Service Code	NDC 63323084202
Hospital Charge Code	3800372
Hospital Revenue Code	250
Min. Negotiated Rate	$81.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$81.18
Rate for Payer: UnitedHealthcare Commercial	$85.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dicyclomine 10 mg/mL Inj Sol [HMC]

Facility

IP

$171.30

Service Code	HCPCS J0500
Hospital Charge Code	3800372
Hospital Revenue Code	250
Min. Negotiated Rate	$154.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$154.17
Rate for Payer: Aetna Commercial	$81.18
Rate for Payer: Aetna Commercial	$83.81
Rate for Payer: Aetna Commercial	$57.85
Rate for Payer: UnitedHealthcare Commercial	$162.74
Rate for Payer: UnitedHealthcare Commercial	$61.07
Rate for Payer: UnitedHealthcare Commercial	$85.69
Rate for Payer: UnitedHealthcare Commercial	$88.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dicyclomine 20 mg Tab [HMC]

Facility

IP

$7.01

Service Code	NDC 00904698861
Hospital Charge Code	3805378
Hospital Revenue Code	250
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.31
Rate for Payer: UnitedHealthcare Commercial	$6.66
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dicyclomine 20 mg Tab [HMC]

Facility

IP

$6.79

Service Code	NDC 51079011920
Hospital Charge Code	3805378
Hospital Revenue Code	250
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.11
Rate for Payer: UnitedHealthcare Commercial	$6.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dicyclomine 20 mg Tab [HMC]

Facility

OP

$7.01

Service Code	NDC 00904698861
Hospital Charge Code	3805378
Hospital Revenue Code	250
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$6.66
Rate for Payer: Aetna Commercial	$6.31
Rate for Payer: Humana Medicare Advantage	$2.94
Rate for Payer: UnitedHealthcare Commercial	$6.66
Rate for Payer: UnitedHealthcare Medicaid	$2.80
Rate for Payer: WPPA Medicare Advantage	$4.21

dicyclomine 20 mg Tab [HMC]

Facility

OP

$6.79

Service Code	NDC 51079011920
Hospital Charge Code	3805378
Hospital Revenue Code	250
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$6.45
Rate for Payer: Aetna Commercial	$6.11
Rate for Payer: Humana Medicare Advantage	$2.85
Rate for Payer: UnitedHealthcare Commercial	$6.45
Rate for Payer: UnitedHealthcare Medicaid	$2.72
Rate for Payer: WPPA Medicare Advantage	$4.07

dicyclomine 20 mg Tab [HMC]

Facility

IP

$6.63

Service Code	NDC 60687038001
Hospital Charge Code	3805378
Hospital Revenue Code	250
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.97
Rate for Payer: UnitedHealthcare Commercial	$6.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

dicyclomine 20 mg Tab [HMC]

Facility

OP

$6.63

Service Code	NDC 60687038001
Hospital Charge Code	3805378
Hospital Revenue Code	250
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$6.30
Rate for Payer: Aetna Commercial	$5.97
Rate for Payer: Humana Medicare Advantage	$2.78
Rate for Payer: UnitedHealthcare Commercial	$6.30
Rate for Payer: UnitedHealthcare Medicaid	$2.65
Rate for Payer: WPPA Medicare Advantage	$3.98

<<
<
205
206
207
208
209
210
211
212
213
214
>
>>