Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET

Facility

$488.28

Service Code	NDC 00904701006
Hospital Charge Code	34714
Hospital Revenue Code	637
Min. Negotiated Rate	$307.62
Max. Negotiated Rate	$439.45
Rate for Payer: Aetna Commercial	$415.04
Rate for Payer: Aetna New Business (MI Preferred)	$317.38
Rate for Payer: Cash Price	$390.62
Rate for Payer: Cofinity Commercial	$341.80
Rate for Payer: Cofinity Commercial	$419.92
Rate for Payer: Cofinity Medicare Advantage	$341.80
Rate for Payer: Encore Health Key Benefits Commercial	$390.62
Rate for Payer: Healthscope Commercial	$439.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$415.04
Rate for Payer: PHP Commercial	$415.04
Rate for Payer: Priority Health Cigna Priority Health	$317.38
Rate for Payer: Priority Health SBD	$307.62

BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET

Facility

$488.28

Service Code	NDC 00904701006
Hospital Charge Code	34714
Hospital Revenue Code	637
Min. Negotiated Rate	$195.31
Max. Negotiated Rate	$439.45
Rate for Payer: Aetna Commercial	$415.04
Rate for Payer: Aetna Medicare	$244.14
Rate for Payer: Aetna New Business (MI Preferred)	$317.38
Rate for Payer: BCBS Complete	$195.31
Rate for Payer: Cash Price	$390.62
Rate for Payer: Cofinity Commercial	$341.80
Rate for Payer: Cofinity Commercial	$419.92
Rate for Payer: Cofinity Medicare Advantage	$341.80
Rate for Payer: Encore Health Key Benefits Commercial	$390.62
Rate for Payer: Healthscope Commercial	$439.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$415.04
Rate for Payer: PHP Commercial	$415.04
Rate for Payer: Priority Health Cigna Priority Health	$317.38
Rate for Payer: Priority Health SBD	$307.62

BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION

Facility

$62.79

Service Code	HCPCS J0592
Hospital Charge Code	115937
Hospital Revenue Code	636
Min. Negotiated Rate	$39.56
Max. Negotiated Rate	$56.51
Rate for Payer: Aetna Commercial	$53.37
Rate for Payer: Aetna Commercial	$45.48
Rate for Payer: Aetna New Business (MI Preferred)	$34.78
Rate for Payer: Aetna New Business (MI Preferred)	$40.81
Rate for Payer: Cash Price	$42.81
Rate for Payer: Cash Price	$50.23
Rate for Payer: Cofinity Commercial	$37.46
Rate for Payer: Cofinity Commercial	$43.95
Rate for Payer: Cofinity Commercial	$54.00
Rate for Payer: Cofinity Commercial	$46.02
Rate for Payer: Cofinity Medicare Advantage	$43.95
Rate for Payer: Cofinity Medicare Advantage	$37.46
Rate for Payer: Encore Health Key Benefits Commercial	$42.81
Rate for Payer: Encore Health Key Benefits Commercial	$50.23
Rate for Payer: Healthscope Commercial	$48.16
Rate for Payer: Healthscope Commercial	$56.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.37
Rate for Payer: PHP Commercial	$45.48
Rate for Payer: PHP Commercial	$53.37
Rate for Payer: Priority Health Cigna Priority Health	$40.81
Rate for Payer: Priority Health Cigna Priority Health	$34.78
Rate for Payer: Priority Health SBD	$39.56
Rate for Payer: Priority Health SBD	$33.71

BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION

Facility

$62.79

Service Code	HCPCS J0592
Hospital Charge Code	115937
Hospital Revenue Code	636
Min. Negotiated Rate	$25.12
Max. Negotiated Rate	$56.51
Rate for Payer: Aetna Commercial	$53.37
Rate for Payer: Aetna Commercial	$45.48
Rate for Payer: Aetna Medicare	$26.75
Rate for Payer: Aetna Medicare	$31.39
Rate for Payer: Aetna New Business (MI Preferred)	$34.78
Rate for Payer: Aetna New Business (MI Preferred)	$40.81
Rate for Payer: BCBS Complete	$25.12
Rate for Payer: BCBS Complete	$21.40
Rate for Payer: Cash Price	$42.81
Rate for Payer: Cash Price	$50.23
Rate for Payer: Cofinity Commercial	$37.46
Rate for Payer: Cofinity Commercial	$43.95
Rate for Payer: Cofinity Commercial	$54.00
Rate for Payer: Cofinity Commercial	$46.02
Rate for Payer: Cofinity Medicare Advantage	$43.95
Rate for Payer: Cofinity Medicare Advantage	$37.46
Rate for Payer: Encore Health Key Benefits Commercial	$42.81
Rate for Payer: Encore Health Key Benefits Commercial	$50.23
Rate for Payer: Healthscope Commercial	$48.16
Rate for Payer: Healthscope Commercial	$56.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.37
Rate for Payer: PHP Commercial	$53.37
Rate for Payer: PHP Commercial	$45.48
Rate for Payer: Priority Health Cigna Priority Health	$34.78
Rate for Payer: Priority Health Cigna Priority Health	$40.81
Rate for Payer: Priority Health SBD	$39.56
Rate for Payer: Priority Health SBD	$33.71

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET

Facility

$195.30

Service Code	NDC 00054017613
Hospital Charge Code	34711
Hospital Revenue Code	637
Min. Negotiated Rate	$78.12
Max. Negotiated Rate	$175.77
Rate for Payer: Aetna Commercial	$166.00
Rate for Payer: Aetna Medicare	$97.65
Rate for Payer: Aetna New Business (MI Preferred)	$126.94
Rate for Payer: BCBS Complete	$78.12
Rate for Payer: Cash Price	$156.24
Rate for Payer: Cofinity Commercial	$136.71
Rate for Payer: Cofinity Commercial	$167.96
Rate for Payer: Cofinity Medicare Advantage	$136.71
Rate for Payer: Encore Health Key Benefits Commercial	$156.24
Rate for Payer: Healthscope Commercial	$175.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$166.00
Rate for Payer: PHP Commercial	$166.00
Rate for Payer: Priority Health Cigna Priority Health	$126.94
Rate for Payer: Priority Health SBD	$123.04

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET

Facility

$140.91

Service Code	NDC 50383092493
Hospital Charge Code	34711
Hospital Revenue Code	637
Min. Negotiated Rate	$56.36
Max. Negotiated Rate	$126.82
Rate for Payer: Aetna Commercial	$119.77
Rate for Payer: Aetna Medicare	$70.45
Rate for Payer: Aetna New Business (MI Preferred)	$91.59
Rate for Payer: BCBS Complete	$56.36
Rate for Payer: Cash Price	$112.73
Rate for Payer: Cofinity Commercial	$121.18
Rate for Payer: Cofinity Commercial	$98.64
Rate for Payer: Cofinity Medicare Advantage	$98.64
Rate for Payer: Encore Health Key Benefits Commercial	$112.73
Rate for Payer: Healthscope Commercial	$126.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.77
Rate for Payer: PHP Commercial	$119.77
Rate for Payer: Priority Health Cigna Priority Health	$91.59
Rate for Payer: Priority Health SBD	$88.77

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET

Facility

$195.30

Service Code	NDC 00054017613
Hospital Charge Code	34711
Hospital Revenue Code	637
Min. Negotiated Rate	$123.04
Max. Negotiated Rate	$175.77
Rate for Payer: Aetna Commercial	$166.00
Rate for Payer: Aetna New Business (MI Preferred)	$126.94
Rate for Payer: Cash Price	$156.24
Rate for Payer: Cofinity Commercial	$136.71
Rate for Payer: Cofinity Commercial	$167.96
Rate for Payer: Cofinity Medicare Advantage	$136.71
Rate for Payer: Encore Health Key Benefits Commercial	$156.24
Rate for Payer: Healthscope Commercial	$175.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$166.00
Rate for Payer: PHP Commercial	$166.00
Rate for Payer: Priority Health Cigna Priority Health	$126.94
Rate for Payer: Priority Health SBD	$123.04

BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET

Facility

$140.91

Service Code	NDC 50383092493
Hospital Charge Code	34711
Hospital Revenue Code	637
Min. Negotiated Rate	$88.77
Max. Negotiated Rate	$126.82
Rate for Payer: Aetna Commercial	$119.77
Rate for Payer: Aetna New Business (MI Preferred)	$91.59
Rate for Payer: Cash Price	$112.73
Rate for Payer: Cofinity Commercial	$121.18
Rate for Payer: Cofinity Commercial	$98.64
Rate for Payer: Cofinity Medicare Advantage	$98.64
Rate for Payer: Encore Health Key Benefits Commercial	$112.73
Rate for Payer: Healthscope Commercial	$126.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.77
Rate for Payer: PHP Commercial	$119.77
Rate for Payer: Priority Health Cigna Priority Health	$91.59
Rate for Payer: Priority Health SBD	$88.77

BUPRENORPHINE HCL 75 MCG BUCCAL FILM

Facility

$21.90

Service Code	NDC 59385002101
Hospital Charge Code	176431
Hospital Revenue Code	637
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$19.71
Rate for Payer: Aetna Commercial	$18.61
Rate for Payer: Aetna New Business (MI Preferred)	$14.23
Rate for Payer: Cash Price	$17.52
Rate for Payer: Cofinity Commercial	$15.33
Rate for Payer: Cofinity Commercial	$18.83
Rate for Payer: Cofinity Medicare Advantage	$15.33
Rate for Payer: Encore Health Key Benefits Commercial	$17.52
Rate for Payer: Healthscope Commercial	$19.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.61
Rate for Payer: PHP Commercial	$18.61
Rate for Payer: Priority Health Cigna Priority Health	$14.23
Rate for Payer: Priority Health SBD	$13.80

BUPRENORPHINE HCL 75 MCG BUCCAL FILM

Facility

$1,313.73

Service Code	NDC 59385002160
Hospital Charge Code	176431
Hospital Revenue Code	637
Min. Negotiated Rate	$525.49
Max. Negotiated Rate	$1,182.36
Rate for Payer: Aetna Commercial	$1,116.67
Rate for Payer: Aetna Medicare	$656.87
Rate for Payer: Aetna New Business (MI Preferred)	$853.92
Rate for Payer: BCBS Complete	$525.49
Rate for Payer: Cash Price	$1,050.98
Rate for Payer: Cofinity Commercial	$1,129.81
Rate for Payer: Cofinity Commercial	$919.61
Rate for Payer: Cofinity Medicare Advantage	$919.61
Rate for Payer: Encore Health Key Benefits Commercial	$1,050.98
Rate for Payer: Healthscope Commercial	$1,182.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,116.67
Rate for Payer: PHP Commercial	$1,116.67
Rate for Payer: Priority Health Cigna Priority Health	$853.92
Rate for Payer: Priority Health SBD	$827.65

BUPRENORPHINE HCL 75 MCG BUCCAL FILM

Facility

$1,313.73

Service Code	NDC 59385002160
Hospital Charge Code	176431
Hospital Revenue Code	637
Min. Negotiated Rate	$827.65
Max. Negotiated Rate	$1,182.36
Rate for Payer: Aetna Commercial	$1,116.67
Rate for Payer: Aetna New Business (MI Preferred)	$853.92
Rate for Payer: Cash Price	$1,050.98
Rate for Payer: Cofinity Commercial	$1,129.81
Rate for Payer: Cofinity Commercial	$919.61
Rate for Payer: Cofinity Medicare Advantage	$919.61
Rate for Payer: Encore Health Key Benefits Commercial	$1,050.98
Rate for Payer: Healthscope Commercial	$1,182.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,116.67
Rate for Payer: PHP Commercial	$1,116.67
Rate for Payer: Priority Health Cigna Priority Health	$853.92
Rate for Payer: Priority Health SBD	$827.65

BUPRENORPHINE HCL 75 MCG BUCCAL FILM

Facility

$21.90

Service Code	NDC 59385002101
Hospital Charge Code	176431
Hospital Revenue Code	637
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$19.71
Rate for Payer: Aetna Commercial	$18.61
Rate for Payer: Aetna Medicare	$10.95
Rate for Payer: Aetna New Business (MI Preferred)	$14.23
Rate for Payer: BCBS Complete	$8.76
Rate for Payer: Cash Price	$17.52
Rate for Payer: Cofinity Commercial	$15.33
Rate for Payer: Cofinity Commercial	$18.83
Rate for Payer: Cofinity Medicare Advantage	$15.33
Rate for Payer: Encore Health Key Benefits Commercial	$17.52
Rate for Payer: Healthscope Commercial	$19.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.61
Rate for Payer: PHP Commercial	$18.61
Rate for Payer: Priority Health Cigna Priority Health	$14.23
Rate for Payer: Priority Health SBD	$13.80

BUPROPION HCL 100 MG TABLET

Facility

$318.72

Service Code	NDC 60505015701
Hospital Charge Code	9321
Hospital Revenue Code	637
Min. Negotiated Rate	$200.79
Max. Negotiated Rate	$286.85
Rate for Payer: Aetna Commercial	$270.91
Rate for Payer: Aetna New Business (MI Preferred)	$207.17
Rate for Payer: Cash Price	$254.98
Rate for Payer: Cofinity Commercial	$223.10
Rate for Payer: Cofinity Commercial	$274.10
Rate for Payer: Cofinity Medicare Advantage	$223.10
Rate for Payer: Encore Health Key Benefits Commercial	$254.98
Rate for Payer: Healthscope Commercial	$286.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$270.91
Rate for Payer: PHP Commercial	$270.91
Rate for Payer: Priority Health Cigna Priority Health	$207.17
Rate for Payer: Priority Health SBD	$200.79

BUPROPION HCL 100 MG TABLET

Facility

$521.76

Service Code	NDC 00904663661
Hospital Charge Code	9321
Hospital Revenue Code	637
Min. Negotiated Rate	$208.70
Max. Negotiated Rate	$469.58
Rate for Payer: Aetna Commercial	$443.50
Rate for Payer: Aetna Medicare	$260.88
Rate for Payer: Aetna New Business (MI Preferred)	$339.14
Rate for Payer: BCBS Complete	$208.70
Rate for Payer: Cash Price	$417.41
Rate for Payer: Cofinity Commercial	$365.23
Rate for Payer: Cofinity Commercial	$448.71
Rate for Payer: Cofinity Medicare Advantage	$365.23
Rate for Payer: Encore Health Key Benefits Commercial	$417.41
Rate for Payer: Healthscope Commercial	$469.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$443.50
Rate for Payer: PHP Commercial	$443.50
Rate for Payer: Priority Health Cigna Priority Health	$339.14
Rate for Payer: Priority Health SBD	$328.71

BUPROPION HCL 100 MG TABLET

Facility

$521.76

Service Code	NDC 00904663661
Hospital Charge Code	9321
Hospital Revenue Code	637
Min. Negotiated Rate	$328.71
Max. Negotiated Rate	$469.58
Rate for Payer: Aetna Commercial	$443.50
Rate for Payer: Aetna New Business (MI Preferred)	$339.14
Rate for Payer: Cash Price	$417.41
Rate for Payer: Cofinity Commercial	$365.23
Rate for Payer: Cofinity Commercial	$448.71
Rate for Payer: Cofinity Medicare Advantage	$365.23
Rate for Payer: Encore Health Key Benefits Commercial	$417.41
Rate for Payer: Healthscope Commercial	$469.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$443.50
Rate for Payer: PHP Commercial	$443.50
Rate for Payer: Priority Health Cigna Priority Health	$339.14
Rate for Payer: Priority Health SBD	$328.71

BUPROPION HCL 100 MG TABLET

Facility

$318.72

Service Code	NDC 60505015701
Hospital Charge Code	9321
Hospital Revenue Code	637
Min. Negotiated Rate	$127.49
Max. Negotiated Rate	$286.85
Rate for Payer: Aetna Commercial	$270.91
Rate for Payer: Aetna Medicare	$159.36
Rate for Payer: Aetna New Business (MI Preferred)	$207.17
Rate for Payer: BCBS Complete	$127.49
Rate for Payer: Cash Price	$254.98
Rate for Payer: Cofinity Commercial	$223.10
Rate for Payer: Cofinity Commercial	$274.10
Rate for Payer: Cofinity Medicare Advantage	$223.10
Rate for Payer: Encore Health Key Benefits Commercial	$254.98
Rate for Payer: Healthscope Commercial	$286.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$270.91
Rate for Payer: PHP Commercial	$270.91
Rate for Payer: Priority Health Cigna Priority Health	$207.17
Rate for Payer: Priority Health SBD	$200.79

BUPROPION HCL 75 MG TABLET

Facility

$452.16

Service Code	NDC 51079094320
Hospital Charge Code	9322
Hospital Revenue Code	637
Min. Negotiated Rate	$284.86
Max. Negotiated Rate	$406.94
Rate for Payer: Aetna Commercial	$384.34
Rate for Payer: Aetna New Business (MI Preferred)	$293.90
Rate for Payer: Cash Price	$361.73
Rate for Payer: Cofinity Commercial	$316.51
Rate for Payer: Cofinity Commercial	$388.86
Rate for Payer: Cofinity Medicare Advantage	$316.51
Rate for Payer: Encore Health Key Benefits Commercial	$361.73
Rate for Payer: Healthscope Commercial	$406.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$384.34
Rate for Payer: PHP Commercial	$384.34
Rate for Payer: Priority Health Cigna Priority Health	$293.90
Rate for Payer: Priority Health SBD	$284.86

BUPROPION HCL 75 MG TABLET

Facility

$452.16

Service Code	NDC 51079094320
Hospital Charge Code	9322
Hospital Revenue Code	637
Min. Negotiated Rate	$180.86
Max. Negotiated Rate	$406.94
Rate for Payer: Aetna Commercial	$384.34
Rate for Payer: Aetna Medicare	$226.08
Rate for Payer: Aetna New Business (MI Preferred)	$293.90
Rate for Payer: BCBS Complete	$180.86
Rate for Payer: Cash Price	$361.73
Rate for Payer: Cofinity Commercial	$316.51
Rate for Payer: Cofinity Commercial	$388.86
Rate for Payer: Cofinity Medicare Advantage	$316.51
Rate for Payer: Encore Health Key Benefits Commercial	$361.73
Rate for Payer: Healthscope Commercial	$406.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$384.34
Rate for Payer: PHP Commercial	$384.34
Rate for Payer: Priority Health Cigna Priority Health	$293.90
Rate for Payer: Priority Health SBD	$284.86

BUPROPION HCL 75 MG TABLET

Facility

$4.53

Service Code	NDC 51079094301
Hospital Charge Code	9322
Hospital Revenue Code	637
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$4.08
Rate for Payer: Aetna Commercial	$3.85
Rate for Payer: Aetna New Business (MI Preferred)	$2.94
Rate for Payer: Cash Price	$3.62
Rate for Payer: Cofinity Commercial	$3.17
Rate for Payer: Cofinity Commercial	$3.90
Rate for Payer: Cofinity Medicare Advantage	$3.17
Rate for Payer: Encore Health Key Benefits Commercial	$3.62
Rate for Payer: Healthscope Commercial	$4.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.85
Rate for Payer: PHP Commercial	$3.85
Rate for Payer: Priority Health Cigna Priority Health	$2.94
Rate for Payer: Priority Health SBD	$2.85

BUPROPION HCL 75 MG TABLET

Facility

$4.53

Service Code	NDC 51079094301
Hospital Charge Code	9322
Hospital Revenue Code	637
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$4.08
Rate for Payer: Aetna Commercial	$3.85
Rate for Payer: Aetna Medicare	$2.27
Rate for Payer: Aetna New Business (MI Preferred)	$2.94
Rate for Payer: BCBS Complete	$1.81
Rate for Payer: Cash Price	$3.62
Rate for Payer: Cofinity Commercial	$3.17
Rate for Payer: Cofinity Commercial	$3.90
Rate for Payer: Cofinity Medicare Advantage	$3.17
Rate for Payer: Encore Health Key Benefits Commercial	$3.62
Rate for Payer: Healthscope Commercial	$4.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.85
Rate for Payer: PHP Commercial	$3.85
Rate for Payer: Priority Health Cigna Priority Health	$2.94
Rate for Payer: Priority Health SBD	$2.85

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE

Facility

$8.28

Service Code	NDC 60687031211
Hospital Charge Code	36775
Hospital Revenue Code	637
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$7.45
Rate for Payer: Aetna Commercial	$7.04
Rate for Payer: Aetna Medicare	$4.14
Rate for Payer: Aetna New Business (MI Preferred)	$5.38
Rate for Payer: BCBS Complete	$3.31
Rate for Payer: Cash Price	$6.62
Rate for Payer: Cofinity Commercial	$5.80
Rate for Payer: Cofinity Commercial	$7.12
Rate for Payer: Cofinity Medicare Advantage	$5.80
Rate for Payer: Encore Health Key Benefits Commercial	$6.62
Rate for Payer: Healthscope Commercial	$7.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.04
Rate for Payer: PHP Commercial	$7.04
Rate for Payer: Priority Health Cigna Priority Health	$5.38
Rate for Payer: Priority Health SBD	$5.22

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE

Facility

$828.00

Service Code	NDC 60687031201
Hospital Charge Code	36775
Hospital Revenue Code	637
Min. Negotiated Rate	$521.64
Max. Negotiated Rate	$745.20
Rate for Payer: Aetna Commercial	$703.80
Rate for Payer: Aetna New Business (MI Preferred)	$538.20
Rate for Payer: Cash Price	$662.40
Rate for Payer: Cofinity Commercial	$579.60
Rate for Payer: Cofinity Commercial	$712.08
Rate for Payer: Cofinity Medicare Advantage	$579.60
Rate for Payer: Encore Health Key Benefits Commercial	$662.40
Rate for Payer: Healthscope Commercial	$745.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$703.80
Rate for Payer: PHP Commercial	$703.80
Rate for Payer: Priority Health Cigna Priority Health	$538.20
Rate for Payer: Priority Health SBD	$521.64

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE

Facility

$828.00

Service Code	NDC 60687031201
Hospital Charge Code	36775
Hospital Revenue Code	637
Min. Negotiated Rate	$331.20
Max. Negotiated Rate	$745.20
Rate for Payer: Aetna Commercial	$703.80
Rate for Payer: Aetna Medicare	$414.00
Rate for Payer: Aetna New Business (MI Preferred)	$538.20
Rate for Payer: BCBS Complete	$331.20
Rate for Payer: Cash Price	$662.40
Rate for Payer: Cofinity Commercial	$579.60
Rate for Payer: Cofinity Commercial	$712.08
Rate for Payer: Cofinity Medicare Advantage	$579.60
Rate for Payer: Encore Health Key Benefits Commercial	$662.40
Rate for Payer: Healthscope Commercial	$745.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$703.80
Rate for Payer: PHP Commercial	$703.80
Rate for Payer: Priority Health Cigna Priority Health	$538.20
Rate for Payer: Priority Health SBD	$521.64

BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE

Facility

$8.28

Service Code	NDC 60687031211
Hospital Charge Code	36775
Hospital Revenue Code	637
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$7.45
Rate for Payer: Aetna Commercial	$7.04
Rate for Payer: Aetna New Business (MI Preferred)	$5.38
Rate for Payer: Cash Price	$6.62
Rate for Payer: Cofinity Commercial	$5.80
Rate for Payer: Cofinity Commercial	$7.12
Rate for Payer: Cofinity Medicare Advantage	$5.80
Rate for Payer: Encore Health Key Benefits Commercial	$6.62
Rate for Payer: Healthscope Commercial	$7.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.04
Rate for Payer: PHP Commercial	$7.04
Rate for Payer: Priority Health Cigna Priority Health	$5.38
Rate for Payer: Priority Health SBD	$5.22

BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE

Facility

$7.17

Service Code	NDC 60687079311
Hospital Charge Code	36776
Hospital Revenue Code	637
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$6.45
Rate for Payer: Aetna Commercial	$6.09
Rate for Payer: Aetna New Business (MI Preferred)	$4.66
Rate for Payer: Cash Price	$5.74
Rate for Payer: Cofinity Commercial	$5.02
Rate for Payer: Cofinity Commercial	$6.17
Rate for Payer: Cofinity Medicare Advantage	$5.02
Rate for Payer: Encore Health Key Benefits Commercial	$5.74
Rate for Payer: Healthscope Commercial	$6.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.09
Rate for Payer: PHP Commercial	$6.09
Rate for Payer: Priority Health Cigna Priority Health	$4.66
Rate for Payer: Priority Health SBD	$4.52

Know your out-of-pocket cost for care.

All Charges