|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$400.90
|
|
|
Service Code
|
NDC 0185-0129-01
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$280.63 |
| Max. Negotiated Rate |
$400.90 |
| Rate for Payer: Aetna Commercial |
$360.81
|
| Rate for Payer: ASR ASR |
$388.87
|
| Rate for Payer: BCBS Trust/PPO |
$310.82
|
| Rate for Payer: BCN Commercial |
$310.82
|
| Rate for Payer: Cash Price |
$320.72
|
| Rate for Payer: Cofinity Commercial |
$376.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.72
|
| Rate for Payer: Healthscope Commercial |
$400.90
|
| Rate for Payer: Healthscope Whirlpool |
$388.87
|
| Rate for Payer: Mclaren Commercial |
$360.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$340.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$280.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$352.79
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$218.45
|
|
|
Service Code
|
NDC 60687-384-25
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.92 |
| Max. Negotiated Rate |
$218.45 |
| Rate for Payer: Aetna Commercial |
$196.60
|
| Rate for Payer: ASR ASR |
$211.90
|
| Rate for Payer: BCBS Trust/PPO |
$169.36
|
| Rate for Payer: BCN Commercial |
$169.36
|
| Rate for Payer: Cash Price |
$174.76
|
| Rate for Payer: Cofinity Commercial |
$205.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.76
|
| Rate for Payer: Healthscope Commercial |
$218.45
|
| Rate for Payer: Healthscope Whirlpool |
$211.90
|
| Rate for Payer: Mclaren Commercial |
$196.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$192.24
|
|
|
BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE
|
Facility
IP
|
$16.24
|
|
|
Service Code
|
NDC 0362-0557-05
|
| Hospital Charge Code |
116394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.37 |
| Max. Negotiated Rate |
$16.24 |
| Rate for Payer: Aetna Commercial |
$14.62
|
| Rate for Payer: ASR ASR |
$15.75
|
| Rate for Payer: BCBS Trust/PPO |
$12.59
|
| Rate for Payer: BCN Commercial |
$12.59
|
| Rate for Payer: Cash Price |
$12.99
|
| Rate for Payer: Cofinity Commercial |
$15.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.99
|
| Rate for Payer: Healthscope Commercial |
$16.24
|
| Rate for Payer: Healthscope Whirlpool |
$15.75
|
| Rate for Payer: Mclaren Commercial |
$14.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.29
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION
|
Facility
IP
|
$27.11
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
105640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$27.11 |
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: ASR ASR |
$26.30
|
| Rate for Payer: BCBS Trust/PPO |
$21.02
|
| Rate for Payer: BCN Commercial |
$21.02
|
| Rate for Payer: Cash Price |
$21.69
|
| Rate for Payer: Cofinity Commercial |
$25.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.69
|
| Rate for Payer: Healthscope Commercial |
$27.11
|
| Rate for Payer: Healthscope Whirlpool |
$26.30
|
| Rate for Payer: Mclaren Commercial |
$24.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.86
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM
|
Facility
IP
|
$12.52
|
|
|
Service Code
|
NDC 43598-579-01
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$12.52 |
| Rate for Payer: Aetna Commercial |
$11.27
|
| Rate for Payer: ASR ASR |
$12.14
|
| Rate for Payer: BCBS Trust/PPO |
$9.71
|
| Rate for Payer: BCN Commercial |
$9.71
|
| Rate for Payer: Cash Price |
$10.02
|
| Rate for Payer: Cofinity Commercial |
$11.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.02
|
| Rate for Payer: Healthscope Commercial |
$12.52
|
| Rate for Payer: Healthscope Whirlpool |
$12.14
|
| Rate for Payer: Mclaren Commercial |
$11.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.02
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM
|
Facility
IP
|
$375.69
|
|
|
Service Code
|
NDC 43598-579-30
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.98 |
| Max. Negotiated Rate |
$375.69 |
| Rate for Payer: Aetna Commercial |
$338.12
|
| Rate for Payer: ASR ASR |
$364.42
|
| Rate for Payer: BCBS Trust/PPO |
$291.27
|
| Rate for Payer: BCN Commercial |
$291.27
|
| Rate for Payer: Cash Price |
$300.55
|
| Rate for Payer: Cofinity Commercial |
$353.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$300.55
|
| Rate for Payer: Healthscope Commercial |
$375.69
|
| Rate for Payer: Healthscope Whirlpool |
$364.42
|
| Rate for Payer: Mclaren Commercial |
$338.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$319.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$330.61
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET
|
Facility
IP
|
$263.55
|
|
|
Service Code
|
NDC 0054-0189-13
|
| Hospital Charge Code |
34714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.48 |
| Max. Negotiated Rate |
$263.55 |
| Rate for Payer: Aetna Commercial |
$237.20
|
| Rate for Payer: ASR ASR |
$255.64
|
| Rate for Payer: BCBS Trust/PPO |
$204.33
|
| Rate for Payer: BCN Commercial |
$204.33
|
| Rate for Payer: Cash Price |
$210.84
|
| Rate for Payer: Cofinity Commercial |
$247.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.84
|
| Rate for Payer: Healthscope Commercial |
$263.55
|
| Rate for Payer: Healthscope Whirlpool |
$255.64
|
| Rate for Payer: Mclaren Commercial |
$237.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$224.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.92
|
|
|
BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION
|
Facility
IP
|
$62.78
|
|
|
Service Code
|
HCPCS J0592
|
| Hospital Charge Code |
115937
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.95 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$56.50
|
| Rate for Payer: Aetna Commercial |
$49.02
|
| Rate for Payer: ASR ASR |
$52.84
|
| Rate for Payer: ASR ASR |
$60.90
|
| Rate for Payer: BCBS Trust/PPO |
$42.23
|
| Rate for Payer: BCBS Trust/PPO |
$48.67
|
| Rate for Payer: BCN Commercial |
$42.23
|
| Rate for Payer: BCN Commercial |
$48.67
|
| Rate for Payer: Cash Price |
$50.22
|
| Rate for Payer: Cash Price |
$43.57
|
| Rate for Payer: Cofinity Commercial |
$51.20
|
| Rate for Payer: Cofinity Commercial |
$59.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.58
|
| Rate for Payer: Healthscope Commercial |
$54.47
|
| Rate for Payer: Healthscope Commercial |
$62.78
|
| Rate for Payer: Healthscope Whirlpool |
$52.84
|
| Rate for Payer: Healthscope Whirlpool |
$60.90
|
| Rate for Payer: Mclaren Commercial |
$56.50
|
| Rate for Payer: Mclaren Commercial |
$49.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$46.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$55.25
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET
|
Facility
IP
|
$381.57
|
|
|
Service Code
|
NDC 0904-7154-04
|
| Hospital Charge Code |
34711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.10 |
| Max. Negotiated Rate |
$381.57 |
| Rate for Payer: Aetna Commercial |
$343.41
|
| Rate for Payer: ASR ASR |
$370.12
|
| Rate for Payer: BCBS Trust/PPO |
$295.83
|
| Rate for Payer: BCN Commercial |
$295.83
|
| Rate for Payer: Cash Price |
$305.26
|
| Rate for Payer: Cofinity Commercial |
$358.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.26
|
| Rate for Payer: Healthscope Commercial |
$381.57
|
| Rate for Payer: Healthscope Whirlpool |
$370.12
|
| Rate for Payer: Mclaren Commercial |
$343.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$324.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$267.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$335.78
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET
|
Facility
IP
|
$192.15
|
|
|
Service Code
|
NDC 0054-0176-13
|
| Hospital Charge Code |
34711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.50 |
| Max. Negotiated Rate |
$192.15 |
| Rate for Payer: Aetna Commercial |
$172.94
|
| Rate for Payer: ASR ASR |
$186.39
|
| Rate for Payer: BCBS Trust/PPO |
$148.97
|
| Rate for Payer: BCN Commercial |
$148.97
|
| Rate for Payer: Cash Price |
$153.72
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.72
|
| Rate for Payer: Healthscope Commercial |
$192.15
|
| Rate for Payer: Healthscope Whirlpool |
$186.39
|
| Rate for Payer: Mclaren Commercial |
$172.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$163.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$169.09
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
IP
|
$669.60
|
|
|
Service Code
|
NDC 60687-312-01
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$468.72 |
| Max. Negotiated Rate |
$669.60 |
| Rate for Payer: Aetna Commercial |
$602.64
|
| Rate for Payer: ASR ASR |
$649.51
|
| Rate for Payer: BCBS Trust/PPO |
$519.14
|
| Rate for Payer: BCN Commercial |
$519.14
|
| Rate for Payer: Cash Price |
$535.68
|
| Rate for Payer: Cofinity Commercial |
$629.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$535.68
|
| Rate for Payer: Healthscope Commercial |
$669.60
|
| Rate for Payer: Healthscope Whirlpool |
$649.51
|
| Rate for Payer: Mclaren Commercial |
$602.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$569.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$468.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$589.25
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
IP
|
$251.68
|
|
|
Service Code
|
NDC 16729-443-15
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.18 |
| Max. Negotiated Rate |
$251.68 |
| Rate for Payer: Aetna Commercial |
$226.51
|
| Rate for Payer: ASR ASR |
$244.13
|
| Rate for Payer: BCBS Trust/PPO |
$195.13
|
| Rate for Payer: BCN Commercial |
$195.13
|
| Rate for Payer: Cash Price |
$201.35
|
| Rate for Payer: Cofinity Commercial |
$236.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.34
|
| Rate for Payer: Healthscope Commercial |
$251.68
|
| Rate for Payer: Healthscope Whirlpool |
$244.13
|
| Rate for Payer: Mclaren Commercial |
$226.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$221.48
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
IP
|
$333.45
|
|
|
Service Code
|
NDC 0115-6811-10
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$233.42 |
| Max. Negotiated Rate |
$333.45 |
| Rate for Payer: Aetna Commercial |
$300.10
|
| Rate for Payer: ASR ASR |
$323.45
|
| Rate for Payer: BCBS Trust/PPO |
$258.52
|
| Rate for Payer: BCN Commercial |
$258.52
|
| Rate for Payer: Cash Price |
$266.76
|
| Rate for Payer: Cofinity Commercial |
$313.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.76
|
| Rate for Payer: Healthscope Commercial |
$333.45
|
| Rate for Payer: Healthscope Whirlpool |
$323.45
|
| Rate for Payer: Mclaren Commercial |
$300.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$283.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$293.44
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
IP
|
$597.12
|
|
|
Service Code
|
NDC 0904-7084-61
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$417.98 |
| Max. Negotiated Rate |
$597.12 |
| Rate for Payer: Aetna Commercial |
$537.41
|
| Rate for Payer: ASR ASR |
$579.21
|
| Rate for Payer: BCBS Trust/PPO |
$462.95
|
| Rate for Payer: BCN Commercial |
$462.95
|
| Rate for Payer: Cash Price |
$477.70
|
| Rate for Payer: Cofinity Commercial |
$561.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$477.70
|
| Rate for Payer: Healthscope Commercial |
$597.12
|
| Rate for Payer: Healthscope Whirlpool |
$579.21
|
| Rate for Payer: Mclaren Commercial |
$537.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$507.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$417.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$525.47
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
IP
|
$129.01
|
|
|
Service Code
|
NDC 68180-319-09
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.31 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Aetna Commercial |
$116.11
|
| Rate for Payer: ASR ASR |
$125.14
|
| Rate for Payer: BCBS Trust/PPO |
$100.02
|
| Rate for Payer: BCN Commercial |
$100.02
|
| Rate for Payer: Cash Price |
$103.21
|
| Rate for Payer: Cofinity Commercial |
$121.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.21
|
| Rate for Payer: Healthscope Commercial |
$129.01
|
| Rate for Payer: Healthscope Whirlpool |
$125.14
|
| Rate for Payer: Mclaren Commercial |
$116.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$113.53
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
IP
|
$6.70
|
|
|
Service Code
|
NDC 60687-312-11
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.03
|
| Rate for Payer: ASR ASR |
$6.50
|
| Rate for Payer: BCBS Trust/PPO |
$5.19
|
| Rate for Payer: BCN Commercial |
$5.19
|
| Rate for Payer: Cash Price |
$5.36
|
| Rate for Payer: Cofinity Commercial |
$6.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.36
|
| Rate for Payer: Healthscope Commercial |
$6.70
|
| Rate for Payer: Healthscope Whirlpool |
$6.50
|
| Rate for Payer: Mclaren Commercial |
$6.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.90
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$220.90
|
|
|
Service Code
|
NDC 51079-985-20
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.63 |
| Max. Negotiated Rate |
$220.90 |
| Rate for Payer: Aetna Commercial |
$198.81
|
| Rate for Payer: ASR ASR |
$214.27
|
| Rate for Payer: BCBS Trust/PPO |
$171.26
|
| Rate for Payer: BCN Commercial |
$171.26
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Commercial |
$207.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.72
|
| Rate for Payer: Healthscope Commercial |
$220.90
|
| Rate for Payer: Healthscope Whirlpool |
$214.27
|
| Rate for Payer: Mclaren Commercial |
$198.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$187.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$194.39
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$91.65
|
|
|
Service Code
|
NDC 23155-023-01
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$91.65 |
| Rate for Payer: Aetna Commercial |
$82.48
|
| Rate for Payer: ASR ASR |
$88.90
|
| Rate for Payer: BCBS Trust/PPO |
$71.06
|
| Rate for Payer: BCN Commercial |
$71.06
|
| Rate for Payer: Cash Price |
$73.32
|
| Rate for Payer: Cofinity Commercial |
$86.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.32
|
| Rate for Payer: Healthscope Commercial |
$91.65
|
| Rate for Payer: Healthscope Whirlpool |
$88.90
|
| Rate for Payer: Mclaren Commercial |
$82.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$80.65
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$2.21
|
|
|
Service Code
|
NDC 51079-985-01
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna Commercial |
$1.99
|
| Rate for Payer: ASR ASR |
$2.14
|
| Rate for Payer: BCBS Trust/PPO |
$1.71
|
| Rate for Payer: BCN Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$2.21
|
| Rate for Payer: Healthscope Whirlpool |
$2.14
|
| Rate for Payer: Mclaren Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.94
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
IP
|
$220.90
|
|
|
Service Code
|
NDC 0904-7122-61
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.63 |
| Max. Negotiated Rate |
$220.90 |
| Rate for Payer: Aetna Commercial |
$198.81
|
| Rate for Payer: ASR ASR |
$214.27
|
| Rate for Payer: BCBS Trust/PPO |
$171.26
|
| Rate for Payer: BCN Commercial |
$171.26
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Commercial |
$207.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.72
|
| Rate for Payer: Healthscope Commercial |
$220.90
|
| Rate for Payer: Healthscope Whirlpool |
$214.27
|
| Rate for Payer: Mclaren Commercial |
$198.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$187.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$194.39
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
IP
|
$365.40
|
|
|
Service Code
|
NDC 0904-6938-06
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$255.78 |
| Max. Negotiated Rate |
$365.40 |
| Rate for Payer: Aetna Commercial |
$328.86
|
| Rate for Payer: ASR ASR |
$354.44
|
| Rate for Payer: BCBS Trust/PPO |
$283.29
|
| Rate for Payer: BCN Commercial |
$283.29
|
| Rate for Payer: Cash Price |
$292.32
|
| Rate for Payer: Cofinity Commercial |
$343.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.32
|
| Rate for Payer: Healthscope Commercial |
$365.40
|
| Rate for Payer: Healthscope Whirlpool |
$354.44
|
| Rate for Payer: Mclaren Commercial |
$328.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$310.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$321.55
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
IP
|
$302.75
|
|
|
Service Code
|
NDC 70010-149-01
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$211.92 |
| Max. Negotiated Rate |
$302.75 |
| Rate for Payer: Aetna Commercial |
$272.48
|
| Rate for Payer: ASR ASR |
$293.67
|
| Rate for Payer: BCBS Trust/PPO |
$234.72
|
| Rate for Payer: BCN Commercial |
$234.72
|
| Rate for Payer: Cash Price |
$242.20
|
| Rate for Payer: Cofinity Commercial |
$284.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.20
|
| Rate for Payer: Healthscope Commercial |
$302.75
|
| Rate for Payer: Healthscope Whirlpool |
$293.67
|
| Rate for Payer: Mclaren Commercial |
$272.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$257.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$266.42
|
|
|
BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE
|
Facility
IP
|
$603.40
|
|
|
Service Code
|
NDC 0527-1552-01
|
| Hospital Charge Code |
8922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$422.38 |
| Max. Negotiated Rate |
$603.40 |
| Rate for Payer: Aetna Commercial |
$543.06
|
| Rate for Payer: ASR ASR |
$585.30
|
| Rate for Payer: BCBS Trust/PPO |
$467.82
|
| Rate for Payer: BCN Commercial |
$467.82
|
| Rate for Payer: Cash Price |
$482.72
|
| Rate for Payer: Cofinity Commercial |
$567.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$482.72
|
| Rate for Payer: Healthscope Commercial |
$603.40
|
| Rate for Payer: Healthscope Whirlpool |
$585.30
|
| Rate for Payer: Mclaren Commercial |
$543.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$512.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$422.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$530.99
|
|
|
CABOTEGRAVIR ER 600 MG/3 ML-RILPIVIRINE ER 900 MG/3ML IM SUSPENSION,ER
|
Facility
IP
|
$16,967.03
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
196915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,876.92 |
| Max. Negotiated Rate |
$16,967.03 |
| Rate for Payer: Aetna Commercial |
$15,270.33
|
| Rate for Payer: ASR ASR |
$16,458.02
|
| Rate for Payer: BCBS Trust/PPO |
$13,154.54
|
| Rate for Payer: BCN Commercial |
$13,154.54
|
| Rate for Payer: Cash Price |
$13,573.62
|
| Rate for Payer: Cofinity Commercial |
$15,949.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,573.62
|
| Rate for Payer: Healthscope Commercial |
$16,967.03
|
| Rate for Payer: Healthscope Whirlpool |
$16,458.02
|
| Rate for Payer: Mclaren Commercial |
$15,270.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14,421.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,876.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14,930.99
|
|
|
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY
|
Facility
IP
|
$243.25
|
|
|
Service Code
|
NDC 49884-161-11
|
| Hospital Charge Code |
15738
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.28 |
| Max. Negotiated Rate |
$243.25 |
| Rate for Payer: Aetna Commercial |
$218.92
|
| Rate for Payer: ASR ASR |
$235.95
|
| Rate for Payer: BCBS Trust/PPO |
$188.59
|
| Rate for Payer: BCN Commercial |
$188.59
|
| Rate for Payer: Cash Price |
$194.60
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.60
|
| Rate for Payer: Healthscope Commercial |
$243.25
|
| Rate for Payer: Healthscope Whirlpool |
$235.95
|
| Rate for Payer: Mclaren Commercial |
$218.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$214.06
|
|
