|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
IP
|
$828.00
|
|
|
Service Code
|
NDC 60687031201
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$621.00 |
| Max. Negotiated Rate |
$828.00 |
| Rate for Payer: Aetna Commercial |
$745.20
|
| Rate for Payer: ASR ASR |
$803.16
|
| Rate for Payer: BCBS Trust/PPO |
$679.95
|
| Rate for Payer: BCN Commercial |
$679.95
|
| Rate for Payer: Cash Price |
$662.40
|
| Rate for Payer: Cofinity Commercial |
$778.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$662.40
|
| Rate for Payer: Healthscope Commercial |
$803.16
|
| Rate for Payer: Healthscope Whirlpool |
$828.00
|
| Rate for Payer: Mclaren Commercial |
$745.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$703.80
|
| Rate for Payer: Nomi Health Commercial |
$678.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$621.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$728.64
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
OP
|
$251.69
|
|
|
Service Code
|
NDC 16729044315
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.12 |
| Max. Negotiated Rate |
$251.69 |
| Rate for Payer: Aetna Commercial |
$226.52
|
| Rate for Payer: Aetna Medicare |
$93.12
|
| Rate for Payer: ASR ASR |
$244.13
|
| Rate for Payer: BCBS Complete |
$100.67
|
| Rate for Payer: BCBS Trust/PPO |
$207.51
|
| Rate for Payer: BCN Commercial |
$207.51
|
| Rate for Payer: Cash Price |
$201.35
|
| Rate for Payer: Cofinity Commercial |
$236.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.35
|
| Rate for Payer: Healthscope Commercial |
$244.13
|
| Rate for Payer: Healthscope Whirlpool |
$251.69
|
| Rate for Payer: Mclaren Commercial |
$226.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$201.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.93
|
| Rate for Payer: Nomi Health Commercial |
$206.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.76
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$220.53
|
| Rate for Payer: Priority Health Narrow Network |
$176.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$221.48
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
OP
|
$828.00
|
|
|
Service Code
|
NDC 60687031201
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.36 |
| Max. Negotiated Rate |
$828.00 |
| Rate for Payer: Aetna Commercial |
$745.20
|
| Rate for Payer: Aetna Medicare |
$306.36
|
| Rate for Payer: ASR ASR |
$803.16
|
| Rate for Payer: BCBS Complete |
$331.20
|
| Rate for Payer: BCBS Trust/PPO |
$682.69
|
| Rate for Payer: BCN Commercial |
$682.69
|
| Rate for Payer: Cash Price |
$662.40
|
| Rate for Payer: Cofinity Commercial |
$778.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$662.40
|
| Rate for Payer: Healthscope Commercial |
$803.16
|
| Rate for Payer: Healthscope Whirlpool |
$828.00
|
| Rate for Payer: Mclaren Commercial |
$745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$662.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$703.80
|
| Rate for Payer: Nomi Health Commercial |
$678.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$621.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$725.49
|
| Rate for Payer: Priority Health Narrow Network |
$580.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$728.64
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
|
IP
|
$23,795.79
|
|
|
Service Code
|
APR-DRG 8423
|
| Min. Negotiated Rate |
$21,514.24 |
| Max. Negotiated Rate |
$23,795.79 |
| Rate for Payer: BCBS Complete |
$23,795.79
|
| Rate for Payer: Mclaren Medicaid |
$22,662.65
|
| Rate for Payer: Meridian Medicaid |
$23,795.79
|
| Rate for Payer: PHP Medicaid |
$21,514.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$22,662.65
|
| Rate for Payer: UHC Medicaid |
$22,662.65
|
| Rate for Payer: UHCCP Medicaid |
$22,662.65
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
|
IP
|
$9,646.70
|
|
|
Service Code
|
APR-DRG 8421
|
| Min. Negotiated Rate |
$8,721.78 |
| Max. Negotiated Rate |
$9,646.70 |
| Rate for Payer: BCBS Complete |
$9,646.70
|
| Rate for Payer: Mclaren Medicaid |
$9,187.34
|
| Rate for Payer: Meridian Medicaid |
$9,646.70
|
| Rate for Payer: PHP Medicaid |
$8,721.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,187.34
|
| Rate for Payer: UHC Medicaid |
$9,187.34
|
| Rate for Payer: UHCCP Medicaid |
$9,187.34
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
|
IP
|
$18,866.71
|
|
|
Service Code
|
APR-DRG 8422
|
| Min. Negotiated Rate |
$17,057.77 |
| Max. Negotiated Rate |
$18,866.71 |
| Rate for Payer: BCBS Complete |
$18,866.71
|
| Rate for Payer: Mclaren Medicaid |
$17,968.30
|
| Rate for Payer: Meridian Medicaid |
$18,866.71
|
| Rate for Payer: PHP Medicaid |
$17,057.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$17,968.30
|
| Rate for Payer: UHC Medicaid |
$17,968.30
|
| Rate for Payer: UHCCP Medicaid |
$17,968.30
|
|
|
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS
|
Facility
|
IP
|
$90,089.50
|
|
|
Service Code
|
APR-DRG 8424
|
| Min. Negotiated Rate |
$81,451.69 |
| Max. Negotiated Rate |
$90,089.50 |
| Rate for Payer: BCBS Complete |
$90,089.50
|
| Rate for Payer: Mclaren Medicaid |
$85,799.52
|
| Rate for Payer: Meridian Medicaid |
$90,089.50
|
| Rate for Payer: PHP Medicaid |
$81,451.69
|
| Rate for Payer: Priority Health Choice Medicaid |
$85,799.52
|
| Rate for Payer: UHC Medicaid |
$85,799.52
|
| Rate for Payer: UHCCP Medicaid |
$85,799.52
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$249.10
|
|
|
Service Code
|
NDC 51079098520
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.17 |
| Max. Negotiated Rate |
$249.10 |
| Rate for Payer: Aetna Commercial |
$224.19
|
| Rate for Payer: Aetna Medicare |
$92.17
|
| Rate for Payer: ASR ASR |
$241.63
|
| Rate for Payer: BCBS Complete |
$99.64
|
| Rate for Payer: BCBS Trust/PPO |
$205.38
|
| Rate for Payer: BCN Commercial |
$205.38
|
| Rate for Payer: Cash Price |
$199.28
|
| Rate for Payer: Cofinity Commercial |
$234.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.28
|
| Rate for Payer: Healthscope Commercial |
$241.63
|
| Rate for Payer: Healthscope Whirlpool |
$249.10
|
| Rate for Payer: Mclaren Commercial |
$224.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.74
|
| Rate for Payer: Nomi Health Commercial |
$204.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$186.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$218.26
|
| Rate for Payer: Priority Health Narrow Network |
$174.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$219.21
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 904712261
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.20 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: BCBS Trust/PPO |
$185.26
|
| Rate for Payer: BCN Commercial |
$185.26
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$218.83
|
| Rate for Payer: Healthscope Whirlpool |
$225.60
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
NDC 23155002301
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.50 |
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: ASR ASR |
$91.18
|
| Rate for Payer: BCBS Trust/PPO |
$77.19
|
| Rate for Payer: BCN Commercial |
$77.19
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$88.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.20
|
| Rate for Payer: Healthscope Commercial |
$91.18
|
| Rate for Payer: Healthscope Whirlpool |
$94.00
|
| Rate for Payer: Mclaren Commercial |
$84.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.90
|
| Rate for Payer: Nomi Health Commercial |
$77.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$82.72
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$2.49
|
|
|
Service Code
|
NDC 51079098501
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: Aetna Medicare |
$0.92
|
| Rate for Payer: ASR ASR |
$2.42
|
| Rate for Payer: BCBS Complete |
$1.00
|
| Rate for Payer: BCBS Trust/PPO |
$2.05
|
| Rate for Payer: BCN Commercial |
$2.05
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.99
|
| Rate for Payer: Healthscope Commercial |
$2.42
|
| Rate for Payer: Healthscope Whirlpool |
$2.49
|
| Rate for Payer: Mclaren Commercial |
$2.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.12
|
| Rate for Payer: Nomi Health Commercial |
$2.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.18
|
| Rate for Payer: Priority Health Narrow Network |
$1.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.19
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$249.10
|
|
|
Service Code
|
NDC 51079098520
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.82 |
| Max. Negotiated Rate |
$249.10 |
| Rate for Payer: Aetna Commercial |
$224.19
|
| Rate for Payer: ASR ASR |
$241.63
|
| Rate for Payer: BCBS Trust/PPO |
$204.56
|
| Rate for Payer: BCN Commercial |
$204.56
|
| Rate for Payer: Cash Price |
$199.28
|
| Rate for Payer: Cofinity Commercial |
$234.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.28
|
| Rate for Payer: Healthscope Commercial |
$241.63
|
| Rate for Payer: Healthscope Whirlpool |
$249.10
|
| Rate for Payer: Mclaren Commercial |
$224.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.74
|
| Rate for Payer: Nomi Health Commercial |
$204.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$186.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$219.21
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$2.49
|
|
|
Service Code
|
NDC 51079098501
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: ASR ASR |
$2.42
|
| Rate for Payer: BCBS Trust/PPO |
$2.05
|
| Rate for Payer: BCN Commercial |
$2.05
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.99
|
| Rate for Payer: Healthscope Commercial |
$2.42
|
| Rate for Payer: Healthscope Whirlpool |
$2.49
|
| Rate for Payer: Mclaren Commercial |
$2.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.12
|
| Rate for Payer: Nomi Health Commercial |
$2.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.19
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
NDC 23155002301
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.78 |
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Medicare |
$34.78
|
| Rate for Payer: ASR ASR |
$91.18
|
| Rate for Payer: BCBS Complete |
$37.60
|
| Rate for Payer: BCBS Trust/PPO |
$77.50
|
| Rate for Payer: BCN Commercial |
$77.50
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$88.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.20
|
| Rate for Payer: Healthscope Commercial |
$91.18
|
| Rate for Payer: Healthscope Whirlpool |
$94.00
|
| Rate for Payer: Mclaren Commercial |
$84.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$75.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.90
|
| Rate for Payer: Nomi Health Commercial |
$77.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$82.36
|
| Rate for Payer: Priority Health Narrow Network |
$65.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$82.72
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 904712261
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.47 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: Aetna Medicare |
$83.47
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: BCBS Trust/PPO |
$186.01
|
| Rate for Payer: BCN Commercial |
$186.01
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$218.83
|
| Rate for Payer: Healthscope Whirlpool |
$225.60
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$180.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$197.67
|
| Rate for Payer: Priority Health Narrow Network |
$158.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$325.50
|
|
|
Service Code
|
NDC 70010014901
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$244.12 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$292.95
|
| Rate for Payer: ASR ASR |
$315.74
|
| Rate for Payer: BCBS Trust/PPO |
$267.30
|
| Rate for Payer: BCN Commercial |
$267.30
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.40
|
| Rate for Payer: Healthscope Commercial |
$315.74
|
| Rate for Payer: Healthscope Whirlpool |
$325.50
|
| Rate for Payer: Mclaren Commercial |
$292.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.68
|
| Rate for Payer: Nomi Health Commercial |
$266.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$244.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$286.44
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$241.92
|
|
|
Service Code
|
NDC 50268055313
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$181.44 |
| Max. Negotiated Rate |
$241.92 |
| Rate for Payer: Aetna Commercial |
$217.73
|
| Rate for Payer: ASR ASR |
$234.66
|
| Rate for Payer: BCBS Trust/PPO |
$198.66
|
| Rate for Payer: BCN Commercial |
$198.66
|
| Rate for Payer: Cash Price |
$193.54
|
| Rate for Payer: Cofinity Commercial |
$227.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.54
|
| Rate for Payer: Healthscope Commercial |
$234.66
|
| Rate for Payer: Healthscope Whirlpool |
$241.92
|
| Rate for Payer: Mclaren Commercial |
$217.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.63
|
| Rate for Payer: Nomi Health Commercial |
$198.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$212.89
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$373.45
|
|
|
Service Code
|
NDC 904693806
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$280.09 |
| Max. Negotiated Rate |
$373.45 |
| Rate for Payer: Aetna Commercial |
$336.11
|
| Rate for Payer: ASR ASR |
$362.25
|
| Rate for Payer: BCBS Trust/PPO |
$306.68
|
| Rate for Payer: BCN Commercial |
$306.68
|
| Rate for Payer: Cash Price |
$298.76
|
| Rate for Payer: Cofinity Commercial |
$351.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.76
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: Healthscope Whirlpool |
$373.45
|
| Rate for Payer: Mclaren Commercial |
$336.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.43
|
| Rate for Payer: Nomi Health Commercial |
$306.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$280.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$328.64
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
IP
|
$8.06
|
|
|
Service Code
|
NDC 50268055311
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$8.06 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: ASR ASR |
$7.82
|
| Rate for Payer: BCBS Trust/PPO |
$6.62
|
| Rate for Payer: BCN Commercial |
$6.62
|
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Cofinity Commercial |
$7.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.45
|
| Rate for Payer: Healthscope Commercial |
$7.82
|
| Rate for Payer: Healthscope Whirlpool |
$8.06
|
| Rate for Payer: Mclaren Commercial |
$7.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.85
|
| Rate for Payer: Nomi Health Commercial |
$6.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.10
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$241.92
|
|
|
Service Code
|
NDC 50268055313
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.51 |
| Max. Negotiated Rate |
$241.92 |
| Rate for Payer: Aetna Commercial |
$217.73
|
| Rate for Payer: Aetna Medicare |
$89.51
|
| Rate for Payer: ASR ASR |
$234.66
|
| Rate for Payer: BCBS Complete |
$96.77
|
| Rate for Payer: BCBS Trust/PPO |
$199.46
|
| Rate for Payer: BCN Commercial |
$199.46
|
| Rate for Payer: Cash Price |
$193.54
|
| Rate for Payer: Cofinity Commercial |
$227.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.54
|
| Rate for Payer: Healthscope Commercial |
$234.66
|
| Rate for Payer: Healthscope Whirlpool |
$241.92
|
| Rate for Payer: Mclaren Commercial |
$217.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$193.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.63
|
| Rate for Payer: Nomi Health Commercial |
$198.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$211.97
|
| Rate for Payer: Priority Health Narrow Network |
$169.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$212.89
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$373.45
|
|
|
Service Code
|
NDC 904693806
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.18 |
| Max. Negotiated Rate |
$373.45 |
| Rate for Payer: Aetna Commercial |
$336.11
|
| Rate for Payer: Aetna Medicare |
$138.18
|
| Rate for Payer: ASR ASR |
$362.25
|
| Rate for Payer: BCBS Complete |
$149.38
|
| Rate for Payer: BCBS Trust/PPO |
$307.91
|
| Rate for Payer: BCN Commercial |
$307.91
|
| Rate for Payer: Cash Price |
$298.76
|
| Rate for Payer: Cofinity Commercial |
$351.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.76
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: Healthscope Whirlpool |
$373.45
|
| Rate for Payer: Mclaren Commercial |
$336.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$298.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.43
|
| Rate for Payer: Nomi Health Commercial |
$306.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$280.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$327.22
|
| Rate for Payer: Priority Health Narrow Network |
$261.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$328.64
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$325.50
|
|
|
Service Code
|
NDC 70010014901
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.44 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$292.95
|
| Rate for Payer: Aetna Medicare |
$120.44
|
| Rate for Payer: ASR ASR |
$315.74
|
| Rate for Payer: BCBS Complete |
$130.20
|
| Rate for Payer: BCBS Trust/PPO |
$268.37
|
| Rate for Payer: BCN Commercial |
$268.37
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.40
|
| Rate for Payer: Healthscope Commercial |
$315.74
|
| Rate for Payer: Healthscope Whirlpool |
$325.50
|
| Rate for Payer: Mclaren Commercial |
$292.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$260.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.68
|
| Rate for Payer: Nomi Health Commercial |
$266.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$244.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$285.20
|
| Rate for Payer: Priority Health Narrow Network |
$228.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$286.44
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET
|
Facility
|
OP
|
$8.06
|
|
|
Service Code
|
NDC 50268055311
|
| Hospital Charge Code |
8958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$8.06 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: Aetna Medicare |
$2.98
|
| Rate for Payer: ASR ASR |
$7.82
|
| Rate for Payer: BCBS Complete |
$3.23
|
| Rate for Payer: BCBS Trust/PPO |
$6.65
|
| Rate for Payer: BCN Commercial |
$6.65
|
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Cofinity Commercial |
$7.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.45
|
| Rate for Payer: Healthscope Commercial |
$7.82
|
| Rate for Payer: Healthscope Whirlpool |
$8.06
|
| Rate for Payer: Mclaren Commercial |
$7.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.85
|
| Rate for Payer: Nomi Health Commercial |
$6.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$7.07
|
| Rate for Payer: Priority Health Narrow Network |
$5.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.10
|
|
|
BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE
|
Facility
|
OP
|
$712.60
|
|
|
Service Code
|
NDC 527155201
|
| Hospital Charge Code |
8922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$263.66 |
| Max. Negotiated Rate |
$712.60 |
| Rate for Payer: Aetna Commercial |
$641.34
|
| Rate for Payer: Aetna Medicare |
$263.66
|
| Rate for Payer: ASR ASR |
$691.22
|
| Rate for Payer: BCBS Complete |
$285.04
|
| Rate for Payer: BCBS Trust/PPO |
$587.54
|
| Rate for Payer: BCN Commercial |
$587.54
|
| Rate for Payer: Cash Price |
$570.08
|
| Rate for Payer: Cofinity Commercial |
$669.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$570.08
|
| Rate for Payer: Healthscope Commercial |
$691.22
|
| Rate for Payer: Healthscope Whirlpool |
$712.60
|
| Rate for Payer: Mclaren Commercial |
$641.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$570.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$605.71
|
| Rate for Payer: Nomi Health Commercial |
$584.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$534.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$624.38
|
| Rate for Payer: Priority Health Narrow Network |
$499.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$627.09
|
|
|
BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE
|
Facility
|
IP
|
$712.60
|
|
|
Service Code
|
NDC 527155201
|
| Hospital Charge Code |
8922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$534.45 |
| Max. Negotiated Rate |
$712.60 |
| Rate for Payer: Aetna Commercial |
$641.34
|
| Rate for Payer: ASR ASR |
$691.22
|
| Rate for Payer: BCBS Trust/PPO |
$585.19
|
| Rate for Payer: BCN Commercial |
$585.19
|
| Rate for Payer: Cash Price |
$570.08
|
| Rate for Payer: Cofinity Commercial |
$669.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$570.08
|
| Rate for Payer: Healthscope Commercial |
$691.22
|
| Rate for Payer: Healthscope Whirlpool |
$712.60
|
| Rate for Payer: Mclaren Commercial |
$641.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$605.71
|
| Rate for Payer: Nomi Health Commercial |
$584.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$534.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$627.09
|
|
