Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$195.79

Service Code	NDC 65162-321-09
Hospital Charge Code	5545
Hospital Revenue Code	637
Min. Negotiated Rate	$137.05
Max. Negotiated Rate	$195.79
Rate for Payer: Aetna Commercial	$176.21
Rate for Payer: ASR ASR	$189.92
Rate for Payer: BCBS Trust/PPO	$151.80
Rate for Payer: BCN Commercial	$151.80
Rate for Payer: Cash Price	$156.64
Rate for Payer: Cofinity Commercial	$184.04
Rate for Payer: Encore Health Key Benefits Commercial	$156.63
Rate for Payer: Healthscope Commercial	$195.79
Rate for Payer: Healthscope Whirlpool	$189.92
Rate for Payer: Mclaren Commercial	$176.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$166.42
Rate for Payer: Priority Health Cigna Priority Health	$137.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$172.30

NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION

Facility

$48.19

Service Code	HCPCS J2404
Hospital Charge Code	12370
Hospital Revenue Code	636
Min. Negotiated Rate	$33.73
Max. Negotiated Rate	$48.19
Rate for Payer: Aetna Commercial	$43.37
Rate for Payer: Aetna Commercial	$45.82
Rate for Payer: Aetna Commercial	$59.72
Rate for Payer: ASR ASR	$49.38
Rate for Payer: ASR ASR	$46.74
Rate for Payer: ASR ASR	$64.36
Rate for Payer: BCBS Trust/PPO	$51.44
Rate for Payer: BCBS Trust/PPO	$39.47
Rate for Payer: BCBS Trust/PPO	$37.36
Rate for Payer: BCN Commercial	$37.36
Rate for Payer: BCN Commercial	$51.44
Rate for Payer: BCN Commercial	$39.47
Rate for Payer: Cash Price	$38.56
Rate for Payer: Cash Price	$53.08
Rate for Payer: Cash Price	$40.73
Rate for Payer: Cofinity Commercial	$47.86
Rate for Payer: Cofinity Commercial	$45.30
Rate for Payer: Cofinity Commercial	$62.37
Rate for Payer: Encore Health Key Benefits Commercial	$38.55
Rate for Payer: Encore Health Key Benefits Commercial	$40.73
Rate for Payer: Encore Health Key Benefits Commercial	$53.08
Rate for Payer: Healthscope Commercial	$66.35
Rate for Payer: Healthscope Commercial	$50.91
Rate for Payer: Healthscope Commercial	$48.19
Rate for Payer: Healthscope Whirlpool	$49.38
Rate for Payer: Healthscope Whirlpool	$46.74
Rate for Payer: Healthscope Whirlpool	$64.36
Rate for Payer: Mclaren Commercial	$45.82
Rate for Payer: Mclaren Commercial	$43.37
Rate for Payer: Mclaren Commercial	$59.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$56.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$43.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$40.96
Rate for Payer: Priority Health Cigna Priority Health	$33.73
Rate for Payer: Priority Health Cigna Priority Health	$35.64
Rate for Payer: Priority Health Cigna Priority Health	$46.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$44.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$58.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$42.41

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$120.69

Service Code	NDC 60505-7089-0
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$84.48
Max. Negotiated Rate	$120.69
Rate for Payer: Aetna Commercial	$108.62
Rate for Payer: ASR ASR	$117.07
Rate for Payer: BCBS Trust/PPO	$93.57
Rate for Payer: BCN Commercial	$93.57
Rate for Payer: Cash Price	$96.55
Rate for Payer: Cofinity Commercial	$113.45
Rate for Payer: Encore Health Key Benefits Commercial	$96.55
Rate for Payer: Healthscope Commercial	$120.69
Rate for Payer: Healthscope Whirlpool	$117.07
Rate for Payer: Mclaren Commercial	$108.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$102.59
Rate for Payer: Priority Health Cigna Priority Health	$84.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$106.21

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$107.05

Service Code	NDC 0536-5895-88
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$74.94
Max. Negotiated Rate	$107.05
Rate for Payer: Aetna Commercial	$96.34
Rate for Payer: ASR ASR	$103.84
Rate for Payer: BCBS Trust/PPO	$83.00
Rate for Payer: BCN Commercial	$83.00
Rate for Payer: Cash Price	$85.64
Rate for Payer: Cofinity Commercial	$100.63
Rate for Payer: Encore Health Key Benefits Commercial	$85.64
Rate for Payer: Healthscope Commercial	$107.05
Rate for Payer: Healthscope Whirlpool	$103.84
Rate for Payer: Mclaren Commercial	$96.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$90.99
Rate for Payer: Priority Health Cigna Priority Health	$74.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$94.20

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$57.49

Service Code	NDC 0536-5895-53
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$40.24
Max. Negotiated Rate	$57.49
Rate for Payer: Aetna Commercial	$51.74
Rate for Payer: ASR ASR	$55.77
Rate for Payer: BCBS Trust/PPO	$44.57
Rate for Payer: BCN Commercial	$44.57
Rate for Payer: Cash Price	$45.99
Rate for Payer: Cofinity Commercial	$54.04
Rate for Payer: Encore Health Key Benefits Commercial	$45.99
Rate for Payer: Healthscope Commercial	$57.49
Rate for Payer: Healthscope Whirlpool	$55.77
Rate for Payer: Mclaren Commercial	$51.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$48.87
Rate for Payer: Priority Health Cigna Priority Health	$40.24
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$50.59

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$8.22

Service Code	NDC 43598-447-71
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$5.75
Max. Negotiated Rate	$8.22
Rate for Payer: Aetna Commercial	$7.40
Rate for Payer: ASR ASR	$7.97
Rate for Payer: BCBS Trust/PPO	$6.37
Rate for Payer: BCN Commercial	$6.37
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cofinity Commercial	$7.73
Rate for Payer: Encore Health Key Benefits Commercial	$6.58
Rate for Payer: Healthscope Commercial	$8.22
Rate for Payer: Healthscope Whirlpool	$7.97
Rate for Payer: Mclaren Commercial	$7.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.99
Rate for Payer: Priority Health Cigna Priority Health	$5.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7.23

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$8.62

Service Code	NDC 60505-7062-0
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$8.62
Rate for Payer: Aetna Commercial	$7.76
Rate for Payer: ASR ASR	$8.36
Rate for Payer: BCBS Trust/PPO	$6.68
Rate for Payer: BCN Commercial	$6.68
Rate for Payer: Cash Price	$6.90
Rate for Payer: Cofinity Commercial	$8.10
Rate for Payer: Encore Health Key Benefits Commercial	$6.90
Rate for Payer: Healthscope Commercial	$8.62
Rate for Payer: Healthscope Whirlpool	$8.36
Rate for Payer: Mclaren Commercial	$7.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7.33
Rate for Payer: Priority Health Cigna Priority Health	$6.03
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7.59

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$62.30

Service Code	NDC 43598-447-70
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$43.61
Max. Negotiated Rate	$62.30
Rate for Payer: Aetna Commercial	$56.07
Rate for Payer: ASR ASR	$60.43
Rate for Payer: BCBS Trust/PPO	$48.30
Rate for Payer: BCN Commercial	$48.30
Rate for Payer: Cash Price	$49.84
Rate for Payer: Cofinity Commercial	$58.56
Rate for Payer: Encore Health Key Benefits Commercial	$49.84
Rate for Payer: Healthscope Commercial	$62.30
Rate for Payer: Healthscope Whirlpool	$60.43
Rate for Payer: Mclaren Commercial	$56.07
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$52.96
Rate for Payer: Priority Health Cigna Priority Health	$43.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$54.82

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$174.77

Service Code	NDC 766143020
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$122.34
Max. Negotiated Rate	$174.77
Rate for Payer: Aetna Commercial	$157.29
Rate for Payer: ASR ASR	$169.53
Rate for Payer: BCBS Trust/PPO	$135.50
Rate for Payer: BCN Commercial	$135.50
Rate for Payer: Cash Price	$139.82
Rate for Payer: Cofinity Commercial	$164.28
Rate for Payer: Encore Health Key Benefits Commercial	$139.82
Rate for Payer: Healthscope Commercial	$174.77
Rate for Payer: Healthscope Whirlpool	$169.53
Rate for Payer: Mclaren Commercial	$157.29
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$148.55
Rate for Payer: Priority Health Cigna Priority Health	$122.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$153.80

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$115.11

Service Code	NDC 0536-1108-88
Hospital Charge Code	27863
Hospital Revenue Code	637
Min. Negotiated Rate	$80.58
Max. Negotiated Rate	$115.11
Rate for Payer: Aetna Commercial	$103.60
Rate for Payer: ASR ASR	$111.66
Rate for Payer: BCBS Trust/PPO	$89.24
Rate for Payer: BCN Commercial	$89.24
Rate for Payer: Cash Price	$92.09
Rate for Payer: Cofinity Commercial	$108.20
Rate for Payer: Encore Health Key Benefits Commercial	$92.09
Rate for Payer: Healthscope Commercial	$115.11
Rate for Payer: Healthscope Whirlpool	$111.66
Rate for Payer: Mclaren Commercial	$103.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$97.84
Rate for Payer: Priority Health Cigna Priority Health	$80.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$101.30

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$92.13

Service Code	NDC 0536-5896-88
Hospital Charge Code	27863
Hospital Revenue Code	637
Min. Negotiated Rate	$64.49
Max. Negotiated Rate	$92.13
Rate for Payer: Aetna Commercial	$82.92
Rate for Payer: ASR ASR	$89.37
Rate for Payer: BCBS Trust/PPO	$71.43
Rate for Payer: BCN Commercial	$71.43
Rate for Payer: Cash Price	$73.71
Rate for Payer: Cofinity Commercial	$86.60
Rate for Payer: Encore Health Key Benefits Commercial	$73.70
Rate for Payer: Healthscope Commercial	$92.13
Rate for Payer: Healthscope Whirlpool	$89.37
Rate for Payer: Mclaren Commercial	$82.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$78.31
Rate for Payer: Priority Health Cigna Priority Health	$64.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$81.07

NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE

Facility

$89.01

Service Code	NDC 45802-089-01
Hospital Charge Code	182298
Hospital Revenue Code	637
Min. Negotiated Rate	$62.31
Max. Negotiated Rate	$89.01
Rate for Payer: Aetna Commercial	$80.11
Rate for Payer: ASR ASR	$86.34
Rate for Payer: BCBS Trust/PPO	$69.01
Rate for Payer: BCN Commercial	$69.01
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cofinity Commercial	$83.67
Rate for Payer: Encore Health Key Benefits Commercial	$71.21
Rate for Payer: Healthscope Commercial	$89.01
Rate for Payer: Healthscope Whirlpool	$86.34
Rate for Payer: Mclaren Commercial	$80.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$75.66
Rate for Payer: Priority Health Cigna Priority Health	$62.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$78.33

NICOTINE (POLACRILEX) 2 MG BUCCAL MINI LOZENGE

Facility

$267.02

Service Code	NDC 45802-089-02
Hospital Charge Code	182298
Hospital Revenue Code	637
Min. Negotiated Rate	$186.91
Max. Negotiated Rate	$267.02
Rate for Payer: Aetna Commercial	$240.32
Rate for Payer: ASR ASR	$259.01
Rate for Payer: BCBS Trust/PPO	$207.02
Rate for Payer: BCN Commercial	$207.02
Rate for Payer: Cash Price	$213.61
Rate for Payer: Cofinity Commercial	$251.00
Rate for Payer: Encore Health Key Benefits Commercial	$213.62
Rate for Payer: Healthscope Commercial	$267.02
Rate for Payer: Healthscope Whirlpool	$259.01
Rate for Payer: Mclaren Commercial	$240.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$226.97
Rate for Payer: Priority Health Cigna Priority Health	$186.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$234.98

NIFEDIPINE 10 MG CAPSULE

Facility

$272.65

Service Code	NDC 23155-194-01
Hospital Charge Code	5558
Hospital Revenue Code	637
Min. Negotiated Rate	$190.86
Max. Negotiated Rate	$272.65
Rate for Payer: Aetna Commercial	$245.38
Rate for Payer: ASR ASR	$264.47
Rate for Payer: BCBS Trust/PPO	$211.39
Rate for Payer: BCN Commercial	$211.39
Rate for Payer: Cash Price	$218.12
Rate for Payer: Cofinity Commercial	$256.29
Rate for Payer: Encore Health Key Benefits Commercial	$218.12
Rate for Payer: Healthscope Commercial	$272.65
Rate for Payer: Healthscope Whirlpool	$264.47
Rate for Payer: Mclaren Commercial	$245.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$231.75
Rate for Payer: Priority Health Cigna Priority Health	$190.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$239.93

NIFEDIPINE 10 MG CAPSULE

Facility

$4.76

Service Code	NDC 60687-425-11
Hospital Charge Code	5558
Hospital Revenue Code	637
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$4.76
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.62
Rate for Payer: BCBS Trust/PPO	$3.69
Rate for Payer: BCN Commercial	$3.69
Rate for Payer: Cash Price	$3.81
Rate for Payer: Cofinity Commercial	$4.47
Rate for Payer: Encore Health Key Benefits Commercial	$3.81
Rate for Payer: Healthscope Commercial	$4.76
Rate for Payer: Healthscope Whirlpool	$4.62
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.05
Rate for Payer: Priority Health Cigna Priority Health	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.19

NIFEDIPINE 10 MG CAPSULE

Facility

$475.68

Service Code	NDC 60687-425-01
Hospital Charge Code	5558
Hospital Revenue Code	637
Min. Negotiated Rate	$332.98
Max. Negotiated Rate	$475.68
Rate for Payer: Aetna Commercial	$428.11
Rate for Payer: ASR ASR	$461.41
Rate for Payer: BCBS Trust/PPO	$368.79
Rate for Payer: BCN Commercial	$368.79
Rate for Payer: Cash Price	$380.54
Rate for Payer: Cofinity Commercial	$447.14
Rate for Payer: Encore Health Key Benefits Commercial	$380.54
Rate for Payer: Healthscope Commercial	$475.68
Rate for Payer: Healthscope Whirlpool	$461.41
Rate for Payer: Mclaren Commercial	$428.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$404.33
Rate for Payer: Priority Health Cigna Priority Health	$332.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$418.60

NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE

Facility

$808.08

Service Code	NDC 47781-308-01
Hospital Charge Code	5593
Hospital Revenue Code	637
Min. Negotiated Rate	$565.66
Max. Negotiated Rate	$808.08
Rate for Payer: Aetna Commercial	$727.27
Rate for Payer: ASR ASR	$783.84
Rate for Payer: BCBS Trust/PPO	$626.50
Rate for Payer: BCN Commercial	$626.50
Rate for Payer: Cash Price	$646.46
Rate for Payer: Cofinity Commercial	$759.60
Rate for Payer: Encore Health Key Benefits Commercial	$646.46
Rate for Payer: Healthscope Commercial	$808.08
Rate for Payer: Healthscope Whirlpool	$783.84
Rate for Payer: Mclaren Commercial	$727.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$686.87
Rate for Payer: Priority Health Cigna Priority Health	$565.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$711.11

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE

Facility

$881.34

Service Code	NDC 68084-446-11
Hospital Charge Code	10724
Hospital Revenue Code	637
Min. Negotiated Rate	$616.94
Max. Negotiated Rate	$881.34
Rate for Payer: Aetna Commercial	$793.21
Rate for Payer: ASR ASR	$854.90
Rate for Payer: BCBS Trust/PPO	$683.30
Rate for Payer: BCN Commercial	$683.30
Rate for Payer: Cash Price	$705.07
Rate for Payer: Cofinity Commercial	$828.46
Rate for Payer: Encore Health Key Benefits Commercial	$705.07
Rate for Payer: Healthscope Commercial	$881.34
Rate for Payer: Healthscope Whirlpool	$854.90
Rate for Payer: Mclaren Commercial	$793.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$749.14
Rate for Payer: Priority Health Cigna Priority Health	$616.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$775.58

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE

Facility

$698.40

Service Code	NDC 47781-303-01
Hospital Charge Code	10724
Hospital Revenue Code	637
Min. Negotiated Rate	$488.88
Max. Negotiated Rate	$698.40
Rate for Payer: Aetna Commercial	$628.56
Rate for Payer: ASR ASR	$677.45
Rate for Payer: BCBS Trust/PPO	$541.47
Rate for Payer: BCN Commercial	$541.47
Rate for Payer: Cash Price	$558.72
Rate for Payer: Cofinity Commercial	$656.50
Rate for Payer: Encore Health Key Benefits Commercial	$558.72
Rate for Payer: Healthscope Commercial	$698.40
Rate for Payer: Healthscope Whirlpool	$677.45
Rate for Payer: Mclaren Commercial	$628.56
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$593.64
Rate for Payer: Priority Health Cigna Priority Health	$488.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$614.59

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE

Facility

$11.12

Service Code	NDC 51079-348-01
Hospital Charge Code	10724
Hospital Revenue Code	637
Min. Negotiated Rate	$7.78
Max. Negotiated Rate	$11.12
Rate for Payer: Aetna Commercial	$10.01
Rate for Payer: ASR ASR	$10.79
Rate for Payer: BCBS Trust/PPO	$8.62
Rate for Payer: BCN Commercial	$8.62
Rate for Payer: Cash Price	$8.90
Rate for Payer: Cofinity Commercial	$10.45
Rate for Payer: Encore Health Key Benefits Commercial	$8.90
Rate for Payer: Healthscope Commercial	$11.12
Rate for Payer: Healthscope Whirlpool	$10.79
Rate for Payer: Mclaren Commercial	$10.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$9.45
Rate for Payer: Priority Health Cigna Priority Health	$7.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.79

NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE

Facility

$881.34

Service Code	NDC 68084-446-01
Hospital Charge Code	10724
Hospital Revenue Code	637
Min. Negotiated Rate	$616.94
Max. Negotiated Rate	$881.34
Rate for Payer: Aetna Commercial	$793.21
Rate for Payer: ASR ASR	$854.90
Rate for Payer: BCBS Trust/PPO	$683.30
Rate for Payer: BCN Commercial	$683.30
Rate for Payer: Cash Price	$705.07
Rate for Payer: Cofinity Commercial	$828.46
Rate for Payer: Encore Health Key Benefits Commercial	$705.07
Rate for Payer: Healthscope Commercial	$881.34
Rate for Payer: Healthscope Whirlpool	$854.90
Rate for Payer: Mclaren Commercial	$793.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$749.14
Rate for Payer: Priority Health Cigna Priority Health	$616.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$775.58

NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH

Facility

$3.15

Service Code	NDC 68382-309-01
Hospital Charge Code	27472
Hospital Revenue Code	637
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.15
Rate for Payer: Aetna Commercial	$2.84
Rate for Payer: ASR ASR	$3.06
Rate for Payer: BCBS Trust/PPO	$2.44
Rate for Payer: BCN Commercial	$2.44
Rate for Payer: Cash Price	$2.52
Rate for Payer: Cofinity Commercial	$2.96
Rate for Payer: Encore Health Key Benefits Commercial	$2.52
Rate for Payer: Healthscope Commercial	$3.15
Rate for Payer: Healthscope Whirlpool	$3.06
Rate for Payer: Mclaren Commercial	$2.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.68
Rate for Payer: Priority Health Cigna Priority Health	$2.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.77

NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH

Facility

$94.61

Service Code	NDC 68382-309-30
Hospital Charge Code	27472
Hospital Revenue Code	637
Min. Negotiated Rate	$66.23
Max. Negotiated Rate	$94.61
Rate for Payer: Aetna Commercial	$85.15
Rate for Payer: ASR ASR	$91.77
Rate for Payer: BCBS Trust/PPO	$73.35
Rate for Payer: BCN Commercial	$73.35
Rate for Payer: Cash Price	$75.69
Rate for Payer: Cofinity Commercial	$88.93
Rate for Payer: Encore Health Key Benefits Commercial	$75.69
Rate for Payer: Healthscope Commercial	$94.61
Rate for Payer: Healthscope Whirlpool	$91.77
Rate for Payer: Mclaren Commercial	$85.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$80.42
Rate for Payer: Priority Health Cigna Priority Health	$66.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$83.26

NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH

Facility

$108.30

Service Code	NDC 49730-111-30
Hospital Charge Code	27472
Hospital Revenue Code	637
Min. Negotiated Rate	$75.81
Max. Negotiated Rate	$108.30
Rate for Payer: Aetna Commercial	$97.47
Rate for Payer: ASR ASR	$105.05
Rate for Payer: BCBS Trust/PPO	$83.96
Rate for Payer: BCN Commercial	$83.96
Rate for Payer: Cash Price	$86.64
Rate for Payer: Cofinity Commercial	$101.80
Rate for Payer: Encore Health Key Benefits Commercial	$86.64
Rate for Payer: Healthscope Commercial	$108.30
Rate for Payer: Healthscope Whirlpool	$105.05
Rate for Payer: Mclaren Commercial	$97.47
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$92.06
Rate for Payer: Priority Health Cigna Priority Health	$75.81
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$95.30

NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH

Facility

$110.02

Service Code	NDC 68382-310-30
Hospital Charge Code	27474
Hospital Revenue Code	637
Min. Negotiated Rate	$77.01
Max. Negotiated Rate	$110.02
Rate for Payer: Aetna Commercial	$99.02
Rate for Payer: ASR ASR	$106.72
Rate for Payer: BCBS Trust/PPO	$85.30
Rate for Payer: BCN Commercial	$85.30
Rate for Payer: Cash Price	$88.01
Rate for Payer: Cofinity Commercial	$103.42
Rate for Payer: Encore Health Key Benefits Commercial	$88.02
Rate for Payer: Healthscope Commercial	$110.02
Rate for Payer: Healthscope Whirlpool	$106.72
Rate for Payer: Mclaren Commercial	$99.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$93.52
Rate for Payer: Priority Health Cigna Priority Health	$77.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$96.82

Know your out-of-pocket cost for care.

All Charges