Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$23.59

Service Code	NDC 00409337504
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$15.33
Max. Negotiated Rate	$23.59
Rate for Payer: Aetna Commercial	$21.23
Rate for Payer: ASR ASR	$22.88
Rate for Payer: ASR Commercial	$22.88
Rate for Payer: BCBS Trust/PPO	$19.22
Rate for Payer: BCN Commercial	$18.29
Rate for Payer: Cash Price	$18.87
Rate for Payer: Cofinity Commercial	$22.17
Rate for Payer: Encore Health Key Benefits Commercial	$18.87
Rate for Payer: Healthscope Commercial	$23.59
Rate for Payer: Healthscope Whirlpool	$22.88
Rate for Payer: Mclaren Commercial	$21.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.05
Rate for Payer: Nomi Health Commercial	$19.34
Rate for Payer: Priority Health Cigna Priority Health	$15.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.76

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$36.17

Service Code	NDC 47335061540
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$23.51
Max. Negotiated Rate	$36.17
Rate for Payer: Aetna Commercial	$32.55
Rate for Payer: ASR ASR	$35.08
Rate for Payer: ASR Commercial	$35.08
Rate for Payer: BCBS Trust/PPO	$29.47
Rate for Payer: BCN Commercial	$28.04
Rate for Payer: Cash Price	$28.94
Rate for Payer: Cofinity Commercial	$34.00
Rate for Payer: Encore Health Key Benefits Commercial	$28.94
Rate for Payer: Healthscope Commercial	$36.17
Rate for Payer: Healthscope Whirlpool	$35.08
Rate for Payer: Mclaren Commercial	$32.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$30.74
Rate for Payer: Nomi Health Commercial	$29.66
Rate for Payer: Priority Health Cigna Priority Health	$23.51
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$31.83

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$18.37

Service Code	NDC 67457085200
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$7.35
Max. Negotiated Rate	$18.37
Rate for Payer: Aetna Commercial	$16.53
Rate for Payer: Aetna Medicare	$9.19
Rate for Payer: ASR ASR	$17.82
Rate for Payer: ASR Commercial	$17.82
Rate for Payer: BCBS Complete	$7.35
Rate for Payer: BCBS Trust/PPO	$15.04
Rate for Payer: BCN Commercial	$14.24
Rate for Payer: Cash Price	$14.70
Rate for Payer: Cofinity Commercial	$17.27
Rate for Payer: Encore Health Key Benefits Commercial	$14.70
Rate for Payer: Healthscope Commercial	$18.37
Rate for Payer: Healthscope Whirlpool	$17.82
Rate for Payer: Mclaren Commercial	$16.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.61
Rate for Payer: Nomi Health Commercial	$15.06
Rate for Payer: Priority Health Cigna Priority Health	$11.94
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.10
Rate for Payer: Priority Health Narrow Network	$12.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$16.17

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$24.04

Service Code	NDC 70121157601
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$24.04
Rate for Payer: Aetna Commercial	$21.64
Rate for Payer: Aetna Medicare	$12.02
Rate for Payer: ASR ASR	$23.32
Rate for Payer: ASR Commercial	$23.32
Rate for Payer: BCBS Complete	$9.62
Rate for Payer: BCBS Trust/PPO	$19.69
Rate for Payer: BCN Commercial	$18.64
Rate for Payer: Cash Price	$19.23
Rate for Payer: Cofinity Commercial	$22.60
Rate for Payer: Encore Health Key Benefits Commercial	$19.23
Rate for Payer: Healthscope Commercial	$24.04
Rate for Payer: Healthscope Whirlpool	$23.32
Rate for Payer: Mclaren Commercial	$21.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.43
Rate for Payer: Nomi Health Commercial	$19.71
Rate for Payer: Priority Health Cigna Priority Health	$15.63
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$21.06
Rate for Payer: Priority Health Narrow Network	$16.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.16

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$24.04

Service Code	NDC 70121157607
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$24.04
Rate for Payer: Aetna Commercial	$21.64
Rate for Payer: Aetna Medicare	$12.02
Rate for Payer: ASR ASR	$23.32
Rate for Payer: ASR Commercial	$23.32
Rate for Payer: BCBS Complete	$9.62
Rate for Payer: BCBS Trust/PPO	$19.69
Rate for Payer: BCN Commercial	$18.64
Rate for Payer: Cash Price	$19.23
Rate for Payer: Cofinity Commercial	$22.60
Rate for Payer: Encore Health Key Benefits Commercial	$19.23
Rate for Payer: Healthscope Commercial	$24.04
Rate for Payer: Healthscope Whirlpool	$23.32
Rate for Payer: Mclaren Commercial	$21.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.43
Rate for Payer: Nomi Health Commercial	$19.71
Rate for Payer: Priority Health Cigna Priority Health	$15.63
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$21.06
Rate for Payer: Priority Health Narrow Network	$16.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.16

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$15.07

Service Code	NDC 43066099710
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$15.07
Rate for Payer: Aetna Commercial	$13.56
Rate for Payer: Aetna Medicare	$7.54
Rate for Payer: ASR ASR	$14.62
Rate for Payer: ASR Commercial	$14.62
Rate for Payer: BCBS Complete	$6.03
Rate for Payer: BCBS Trust/PPO	$12.34
Rate for Payer: BCN Commercial	$11.68
Rate for Payer: Cash Price	$12.05
Rate for Payer: Cofinity Commercial	$14.17
Rate for Payer: Encore Health Key Benefits Commercial	$12.06
Rate for Payer: Healthscope Commercial	$15.07
Rate for Payer: Healthscope Whirlpool	$14.62
Rate for Payer: Mclaren Commercial	$13.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.81
Rate for Payer: Nomi Health Commercial	$12.36
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13.20
Rate for Payer: Priority Health Narrow Network	$10.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.26

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$20.24

Service Code	NDC 36000016201
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$20.24
Rate for Payer: Aetna Commercial	$18.22
Rate for Payer: Aetna Medicare	$10.12
Rate for Payer: ASR ASR	$19.63
Rate for Payer: ASR Commercial	$19.63
Rate for Payer: BCBS Complete	$8.10
Rate for Payer: BCBS Trust/PPO	$16.57
Rate for Payer: BCN Commercial	$15.69
Rate for Payer: Cash Price	$16.19
Rate for Payer: Cofinity Commercial	$19.03
Rate for Payer: Encore Health Key Benefits Commercial	$16.19
Rate for Payer: Healthscope Commercial	$20.24
Rate for Payer: Healthscope Whirlpool	$19.63
Rate for Payer: Mclaren Commercial	$18.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.20
Rate for Payer: Nomi Health Commercial	$16.60
Rate for Payer: Priority Health Cigna Priority Health	$13.16
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.73
Rate for Payer: Priority Health Narrow Network	$14.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.81

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$36.17

Service Code	NDC 47335061544
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$14.47
Max. Negotiated Rate	$36.17
Rate for Payer: Aetna Commercial	$32.55
Rate for Payer: Aetna Medicare	$18.09
Rate for Payer: ASR ASR	$35.08
Rate for Payer: ASR Commercial	$35.08
Rate for Payer: BCBS Complete	$14.47
Rate for Payer: BCBS Trust/PPO	$29.62
Rate for Payer: BCN Commercial	$28.04
Rate for Payer: Cash Price	$28.94
Rate for Payer: Cofinity Commercial	$34.00
Rate for Payer: Encore Health Key Benefits Commercial	$28.94
Rate for Payer: Healthscope Commercial	$36.17
Rate for Payer: Healthscope Whirlpool	$35.08
Rate for Payer: Mclaren Commercial	$32.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$30.74
Rate for Payer: Nomi Health Commercial	$29.66
Rate for Payer: Priority Health Cigna Priority Health	$23.51
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$31.69
Rate for Payer: Priority Health Narrow Network	$25.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$31.83

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$15.07

Service Code	NDC 43066099710
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$15.07
Rate for Payer: Aetna Commercial	$13.56
Rate for Payer: ASR ASR	$14.62
Rate for Payer: ASR Commercial	$14.62
Rate for Payer: BCBS Trust/PPO	$12.28
Rate for Payer: BCN Commercial	$11.68
Rate for Payer: Cash Price	$12.05
Rate for Payer: Cofinity Commercial	$14.17
Rate for Payer: Encore Health Key Benefits Commercial	$12.06
Rate for Payer: Healthscope Commercial	$15.07
Rate for Payer: Healthscope Whirlpool	$14.62
Rate for Payer: Mclaren Commercial	$13.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.81
Rate for Payer: Nomi Health Commercial	$12.36
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.26

NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION

Facility

$25.45

Service Code	NDC 00143931801
Hospital Charge Code	10734
Hospital Revenue Code	250
Min. Negotiated Rate	$16.54
Max. Negotiated Rate	$25.45
Rate for Payer: Aetna Commercial	$22.91
Rate for Payer: ASR ASR	$24.69
Rate for Payer: ASR Commercial	$24.69
Rate for Payer: BCBS Trust/PPO	$20.74
Rate for Payer: BCN Commercial	$19.73
Rate for Payer: Cash Price	$20.36
Rate for Payer: Cofinity Commercial	$23.92
Rate for Payer: Encore Health Key Benefits Commercial	$20.36
Rate for Payer: Healthscope Commercial	$25.45
Rate for Payer: Healthscope Whirlpool	$24.69
Rate for Payer: Mclaren Commercial	$22.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.63
Rate for Payer: Nomi Health Commercial	$20.87
Rate for Payer: Priority Health Cigna Priority Health	$16.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.40

NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION

Facility

$31.50

Service Code	NDC 44567064101
Hospital Charge Code	119763
Hospital Revenue Code	250
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Commercial	$28.35
Rate for Payer: ASR ASR	$30.55
Rate for Payer: ASR Commercial	$30.55
Rate for Payer: BCBS Trust/PPO	$25.67
Rate for Payer: BCN Commercial	$24.42
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cofinity Commercial	$29.61
Rate for Payer: Encore Health Key Benefits Commercial	$25.20
Rate for Payer: Healthscope Commercial	$31.50
Rate for Payer: Healthscope Whirlpool	$30.55
Rate for Payer: Mclaren Commercial	$28.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26.77
Rate for Payer: Nomi Health Commercial	$25.83
Rate for Payer: Priority Health Cigna Priority Health	$20.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$27.72

NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION

Facility

$31.50

Service Code	NDC 44567064110
Hospital Charge Code	119763
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Commercial	$28.35
Rate for Payer: Aetna Medicare	$15.75
Rate for Payer: ASR ASR	$30.55
Rate for Payer: ASR Commercial	$30.55
Rate for Payer: BCBS Complete	$12.60
Rate for Payer: BCBS Trust/PPO	$25.80
Rate for Payer: BCN Commercial	$24.42
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cofinity Commercial	$29.61
Rate for Payer: Encore Health Key Benefits Commercial	$25.20
Rate for Payer: Healthscope Commercial	$31.50
Rate for Payer: Healthscope Whirlpool	$30.55
Rate for Payer: Mclaren Commercial	$28.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26.77
Rate for Payer: Nomi Health Commercial	$25.83
Rate for Payer: Priority Health Cigna Priority Health	$20.48
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27.60
Rate for Payer: Priority Health Narrow Network	$22.08
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$27.72

NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION

Facility

$31.50

Service Code	NDC 44567064101
Hospital Charge Code	119763
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Commercial	$28.35
Rate for Payer: Aetna Medicare	$15.75
Rate for Payer: ASR ASR	$30.55
Rate for Payer: ASR Commercial	$30.55
Rate for Payer: BCBS Complete	$12.60
Rate for Payer: BCBS Trust/PPO	$25.80
Rate for Payer: BCN Commercial	$24.42
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cofinity Commercial	$29.61
Rate for Payer: Encore Health Key Benefits Commercial	$25.20
Rate for Payer: Healthscope Commercial	$31.50
Rate for Payer: Healthscope Whirlpool	$30.55
Rate for Payer: Mclaren Commercial	$28.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26.77
Rate for Payer: Nomi Health Commercial	$25.83
Rate for Payer: Priority Health Cigna Priority Health	$20.48
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27.60
Rate for Payer: Priority Health Narrow Network	$22.08
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$27.72

NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION

Facility

$31.50

Service Code	NDC 44567064110
Hospital Charge Code	119763
Hospital Revenue Code	250
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Commercial	$28.35
Rate for Payer: ASR ASR	$30.55
Rate for Payer: ASR Commercial	$30.55
Rate for Payer: BCBS Trust/PPO	$25.67
Rate for Payer: BCN Commercial	$24.42
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cofinity Commercial	$29.61
Rate for Payer: Encore Health Key Benefits Commercial	$25.20
Rate for Payer: Healthscope Commercial	$31.50
Rate for Payer: Healthscope Whirlpool	$30.55
Rate for Payer: Mclaren Commercial	$28.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26.77
Rate for Payer: Nomi Health Commercial	$25.83
Rate for Payer: Priority Health Cigna Priority Health	$20.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$27.72

NORTRIPTYLINE 10 MG CAPSULE

Facility

$173.38

Service Code	NDC 50268060315
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$173.38
Rate for Payer: Aetna Commercial	$156.04
Rate for Payer: ASR ASR	$168.18
Rate for Payer: ASR Commercial	$168.18
Rate for Payer: BCBS Trust/PPO	$141.29
Rate for Payer: BCN Commercial	$134.42
Rate for Payer: Cash Price	$138.70
Rate for Payer: Cofinity Commercial	$162.98
Rate for Payer: Encore Health Key Benefits Commercial	$138.70
Rate for Payer: Healthscope Commercial	$173.38
Rate for Payer: Healthscope Whirlpool	$168.18
Rate for Payer: Mclaren Commercial	$156.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$147.37
Rate for Payer: Nomi Health Commercial	$142.17
Rate for Payer: Priority Health Cigna Priority Health	$112.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$152.57

NORTRIPTYLINE 10 MG CAPSULE

Facility

$173.38

Service Code	NDC 50268060315
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$69.35
Max. Negotiated Rate	$173.38
Rate for Payer: Aetna Commercial	$156.04
Rate for Payer: Aetna Medicare	$86.69
Rate for Payer: ASR ASR	$168.18
Rate for Payer: ASR Commercial	$168.18
Rate for Payer: BCBS Complete	$69.35
Rate for Payer: BCBS Trust/PPO	$141.98
Rate for Payer: BCN Commercial	$134.42
Rate for Payer: Cash Price	$138.70
Rate for Payer: Cofinity Commercial	$162.98
Rate for Payer: Encore Health Key Benefits Commercial	$138.70
Rate for Payer: Healthscope Commercial	$173.38
Rate for Payer: Healthscope Whirlpool	$168.18
Rate for Payer: Mclaren Commercial	$156.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$147.37
Rate for Payer: Nomi Health Commercial	$142.17
Rate for Payer: Priority Health Cigna Priority Health	$112.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$151.92
Rate for Payer: Priority Health Narrow Network	$121.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$152.57

NORTRIPTYLINE 25 MG CAPSULE

Facility

$206.80

Service Code	NDC 51672400201
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$82.72
Max. Negotiated Rate	$206.80
Rate for Payer: Aetna Commercial	$186.12
Rate for Payer: Aetna Medicare	$103.40
Rate for Payer: ASR ASR	$200.60
Rate for Payer: ASR Commercial	$200.60
Rate for Payer: BCBS Complete	$82.72
Rate for Payer: BCBS Trust/PPO	$169.35
Rate for Payer: BCN Commercial	$160.33
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cofinity Commercial	$194.39
Rate for Payer: Encore Health Key Benefits Commercial	$165.44
Rate for Payer: Healthscope Commercial	$206.80
Rate for Payer: Healthscope Whirlpool	$200.60
Rate for Payer: Mclaren Commercial	$186.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.78
Rate for Payer: Nomi Health Commercial	$169.58
Rate for Payer: Priority Health Cigna Priority Health	$134.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$181.20
Rate for Payer: Priority Health Narrow Network	$144.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$181.98

NORTRIPTYLINE 25 MG CAPSULE

Facility

$356.25

Service Code	NDC 60687029301
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$231.56
Max. Negotiated Rate	$356.25
Rate for Payer: Aetna Commercial	$320.62
Rate for Payer: ASR ASR	$345.56
Rate for Payer: ASR Commercial	$345.56
Rate for Payer: BCBS Trust/PPO	$290.31
Rate for Payer: BCN Commercial	$276.20
Rate for Payer: Cash Price	$285.00
Rate for Payer: Cofinity Commercial	$334.88
Rate for Payer: Encore Health Key Benefits Commercial	$285.00
Rate for Payer: Healthscope Commercial	$356.25
Rate for Payer: Healthscope Whirlpool	$345.56
Rate for Payer: Mclaren Commercial	$320.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$302.81
Rate for Payer: Nomi Health Commercial	$292.12
Rate for Payer: Priority Health Cigna Priority Health	$231.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$313.50

NORTRIPTYLINE 25 MG CAPSULE

Facility

$356.25

Service Code	NDC 60687029301
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$142.50
Max. Negotiated Rate	$356.25
Rate for Payer: Aetna Commercial	$320.62
Rate for Payer: Aetna Medicare	$178.12
Rate for Payer: ASR ASR	$345.56
Rate for Payer: ASR Commercial	$345.56
Rate for Payer: BCBS Complete	$142.50
Rate for Payer: BCBS Trust/PPO	$291.73
Rate for Payer: BCN Commercial	$276.20
Rate for Payer: Cash Price	$285.00
Rate for Payer: Cofinity Commercial	$334.88
Rate for Payer: Encore Health Key Benefits Commercial	$285.00
Rate for Payer: Healthscope Commercial	$356.25
Rate for Payer: Healthscope Whirlpool	$345.56
Rate for Payer: Mclaren Commercial	$320.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$302.81
Rate for Payer: Nomi Health Commercial	$292.12
Rate for Payer: Priority Health Cigna Priority Health	$231.56
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$312.15
Rate for Payer: Priority Health Narrow Network	$249.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$313.50

NORTRIPTYLINE 25 MG CAPSULE

Facility

$182.88

Service Code	NDC 50268060415
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$118.87
Max. Negotiated Rate	$182.88
Rate for Payer: Aetna Commercial	$164.59
Rate for Payer: ASR ASR	$177.39
Rate for Payer: ASR Commercial	$177.39
Rate for Payer: BCBS Trust/PPO	$149.03
Rate for Payer: BCN Commercial	$141.79
Rate for Payer: Cash Price	$146.30
Rate for Payer: Cofinity Commercial	$171.91
Rate for Payer: Encore Health Key Benefits Commercial	$146.30
Rate for Payer: Healthscope Commercial	$182.88
Rate for Payer: Healthscope Whirlpool	$177.39
Rate for Payer: Mclaren Commercial	$164.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.45
Rate for Payer: Nomi Health Commercial	$149.96
Rate for Payer: Priority Health Cigna Priority Health	$118.87
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$160.93

NORTRIPTYLINE 25 MG CAPSULE

Facility

$182.88

Service Code	NDC 50268060415
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$73.15
Max. Negotiated Rate	$182.88
Rate for Payer: Aetna Commercial	$164.59
Rate for Payer: Aetna Medicare	$91.44
Rate for Payer: ASR ASR	$177.39
Rate for Payer: ASR Commercial	$177.39
Rate for Payer: BCBS Complete	$73.15
Rate for Payer: BCBS Trust/PPO	$149.76
Rate for Payer: BCN Commercial	$141.79
Rate for Payer: Cash Price	$146.30
Rate for Payer: Cofinity Commercial	$171.91
Rate for Payer: Encore Health Key Benefits Commercial	$146.30
Rate for Payer: Healthscope Commercial	$182.88
Rate for Payer: Healthscope Whirlpool	$177.39
Rate for Payer: Mclaren Commercial	$164.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.45
Rate for Payer: Nomi Health Commercial	$149.96
Rate for Payer: Priority Health Cigna Priority Health	$118.87
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$160.24
Rate for Payer: Priority Health Narrow Network	$128.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$160.93

NORTRIPTYLINE 25 MG CAPSULE

Facility

$281.30

Service Code	NDC 51672400205
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$112.52
Max. Negotiated Rate	$281.30
Rate for Payer: Aetna Commercial	$253.17
Rate for Payer: Aetna Medicare	$140.65
Rate for Payer: ASR ASR	$272.86
Rate for Payer: ASR Commercial	$272.86
Rate for Payer: BCBS Complete	$112.52
Rate for Payer: BCBS Trust/PPO	$230.36
Rate for Payer: BCN Commercial	$218.09
Rate for Payer: Cash Price	$225.04
Rate for Payer: Cofinity Commercial	$264.42
Rate for Payer: Encore Health Key Benefits Commercial	$225.04
Rate for Payer: Healthscope Commercial	$281.30
Rate for Payer: Healthscope Whirlpool	$272.86
Rate for Payer: Mclaren Commercial	$253.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$239.10
Rate for Payer: Nomi Health Commercial	$230.67
Rate for Payer: Priority Health Cigna Priority Health	$182.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$246.48
Rate for Payer: Priority Health Narrow Network	$197.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$247.54

NORTRIPTYLINE 25 MG CAPSULE

Facility

$206.80

Service Code	NDC 51672400201
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$134.42
Max. Negotiated Rate	$206.80
Rate for Payer: Aetna Commercial	$186.12
Rate for Payer: ASR ASR	$200.60
Rate for Payer: ASR Commercial	$200.60
Rate for Payer: BCBS Trust/PPO	$168.52
Rate for Payer: BCN Commercial	$160.33
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cofinity Commercial	$194.39
Rate for Payer: Encore Health Key Benefits Commercial	$165.44
Rate for Payer: Healthscope Commercial	$206.80
Rate for Payer: Healthscope Whirlpool	$200.60
Rate for Payer: Mclaren Commercial	$186.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.78
Rate for Payer: Nomi Health Commercial	$169.58
Rate for Payer: Priority Health Cigna Priority Health	$134.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$181.98

NORTRIPTYLINE 25 MG CAPSULE

Facility

$3.66

Service Code	NDC 50268060411
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$3.66
Rate for Payer: Aetna Commercial	$3.29
Rate for Payer: Aetna Medicare	$1.83
Rate for Payer: ASR ASR	$3.55
Rate for Payer: ASR Commercial	$3.55
Rate for Payer: BCBS Complete	$1.46
Rate for Payer: BCBS Trust/PPO	$3.00
Rate for Payer: BCN Commercial	$2.84
Rate for Payer: Cash Price	$2.93
Rate for Payer: Cofinity Commercial	$3.44
Rate for Payer: Encore Health Key Benefits Commercial	$2.93
Rate for Payer: Healthscope Commercial	$3.66
Rate for Payer: Healthscope Whirlpool	$3.55
Rate for Payer: Mclaren Commercial	$3.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.11
Rate for Payer: Nomi Health Commercial	$3.00
Rate for Payer: Priority Health Cigna Priority Health	$2.38
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.21
Rate for Payer: Priority Health Narrow Network	$2.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.22

NORTRIPTYLINE 25 MG CAPSULE

Facility

$3.56

Service Code	NDC 60687029311
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$3.56
Rate for Payer: Aetna Commercial	$3.20
Rate for Payer: Aetna Medicare	$1.78
Rate for Payer: ASR ASR	$3.45
Rate for Payer: ASR Commercial	$3.45
Rate for Payer: BCBS Complete	$1.42
Rate for Payer: BCBS Trust/PPO	$2.92
Rate for Payer: BCN Commercial	$2.76
Rate for Payer: Cash Price	$2.85
Rate for Payer: Cofinity Commercial	$3.35
Rate for Payer: Encore Health Key Benefits Commercial	$2.85
Rate for Payer: Healthscope Commercial	$3.56
Rate for Payer: Healthscope Whirlpool	$3.45
Rate for Payer: Mclaren Commercial	$3.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.03
Rate for Payer: Nomi Health Commercial	$2.92
Rate for Payer: Priority Health Cigna Priority Health	$2.31
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.12
Rate for Payer: Priority Health Narrow Network	$2.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.13

Know your out-of-pocket cost for care.

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