|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM
|
Facility
|
OP
|
$12.73
|
|
|
Service Code
|
NDC 43598057901
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.09 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Aetna Commercial |
$11.46
|
| Rate for Payer: Aetna Medicare |
$6.36
|
| Rate for Payer: ASR ASR |
$12.35
|
| Rate for Payer: ASR Commercial |
$12.35
|
| Rate for Payer: BCBS Complete |
$5.09
|
| Rate for Payer: BCBS Trust/PPO |
$10.42
|
| Rate for Payer: BCN Commercial |
$9.87
|
| Rate for Payer: Cash Price |
$10.18
|
| Rate for Payer: Cofinity Commercial |
$11.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.18
|
| Rate for Payer: Healthscope Commercial |
$12.73
|
| Rate for Payer: Healthscope Whirlpool |
$12.35
|
| Rate for Payer: Mclaren Commercial |
$11.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.82
|
| Rate for Payer: Nomi Health Commercial |
$10.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.15
|
| Rate for Payer: Priority Health Narrow Network |
$8.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.20
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM
|
Facility
|
IP
|
$12.73
|
|
|
Service Code
|
NDC 43598057901
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Aetna Commercial |
$11.46
|
| Rate for Payer: ASR ASR |
$12.35
|
| Rate for Payer: ASR Commercial |
$12.35
|
| Rate for Payer: BCBS Trust/PPO |
$10.37
|
| Rate for Payer: BCN Commercial |
$9.87
|
| Rate for Payer: Cash Price |
$10.18
|
| Rate for Payer: Cofinity Commercial |
$11.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.18
|
| Rate for Payer: Healthscope Commercial |
$12.73
|
| Rate for Payer: Healthscope Whirlpool |
$12.35
|
| Rate for Payer: Mclaren Commercial |
$11.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.82
|
| Rate for Payer: Nomi Health Commercial |
$10.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.20
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$263.55
|
|
|
Service Code
|
NDC 00054018913
|
| Hospital Charge Code |
34714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.42 |
| Max. Negotiated Rate |
$263.55 |
| Rate for Payer: Aetna Commercial |
$237.20
|
| Rate for Payer: Aetna Medicare |
$131.78
|
| Rate for Payer: ASR ASR |
$255.64
|
| Rate for Payer: ASR Commercial |
$255.64
|
| Rate for Payer: BCBS Complete |
$105.42
|
| Rate for Payer: BCBS Trust/PPO |
$215.82
|
| 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 Commercial |
$224.02
|
| Rate for Payer: Nomi Health Commercial |
$216.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$230.92
|
| Rate for Payer: Priority Health Narrow Network |
$184.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.92
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$263.55
|
|
|
Service Code
|
NDC 00054018913
|
| Hospital Charge Code |
34714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.31 |
| Max. Negotiated Rate |
$263.55 |
| Rate for Payer: Aetna Commercial |
$237.20
|
| Rate for Payer: ASR ASR |
$255.64
|
| Rate for Payer: ASR Commercial |
$255.64
|
| Rate for Payer: BCBS Trust/PPO |
$214.77
|
| 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 Commercial |
$224.02
|
| Rate for Payer: Nomi Health Commercial |
$216.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.92
|
|
|
BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$62.78
|
|
|
Service Code
|
HCPCS J0592
|
| Hospital Charge Code |
115937
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$56.50
|
| Rate for Payer: Aetna Commercial |
$49.02
|
| Rate for Payer: Aetna Medicare |
$27.24
|
| Rate for Payer: Aetna Medicare |
$31.39
|
| Rate for Payer: ASR ASR |
$60.90
|
| Rate for Payer: ASR ASR |
$52.84
|
| Rate for Payer: ASR Commercial |
$52.84
|
| Rate for Payer: ASR Commercial |
$60.90
|
| Rate for Payer: BCBS Complete |
$25.11
|
| Rate for Payer: BCBS Complete |
$21.79
|
| Rate for Payer: BCBS Trust/PPO |
$51.41
|
| Rate for Payer: BCBS Trust/PPO |
$44.61
|
| Rate for Payer: BCN Commercial |
$42.23
|
| Rate for Payer: BCN Commercial |
$48.67
|
| Rate for Payer: Cash Price |
$43.57
|
| Rate for Payer: Cash Price |
$43.57
|
| Rate for Payer: Cash Price |
$50.22
|
| Rate for Payer: Cash Price |
$50.22
|
| 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 |
$62.78
|
| Rate for Payer: Healthscope Commercial |
$54.47
|
| Rate for Payer: Healthscope Whirlpool |
$60.90
|
| Rate for Payer: Healthscope Whirlpool |
$52.84
|
| Rate for Payer: Mclaren Commercial |
$49.02
|
| Rate for Payer: Mclaren Commercial |
$56.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.30
|
| Rate for Payer: Nomi Health Commercial |
$51.48
|
| Rate for Payer: Nomi Health Commercial |
$44.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.34
|
| Rate for Payer: Priority Health Narrow Network |
$3.47
|
| Rate for Payer: Priority Health Narrow Network |
$3.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$55.25
|
|
|
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 |
$40.81 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$56.50
|
| Rate for Payer: Aetna Commercial |
$49.02
|
| Rate for Payer: ASR ASR |
$60.90
|
| Rate for Payer: ASR ASR |
$52.84
|
| Rate for Payer: ASR Commercial |
$52.84
|
| Rate for Payer: ASR Commercial |
$60.90
|
| Rate for Payer: BCBS Trust/PPO |
$44.39
|
| Rate for Payer: BCBS Trust/PPO |
$51.16
|
| Rate for Payer: BCN Commercial |
$48.67
|
| Rate for Payer: BCN Commercial |
$42.23
|
| 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 |
$43.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.22
|
| 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 |
$49.02
|
| Rate for Payer: Mclaren Commercial |
$56.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.36
|
| Rate for Payer: Nomi Health Commercial |
$44.67
|
| Rate for Payer: Nomi Health Commercial |
$51.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.41
|
| 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
|
OP
|
$386.40
|
|
|
Service Code
|
NDC 00904715404
|
| Hospital Charge Code |
34711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.56 |
| Max. Negotiated Rate |
$386.40 |
| Rate for Payer: Aetna Commercial |
$347.76
|
| Rate for Payer: Aetna Medicare |
$193.20
|
| Rate for Payer: ASR ASR |
$374.81
|
| Rate for Payer: ASR Commercial |
$374.81
|
| Rate for Payer: BCBS Complete |
$154.56
|
| Rate for Payer: BCBS Trust/PPO |
$316.42
|
| Rate for Payer: BCN Commercial |
$299.58
|
| Rate for Payer: Cash Price |
$309.12
|
| Rate for Payer: Cofinity Commercial |
$363.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.12
|
| Rate for Payer: Healthscope Commercial |
$386.40
|
| Rate for Payer: Healthscope Whirlpool |
$374.81
|
| Rate for Payer: Mclaren Commercial |
$347.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.44
|
| Rate for Payer: Nomi Health Commercial |
$316.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$338.56
|
| Rate for Payer: Priority Health Narrow Network |
$270.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$340.03
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$386.40
|
|
|
Service Code
|
NDC 00904715404
|
| Hospital Charge Code |
34711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.16 |
| Max. Negotiated Rate |
$386.40 |
| Rate for Payer: Aetna Commercial |
$347.76
|
| Rate for Payer: ASR ASR |
$374.81
|
| Rate for Payer: ASR Commercial |
$374.81
|
| Rate for Payer: BCBS Trust/PPO |
$314.88
|
| Rate for Payer: BCN Commercial |
$299.58
|
| Rate for Payer: Cash Price |
$309.12
|
| Rate for Payer: Cofinity Commercial |
$363.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.12
|
| Rate for Payer: Healthscope Commercial |
$386.40
|
| Rate for Payer: Healthscope Whirlpool |
$374.81
|
| Rate for Payer: Mclaren Commercial |
$347.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.44
|
| Rate for Payer: Nomi Health Commercial |
$316.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$340.03
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$195.30
|
|
|
Service Code
|
NDC 00054017613
|
| Hospital Charge Code |
34711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.12 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna Commercial |
$175.77
|
| Rate for Payer: Aetna Medicare |
$97.65
|
| Rate for Payer: ASR ASR |
$189.44
|
| Rate for Payer: ASR Commercial |
$189.44
|
| Rate for Payer: BCBS Complete |
$78.12
|
| Rate for Payer: BCBS Trust/PPO |
$159.93
|
| Rate for Payer: BCN Commercial |
$151.42
|
| Rate for Payer: Cash Price |
$156.24
|
| Rate for Payer: Cofinity Commercial |
$183.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.24
|
| Rate for Payer: Healthscope Commercial |
$195.30
|
| Rate for Payer: Healthscope Whirlpool |
$189.44
|
| Rate for Payer: Mclaren Commercial |
$175.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.00
|
| Rate for Payer: Nomi Health Commercial |
$160.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$171.12
|
| Rate for Payer: Priority Health Narrow Network |
$136.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$171.86
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$195.30
|
|
|
Service Code
|
NDC 00054017613
|
| Hospital Charge Code |
34711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.94 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna Commercial |
$175.77
|
| Rate for Payer: ASR ASR |
$189.44
|
| Rate for Payer: ASR Commercial |
$189.44
|
| Rate for Payer: BCBS Trust/PPO |
$159.15
|
| Rate for Payer: BCN Commercial |
$151.42
|
| Rate for Payer: Cash Price |
$156.24
|
| Rate for Payer: Cofinity Commercial |
$183.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.24
|
| Rate for Payer: Healthscope Commercial |
$195.30
|
| Rate for Payer: Healthscope Whirlpool |
$189.44
|
| Rate for Payer: Mclaren Commercial |
$175.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.00
|
| Rate for Payer: Nomi Health Commercial |
$160.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$171.86
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
OP
|
$251.68
|
|
|
Service Code
|
NDC 16729044315
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.67 |
| Max. Negotiated Rate |
$251.68 |
| Rate for Payer: Aetna Commercial |
$226.51
|
| Rate for Payer: Aetna Medicare |
$125.84
|
| Rate for Payer: ASR ASR |
$244.13
|
| Rate for Payer: ASR Commercial |
$244.13
|
| Rate for Payer: BCBS Complete |
$100.67
|
| Rate for Payer: BCBS Trust/PPO |
$206.10
|
| 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 Commercial |
$213.93
|
| Rate for Payer: Nomi Health Commercial |
$206.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$220.52
|
| 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
|
IP
|
$8.28
|
|
|
Service Code
|
NDC 60687031211
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.38 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: ASR ASR |
$8.03
|
| Rate for Payer: ASR Commercial |
$8.03
|
| Rate for Payer: BCBS Trust/PPO |
$6.75
|
| Rate for Payer: BCN Commercial |
$6.42
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Cofinity Commercial |
$7.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.62
|
| Rate for Payer: Healthscope Commercial |
$8.28
|
| Rate for Payer: Healthscope Whirlpool |
$8.03
|
| Rate for Payer: Mclaren Commercial |
$7.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.04
|
| Rate for Payer: Nomi Health Commercial |
$6.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.29
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
OP
|
$615.84
|
|
|
Service Code
|
NDC 00904708461
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$246.34 |
| Max. Negotiated Rate |
$615.84 |
| Rate for Payer: Aetna Commercial |
$554.26
|
| Rate for Payer: Aetna Medicare |
$307.92
|
| Rate for Payer: ASR ASR |
$597.36
|
| Rate for Payer: ASR Commercial |
$597.36
|
| Rate for Payer: BCBS Complete |
$246.34
|
| Rate for Payer: BCBS Trust/PPO |
$504.31
|
| Rate for Payer: BCN Commercial |
$477.46
|
| Rate for Payer: Cash Price |
$492.67
|
| Rate for Payer: Cofinity Commercial |
$578.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$492.67
|
| Rate for Payer: Healthscope Commercial |
$615.84
|
| Rate for Payer: Healthscope Whirlpool |
$597.36
|
| Rate for Payer: Mclaren Commercial |
$554.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$523.46
|
| Rate for Payer: Nomi Health Commercial |
$504.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$400.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$539.60
|
| Rate for Payer: Priority Health Narrow Network |
$431.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$541.94
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
OP
|
$8.28
|
|
|
Service Code
|
NDC 60687031211
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Aetna Medicare |
$4.14
|
| Rate for Payer: ASR ASR |
$8.03
|
| Rate for Payer: ASR Commercial |
$8.03
|
| Rate for Payer: BCBS Complete |
$3.31
|
| Rate for Payer: BCBS Trust/PPO |
$6.78
|
| Rate for Payer: BCN Commercial |
$6.42
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: Cofinity Commercial |
$7.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.62
|
| Rate for Payer: Healthscope Commercial |
$8.28
|
| Rate for Payer: Healthscope Whirlpool |
$8.03
|
| Rate for Payer: Mclaren Commercial |
$7.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.04
|
| Rate for Payer: Nomi Health Commercial |
$6.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.25
|
| Rate for Payer: Priority Health Narrow Network |
$5.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.29
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
IP
|
$177.66
|
|
|
Service Code
|
NDC 68180031909
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.48 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna Commercial |
$159.89
|
| Rate for Payer: ASR ASR |
$172.33
|
| Rate for Payer: ASR Commercial |
$172.33
|
| Rate for Payer: BCBS Trust/PPO |
$144.78
|
| Rate for Payer: BCN Commercial |
$137.74
|
| Rate for Payer: Cash Price |
$142.13
|
| Rate for Payer: Cofinity Commercial |
$167.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.13
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Healthscope Whirlpool |
$172.33
|
| Rate for Payer: Mclaren Commercial |
$159.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.01
|
| Rate for Payer: Nomi Health Commercial |
$145.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$156.34
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
OP
|
$177.66
|
|
|
Service Code
|
NDC 68180031909
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.06 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna Commercial |
$159.89
|
| Rate for Payer: Aetna Medicare |
$88.83
|
| Rate for Payer: ASR ASR |
$172.33
|
| Rate for Payer: ASR Commercial |
$172.33
|
| Rate for Payer: BCBS Complete |
$71.06
|
| Rate for Payer: BCBS Trust/PPO |
$145.49
|
| Rate for Payer: BCN Commercial |
$137.74
|
| Rate for Payer: Cash Price |
$142.13
|
| Rate for Payer: Cofinity Commercial |
$167.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.13
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Healthscope Whirlpool |
$172.33
|
| Rate for Payer: Mclaren Commercial |
$159.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.01
|
| Rate for Payer: Nomi Health Commercial |
$145.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$155.67
|
| Rate for Payer: Priority Health Narrow Network |
$124.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$156.34
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
IP
|
$251.68
|
|
|
Service Code
|
NDC 16729044315
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.59 |
| Max. Negotiated Rate |
$251.68 |
| Rate for Payer: Aetna Commercial |
$226.51
|
| Rate for Payer: ASR ASR |
$244.13
|
| Rate for Payer: ASR Commercial |
$244.13
|
| Rate for Payer: BCBS Trust/PPO |
$205.09
|
| 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 Commercial |
$213.93
|
| Rate for Payer: Nomi Health Commercial |
$206.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$221.48
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE
|
Facility
|
IP
|
$615.84
|
|
|
Service Code
|
NDC 00904708461
|
| Hospital Charge Code |
36775
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$400.30 |
| Max. Negotiated Rate |
$615.84 |
| Rate for Payer: Aetna Commercial |
$554.26
|
| Rate for Payer: ASR ASR |
$597.36
|
| Rate for Payer: ASR Commercial |
$597.36
|
| Rate for Payer: BCBS Trust/PPO |
$501.85
|
| Rate for Payer: BCN Commercial |
$477.46
|
| Rate for Payer: Cash Price |
$492.67
|
| Rate for Payer: Cofinity Commercial |
$578.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$492.67
|
| Rate for Payer: Healthscope Commercial |
$615.84
|
| Rate for Payer: Healthscope Whirlpool |
$597.36
|
| Rate for Payer: Mclaren Commercial |
$554.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$523.46
|
| Rate for Payer: Nomi Health Commercial |
$504.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$400.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$541.94
|
|
|
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 |
$331.20 |
| Max. Negotiated Rate |
$828.00 |
| Rate for Payer: Aetna Commercial |
$745.20
|
| Rate for Payer: Aetna Medicare |
$414.00
|
| Rate for Payer: ASR ASR |
$803.16
|
| Rate for Payer: ASR Commercial |
$803.16
|
| Rate for Payer: BCBS Complete |
$331.20
|
| Rate for Payer: BCBS Trust/PPO |
$678.05
|
| Rate for Payer: BCN Commercial |
$641.95
|
| 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 |
$828.00
|
| Rate for Payer: Healthscope Whirlpool |
$803.16
|
| 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: Priority Health Cigna Priority Health |
$538.20
|
| Rate for Payer: 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
|
|
|
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 |
$538.20 |
| Max. Negotiated Rate |
$828.00 |
| Rate for Payer: Aetna Commercial |
$745.20
|
| Rate for Payer: ASR ASR |
$803.16
|
| Rate for Payer: ASR Commercial |
$803.16
|
| Rate for Payer: BCBS Trust/PPO |
$674.74
|
| Rate for Payer: BCN Commercial |
$641.95
|
| 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 |
$828.00
|
| Rate for Payer: Healthscope Whirlpool |
$803.16
|
| 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: Priority Health Cigna Priority Health |
$538.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$728.64
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 51079098501
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna Commercial |
$2.27
|
| Rate for Payer: ASR ASR |
$2.44
|
| Rate for Payer: ASR Commercial |
$2.44
|
| Rate for Payer: BCBS Trust/PPO |
$2.05
|
| Rate for Payer: BCN Commercial |
$1.95
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.52
|
| Rate for Payer: Healthscope Whirlpool |
$2.44
|
| Rate for Payer: Mclaren Commercial |
$2.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.14
|
| Rate for Payer: Nomi Health Commercial |
$2.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.22
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 51079098520
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$251.45 |
| Rate for Payer: Aetna Commercial |
$226.30
|
| Rate for Payer: ASR ASR |
$243.91
|
| Rate for Payer: ASR Commercial |
$243.91
|
| Rate for Payer: BCBS Trust/PPO |
$204.91
|
| Rate for Payer: BCN Commercial |
$194.95
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$236.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$251.45
|
| Rate for Payer: Healthscope Whirlpool |
$243.91
|
| Rate for Payer: Mclaren Commercial |
$226.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: Nomi Health Commercial |
$206.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$221.28
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$209.15
|
|
|
Service Code
|
NDC 00904712261
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.66 |
| Max. Negotiated Rate |
$209.15 |
| Rate for Payer: Aetna Commercial |
$188.24
|
| Rate for Payer: Aetna Medicare |
$104.58
|
| Rate for Payer: ASR ASR |
$202.88
|
| Rate for Payer: ASR Commercial |
$202.88
|
| Rate for Payer: BCBS Complete |
$83.66
|
| Rate for Payer: BCBS Trust/PPO |
$171.27
|
| Rate for Payer: BCN Commercial |
$162.15
|
| Rate for Payer: Cash Price |
$167.32
|
| Rate for Payer: Cofinity Commercial |
$196.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.32
|
| Rate for Payer: Healthscope Commercial |
$209.15
|
| Rate for Payer: Healthscope Whirlpool |
$202.88
|
| Rate for Payer: Mclaren Commercial |
$188.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.78
|
| Rate for Payer: Nomi Health Commercial |
$171.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$183.26
|
| Rate for Payer: Priority Health Narrow Network |
$146.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$184.05
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
NDC 23155002301
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.10 |
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: ASR ASR |
$91.18
|
| Rate for Payer: ASR Commercial |
$91.18
|
| Rate for Payer: BCBS Trust/PPO |
$76.60
|
| Rate for Payer: BCN Commercial |
$72.88
|
| 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 |
$94.00
|
| Rate for Payer: Healthscope Whirlpool |
$91.18
|
| 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: Priority Health Cigna Priority Health |
$61.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$82.72
|
|
|
BUSPIRONE 5 MG TABLET
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
NDC 23155002301
|
| Hospital Charge Code |
9324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.60 |
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Medicare |
$47.00
|
| Rate for Payer: ASR ASR |
$91.18
|
| Rate for Payer: ASR Commercial |
$91.18
|
| Rate for Payer: BCBS Complete |
$37.60
|
| Rate for Payer: BCBS Trust/PPO |
$76.98
|
| Rate for Payer: BCN Commercial |
$72.88
|
| 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 |
$94.00
|
| Rate for Payer: Healthscope Whirlpool |
$91.18
|
| 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: Priority Health Cigna Priority Health |
$61.10
|
| Rate for Payer: 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
|
|
