BUPROPION HCL 150 MG TABLET,12 HR SUSTAINED-RELEASE(SMOKING DETERRENT) [214775]
|
Facility
|
IP
|
$0.43
|
|
Service Code
|
NDC 43598-863-60
|
Hospital Charge Code |
901700030
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.24 |
Max. Negotiated Rate |
$0.34 |
Rate for Payer: Cash Price |
$0.24
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
Rate for Payer: Multiplan Commercial |
$0.32
|
|
BUPROPION HCL 150 MG TABLET,12 HR SUSTAINED-RELEASE(SMOKING DETERRENT) [214775]
|
Facility
|
OP
|
$0.43
|
|
Service Code
|
NDC 43598-863-60
|
Hospital Charge Code |
901700030
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.24 |
Max. Negotiated Rate |
$0.34 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
Rate for Payer: Cash Price |
$0.24
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.34
|
Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
Rate for Payer: Multiplan Commercial |
$0.32
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
|
OP
|
$0.64
|
|
Service Code
|
NDC 60505-0158-1
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.35 |
Max. Negotiated Rate |
$0.51 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
Rate for Payer: Cash Price |
$0.35
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
Rate for Payer: Multiplan Commercial |
$0.48
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
|
IP
|
$0.34
|
|
Service Code
|
NDC 23155-191-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.19 |
Max. Negotiated Rate |
$0.27 |
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
Rate for Payer: Multiplan Commercial |
$0.26
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
|
OP
|
$0.04
|
|
Service Code
|
NDC 0904-7529-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.03 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
Rate for Payer: Cash Price |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
Rate for Payer: Multiplan Commercial |
$0.03
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
|
OP
|
$0.60
|
|
Service Code
|
NDC 68001-308-00
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.33 |
Max. Negotiated Rate |
$0.48 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.36
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.36
|
Rate for Payer: Cash Price |
$0.33
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.36
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
Rate for Payer: Multiplan Commercial |
$0.45
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
|
IP
|
$0.04
|
|
Service Code
|
NDC 0904-7529-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.03 |
Rate for Payer: Cash Price |
$0.02
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
Rate for Payer: Multiplan Commercial |
$0.03
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
|
OP
|
$0.34
|
|
Service Code
|
NDC 23155-191-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.19 |
Max. Negotiated Rate |
$0.27 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.27
|
Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
Rate for Payer: Multiplan Commercial |
$0.26
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
|
IP
|
$0.60
|
|
Service Code
|
NDC 68001-308-00
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.33 |
Max. Negotiated Rate |
$0.48 |
Rate for Payer: Cash Price |
$0.33
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.48
|
Rate for Payer: Health Smart Auto/Commercial |
$0.36
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
Rate for Payer: Multiplan Commercial |
$0.45
|
|
BUPROPION HCL 75 MG TABLET [9322]
|
Facility
|
IP
|
$0.64
|
|
Service Code
|
NDC 60505-0158-1
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.35 |
Max. Negotiated Rate |
$0.51 |
Rate for Payer: Cash Price |
$0.35
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.51
|
Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
Rate for Payer: Multiplan Commercial |
$0.48
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
|
OP
|
$0.19
|
|
Service Code
|
NDC 42806-410-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.15 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
Rate for Payer: Cash Price |
$0.10
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.14
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
|
OP
|
$0.96
|
|
Service Code
|
NDC 68084-697-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.53 |
Max. Negotiated Rate |
$0.77 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
Rate for Payer: Cash Price |
$0.53
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
Rate for Payer: Multiplan Commercial |
$0.72
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
|
IP
|
$0.96
|
|
Service Code
|
NDC 68084-697-11
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.53 |
Max. Negotiated Rate |
$0.77 |
Rate for Payer: Cash Price |
$0.53
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
Rate for Payer: Multiplan Commercial |
$0.72
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
|
IP
|
$0.96
|
|
Service Code
|
NDC 68084-697-01
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.53 |
Max. Negotiated Rate |
$0.77 |
Rate for Payer: Cash Price |
$0.53
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
Rate for Payer: Multiplan Commercial |
$0.72
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
|
OP
|
$0.30
|
|
Service Code
|
NDC 0591-3540-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.17 |
Max. Negotiated Rate |
$0.24 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.18
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.18
|
Rate for Payer: Cash Price |
$0.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.18
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
Rate for Payer: Multiplan Commercial |
$0.23
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
|
OP
|
$0.96
|
|
Service Code
|
NDC 68084-697-11
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.53 |
Max. Negotiated Rate |
$0.77 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
Rate for Payer: Cash Price |
$0.53
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.77
|
Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
Rate for Payer: Multiplan Commercial |
$0.72
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
|
IP
|
$0.30
|
|
Service Code
|
NDC 0591-3540-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.17 |
Max. Negotiated Rate |
$0.24 |
Rate for Payer: Cash Price |
$0.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
Rate for Payer: Multiplan Commercial |
$0.23
|
|
BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE [18385]
|
Facility
|
IP
|
$0.19
|
|
Service Code
|
NDC 42806-410-60
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.15 |
Rate for Payer: Cash Price |
$0.10
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.14
|
|
BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]
|
Facility
|
OP
|
$0.73
|
|
Service Code
|
NDC 68084-708-25
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.40 |
Max. Negotiated Rate |
$0.58 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
Rate for Payer: Cash Price |
$0.40
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
Rate for Payer: Multiplan Commercial |
$0.55
|
|
BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]
|
Facility
|
IP
|
$0.73
|
|
Service Code
|
NDC 68084-708-95
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.40 |
Max. Negotiated Rate |
$0.58 |
Rate for Payer: Cash Price |
$0.40
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
Rate for Payer: Multiplan Commercial |
$0.55
|
|
BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]
|
Facility
|
OP
|
$0.73
|
|
Service Code
|
NDC 68084-708-95
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.40 |
Max. Negotiated Rate |
$0.58 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.44
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.44
|
Rate for Payer: Cash Price |
$0.40
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.44
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
Rate for Payer: Multiplan Commercial |
$0.55
|
|
BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]
|
Facility
|
OP
|
$0.30
|
|
Service Code
|
NDC 43547-289-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.17 |
Max. Negotiated Rate |
$0.24 |
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.18
|
Rate for Payer: Aetna of CA Government/Medicare |
$0.18
|
Rate for Payer: Cash Price |
$0.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.18
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
Rate for Payer: Multiplan Commercial |
$0.23
|
|
BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]
|
Facility
|
IP
|
$0.30
|
|
Service Code
|
NDC 43547-289-10
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.17 |
Max. Negotiated Rate |
$0.24 |
Rate for Payer: Cash Price |
$0.16
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.24
|
Rate for Payer: Health Smart Auto/Commercial |
$0.18
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
Rate for Payer: Multiplan Commercial |
$0.23
|
|
BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]
|
Facility
|
IP
|
$0.32
|
|
Service Code
|
NDC 43547-289-50
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.18 |
Max. Negotiated Rate |
$0.26 |
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
Rate for Payer: Multiplan Commercial |
$0.24
|
|
BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE [18386]
|
Facility
|
IP
|
$0.73
|
|
Service Code
|
NDC 68084-708-25
|
Hospital Charge Code |
901700029
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.40 |
Max. Negotiated Rate |
$0.58 |
Rate for Payer: Cash Price |
$0.40
|
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
Rate for Payer: Health Smart Auto/Commercial |
$0.44
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
Rate for Payer: Multiplan Commercial |
$0.55
|
|