|
SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT
|
Facility
|
OP
|
$10,683.35
|
|
|
Service Code
|
CPT 30520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,727.75 |
| Max. Negotiated Rate |
$10,683.35 |
| Rate for Payer: Aetna Medicare |
$3,435.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,129.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,129.43
|
| Rate for Payer: BCBS Complete |
$1,814.30
|
| Rate for Payer: BCBS MAPPO |
$3,303.54
|
| Rate for Payer: BCBS Trust/PPO |
$2,426.08
|
| Rate for Payer: BCN Commercial |
$2,426.08
|
| Rate for Payer: BCN Medicare Advantage |
$3,303.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,303.54
|
| Rate for Payer: Mclaren Medicaid |
$1,727.75
|
| Rate for Payer: Mclaren Medicare |
$3,303.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,468.72
|
| Rate for Payer: Meridian Medicaid |
$3,468.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,799.07
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,633.89
|
| Rate for Payer: Nomi Health Commercial |
$9,910.62
|
| Rate for Payer: PACE Medicare |
$3,138.36
|
| Rate for Payer: PACE SWMI |
$3,303.54
|
| Rate for Payer: PHP Medicare Advantage |
$3,303.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,727.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,683.35
|
| Rate for Payer: Priority Health Medicare |
$3,303.54
|
| Rate for Payer: Priority Health Tiered Network |
$8,546.68
|
| Rate for Payer: Railroad Medicare Medicare |
$3,303.54
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,303.54
|
| Rate for Payer: UHC Medicaid |
$1,727.75
|
| Rate for Payer: UHCCP Medicaid |
$1,727.75
|
| Rate for Payer: VA VA |
$3,303.54
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
|
IP
|
$3.52
|
|
|
Service Code
|
NDC 60687025311
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna Commercial |
$2.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.29
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cofinity Advantage |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$3.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.82
|
| Rate for Payer: Healthscope Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.64
|
| Rate for Payer: PHP Commercial |
$2.99
|
| Rate for Payer: Priority Health SBD |
$2.22
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
NDC 59762491003
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.65 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna Medicare |
$97.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: BCBS Complete |
$78.02
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Advantage |
$136.53
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.78
|
| Rate for Payer: UHC Core |
$101.62
|
| Rate for Payer: UHC Exchange |
$76.65
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
|
OP
|
$3.52
|
|
|
Service Code
|
NDC 60687025311
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna Commercial |
$2.99
|
| Rate for Payer: Aetna Medicare |
$1.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.29
|
| Rate for Payer: BCBS Complete |
$1.41
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cofinity Advantage |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$3.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.82
|
| Rate for Payer: Healthscope Commercial |
$3.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.64
|
| Rate for Payer: PHP Commercial |
$2.99
|
| Rate for Payer: Priority Health SBD |
$2.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.29
|
| Rate for Payer: UHC Core |
$1.83
|
| Rate for Payer: UHC Exchange |
$1.38
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
|
OP
|
$88.83
|
|
|
Service Code
|
NDC 68180035309
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.91 |
| Max. Negotiated Rate |
$79.95 |
| Rate for Payer: Aetna Commercial |
$75.51
|
| Rate for Payer: Aetna Medicare |
$44.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.74
|
| Rate for Payer: BCBS Complete |
$35.53
|
| Rate for Payer: Cash Price |
$71.06
|
| Rate for Payer: Cofinity Advantage |
$62.18
|
| Rate for Payer: Cofinity Commercial |
$76.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.06
|
| Rate for Payer: Healthscope Commercial |
$79.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.62
|
| Rate for Payer: PHP Commercial |
$75.51
|
| Rate for Payer: Priority Health SBD |
$55.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.74
|
| Rate for Payer: UHC Core |
$46.28
|
| Rate for Payer: UHC Exchange |
$34.91
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
|
OP
|
$351.50
|
|
|
Service Code
|
NDC 60687025301
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.14 |
| Max. Negotiated Rate |
$316.35 |
| Rate for Payer: Aetna Commercial |
$298.77
|
| Rate for Payer: Aetna Medicare |
$175.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$228.47
|
| Rate for Payer: BCBS Complete |
$140.60
|
| Rate for Payer: Cash Price |
$281.20
|
| Rate for Payer: Cofinity Advantage |
$246.05
|
| Rate for Payer: Cofinity Commercial |
$302.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$281.20
|
| Rate for Payer: Healthscope Commercial |
$316.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$281.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$298.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$263.62
|
| Rate for Payer: PHP Commercial |
$298.77
|
| Rate for Payer: Priority Health SBD |
$221.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$228.47
|
| Rate for Payer: UHC Core |
$183.13
|
| Rate for Payer: UHC Exchange |
$138.14
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
|
IP
|
$351.50
|
|
|
Service Code
|
NDC 60687025301
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$221.44 |
| Max. Negotiated Rate |
$316.35 |
| Rate for Payer: Aetna Commercial |
$298.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$228.47
|
| Rate for Payer: Cash Price |
$281.20
|
| Rate for Payer: Cofinity Advantage |
$246.05
|
| Rate for Payer: Cofinity Commercial |
$302.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$281.20
|
| Rate for Payer: Healthscope Commercial |
$316.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$298.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$263.62
|
| Rate for Payer: PHP Commercial |
$298.77
|
| Rate for Payer: Priority Health SBD |
$221.44
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 59762491003
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.88 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Advantage |
$136.53
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health SBD |
$122.88
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
|
IP
|
$88.83
|
|
|
Service Code
|
NDC 68180035309
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.96 |
| Max. Negotiated Rate |
$79.95 |
| Rate for Payer: Aetna Commercial |
$75.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.74
|
| Rate for Payer: Cash Price |
$71.06
|
| Rate for Payer: Cofinity Advantage |
$62.18
|
| Rate for Payer: Cofinity Commercial |
$76.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.06
|
| Rate for Payer: Healthscope Commercial |
$79.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.62
|
| Rate for Payer: PHP Commercial |
$75.51
|
| Rate for Payer: Priority Health SBD |
$55.96
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 51079014901
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Aetna Medicare |
$2.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.96
|
| Rate for Payer: BCBS Complete |
$1.82
|
| Rate for Payer: Cash Price |
$3.65
|
| Rate for Payer: Cofinity Advantage |
$3.19
|
| Rate for Payer: Cofinity Commercial |
$3.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.65
|
| Rate for Payer: Healthscope Commercial |
$4.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.42
|
| Rate for Payer: PHP Commercial |
$3.88
|
| Rate for Payer: Priority Health SBD |
$2.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.96
|
| Rate for Payer: UHC Core |
$2.38
|
| Rate for Payer: UHC Exchange |
$1.79
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$455.90
|
|
|
Service Code
|
NDC 51079014920
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.17 |
| Max. Negotiated Rate |
$410.31 |
| Rate for Payer: Aetna Commercial |
$387.51
|
| Rate for Payer: Aetna Medicare |
$227.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.33
|
| Rate for Payer: BCBS Complete |
$182.36
|
| Rate for Payer: Cash Price |
$364.72
|
| Rate for Payer: Cofinity Advantage |
$319.13
|
| Rate for Payer: Cofinity Commercial |
$392.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.72
|
| Rate for Payer: Healthscope Commercial |
$410.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$364.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$341.93
|
| Rate for Payer: PHP Commercial |
$387.51
|
| Rate for Payer: Priority Health SBD |
$287.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$296.33
|
| Rate for Payer: UHC Core |
$237.52
|
| Rate for Payer: UHC Exchange |
$179.17
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$59.22
|
|
|
Service Code
|
NDC 68180035109
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$53.30 |
| Rate for Payer: Aetna Commercial |
$50.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.49
|
| Rate for Payer: Cash Price |
$47.38
|
| Rate for Payer: Cofinity Advantage |
$41.45
|
| Rate for Payer: Cofinity Commercial |
$50.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.38
|
| Rate for Payer: Healthscope Commercial |
$53.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.41
|
| Rate for Payer: PHP Commercial |
$50.34
|
| Rate for Payer: Priority Health SBD |
$37.31
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$271.70
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.78 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna Medicare |
$135.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: BCBS Complete |
$108.68
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$217.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.60
|
| Rate for Payer: UHC Core |
$141.56
|
| Rate for Payer: UHC Exchange |
$106.78
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$455.90
|
|
|
Service Code
|
NDC 51079014920
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.22 |
| Max. Negotiated Rate |
$410.31 |
| Rate for Payer: Aetna Commercial |
$387.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.33
|
| Rate for Payer: Cash Price |
$364.72
|
| Rate for Payer: Cofinity Advantage |
$319.13
|
| Rate for Payer: Cofinity Commercial |
$392.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.72
|
| Rate for Payer: Healthscope Commercial |
$410.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$341.93
|
| Rate for Payer: PHP Commercial |
$387.51
|
| Rate for Payer: Priority Health SBD |
$287.22
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$271.70
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.17 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$59.22
|
|
|
Service Code
|
NDC 68180035109
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.27 |
| Max. Negotiated Rate |
$53.30 |
| Rate for Payer: Aetna Commercial |
$50.34
|
| Rate for Payer: Aetna Medicare |
$29.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.49
|
| Rate for Payer: BCBS Complete |
$23.69
|
| Rate for Payer: Cash Price |
$47.38
|
| Rate for Payer: Cofinity Advantage |
$41.45
|
| Rate for Payer: Cofinity Commercial |
$50.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.38
|
| Rate for Payer: Healthscope Commercial |
$53.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.41
|
| Rate for Payer: PHP Commercial |
$50.34
|
| Rate for Payer: Priority Health SBD |
$37.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.49
|
| Rate for Payer: UHC Core |
$30.85
|
| Rate for Payer: UHC Exchange |
$23.27
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$2.72
|
|
|
Service Code
|
NDC 60687023111
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: Aetna Medicare |
$1.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: BCBS Complete |
$1.09
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Advantage |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.04
|
| Rate for Payer: PHP Commercial |
$2.31
|
| Rate for Payer: Priority Health SBD |
$1.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.77
|
| Rate for Payer: UHC Core |
$1.42
|
| Rate for Payer: UHC Exchange |
$1.07
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 51079014901
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.96
|
| Rate for Payer: Cash Price |
$3.65
|
| Rate for Payer: Cofinity Advantage |
$3.19
|
| Rate for Payer: Cofinity Commercial |
$3.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.65
|
| Rate for Payer: Healthscope Commercial |
$4.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.42
|
| Rate for Payer: PHP Commercial |
$3.88
|
| Rate for Payer: Priority Health SBD |
$2.87
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$2.72
|
|
|
Service Code
|
NDC 60687023111
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Advantage |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.04
|
| Rate for Payer: PHP Commercial |
$2.31
|
| Rate for Payer: Priority Health SBD |
$1.71
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$306.85
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.32 |
| Max. Negotiated Rate |
$276.17 |
| Rate for Payer: Aetna Commercial |
$260.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.45
|
| Rate for Payer: Cash Price |
$245.48
|
| Rate for Payer: Cofinity Advantage |
$214.79
|
| Rate for Payer: Cofinity Commercial |
$263.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.48
|
| Rate for Payer: Healthscope Commercial |
$276.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.14
|
| Rate for Payer: PHP Commercial |
$260.82
|
| Rate for Payer: Priority Health SBD |
$193.32
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$3.07
|
|
|
Service Code
|
NDC 60687024211
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.00
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cofinity Advantage |
$2.15
|
| Rate for Payer: Cofinity Commercial |
$2.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.46
|
| Rate for Payer: Healthscope Commercial |
$2.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.30
|
| Rate for Payer: PHP Commercial |
$2.61
|
| Rate for Payer: Priority Health SBD |
$1.93
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$306.85
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.59 |
| Max. Negotiated Rate |
$276.17 |
| Rate for Payer: Aetna Commercial |
$260.82
|
| Rate for Payer: Aetna Medicare |
$153.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.45
|
| Rate for Payer: BCBS Complete |
$122.74
|
| Rate for Payer: Cash Price |
$245.48
|
| Rate for Payer: Cofinity Advantage |
$214.79
|
| Rate for Payer: Cofinity Commercial |
$263.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.48
|
| Rate for Payer: Healthscope Commercial |
$276.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$245.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.14
|
| Rate for Payer: PHP Commercial |
$260.82
|
| Rate for Payer: Priority Health SBD |
$193.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$199.45
|
| Rate for Payer: UHC Core |
$159.87
|
| Rate for Payer: UHC Exchange |
$120.59
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$3.07
|
|
|
Service Code
|
NDC 60687024211
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.61
|
| Rate for Payer: Aetna Medicare |
$1.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.00
|
| Rate for Payer: BCBS Complete |
$1.23
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cofinity Advantage |
$2.15
|
| Rate for Payer: Cofinity Commercial |
$2.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.46
|
| Rate for Payer: Healthscope Commercial |
$2.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.30
|
| Rate for Payer: PHP Commercial |
$2.61
|
| Rate for Payer: Priority Health SBD |
$1.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.00
|
| Rate for Payer: UHC Core |
$1.60
|
| Rate for Payer: UHC Exchange |
$1.21
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.13 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.64
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Advantage |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$194.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.20
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health SBD |
$142.13
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$279.30
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.96 |
| Max. Negotiated Rate |
$251.37 |
| Rate for Payer: Aetna Commercial |
$237.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.54
|
| Rate for Payer: Cash Price |
$223.44
|
| Rate for Payer: Cofinity Advantage |
$195.51
|
| Rate for Payer: Cofinity Commercial |
$240.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.44
|
| Rate for Payer: Healthscope Commercial |
$251.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$209.47
|
| Rate for Payer: PHP Commercial |
$237.41
|
| Rate for Payer: Priority Health SBD |
$175.96
|
|
