|
SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET
|
Facility
IP
|
$2,275.50
|
|
|
Service Code
|
NDC 0078-0777-20
|
| Hospital Charge Code |
174640
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,387.83 |
| Max. Negotiated Rate |
$2,047.95 |
| Rate for Payer: Aetna Commercial |
$1,934.18
|
| Rate for Payer: BCBS Trust/PPO |
$1,758.51
|
| Rate for Payer: BCN Commercial |
$1,758.51
|
| Rate for Payer: Cash Price |
$1,820.40
|
| Rate for Payer: Cofinity Commercial |
$1,956.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,820.40
|
| Rate for Payer: Healthscope Commercial |
$2,047.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,706.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,934.18
|
| Rate for Payer: PHP Commercial |
$1,934.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,592.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,979.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,387.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,002.44
|
| Rate for Payer: UHC Core |
$1,900.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,706.62
|
|
|
SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY
|
Facility
IP
|
$24.97
|
|
|
Service Code
|
NDC 4858200155
|
| Hospital Charge Code |
118454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.23 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: BCBS Trust/PPO |
$19.30
|
| Rate for Payer: BCN Commercial |
$19.30
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.97
|
| Rate for Payer: UHC Core |
$20.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.73
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
IP
|
$27.27
|
|
|
Service Code
|
NDC 50742-505-01
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$24.54 |
| Rate for Payer: Aetna Commercial |
$23.18
|
| Rate for Payer: BCBS Trust/PPO |
$21.07
|
| Rate for Payer: BCN Commercial |
$21.07
|
| Rate for Payer: Cash Price |
$21.82
|
| Rate for Payer: Cofinity Commercial |
$23.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.82
|
| Rate for Payer: Healthscope Commercial |
$24.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.18
|
| Rate for Payer: PHP Commercial |
$23.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.00
|
| Rate for Payer: UHC Core |
$22.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.45
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
IP
|
$43.81
|
|
|
Service Code
|
NDC 10019-553-90
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.72 |
| Max. Negotiated Rate |
$39.43 |
| Rate for Payer: Aetna Commercial |
$37.24
|
| Rate for Payer: BCBS Trust/PPO |
$33.86
|
| Rate for Payer: BCN Commercial |
$33.86
|
| Rate for Payer: Cash Price |
$35.05
|
| Rate for Payer: Cofinity Commercial |
$37.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.05
|
| Rate for Payer: Healthscope Commercial |
$39.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.24
|
| Rate for Payer: PHP Commercial |
$37.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.55
|
| Rate for Payer: UHC Core |
$36.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.86
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
IP
|
$222.45
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.67 |
| Max. Negotiated Rate |
$200.20 |
| Rate for Payer: BCBS Trust/PPO |
$171.91
|
| Rate for Payer: Aetna Commercial |
$189.08
|
| Rate for Payer: BCN Commercial |
$171.91
|
| Rate for Payer: Cash Price |
$177.96
|
| Rate for Payer: Cofinity Commercial |
$191.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.96
|
| Rate for Payer: Healthscope Commercial |
$200.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$189.08
|
| Rate for Payer: PHP Commercial |
$189.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$193.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$135.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$195.76
|
| Rate for Payer: UHC Core |
$185.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.84
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
IP
|
$63.25
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$56.92 |
| Rate for Payer: Aetna Commercial |
$53.76
|
| Rate for Payer: BCBS Trust/PPO |
$48.88
|
| Rate for Payer: BCN Commercial |
$48.88
|
| Rate for Payer: Cash Price |
$50.60
|
| Rate for Payer: Cofinity Commercial |
$54.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.60
|
| Rate for Payer: Healthscope Commercial |
$56.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.76
|
| Rate for Payer: PHP Commercial |
$53.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.66
|
| Rate for Payer: UHC Core |
$52.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.44
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH
|
Facility
IP
|
$237.14
|
|
|
Service Code
|
NDC 50742-505-10
|
| Hospital Charge Code |
27696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.63 |
| Max. Negotiated Rate |
$213.43 |
| Rate for Payer: Aetna Commercial |
$201.57
|
| Rate for Payer: BCBS Trust/PPO |
$183.26
|
| Rate for Payer: BCN Commercial |
$183.26
|
| Rate for Payer: Cash Price |
$189.71
|
| Rate for Payer: Cofinity Commercial |
$203.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.71
|
| Rate for Payer: Healthscope Commercial |
$213.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.57
|
| Rate for Payer: PHP Commercial |
$201.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$206.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$144.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$208.68
|
| Rate for Payer: UHC Core |
$198.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.86
|
|
|
SCREENING OF A PATIENT
|
Professional
|
$15.00
|
|
|
Service Code
|
HCPCS D0190
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$20.16 |
| Rate for Payer: Aetna Commercial |
$13.35
|
| Rate for Payer: BCBS Complete |
$20.16
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Mclaren Medicaid |
$19.20
|
| Rate for Payer: Meridian Medicaid |
$20.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.50
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET
|
Facility
IP
|
$189.00
|
|
|
Service Code
|
NDC 63739-432-10
|
| Hospital Charge Code |
24216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.27 |
| Max. Negotiated Rate |
$170.10 |
| Rate for Payer: Aetna Commercial |
$160.65
|
| Rate for Payer: BCBS Trust/PPO |
$146.06
|
| Rate for Payer: BCN Commercial |
$146.06
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cofinity Commercial |
$162.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.20
|
| Rate for Payer: Healthscope Commercial |
$170.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$160.65
|
| Rate for Payer: PHP Commercial |
$160.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$164.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$115.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$166.32
|
| Rate for Payer: UHC Core |
$157.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.75
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET
|
Facility
IP
|
$145.20
|
|
|
Service Code
|
NDC 60687-622-01
|
| Hospital Charge Code |
24216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.56 |
| Max. Negotiated Rate |
$130.68 |
| Rate for Payer: Aetna Commercial |
$123.42
|
| Rate for Payer: BCBS Trust/PPO |
$112.21
|
| Rate for Payer: BCN Commercial |
$112.21
|
| Rate for Payer: Cash Price |
$116.16
|
| Rate for Payer: Cofinity Commercial |
$124.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.16
|
| Rate for Payer: Healthscope Commercial |
$130.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$123.42
|
| Rate for Payer: PHP Commercial |
$123.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$126.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$88.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$127.78
|
| Rate for Payer: UHC Core |
$121.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.90
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET
|
Facility
IP
|
$88.20
|
|
|
Service Code
|
NDC 96295-13881
|
| Hospital Charge Code |
24216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.79 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: BCBS Trust/PPO |
$68.16
|
| Rate for Payer: BCN Commercial |
$68.16
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.97
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$76.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.62
|
| Rate for Payer: UHC Core |
$73.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET
|
Facility
IP
|
$1.46
|
|
|
Service Code
|
NDC 60687-622-11
|
| Hospital Charge Code |
24216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna Commercial |
$1.24
|
| Rate for Payer: BCBS Trust/PPO |
$1.13
|
| Rate for Payer: BCN Commercial |
$1.13
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cofinity Commercial |
$1.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.17
|
| Rate for Payer: Healthscope Commercial |
$1.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.24
|
| Rate for Payer: PHP Commercial |
$1.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.28
|
| Rate for Payer: UHC Core |
$1.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.10
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET
|
Facility
IP
|
$103.62
|
|
|
Service Code
|
NDC 60258-951-06
|
| Hospital Charge Code |
24216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.20 |
| Max. Negotiated Rate |
$93.26 |
| Rate for Payer: Aetna Commercial |
$88.08
|
| Rate for Payer: BCBS Trust/PPO |
$80.08
|
| Rate for Payer: BCN Commercial |
$80.08
|
| Rate for Payer: Cash Price |
$82.90
|
| Rate for Payer: Cofinity Commercial |
$89.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.90
|
| Rate for Payer: Healthscope Commercial |
$93.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$88.08
|
| Rate for Payer: PHP Commercial |
$88.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$90.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$91.19
|
| Rate for Payer: UHC Core |
$86.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.72
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
IP
|
$163.80
|
|
|
Service Code
|
NDC 51645-851-01
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.90 |
| Max. Negotiated Rate |
$147.42 |
| Rate for Payer: Aetna Commercial |
$139.23
|
| Rate for Payer: BCBS Trust/PPO |
$126.58
|
| Rate for Payer: BCN Commercial |
$126.58
|
| Rate for Payer: Cash Price |
$131.04
|
| Rate for Payer: Cofinity Commercial |
$140.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.04
|
| Rate for Payer: Healthscope Commercial |
$147.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.23
|
| Rate for Payer: PHP Commercial |
$139.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$142.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$144.14
|
| Rate for Payer: UHC Core |
$136.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.85
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
IP
|
$163.80
|
|
|
Service Code
|
NDC 3786400033
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.90 |
| Max. Negotiated Rate |
$147.42 |
| Rate for Payer: Aetna Commercial |
$139.23
|
| Rate for Payer: BCBS Trust/PPO |
$126.58
|
| Rate for Payer: BCN Commercial |
$126.58
|
| Rate for Payer: Cash Price |
$131.04
|
| Rate for Payer: Cofinity Commercial |
$140.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.04
|
| Rate for Payer: Healthscope Commercial |
$147.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.23
|
| Rate for Payer: PHP Commercial |
$139.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$142.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$144.14
|
| Rate for Payer: UHC Core |
$136.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.85
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
IP
|
$132.00
|
|
|
Service Code
|
NDC 0904-6522-61
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.51 |
| Max. Negotiated Rate |
$118.80 |
| Rate for Payer: Aetna Commercial |
$112.20
|
| Rate for Payer: BCBS Trust/PPO |
$102.01
|
| Rate for Payer: BCN Commercial |
$102.01
|
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Cofinity Commercial |
$113.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.60
|
| Rate for Payer: Healthscope Commercial |
$118.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.20
|
| Rate for Payer: PHP Commercial |
$112.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$114.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$80.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$116.16
|
| Rate for Payer: UHC Core |
$110.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.00
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
IP
|
$154.00
|
|
|
Service Code
|
NDC 70000-0447-2
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.92 |
| Max. Negotiated Rate |
$138.60 |
| Rate for Payer: Aetna Commercial |
$130.90
|
| Rate for Payer: BCBS Trust/PPO |
$119.01
|
| Rate for Payer: BCN Commercial |
$119.01
|
| Rate for Payer: Cash Price |
$123.20
|
| Rate for Payer: Cofinity Commercial |
$132.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.20
|
| Rate for Payer: Healthscope Commercial |
$138.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$115.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.90
|
| Rate for Payer: PHP Commercial |
$130.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$133.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$93.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$135.52
|
| Rate for Payer: UHC Core |
$128.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$115.50
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
IP
|
$140.00
|
|
|
Service Code
|
NDC 0904-7252-61
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.39 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna Commercial |
$119.00
|
| Rate for Payer: BCBS Trust/PPO |
$108.19
|
| Rate for Payer: BCN Commercial |
$108.19
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cofinity Commercial |
$120.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.00
|
| Rate for Payer: Healthscope Commercial |
$126.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.00
|
| Rate for Payer: PHP Commercial |
$119.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$121.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$85.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.20
|
| Rate for Payer: UHC Core |
$116.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.00
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
IP
|
$132.30
|
|
|
Service Code
|
NDC 0904-6725-59
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.69 |
| Max. Negotiated Rate |
$119.07 |
| Rate for Payer: Aetna Commercial |
$112.46
|
| Rate for Payer: BCBS Trust/PPO |
$102.24
|
| Rate for Payer: BCN Commercial |
$102.24
|
| Rate for Payer: Cash Price |
$105.84
|
| Rate for Payer: Cofinity Commercial |
$113.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.84
|
| Rate for Payer: Healthscope Commercial |
$119.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.46
|
| Rate for Payer: PHP Commercial |
$112.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$115.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$80.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$116.42
|
| Rate for Payer: UHC Core |
$110.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.22
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
IP
|
$149.10
|
|
|
Service Code
|
NDC 67618-300-10
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.94 |
| Max. Negotiated Rate |
$134.19 |
| Rate for Payer: Aetna Commercial |
$126.74
|
| Rate for Payer: BCBS Trust/PPO |
$115.22
|
| Rate for Payer: BCN Commercial |
$115.22
|
| Rate for Payer: Cash Price |
$119.28
|
| Rate for Payer: Cofinity Commercial |
$128.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.28
|
| Rate for Payer: Healthscope Commercial |
$134.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$126.74
|
| Rate for Payer: PHP Commercial |
$126.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$129.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$90.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$131.21
|
| Rate for Payer: UHC Core |
$124.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.82
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
IP
|
$195.05
|
|
|
Service Code
|
NDC 59762-4910-3
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.96 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: BCBS Trust/PPO |
$150.73
|
| Rate for Payer: BCN Commercial |
$150.73
|
| Rate for Payer: Cash Price |
$156.04
|
| 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: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$169.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$118.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.64
|
| Rate for Payer: UHC Core |
$162.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
IP
|
$3.18
|
|
|
Service Code
|
NDC 60687-253-11
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: BCBS Trust/PPO |
$2.46
|
| Rate for Payer: BCN Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cofinity Commercial |
$2.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.54
|
| Rate for Payer: Healthscope Commercial |
$2.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.70
|
| Rate for Payer: PHP Commercial |
$2.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.80
|
| Rate for Payer: UHC Core |
$2.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.38
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
IP
|
$312.55
|
|
|
Service Code
|
NDC 0904-6926-61
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.62 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$265.67
|
| Rate for Payer: BCBS Trust/PPO |
$241.54
|
| Rate for Payer: BCN Commercial |
$241.54
|
| Rate for Payer: Cash Price |
$250.04
|
| Rate for Payer: Cofinity Commercial |
$268.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.04
|
| Rate for Payer: Healthscope Commercial |
$281.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$265.67
|
| Rate for Payer: PHP Commercial |
$265.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$271.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$190.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$275.04
|
| Rate for Payer: UHC Core |
$260.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.41
|
|
|
SERTRALINE 100 MG TABLET
|
Facility
IP
|
$317.30
|
|
|
Service Code
|
NDC 60687-253-01
|
| Hospital Charge Code |
11350
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.52 |
| Max. Negotiated Rate |
$285.57 |
| Rate for Payer: Aetna Commercial |
$269.70
|
| Rate for Payer: BCBS Trust/PPO |
$245.21
|
| Rate for Payer: BCN Commercial |
$245.21
|
| Rate for Payer: Cash Price |
$253.84
|
| Rate for Payer: Cofinity Commercial |
$272.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.84
|
| Rate for Payer: Healthscope Commercial |
$285.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$269.70
|
| Rate for Payer: PHP Commercial |
$269.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$222.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$276.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$193.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$279.22
|
| Rate for Payer: UHC Core |
$264.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.98
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE
|
Facility
IP
|
$249.70
|
|
|
Service Code
|
NDC 59762-0067-1
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.29 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna Commercial |
$212.24
|
| Rate for Payer: BCBS Trust/PPO |
$192.97
|
| Rate for Payer: BCN Commercial |
$192.97
|
| Rate for Payer: Cash Price |
$199.76
|
| Rate for Payer: Cofinity Commercial |
$214.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.76
|
| Rate for Payer: Healthscope Commercial |
$224.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.24
|
| Rate for Payer: PHP Commercial |
$212.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$217.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$152.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$219.74
|
| Rate for Payer: UHC Core |
$208.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.28
|
|
