|
SERTRALINE 20 MG/ML ORAL CONCENTRATE
|
Facility
IP
|
$9.76
|
|
|
Service Code
|
NDC 9900-0003-50
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$8.78 |
| Rate for Payer: Aetna Commercial |
$8.30
|
| Rate for Payer: BCBS Trust/PPO |
$7.54
|
| Rate for Payer: BCN Commercial |
$7.54
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Cofinity Commercial |
$8.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.81
|
| Rate for Payer: Healthscope Commercial |
$8.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.30
|
| Rate for Payer: PHP Commercial |
$8.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.59
|
| Rate for Payer: UHC Core |
$8.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.32
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
IP
|
$242.25
|
|
|
Service Code
|
NDC 60687-231-01
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.75 |
| Max. Negotiated Rate |
$218.02 |
| Rate for Payer: Aetna Commercial |
$205.91
|
| Rate for Payer: BCBS Trust/PPO |
$187.21
|
| Rate for Payer: BCN Commercial |
$187.21
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cofinity Commercial |
$208.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.80
|
| Rate for Payer: Healthscope Commercial |
$218.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$205.91
|
| Rate for Payer: PHP Commercial |
$205.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$210.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$147.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.18
|
| Rate for Payer: UHC Core |
$202.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.69
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
IP
|
$2.43
|
|
|
Service Code
|
NDC 60687-231-11
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$2.07
|
| Rate for Payer: BCBS Trust/PPO |
$1.88
|
| Rate for Payer: BCN Commercial |
$1.88
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$2.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.94
|
| Rate for Payer: Healthscope Commercial |
$2.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.07
|
| Rate for Payer: PHP Commercial |
$2.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.14
|
| Rate for Payer: UHC Core |
$2.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.82
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
IP
|
$236.55
|
|
|
Service Code
|
NDC 0904-6924-61
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.27 |
| Max. Negotiated Rate |
$212.90 |
| Rate for Payer: Aetna Commercial |
$201.07
|
| Rate for Payer: BCBS Trust/PPO |
$182.81
|
| Rate for Payer: BCN Commercial |
$182.81
|
| Rate for Payer: Cash Price |
$189.24
|
| Rate for Payer: Cofinity Commercial |
$203.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.24
|
| Rate for Payer: Healthscope Commercial |
$212.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.07
|
| Rate for Payer: PHP Commercial |
$201.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$205.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$144.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$208.16
|
| Rate for Payer: UHC Core |
$197.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.41
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$69.80
|
|
|
Service Code
|
NDC 68180-352-09
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.57 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: BCBS Trust/PPO |
$53.94
|
| Rate for Payer: BCN Commercial |
$53.94
|
| Rate for Payer: Cash Price |
$55.84
|
| Rate for Payer: Cofinity Commercial |
$60.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$62.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.33
|
| Rate for Payer: PHP Commercial |
$59.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$60.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.42
|
| Rate for Payer: UHC Core |
$58.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.35
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$2.87
|
|
|
Service Code
|
NDC 60687-242-11
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna Commercial |
$2.44
|
| Rate for Payer: BCBS Trust/PPO |
$2.22
|
| Rate for Payer: BCN Commercial |
$2.22
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cofinity Commercial |
$2.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.30
|
| Rate for Payer: Healthscope Commercial |
$2.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.44
|
| Rate for Payer: PHP Commercial |
$2.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.53
|
| Rate for Payer: UHC Core |
$2.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.15
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$271.70
|
|
|
Service Code
|
NDC 0904-6925-61
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.71 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: BCBS Trust/PPO |
$209.97
|
| Rate for Payer: BCN Commercial |
$209.97
|
| Rate for Payer: Cash Price |
$217.36
|
| 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: Lakeland Regional Health Systems Commercial |
$203.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$230.94
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$236.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$165.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$239.10
|
| Rate for Payer: UHC Core |
$226.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.78
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$286.90
|
|
|
Service Code
|
NDC 60687-242-01
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.98 |
| Max. Negotiated Rate |
$258.21 |
| Rate for Payer: Aetna Commercial |
$243.86
|
| Rate for Payer: BCBS Trust/PPO |
$221.72
|
| Rate for Payer: BCN Commercial |
$221.72
|
| Rate for Payer: Cash Price |
$229.52
|
| Rate for Payer: Cofinity Commercial |
$246.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.52
|
| Rate for Payer: Healthscope Commercial |
$258.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$243.86
|
| Rate for Payer: PHP Commercial |
$243.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$249.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$174.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.47
|
| Rate for Payer: UHC Core |
$239.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.18
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$225.60
|
|
|
Service Code
|
NDC 59762-4900-3
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.59 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: BCBS Trust/PPO |
$174.34
|
| Rate for Payer: BCN Commercial |
$174.34
|
| Rate for Payer: Cash Price |
$180.48
|
| 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: Lakeland Regional Health Systems Commercial |
$169.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.76
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$196.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$137.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.53
|
| Rate for Payer: UHC Core |
$188.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.20
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$188.00
|
|
|
Service Code
|
NDC 65862-012-01
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: BCBS Trust/PPO |
$145.29
|
| Rate for Payer: BCN Commercial |
$145.29
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cofinity Commercial |
$161.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.40
|
| Rate for Payer: Healthscope Commercial |
$169.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$159.80
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$163.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$114.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$165.44
|
| Rate for Payer: UHC Core |
$156.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.00
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
IP
|
$214.38
|
|
|
Service Code
|
NDC 0074-4456-04
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.75 |
| Max. Negotiated Rate |
$192.94 |
| Rate for Payer: Aetna Commercial |
$182.22
|
| Rate for Payer: BCBS Trust/PPO |
$165.67
|
| Rate for Payer: BCN Commercial |
$165.67
|
| Rate for Payer: Cash Price |
$171.50
|
| Rate for Payer: Cofinity Commercial |
$184.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.50
|
| Rate for Payer: Healthscope Commercial |
$192.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$182.22
|
| Rate for Payer: PHP Commercial |
$182.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$186.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.65
|
| Rate for Payer: UHC Core |
$179.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.78
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
IP
|
$211.75
|
|
|
Service Code
|
NDC 66794-015-25
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.15 |
| Max. Negotiated Rate |
$190.58 |
| Rate for Payer: Aetna Commercial |
$179.99
|
| Rate for Payer: BCBS Trust/PPO |
$163.64
|
| Rate for Payer: BCN Commercial |
$163.64
|
| Rate for Payer: Cash Price |
$169.40
|
| Rate for Payer: Cofinity Commercial |
$182.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.40
|
| Rate for Payer: Healthscope Commercial |
$190.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.99
|
| Rate for Payer: PHP Commercial |
$179.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$184.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$129.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$186.34
|
| Rate for Payer: UHC Core |
$176.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.81
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
IP
|
$223.13
|
|
|
Service Code
|
NDC 10019-651-64
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.09 |
| Max. Negotiated Rate |
$200.82 |
| Rate for Payer: Aetna Commercial |
$189.66
|
| Rate for Payer: BCBS Trust/PPO |
$172.43
|
| Rate for Payer: BCN Commercial |
$172.43
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Cofinity Commercial |
$191.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.50
|
| Rate for Payer: Healthscope Commercial |
$200.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$189.66
|
| Rate for Payer: PHP Commercial |
$189.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$194.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$136.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$196.35
|
| Rate for Payer: UHC Core |
$186.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.35
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
IP
|
$211.75
|
|
|
Service Code
|
NDC 66794-022-25
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.15 |
| Max. Negotiated Rate |
$190.58 |
| Rate for Payer: Aetna Commercial |
$179.99
|
| Rate for Payer: BCBS Trust/PPO |
$163.64
|
| Rate for Payer: BCN Commercial |
$163.64
|
| Rate for Payer: Cash Price |
$169.40
|
| Rate for Payer: Cofinity Commercial |
$182.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.40
|
| Rate for Payer: Healthscope Commercial |
$190.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.99
|
| Rate for Payer: PHP Commercial |
$179.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$184.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$129.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$186.34
|
| Rate for Payer: UHC Core |
$176.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.81
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
IP
|
$214.38
|
|
|
Service Code
|
NDC 0074-4456-51
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.75 |
| Max. Negotiated Rate |
$192.94 |
| Rate for Payer: Aetna Commercial |
$182.22
|
| Rate for Payer: BCBS Trust/PPO |
$165.67
|
| Rate for Payer: BCN Commercial |
$165.67
|
| Rate for Payer: Cash Price |
$171.50
|
| Rate for Payer: Cofinity Commercial |
$184.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.50
|
| Rate for Payer: Healthscope Commercial |
$192.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$182.22
|
| Rate for Payer: PHP Commercial |
$182.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$186.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.65
|
| Rate for Payer: UHC Core |
$179.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.78
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
|
Facility
OP
|
$629.53
|
|
|
Service Code
|
CPT 45330
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$599.55 |
| Max. Negotiated Rate |
$629.53 |
| Rate for Payer: BCBS Complete |
$629.53
|
| Rate for Payer: Mclaren Medicaid |
$599.55
|
| Rate for Payer: Meridian Medicaid |
$629.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$599.55
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE
|
Facility
OP
|
$629.53
|
|
|
Service Code
|
CPT 45331
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$599.55 |
| Max. Negotiated Rate |
$629.53 |
| Rate for Payer: BCBS Complete |
$629.53
|
| Rate for Payer: Mclaren Medicaid |
$599.55
|
| Rate for Payer: Meridian Medicaid |
$629.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$599.55
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE
|
Facility
OP
|
$812.82
|
|
|
Service Code
|
CPT 45338
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$774.12 |
| Max. Negotiated Rate |
$812.82 |
| Rate for Payer: BCBS Complete |
$812.82
|
| Rate for Payer: Mclaren Medicaid |
$774.12
|
| Rate for Payer: Meridian Medicaid |
$812.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$774.12
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
IP
|
$5.16
|
|
|
Service Code
|
NDC 9900-0009-76
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: BCBS Trust/PPO |
$3.99
|
| Rate for Payer: BCN Commercial |
$3.99
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$4.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$4.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.39
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.54
|
| Rate for Payer: UHC Core |
$4.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.87
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
IP
|
$78.05
|
|
|
Service Code
|
NDC 12165-100-03
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$70.24 |
| Rate for Payer: Aetna Commercial |
$66.34
|
| Rate for Payer: BCBS Trust/PPO |
$60.32
|
| Rate for Payer: BCN Commercial |
$60.32
|
| Rate for Payer: Cash Price |
$62.44
|
| Rate for Payer: Cofinity Commercial |
$67.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.44
|
| Rate for Payer: Healthscope Commercial |
$70.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.34
|
| Rate for Payer: PHP Commercial |
$66.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.68
|
| Rate for Payer: UHC Core |
$65.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.54
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
IP
|
$17.55
|
|
|
Service Code
|
NDC 67877-124-50
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.70 |
| Max. Negotiated Rate |
$15.80 |
| Rate for Payer: Aetna Commercial |
$14.92
|
| Rate for Payer: BCBS Trust/PPO |
$13.56
|
| Rate for Payer: BCN Commercial |
$13.56
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cofinity Commercial |
$15.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.04
|
| Rate for Payer: Healthscope Commercial |
$15.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.92
|
| Rate for Payer: PHP Commercial |
$14.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.44
|
| Rate for Payer: UHC Core |
$14.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.16
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
IP
|
$67.20
|
|
|
Service Code
|
NDC 67877-124-40
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.99 |
| Max. Negotiated Rate |
$60.48 |
| Rate for Payer: Aetna Commercial |
$57.12
|
| Rate for Payer: BCBS Trust/PPO |
$51.93
|
| Rate for Payer: BCN Commercial |
$51.93
|
| Rate for Payer: Cash Price |
$53.76
|
| Rate for Payer: Cofinity Commercial |
$57.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.76
|
| Rate for Payer: Healthscope Commercial |
$60.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.12
|
| Rate for Payer: PHP Commercial |
$57.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$58.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$40.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.14
|
| Rate for Payer: UHC Core |
$56.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.40
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
IP
|
$19.58
|
|
|
Service Code
|
NDC 67877-124-05
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$17.62 |
| Rate for Payer: Aetna Commercial |
$16.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.13
|
| Rate for Payer: BCN Commercial |
$15.13
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.64
|
| Rate for Payer: PHP Commercial |
$16.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.23
|
| Rate for Payer: UHC Core |
$16.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.68
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
IP
|
$1.78
|
|
|
Service Code
|
NDC 9900-0003-51
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: BCBS Trust/PPO |
$1.38
|
| Rate for Payer: BCN Commercial |
$1.38
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cofinity Commercial |
$1.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.42
|
| Rate for Payer: Healthscope Commercial |
$1.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.51
|
| Rate for Payer: PHP Commercial |
$1.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.57
|
| Rate for Payer: UHC Core |
$1.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.34
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
IP
|
$0.97
|
|
|
Service Code
|
NDC 9900-0009-26
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna Commercial |
$0.82
|
| Rate for Payer: BCBS Trust/PPO |
$0.75
|
| Rate for Payer: BCN Commercial |
$0.75
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cofinity Commercial |
$0.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.78
|
| Rate for Payer: Healthscope Commercial |
$0.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.82
|
| Rate for Payer: PHP Commercial |
$0.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.85
|
| Rate for Payer: UHC Core |
$0.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.73
|
|
