|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
IP
|
$120.07
|
|
|
Service Code
|
NDC 24208-670-04
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.23 |
| Max. Negotiated Rate |
$108.06 |
| Rate for Payer: PHP Commercial |
$102.06
|
| Rate for Payer: Aetna Commercial |
$102.06
|
| Rate for Payer: BCBS Trust/PPO |
$92.79
|
| Rate for Payer: BCN Commercial |
$92.79
|
| Rate for Payer: Cash Price |
$96.06
|
| Rate for Payer: Cofinity Commercial |
$103.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.06
|
| Rate for Payer: Healthscope Commercial |
$108.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$102.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$104.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$73.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.66
|
| Rate for Payer: UHC Core |
$100.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.05
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$51.29
|
|
|
Service Code
|
NDC 0121-0853-20
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.28 |
| Max. Negotiated Rate |
$46.16 |
| Rate for Payer: Aetna Commercial |
$43.60
|
| Rate for Payer: BCBS Trust/PPO |
$39.64
|
| Rate for Payer: BCN Commercial |
$39.64
|
| Rate for Payer: Cash Price |
$41.03
|
| Rate for Payer: Cofinity Commercial |
$44.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.03
|
| Rate for Payer: Healthscope Commercial |
$46.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.60
|
| Rate for Payer: PHP Commercial |
$43.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$44.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$31.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.14
|
| Rate for Payer: UHC Core |
$42.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.47
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$13.84
|
|
|
Service Code
|
NDC 9900-0004-14
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$12.46 |
| Rate for Payer: Aetna Commercial |
$11.76
|
| Rate for Payer: BCBS Trust/PPO |
$10.70
|
| Rate for Payer: BCN Commercial |
$10.70
|
| Rate for Payer: Cash Price |
$11.07
|
| Rate for Payer: Cofinity Commercial |
$11.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.07
|
| Rate for Payer: Healthscope Commercial |
$12.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.76
|
| Rate for Payer: PHP Commercial |
$11.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.18
|
| Rate for Payer: UHC Core |
$11.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.38
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$148.76
|
|
|
Service Code
|
NDC 65862-496-47
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.73 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: BCBS Trust/PPO |
$114.96
|
| Rate for Payer: BCN Commercial |
$114.96
|
| Rate for Payer: Cash Price |
$119.01
|
| Rate for Payer: Cofinity Commercial |
$127.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.01
|
| Rate for Payer: Healthscope Commercial |
$133.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$126.45
|
| Rate for Payer: PHP Commercial |
$126.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$129.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$90.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.91
|
| Rate for Payer: UHC Core |
$124.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.57
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$51.29
|
|
|
Service Code
|
NDC 0121-0853-40
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.28 |
| Max. Negotiated Rate |
$46.16 |
| Rate for Payer: Aetna Commercial |
$43.60
|
| Rate for Payer: BCBS Trust/PPO |
$39.64
|
| Rate for Payer: BCN Commercial |
$39.64
|
| Rate for Payer: Cash Price |
$41.03
|
| Rate for Payer: Cofinity Commercial |
$44.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.03
|
| Rate for Payer: Healthscope Commercial |
$46.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.60
|
| Rate for Payer: PHP Commercial |
$43.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$44.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$31.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.14
|
| Rate for Payer: UHC Core |
$42.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.47
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
IP
|
$101.05
|
|
|
Service Code
|
NDC 53746-271-01
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.63 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: BCBS Trust/PPO |
$78.09
|
| Rate for Payer: BCN Commercial |
$78.09
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.89
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$87.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$61.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.92
|
| Rate for Payer: UHC Core |
$84.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
IP
|
$136.30
|
|
|
Service Code
|
NDC 53746-272-01
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.13 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: BCBS Trust/PPO |
$105.33
|
| Rate for Payer: BCN Commercial |
$105.33
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$118.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$83.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.94
|
| Rate for Payer: UHC Core |
$113.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
IP
|
$286.70
|
|
|
Service Code
|
NDC 0904-2725-61
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.86 |
| Max. Negotiated Rate |
$258.03 |
| Rate for Payer: Aetna Commercial |
$243.70
|
| Rate for Payer: BCBS Trust/PPO |
$221.56
|
| Rate for Payer: BCN Commercial |
$221.56
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.36
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$243.70
|
| Rate for Payer: PHP Commercial |
$243.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$249.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$174.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.30
|
| Rate for Payer: UHC Core |
$239.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.02
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
IP
|
$126.90
|
|
|
Service Code
|
NDC 65162-272-10
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.40 |
| Max. Negotiated Rate |
$114.21 |
| Rate for Payer: Aetna Commercial |
$107.86
|
| Rate for Payer: BCBS Trust/PPO |
$98.07
|
| Rate for Payer: BCN Commercial |
$98.07
|
| Rate for Payer: Cash Price |
$101.52
|
| Rate for Payer: Cofinity Commercial |
$109.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.52
|
| Rate for Payer: Healthscope Commercial |
$114.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.86
|
| Rate for Payer: PHP Commercial |
$107.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$110.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$111.67
|
| Rate for Payer: UHC Core |
$105.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.18
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
IP
|
$408.90
|
|
|
Service Code
|
NDC 0591-0796-01
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$249.39 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: BCBS Trust/PPO |
$316.00
|
| Rate for Payer: BCN Commercial |
$316.00
|
| Rate for Payer: Cash Price |
$327.12
|
| Rate for Payer: Cofinity Commercial |
$351.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.12
|
| Rate for Payer: Healthscope Commercial |
$368.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$306.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$347.56
|
| Rate for Payer: PHP Commercial |
$347.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$355.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$249.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$359.83
|
| Rate for Payer: UHC Core |
$341.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$306.68
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
IP
|
$753.12
|
|
|
Service Code
|
NDC 0013-0101-10
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$459.33 |
| Max. Negotiated Rate |
$677.81 |
| Rate for Payer: Aetna Commercial |
$640.15
|
| Rate for Payer: BCBS Trust/PPO |
$582.01
|
| Rate for Payer: BCN Commercial |
$582.01
|
| Rate for Payer: Cash Price |
$602.50
|
| Rate for Payer: Cofinity Commercial |
$647.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.50
|
| Rate for Payer: Healthscope Commercial |
$677.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$564.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$640.15
|
| Rate for Payer: PHP Commercial |
$640.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$527.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$655.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$459.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$662.75
|
| Rate for Payer: UHC Core |
$628.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$564.84
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
IP
|
$71.20
|
|
|
Service Code
|
NDC 62756-522-69
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: BCBS Trust/PPO |
$55.02
|
| Rate for Payer: BCN Commercial |
$55.02
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$43.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.66
|
| Rate for Payer: UHC Core |
$59.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
IP
|
$7.92
|
|
|
Service Code
|
NDC 63304-099-11
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.83 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: BCBS Trust/PPO |
$6.12
|
| Rate for Payer: BCN Commercial |
$6.12
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cofinity Commercial |
$6.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.34
|
| Rate for Payer: Healthscope Commercial |
$7.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.73
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.97
|
| Rate for Payer: UHC Core |
$6.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.94
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
IP
|
$21.65
|
|
|
Service Code
|
NDC 65862-148-36
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$19.48 |
| Rate for Payer: Aetna Commercial |
$18.40
|
| Rate for Payer: BCBS Trust/PPO |
$16.73
|
| Rate for Payer: BCN Commercial |
$16.73
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cofinity Commercial |
$18.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.32
|
| Rate for Payer: Healthscope Commercial |
$19.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.40
|
| Rate for Payer: PHP Commercial |
$18.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.05
|
| Rate for Payer: UHC Core |
$18.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.24
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
IP
|
$71.20
|
|
|
Service Code
|
NDC 63304-099-19
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: BCBS Trust/PPO |
$55.02
|
| Rate for Payer: BCN Commercial |
$55.02
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$43.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.66
|
| Rate for Payer: UHC Core |
$59.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
IP
|
$41.78
|
|
|
Service Code
|
NDC 0378-5630-59
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$37.60 |
| Rate for Payer: Aetna Commercial |
$35.51
|
| Rate for Payer: BCBS Trust/PPO |
$32.29
|
| Rate for Payer: BCN Commercial |
$32.29
|
| Rate for Payer: Cash Price |
$33.42
|
| Rate for Payer: Cofinity Commercial |
$35.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.42
|
| Rate for Payer: Healthscope Commercial |
$37.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.51
|
| Rate for Payer: PHP Commercial |
$35.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$36.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.77
|
| Rate for Payer: UHC Core |
$34.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.34
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
IP
|
$21.21
|
|
|
Service Code
|
NDC 65862-146-36
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$18.03
|
| Rate for Payer: BCBS Trust/PPO |
$16.39
|
| Rate for Payer: BCN Commercial |
$16.39
|
| Rate for Payer: Cash Price |
$16.97
|
| Rate for Payer: Cofinity Commercial |
$18.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.97
|
| Rate for Payer: Healthscope Commercial |
$19.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.03
|
| Rate for Payer: PHP Commercial |
$18.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.66
|
| Rate for Payer: UHC Core |
$17.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.91
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
IP
|
$71.20
|
|
|
Service Code
|
NDC 62756-520-69
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: BCBS Trust/PPO |
$55.02
|
| Rate for Payer: BCN Commercial |
$55.02
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$43.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.66
|
| Rate for Payer: UHC Core |
$59.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
IP
|
$222.84
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$135.91 |
| Max. Negotiated Rate |
$200.56 |
| Rate for Payer: Aetna Commercial |
$189.41
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna Commercial |
$22.42
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| Rate for Payer: BCBS Trust/PPO |
$21.01
|
| Rate for Payer: BCBS Trust/PPO |
$16.00
|
| Rate for Payer: BCBS Trust/PPO |
$172.21
|
| Rate for Payer: BCBS Trust/PPO |
$20.39
|
| Rate for Payer: BCN Commercial |
$20.39
|
| Rate for Payer: BCN Commercial |
$172.21
|
| Rate for Payer: BCN Commercial |
$16.00
|
| Rate for Payer: BCN Commercial |
$21.01
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$178.27
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$191.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$200.56
|
| Rate for Payer: Healthscope Commercial |
$23.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$189.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.42
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$22.42
|
| Rate for Payer: PHP Commercial |
$189.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$193.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$135.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$196.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.21
|
| Rate for Payer: UHC Core |
$22.03
|
| Rate for Payer: UHC Core |
$22.70
|
| Rate for Payer: UHC Core |
$186.07
|
| Rate for Payer: UHC Core |
$17.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.39
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS
|
Facility
OP
|
$1,933.98
|
|
|
Service Code
|
CPT 46270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,841.89 |
| Max. Negotiated Rate |
$1,933.98 |
| Rate for Payer: BCBS Complete |
$1,933.98
|
| Rate for Payer: Mclaren Medicaid |
$1,841.89
|
| Rate for Payer: Meridian Medicaid |
$1,933.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,841.89
|
|
|
SUTURE OF INFRAPATELLAR TENDON; PRIMARY
|
Facility
OP
|
$4,927.66
|
|
|
Service Code
|
CPT 27380
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,693.01 |
| Max. Negotiated Rate |
$4,927.66 |
| Rate for Payer: BCBS Complete |
$4,927.66
|
| Rate for Payer: Mclaren Medicaid |
$4,693.01
|
| Rate for Payer: Meridian Medicaid |
$4,927.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,693.01
|
|
|
TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE
|
Facility
IP
|
$495.84
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
12933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$302.41 |
| Max. Negotiated Rate |
$446.26 |
| Rate for Payer: Aetna Commercial |
$421.46
|
| Rate for Payer: Aetna Commercial |
$478.18
|
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: BCBS Trust/PPO |
$434.75
|
| Rate for Payer: BCBS Trust/PPO |
$345.06
|
| Rate for Payer: BCBS Trust/PPO |
$383.19
|
| Rate for Payer: BCN Commercial |
$434.75
|
| Rate for Payer: BCN Commercial |
$345.06
|
| Rate for Payer: BCN Commercial |
$383.19
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cash Price |
$450.05
|
| Rate for Payer: Cash Price |
$396.67
|
| Rate for Payer: Cofinity Commercial |
$426.42
|
| Rate for Payer: Cofinity Commercial |
$383.99
|
| Rate for Payer: Cofinity Commercial |
$483.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$450.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$396.67
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Healthscope Commercial |
$446.26
|
| Rate for Payer: Healthscope Commercial |
$506.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$421.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$334.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$371.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$421.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$379.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$478.18
|
| Rate for Payer: PHP Commercial |
$421.46
|
| Rate for Payer: PHP Commercial |
$478.18
|
| Rate for Payer: PHP Commercial |
$379.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$347.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$312.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$393.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$431.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$489.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$388.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$272.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$302.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$343.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$495.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$436.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$392.92
|
| Rate for Payer: UHC Core |
$414.03
|
| Rate for Payer: UHC Core |
$372.83
|
| Rate for Payer: UHC Core |
$469.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$334.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$421.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$371.88
|
|
|
TAMOXIFEN 10 MG TABLET
|
Facility
IP
|
$270.72
|
|
|
Service Code
|
NDC 0378-0144-91
|
| Hospital Charge Code |
7711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.11 |
| Max. Negotiated Rate |
$243.65 |
| Rate for Payer: Aetna Commercial |
$230.11
|
| Rate for Payer: BCBS Trust/PPO |
$209.21
|
| Rate for Payer: BCN Commercial |
$209.21
|
| Rate for Payer: Cash Price |
$216.58
|
| Rate for Payer: Cofinity Commercial |
$232.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.58
|
| Rate for Payer: Healthscope Commercial |
$243.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$230.11
|
| Rate for Payer: PHP Commercial |
$230.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$235.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$165.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$238.23
|
| Rate for Payer: UHC Core |
$226.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.04
|
|
|
TAMOXIFEN 10 MG TABLET
|
Facility
IP
|
$341.05
|
|
|
Service Code
|
NDC 63739-269-10
|
| Hospital Charge Code |
7711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.01 |
| Max. Negotiated Rate |
$306.94 |
| Rate for Payer: Aetna Commercial |
$289.89
|
| Rate for Payer: BCBS Trust/PPO |
$263.56
|
| Rate for Payer: BCN Commercial |
$263.56
|
| Rate for Payer: Cash Price |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$293.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.84
|
| Rate for Payer: Healthscope Commercial |
$306.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$289.89
|
| Rate for Payer: PHP Commercial |
$289.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$296.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$208.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$300.12
|
| Rate for Payer: UHC Core |
$284.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.79
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
IP
|
$2.33
|
|
|
Service Code
|
NDC 68084-299-11
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Aetna Commercial |
$1.98
|
| Rate for Payer: BCBS Trust/PPO |
$1.80
|
| Rate for Payer: BCN Commercial |
$1.80
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cofinity Commercial |
$2.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.86
|
| Rate for Payer: Healthscope Commercial |
$2.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.98
|
| Rate for Payer: PHP Commercial |
$1.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.05
|
| Rate for Payer: UHC Core |
$1.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.75
|
|
