|
SERTRALINE 20 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$249.70
|
|
|
Service Code
|
NDC 59762006701
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.30 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna Commercial |
$212.24
|
| Rate for Payer: BCBS Trust/PPO |
$203.83
|
| 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 Commercial |
$212.24
|
| Rate for Payer: Nomi Health Commercial |
$204.75
|
| Rate for Payer: PHP Commercial |
$212.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.30
|
| Rate for Payer: Priority Health HMO/PPO |
$217.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.30
|
| 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
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$9.76
|
|
|
Service Code
|
NDC 09900000350
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$8.78 |
| Rate for Payer: Aetna Commercial |
$8.30
|
| Rate for Payer: BCBS Trust/PPO |
$7.97
|
| 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 Commercial |
$8.30
|
| Rate for Payer: Nomi Health Commercial |
$8.00
|
| Rate for Payer: PHP Commercial |
$8.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.34
|
| Rate for Payer: Priority Health HMO/PPO |
$8.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.54
|
| 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 20 MG/ML ORAL CONCENTRATE
|
Facility
|
OP
|
$9.76
|
|
|
Service Code
|
NDC 09900000350
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$8.78 |
| Rate for Payer: Aetna Commercial |
$8.30
|
| Rate for Payer: Aetna Medicare |
$2.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.05
|
| Rate for Payer: BCBS Complete |
$3.90
|
| Rate for Payer: BCBS MAPPO |
$2.44
|
| Rate for Payer: BCBS Trust/PPO |
$8.02
|
| Rate for Payer: BCN Commercial |
$7.59
|
| Rate for Payer: BCN Medicare Advantage |
$2.44
|
| 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: Health Alliance Plan Medicare Advantage |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$8.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.30
|
| Rate for Payer: Nomi Health Commercial |
$8.00
|
| Rate for Payer: PACE Senior Care Partners |
$2.32
|
| Rate for Payer: PACE SWMI |
$2.44
|
| Rate for Payer: PHP Commercial |
$8.30
|
| Rate for Payer: PHP Medicare Advantage |
$2.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.34
|
| Rate for Payer: Priority Health HMO/PPO |
$8.49
|
| Rate for Payer: Priority Health Medicare |
$2.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.54
|
| Rate for Payer: Railroad Medicare Medicare |
$2.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.59
|
| Rate for Payer: UHC Core |
$8.15
|
| Rate for Payer: UHC Dual Complete DSNP |
$2.44
|
| Rate for Payer: UHC Exchange |
$2.44
|
| Rate for Payer: UHC Medicare Advantage |
$2.44
|
| Rate for Payer: VA VA |
$2.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.32
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE
|
Facility
|
OP
|
$249.70
|
|
|
Service Code
|
NDC 59762006701
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.30 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna Commercial |
$212.24
|
| Rate for Payer: Aetna Medicare |
$64.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$78.03
|
| Rate for Payer: Amish Plain Church Group Commercial |
$78.03
|
| Rate for Payer: BCBS Complete |
$99.88
|
| Rate for Payer: BCBS MAPPO |
$62.42
|
| Rate for Payer: BCBS Trust/PPO |
$205.28
|
| Rate for Payer: BCN Commercial |
$194.14
|
| Rate for Payer: BCN Medicare Advantage |
$62.42
|
| 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: Health Alliance Plan Medicare Advantage |
$62.42
|
| Rate for Payer: Healthscope Commercial |
$224.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$65.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.24
|
| Rate for Payer: Nomi Health Commercial |
$204.75
|
| Rate for Payer: PACE Senior Care Partners |
$59.30
|
| Rate for Payer: PACE SWMI |
$62.42
|
| Rate for Payer: PHP Commercial |
$212.24
|
| Rate for Payer: PHP Medicare Advantage |
$62.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.30
|
| Rate for Payer: Priority Health HMO/PPO |
$217.24
|
| Rate for Payer: Priority Health Medicare |
$63.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.30
|
| Rate for Payer: Railroad Medicare Medicare |
$62.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$219.74
|
| Rate for Payer: UHC Core |
$208.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$62.42
|
| Rate for Payer: UHC Exchange |
$62.42
|
| Rate for Payer: UHC Medicare Advantage |
$62.42
|
| Rate for Payer: VA VA |
$62.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.28
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.14 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: BCBS Trust/PPO |
$218.69
|
| Rate for Payer: BCN Commercial |
$207.03
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.72
|
| Rate for Payer: Nomi Health Commercial |
$219.68
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.14
|
| Rate for Payer: Priority Health HMO/PPO |
$233.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$179.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$235.75
|
| Rate for Payer: UHC Core |
$223.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.92
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$267.90
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.63 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna Medicare |
$69.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$83.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$83.72
|
| Rate for Payer: BCBS Complete |
$107.16
|
| Rate for Payer: BCBS MAPPO |
$66.98
|
| Rate for Payer: BCBS Trust/PPO |
$220.24
|
| Rate for Payer: BCN Commercial |
$208.29
|
| Rate for Payer: BCN Medicare Advantage |
$66.98
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$66.98
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$70.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$77.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.72
|
| Rate for Payer: Nomi Health Commercial |
$219.68
|
| Rate for Payer: PACE Senior Care Partners |
$63.63
|
| Rate for Payer: PACE SWMI |
$66.98
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: PHP Medicare Advantage |
$66.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.14
|
| Rate for Payer: Priority Health HMO/PPO |
$233.07
|
| Rate for Payer: Priority Health Medicare |
$67.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$179.49
|
| Rate for Payer: Railroad Medicare Medicare |
$66.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$235.75
|
| Rate for Payer: UHC Core |
$223.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$66.98
|
| Rate for Payer: UHC Exchange |
$66.98
|
| Rate for Payer: UHC Medicare Advantage |
$66.98
|
| Rate for Payer: VA VA |
$66.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.92
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$2.68
|
|
|
Service Code
|
NDC 60687023111
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: BCBS Trust/PPO |
$2.19
|
| Rate for Payer: BCN Commercial |
$2.07
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.14
|
| Rate for Payer: Healthscope Commercial |
$2.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.28
|
| Rate for Payer: Nomi Health Commercial |
$2.20
|
| Rate for Payer: PHP Commercial |
$2.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: Priority Health HMO/PPO |
$2.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.36
|
| Rate for Payer: UHC Core |
$2.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.01
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$2.68
|
|
|
Service Code
|
NDC 60687023111
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: Aetna Medicare |
$0.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.84
|
| Rate for Payer: BCBS Complete |
$1.07
|
| Rate for Payer: BCBS MAPPO |
$0.67
|
| Rate for Payer: BCBS Trust/PPO |
$2.20
|
| Rate for Payer: BCN Commercial |
$2.08
|
| Rate for Payer: BCN Medicare Advantage |
$0.67
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.67
|
| Rate for Payer: Healthscope Commercial |
$2.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.28
|
| Rate for Payer: Nomi Health Commercial |
$2.20
|
| Rate for Payer: PACE Senior Care Partners |
$0.64
|
| Rate for Payer: PACE SWMI |
$0.67
|
| Rate for Payer: PHP Commercial |
$2.28
|
| Rate for Payer: PHP Medicare Advantage |
$0.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: Priority Health HMO/PPO |
$2.33
|
| Rate for Payer: Priority Health Medicare |
$0.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.80
|
| Rate for Payer: Railroad Medicare Medicare |
$0.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.36
|
| Rate for Payer: UHC Core |
$2.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.67
|
| Rate for Payer: UHC Exchange |
$0.67
|
| Rate for Payer: UHC Medicare Advantage |
$0.67
|
| Rate for Payer: VA VA |
$0.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.01
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$244.15
|
|
|
Service Code
|
NDC 00904692461
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.70 |
| Max. Negotiated Rate |
$219.74 |
| Rate for Payer: Aetna Commercial |
$207.53
|
| Rate for Payer: BCBS Trust/PPO |
$199.30
|
| Rate for Payer: BCN Commercial |
$188.68
|
| Rate for Payer: Cash Price |
$195.32
|
| Rate for Payer: Cofinity Commercial |
$209.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.32
|
| Rate for Payer: Healthscope Commercial |
$219.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.53
|
| Rate for Payer: Nomi Health Commercial |
$200.20
|
| Rate for Payer: PHP Commercial |
$207.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.70
|
| Rate for Payer: Priority Health HMO/PPO |
$212.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$163.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$214.85
|
| Rate for Payer: UHC Core |
$203.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.11
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$244.15
|
|
|
Service Code
|
NDC 00904692461
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.99 |
| Max. Negotiated Rate |
$219.74 |
| Rate for Payer: Aetna Commercial |
$207.53
|
| Rate for Payer: Aetna Medicare |
$63.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$76.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$76.30
|
| Rate for Payer: BCBS Complete |
$97.66
|
| Rate for Payer: BCBS MAPPO |
$61.04
|
| Rate for Payer: BCBS Trust/PPO |
$200.72
|
| Rate for Payer: BCN Commercial |
$189.83
|
| Rate for Payer: BCN Medicare Advantage |
$61.04
|
| Rate for Payer: Cash Price |
$195.32
|
| Rate for Payer: Cofinity Commercial |
$209.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$61.04
|
| Rate for Payer: Healthscope Commercial |
$219.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$64.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$70.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.53
|
| Rate for Payer: Nomi Health Commercial |
$200.20
|
| Rate for Payer: PACE Senior Care Partners |
$57.99
|
| Rate for Payer: PACE SWMI |
$61.04
|
| Rate for Payer: PHP Commercial |
$207.53
|
| Rate for Payer: PHP Medicare Advantage |
$61.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.70
|
| Rate for Payer: Priority Health HMO/PPO |
$212.41
|
| Rate for Payer: Priority Health Medicare |
$61.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$163.58
|
| Rate for Payer: Railroad Medicare Medicare |
$61.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$214.85
|
| Rate for Payer: UHC Core |
$203.87
|
| Rate for Payer: UHC Dual Complete DSNP |
$61.04
|
| Rate for Payer: UHC Exchange |
$61.04
|
| Rate for Payer: UHC Medicare Advantage |
$61.04
|
| Rate for Payer: VA VA |
$61.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.11
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.58 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna Medicare |
$58.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$70.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$70.50
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: BCBS MAPPO |
$56.40
|
| Rate for Payer: BCBS Trust/PPO |
$185.47
|
| Rate for Payer: BCN Commercial |
$175.40
|
| Rate for Payer: BCN Medicare Advantage |
$56.40
|
| 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: Health Alliance Plan Medicare Advantage |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$59.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$64.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: PACE Senior Care Partners |
$53.58
|
| Rate for Payer: PACE SWMI |
$56.40
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: PHP Medicare Advantage |
$56.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health HMO/PPO |
$196.27
|
| Rate for Payer: Priority Health Medicare |
$56.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$151.15
|
| Rate for Payer: Railroad Medicare Medicare |
$56.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.53
|
| Rate for Payer: UHC Core |
$188.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$56.40
|
| Rate for Payer: UHC Exchange |
$56.40
|
| Rate for Payer: UHC Medicare Advantage |
$56.40
|
| Rate for Payer: VA VA |
$56.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.20
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.64 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: BCBS Trust/PPO |
$184.16
|
| 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 Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health HMO/PPO |
$196.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$151.15
|
| 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
|
OP
|
$69.80
|
|
|
Service Code
|
NDC 68180035209
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.58 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Aetna Medicare |
$18.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.81
|
| Rate for Payer: BCBS Complete |
$27.92
|
| Rate for Payer: BCBS MAPPO |
$17.45
|
| Rate for Payer: BCBS Trust/PPO |
$57.38
|
| Rate for Payer: BCN Commercial |
$54.27
|
| Rate for Payer: BCN Medicare Advantage |
$17.45
|
| 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: Health Alliance Plan Medicare Advantage |
$17.45
|
| Rate for Payer: Healthscope Commercial |
$62.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.35
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.33
|
| Rate for Payer: Nomi Health Commercial |
$57.24
|
| Rate for Payer: PACE Senior Care Partners |
$16.58
|
| Rate for Payer: PACE SWMI |
$17.45
|
| Rate for Payer: PHP Commercial |
$59.33
|
| Rate for Payer: PHP Medicare Advantage |
$17.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: Priority Health HMO/PPO |
$60.73
|
| Rate for Payer: Priority Health Medicare |
$17.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.77
|
| Rate for Payer: Railroad Medicare Medicare |
$17.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.42
|
| Rate for Payer: UHC Core |
$58.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.45
|
| Rate for Payer: UHC Exchange |
$17.45
|
| Rate for Payer: UHC Medicare Advantage |
$17.45
|
| Rate for Payer: VA VA |
$17.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.35
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 60687024211
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: BCBS Trust/PPO |
$2.49
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.59
|
| Rate for Payer: Nomi Health Commercial |
$2.50
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: Priority Health HMO/PPO |
$2.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.68
|
| Rate for Payer: UHC Core |
$2.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$3.05
|
|
|
Service Code
|
NDC 60687024211
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Aetna Medicare |
$0.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.95
|
| Rate for Payer: BCBS Complete |
$1.22
|
| Rate for Payer: BCBS MAPPO |
$0.76
|
| Rate for Payer: BCBS Trust/PPO |
$2.51
|
| Rate for Payer: BCN Commercial |
$2.37
|
| Rate for Payer: BCN Medicare Advantage |
$0.76
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.76
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.59
|
| Rate for Payer: Nomi Health Commercial |
$2.50
|
| Rate for Payer: PACE Senior Care Partners |
$0.72
|
| Rate for Payer: PACE SWMI |
$0.76
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: PHP Medicare Advantage |
$0.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: Priority Health HMO/PPO |
$2.65
|
| Rate for Payer: Priority Health Medicare |
$0.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.04
|
| Rate for Payer: Railroad Medicare Medicare |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.68
|
| Rate for Payer: UHC Core |
$2.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Medicare Advantage |
$0.76
|
| Rate for Payer: VA VA |
$0.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
NDC 65862001201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.20 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: BCBS Trust/PPO |
$153.46
|
| 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 Commercial |
$159.80
|
| Rate for Payer: Nomi Health Commercial |
$154.16
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.20
|
| Rate for Payer: Priority Health HMO/PPO |
$163.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$125.96
|
| 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
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$277.40
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.88 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna Medicare |
$72.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$86.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$86.69
|
| Rate for Payer: BCBS Complete |
$110.96
|
| Rate for Payer: BCBS MAPPO |
$69.35
|
| Rate for Payer: BCBS Trust/PPO |
$228.05
|
| Rate for Payer: BCN Commercial |
$215.68
|
| Rate for Payer: BCN Medicare Advantage |
$69.35
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$69.35
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$72.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$79.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Nomi Health Commercial |
$227.47
|
| Rate for Payer: PACE Senior Care Partners |
$65.88
|
| Rate for Payer: PACE SWMI |
$69.35
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: PHP Medicare Advantage |
$69.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.31
|
| Rate for Payer: Priority Health HMO/PPO |
$241.34
|
| Rate for Payer: Priority Health Medicare |
$70.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.86
|
| Rate for Payer: Railroad Medicare Medicare |
$69.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$244.11
|
| Rate for Payer: UHC Core |
$231.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$69.35
|
| Rate for Payer: UHC Exchange |
$69.35
|
| Rate for Payer: UHC Medicare Advantage |
$69.35
|
| Rate for Payer: VA VA |
$69.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.05
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$304.95
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.22 |
| Max. Negotiated Rate |
$274.46 |
| Rate for Payer: Aetna Commercial |
$259.21
|
| Rate for Payer: BCBS Trust/PPO |
$248.93
|
| Rate for Payer: BCN Commercial |
$235.67
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$262.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$274.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.21
|
| Rate for Payer: Nomi Health Commercial |
$250.06
|
| Rate for Payer: PHP Commercial |
$259.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.22
|
| Rate for Payer: Priority Health HMO/PPO |
$265.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$204.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$268.36
|
| Rate for Payer: UHC Core |
$254.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.71
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$304.95
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.43 |
| Max. Negotiated Rate |
$274.46 |
| Rate for Payer: Aetna Commercial |
$259.21
|
| Rate for Payer: Aetna Medicare |
$79.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$95.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$95.30
|
| Rate for Payer: BCBS Complete |
$121.98
|
| Rate for Payer: BCBS MAPPO |
$76.24
|
| Rate for Payer: BCBS Trust/PPO |
$250.70
|
| Rate for Payer: BCN Commercial |
$237.10
|
| Rate for Payer: BCN Medicare Advantage |
$76.24
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$262.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$76.24
|
| Rate for Payer: Healthscope Commercial |
$274.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$80.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$87.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.21
|
| Rate for Payer: Nomi Health Commercial |
$250.06
|
| Rate for Payer: PACE Senior Care Partners |
$72.43
|
| Rate for Payer: PACE SWMI |
$76.24
|
| Rate for Payer: PHP Commercial |
$259.21
|
| Rate for Payer: PHP Medicare Advantage |
$76.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.22
|
| Rate for Payer: Priority Health HMO/PPO |
$265.31
|
| Rate for Payer: Priority Health Medicare |
$77.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$204.32
|
| Rate for Payer: Railroad Medicare Medicare |
$76.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$268.36
|
| Rate for Payer: UHC Core |
$254.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$76.24
|
| Rate for Payer: UHC Exchange |
$76.24
|
| Rate for Payer: UHC Medicare Advantage |
$76.24
|
| Rate for Payer: VA VA |
$76.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.71
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$277.40
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.31 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: BCBS Trust/PPO |
$226.44
|
| Rate for Payer: BCN Commercial |
$214.37
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Nomi Health Commercial |
$227.47
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.31
|
| Rate for Payer: Priority Health HMO/PPO |
$241.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$244.11
|
| Rate for Payer: UHC Core |
$231.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.05
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$69.80
|
|
|
Service Code
|
NDC 68180035209
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.37 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: BCBS Trust/PPO |
$56.98
|
| 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 Commercial |
$59.33
|
| Rate for Payer: Nomi Health Commercial |
$57.24
|
| Rate for Payer: PHP Commercial |
$59.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: Priority Health HMO/PPO |
$60.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.77
|
| 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
|
OP
|
$188.00
|
|
|
Service Code
|
NDC 65862001201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.65 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: Aetna Medicare |
$48.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$58.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$58.75
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: BCBS MAPPO |
$47.00
|
| Rate for Payer: BCBS Trust/PPO |
$154.55
|
| Rate for Payer: BCN Commercial |
$146.17
|
| Rate for Payer: BCN Medicare Advantage |
$47.00
|
| 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: Health Alliance Plan Medicare Advantage |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$169.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$49.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$54.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.80
|
| Rate for Payer: Nomi Health Commercial |
$154.16
|
| Rate for Payer: PACE Senior Care Partners |
$44.65
|
| Rate for Payer: PACE SWMI |
$47.00
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: PHP Medicare Advantage |
$47.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.20
|
| Rate for Payer: Priority Health HMO/PPO |
$163.56
|
| Rate for Payer: Priority Health Medicare |
$47.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$125.96
|
| Rate for Payer: Railroad Medicare Medicare |
$47.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$165.44
|
| Rate for Payer: UHC Core |
$156.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$47.00
|
| Rate for Payer: UHC Exchange |
$47.00
|
| Rate for Payer: UHC Medicare Advantage |
$47.00
|
| Rate for Payer: VA VA |
$47.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.00
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
|
OP
|
$211.75
|
|
|
Service Code
|
NDC 66794001525
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.29 |
| Max. Negotiated Rate |
$190.58 |
| Rate for Payer: Aetna Commercial |
$179.99
|
| Rate for Payer: Aetna Medicare |
$55.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66.17
|
| Rate for Payer: BCBS Complete |
$84.70
|
| Rate for Payer: BCBS MAPPO |
$52.94
|
| Rate for Payer: BCBS Trust/PPO |
$174.08
|
| Rate for Payer: BCN Commercial |
$164.64
|
| Rate for Payer: BCN Medicare Advantage |
$52.94
|
| 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: Health Alliance Plan Medicare Advantage |
$52.94
|
| Rate for Payer: Healthscope Commercial |
$190.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$55.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$60.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.99
|
| Rate for Payer: Nomi Health Commercial |
$173.64
|
| Rate for Payer: PACE Senior Care Partners |
$50.29
|
| Rate for Payer: PACE SWMI |
$52.94
|
| Rate for Payer: PHP Commercial |
$179.99
|
| Rate for Payer: PHP Medicare Advantage |
$52.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.64
|
| Rate for Payer: Priority Health HMO/PPO |
$184.22
|
| Rate for Payer: Priority Health Medicare |
$53.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$141.87
|
| Rate for Payer: Railroad Medicare Medicare |
$52.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$186.34
|
| Rate for Payer: UHC Core |
$176.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$52.94
|
| Rate for Payer: UHC Exchange |
$52.94
|
| Rate for Payer: UHC Medicare Advantage |
$52.94
|
| Rate for Payer: VA VA |
$52.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.81
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
|
OP
|
$211.75
|
|
|
Service Code
|
NDC 66794002225
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.29 |
| Max. Negotiated Rate |
$190.58 |
| Rate for Payer: Aetna Commercial |
$179.99
|
| Rate for Payer: Aetna Medicare |
$55.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66.17
|
| Rate for Payer: BCBS Complete |
$84.70
|
| Rate for Payer: BCBS MAPPO |
$52.94
|
| Rate for Payer: BCBS Trust/PPO |
$174.08
|
| Rate for Payer: BCN Commercial |
$164.64
|
| Rate for Payer: BCN Medicare Advantage |
$52.94
|
| 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: Health Alliance Plan Medicare Advantage |
$52.94
|
| Rate for Payer: Healthscope Commercial |
$190.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$55.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$60.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.99
|
| Rate for Payer: Nomi Health Commercial |
$173.64
|
| Rate for Payer: PACE Senior Care Partners |
$50.29
|
| Rate for Payer: PACE SWMI |
$52.94
|
| Rate for Payer: PHP Commercial |
$179.99
|
| Rate for Payer: PHP Medicare Advantage |
$52.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.64
|
| Rate for Payer: Priority Health HMO/PPO |
$184.22
|
| Rate for Payer: Priority Health Medicare |
$53.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$141.87
|
| Rate for Payer: Railroad Medicare Medicare |
$52.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$186.34
|
| Rate for Payer: UHC Core |
$176.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$52.94
|
| Rate for Payer: UHC Exchange |
$52.94
|
| Rate for Payer: UHC Medicare Advantage |
$52.94
|
| Rate for Payer: VA VA |
$52.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.81
|
|
|
SEVOFLURANE INHALATION LIQUID
|
Facility
|
IP
|
$214.38
|
|
|
Service Code
|
NDC 00074445651
|
| Hospital Charge Code |
15119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.35 |
| Max. Negotiated Rate |
$192.94 |
| Rate for Payer: Aetna Commercial |
$182.22
|
| Rate for Payer: BCBS Trust/PPO |
$175.00
|
| 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 Commercial |
$182.22
|
| Rate for Payer: Nomi Health Commercial |
$175.79
|
| Rate for Payer: PHP Commercial |
$182.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.35
|
| Rate for Payer: Priority Health HMO/PPO |
$186.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$143.63
|
| 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
|
|
