|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.69
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: BCBS Trust/PPO |
$43.01
|
| Rate for Payer: BCN Commercial |
$40.72
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO |
$45.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.37
|
| Rate for Payer: UHC Core |
$44.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.52
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.69
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna Medicare |
$13.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.47
|
| Rate for Payer: BCBS Complete |
$21.08
|
| Rate for Payer: BCBS MAPPO |
$13.17
|
| Rate for Payer: BCBS Trust/PPO |
$43.32
|
| Rate for Payer: BCN Commercial |
$40.97
|
| Rate for Payer: BCN Medicare Advantage |
$13.17
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.17
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: PACE Senior Care Partners |
$12.51
|
| Rate for Payer: PACE SWMI |
$13.17
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: PHP Medicare Advantage |
$13.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO |
$45.84
|
| Rate for Payer: Priority Health Medicare |
$13.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.30
|
| Rate for Payer: Railroad Medicare Medicare |
$13.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.37
|
| Rate for Payer: UHC Core |
$44.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.17
|
| Rate for Payer: UHC Exchange |
$13.17
|
| Rate for Payer: UHC Medicare Advantage |
$13.17
|
| Rate for Payer: VA VA |
$13.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.52
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.69
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna Medicare |
$13.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.47
|
| Rate for Payer: BCBS Complete |
$21.08
|
| Rate for Payer: BCBS MAPPO |
$13.17
|
| Rate for Payer: BCBS Trust/PPO |
$43.32
|
| Rate for Payer: BCN Commercial |
$40.97
|
| Rate for Payer: BCN Medicare Advantage |
$13.17
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.17
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: PACE Senior Care Partners |
$12.51
|
| Rate for Payer: PACE SWMI |
$13.17
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: PHP Medicare Advantage |
$13.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO |
$45.84
|
| Rate for Payer: Priority Health Medicare |
$13.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.30
|
| Rate for Payer: Railroad Medicare Medicare |
$13.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.37
|
| Rate for Payer: UHC Core |
$44.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.17
|
| Rate for Payer: UHC Exchange |
$13.17
|
| Rate for Payer: UHC Medicare Advantage |
$13.17
|
| Rate for Payer: VA VA |
$13.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.52
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$13.84
|
|
|
Service Code
|
NDC 09900000414
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$12.46 |
| Rate for Payer: Aetna Commercial |
$11.76
|
| Rate for Payer: Aetna Medicare |
$3.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.32
|
| Rate for Payer: BCBS Complete |
$5.54
|
| Rate for Payer: BCBS MAPPO |
$3.46
|
| Rate for Payer: BCBS Trust/PPO |
$11.38
|
| Rate for Payer: BCN Commercial |
$10.76
|
| Rate for Payer: BCN Medicare Advantage |
$3.46
|
| 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: Health Alliance Plan Medicare Advantage |
$3.46
|
| Rate for Payer: Healthscope Commercial |
$12.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.76
|
| Rate for Payer: Nomi Health Commercial |
$11.35
|
| Rate for Payer: PACE Senior Care Partners |
$3.29
|
| Rate for Payer: PACE SWMI |
$3.46
|
| Rate for Payer: PHP Commercial |
$11.76
|
| Rate for Payer: PHP Medicare Advantage |
$3.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.00
|
| Rate for Payer: Priority Health HMO/PPO |
$12.04
|
| Rate for Payer: Priority Health Medicare |
$3.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.27
|
| Rate for Payer: Railroad Medicare Medicare |
$3.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.18
|
| Rate for Payer: UHC Core |
$11.56
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.46
|
| Rate for Payer: UHC Exchange |
$3.46
|
| Rate for Payer: UHC Medicare Advantage |
$3.46
|
| Rate for Payer: VA VA |
$3.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.38
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$13.84
|
|
|
Service Code
|
NDC 09900000414
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$12.46 |
| Rate for Payer: Aetna Commercial |
$11.76
|
| Rate for Payer: BCBS Trust/PPO |
$11.30
|
| 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 Commercial |
$11.76
|
| Rate for Payer: Nomi Health Commercial |
$11.35
|
| Rate for Payer: PHP Commercial |
$11.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.00
|
| Rate for Payer: Priority Health HMO/PPO |
$12.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.27
|
| 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
|
OP
|
$148.76
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.33 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: Aetna Medicare |
$38.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.49
|
| Rate for Payer: BCBS Complete |
$59.50
|
| Rate for Payer: BCBS MAPPO |
$37.19
|
| Rate for Payer: BCBS Trust/PPO |
$122.30
|
| Rate for Payer: BCN Commercial |
$115.66
|
| Rate for Payer: BCN Medicare Advantage |
$37.19
|
| 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: Health Alliance Plan Medicare Advantage |
$37.19
|
| Rate for Payer: Healthscope Commercial |
$133.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.45
|
| Rate for Payer: Nomi Health Commercial |
$121.98
|
| Rate for Payer: PACE Senior Care Partners |
$35.33
|
| Rate for Payer: PACE SWMI |
$37.19
|
| Rate for Payer: PHP Commercial |
$126.45
|
| Rate for Payer: PHP Medicare Advantage |
$37.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.69
|
| Rate for Payer: Priority Health HMO/PPO |
$129.42
|
| Rate for Payer: Priority Health Medicare |
$37.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.67
|
| Rate for Payer: Railroad Medicare Medicare |
$37.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.91
|
| Rate for Payer: UHC Core |
$124.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$37.19
|
| Rate for Payer: UHC Exchange |
$37.19
|
| Rate for Payer: UHC Medicare Advantage |
$37.19
|
| Rate for Payer: VA VA |
$37.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.57
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.69
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: BCBS Trust/PPO |
$43.01
|
| Rate for Payer: BCN Commercial |
$40.72
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO |
$45.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.37
|
| Rate for Payer: UHC Core |
$44.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.52
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
NDC 53746027101
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.68 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: BCBS Trust/PPO |
$82.49
|
| 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 Commercial |
$85.89
|
| Rate for Payer: Nomi Health Commercial |
$82.86
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.68
|
| Rate for Payer: Priority Health HMO/PPO |
$87.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.70
|
| 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 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$101.05
|
|
|
Service Code
|
NDC 53746027101
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna Medicare |
$26.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.58
|
| Rate for Payer: BCBS Complete |
$40.42
|
| Rate for Payer: BCBS MAPPO |
$25.26
|
| Rate for Payer: BCBS Trust/PPO |
$83.07
|
| Rate for Payer: BCN Commercial |
$78.57
|
| Rate for Payer: BCN Medicare Advantage |
$25.26
|
| 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: Health Alliance Plan Medicare Advantage |
$25.26
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: Nomi Health Commercial |
$82.86
|
| Rate for Payer: PACE Senior Care Partners |
$24.00
|
| Rate for Payer: PACE SWMI |
$25.26
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: PHP Medicare Advantage |
$25.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.68
|
| Rate for Payer: Priority Health HMO/PPO |
$87.91
|
| Rate for Payer: Priority Health Medicare |
$25.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.70
|
| Rate for Payer: Railroad Medicare Medicare |
$25.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.92
|
| Rate for Payer: UHC Core |
$84.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$25.26
|
| Rate for Payer: UHC Exchange |
$25.26
|
| Rate for Payer: UHC Medicare Advantage |
$25.26
|
| Rate for Payer: VA VA |
$25.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$136.30
|
|
|
Service Code
|
NDC 53746027201
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.37 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna Medicare |
$35.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42.59
|
| Rate for Payer: BCBS Complete |
$54.52
|
| Rate for Payer: BCBS MAPPO |
$34.08
|
| Rate for Payer: BCBS Trust/PPO |
$112.05
|
| Rate for Payer: BCN Commercial |
$105.97
|
| Rate for Payer: BCN Medicare Advantage |
$34.08
|
| 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: Health Alliance Plan Medicare Advantage |
$34.08
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$35.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: Nomi Health Commercial |
$111.77
|
| Rate for Payer: PACE Senior Care Partners |
$32.37
|
| Rate for Payer: PACE SWMI |
$34.08
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: PHP Medicare Advantage |
$34.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.60
|
| Rate for Payer: Priority Health HMO/PPO |
$118.58
|
| Rate for Payer: Priority Health Medicare |
$34.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$91.32
|
| Rate for Payer: Railroad Medicare Medicare |
$34.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.94
|
| Rate for Payer: UHC Core |
$113.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$34.08
|
| Rate for Payer: UHC Exchange |
$34.08
|
| Rate for Payer: UHC Medicare Advantage |
$34.08
|
| Rate for Payer: VA VA |
$34.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.41 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: BCBS Trust/PPO |
$237.87
|
| Rate for Payer: BCN Commercial |
$225.19
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health HMO/PPO |
$253.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$195.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$256.43
|
| Rate for Payer: UHC Core |
$243.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.21 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna Medicare |
$75.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$91.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$91.06
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: BCBS MAPPO |
$72.85
|
| Rate for Payer: BCBS Trust/PPO |
$239.56
|
| Rate for Payer: BCN Commercial |
$226.56
|
| Rate for Payer: BCN Medicare Advantage |
$72.85
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$72.85
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$76.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$83.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: PACE Senior Care Partners |
$69.21
|
| Rate for Payer: PACE SWMI |
$72.85
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: PHP Medicare Advantage |
$72.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health HMO/PPO |
$253.52
|
| Rate for Payer: Priority Health Medicare |
$73.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$195.24
|
| Rate for Payer: Railroad Medicare Medicare |
$72.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$256.43
|
| Rate for Payer: UHC Core |
$243.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$72.85
|
| Rate for Payer: UHC Exchange |
$72.85
|
| Rate for Payer: UHC Medicare Advantage |
$72.85
|
| Rate for Payer: VA VA |
$72.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$136.30
|
|
|
Service Code
|
NDC 53746027201
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.60 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: BCBS Trust/PPO |
$111.26
|
| 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 Commercial |
$115.86
|
| Rate for Payer: Nomi Health Commercial |
$111.77
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.60
|
| Rate for Payer: Priority Health HMO/PPO |
$118.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$91.32
|
| 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
|
OP
|
$129.25
|
|
|
Service Code
|
NDC 65162027210
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.70 |
| Max. Negotiated Rate |
$116.32 |
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: Aetna Medicare |
$33.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$40.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$40.39
|
| Rate for Payer: BCBS Complete |
$51.70
|
| Rate for Payer: BCBS MAPPO |
$32.31
|
| Rate for Payer: BCBS Trust/PPO |
$106.26
|
| Rate for Payer: BCN Commercial |
$100.49
|
| Rate for Payer: BCN Medicare Advantage |
$32.31
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$32.31
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$33.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.86
|
| Rate for Payer: Nomi Health Commercial |
$105.98
|
| Rate for Payer: PACE Senior Care Partners |
$30.70
|
| Rate for Payer: PACE SWMI |
$32.31
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: PHP Medicare Advantage |
$32.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.01
|
| Rate for Payer: Priority Health HMO/PPO |
$112.45
|
| Rate for Payer: Priority Health Medicare |
$32.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$86.60
|
| Rate for Payer: Railroad Medicare Medicare |
$32.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$113.74
|
| Rate for Payer: UHC Core |
$107.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$32.31
|
| Rate for Payer: UHC Exchange |
$32.31
|
| Rate for Payer: UHC Medicare Advantage |
$32.31
|
| Rate for Payer: VA VA |
$32.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.94
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
NDC 65162027210
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.01 |
| Max. Negotiated Rate |
$116.32 |
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: BCBS Trust/PPO |
$105.51
|
| Rate for Payer: BCN Commercial |
$99.88
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.86
|
| Rate for Payer: Nomi Health Commercial |
$105.98
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.01
|
| Rate for Payer: Priority Health HMO/PPO |
$112.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$86.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$113.74
|
| Rate for Payer: UHC Core |
$107.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.94
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$725.76
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.37 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Aetna Commercial |
$616.90
|
| Rate for Payer: Aetna Medicare |
$188.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$226.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$226.80
|
| Rate for Payer: BCBS Complete |
$290.30
|
| Rate for Payer: BCBS MAPPO |
$181.44
|
| Rate for Payer: BCBS Trust/PPO |
$596.65
|
| Rate for Payer: BCN Commercial |
$564.28
|
| Rate for Payer: BCN Medicare Advantage |
$181.44
|
| Rate for Payer: Cash Price |
$580.61
|
| Rate for Payer: Cofinity Commercial |
$624.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$580.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$181.44
|
| Rate for Payer: Healthscope Commercial |
$653.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$544.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$190.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$616.90
|
| Rate for Payer: Nomi Health Commercial |
$595.12
|
| Rate for Payer: PACE Senior Care Partners |
$172.37
|
| Rate for Payer: PACE SWMI |
$181.44
|
| Rate for Payer: PHP Commercial |
$616.90
|
| Rate for Payer: PHP Medicare Advantage |
$181.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$471.74
|
| Rate for Payer: Priority Health HMO/PPO |
$631.41
|
| Rate for Payer: Priority Health Medicare |
$183.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$486.26
|
| Rate for Payer: Railroad Medicare Medicare |
$181.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$638.67
|
| Rate for Payer: UHC Core |
$606.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$181.44
|
| Rate for Payer: UHC Exchange |
$181.44
|
| Rate for Payer: UHC Medicare Advantage |
$181.44
|
| Rate for Payer: VA VA |
$181.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$544.32
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$725.76
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$471.74 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Aetna Commercial |
$616.90
|
| Rate for Payer: BCBS Trust/PPO |
$592.44
|
| Rate for Payer: BCN Commercial |
$560.87
|
| Rate for Payer: Cash Price |
$580.61
|
| Rate for Payer: Cofinity Commercial |
$624.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$580.61
|
| Rate for Payer: Healthscope Commercial |
$653.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$544.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$616.90
|
| Rate for Payer: Nomi Health Commercial |
$595.12
|
| Rate for Payer: PHP Commercial |
$616.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$471.74
|
| Rate for Payer: Priority Health HMO/PPO |
$631.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$486.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$638.67
|
| Rate for Payer: UHC Core |
$606.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$544.32
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$408.90
|
|
|
Service Code
|
NDC 00591079601
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.11 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: Aetna Medicare |
$106.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$127.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$127.78
|
| Rate for Payer: BCBS Complete |
$163.56
|
| Rate for Payer: BCBS MAPPO |
$102.22
|
| Rate for Payer: BCBS Trust/PPO |
$336.16
|
| Rate for Payer: BCN Commercial |
$317.92
|
| Rate for Payer: BCN Medicare Advantage |
$102.22
|
| 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: Health Alliance Plan Medicare Advantage |
$102.22
|
| Rate for Payer: Healthscope Commercial |
$368.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$306.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$107.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$117.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$347.56
|
| Rate for Payer: Nomi Health Commercial |
$335.30
|
| Rate for Payer: PACE Senior Care Partners |
$97.11
|
| Rate for Payer: PACE SWMI |
$102.22
|
| Rate for Payer: PHP Commercial |
$347.56
|
| Rate for Payer: PHP Medicare Advantage |
$102.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.78
|
| Rate for Payer: Priority Health HMO/PPO |
$355.74
|
| Rate for Payer: Priority Health Medicare |
$103.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$273.96
|
| Rate for Payer: Railroad Medicare Medicare |
$102.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$359.83
|
| Rate for Payer: UHC Core |
$341.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$102.22
|
| Rate for Payer: UHC Exchange |
$102.22
|
| Rate for Payer: UHC Medicare Advantage |
$102.22
|
| Rate for Payer: VA VA |
$102.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$306.68
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$408.90
|
|
|
Service Code
|
NDC 00591079601
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$265.78 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: BCBS Trust/PPO |
$333.79
|
| 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 Commercial |
$347.56
|
| Rate for Payer: Nomi Health Commercial |
$335.30
|
| Rate for Payer: PHP Commercial |
$347.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.78
|
| Rate for Payer: Priority Health HMO/PPO |
$355.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$273.96
|
| 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
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
OP
|
$21.99
|
|
|
Service Code
|
NDC 65862014836
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$19.79 |
| Rate for Payer: Aetna Commercial |
$18.69
|
| Rate for Payer: Aetna Medicare |
$5.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.87
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.87
|
| Rate for Payer: BCBS Complete |
$8.80
|
| Rate for Payer: BCBS MAPPO |
$5.50
|
| Rate for Payer: BCBS Trust/PPO |
$18.08
|
| Rate for Payer: BCN Commercial |
$17.10
|
| Rate for Payer: BCN Medicare Advantage |
$5.50
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: Cofinity Commercial |
$18.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.50
|
| Rate for Payer: Healthscope Commercial |
$19.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.69
|
| Rate for Payer: Nomi Health Commercial |
$18.03
|
| Rate for Payer: PACE Senior Care Partners |
$5.22
|
| Rate for Payer: PACE SWMI |
$5.50
|
| Rate for Payer: PHP Commercial |
$18.69
|
| Rate for Payer: PHP Medicare Advantage |
$5.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.29
|
| Rate for Payer: Priority Health HMO/PPO |
$19.13
|
| Rate for Payer: Priority Health Medicare |
$5.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.73
|
| Rate for Payer: Railroad Medicare Medicare |
$5.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.35
|
| Rate for Payer: UHC Core |
$18.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.50
|
| Rate for Payer: UHC Exchange |
$5.50
|
| Rate for Payer: UHC Medicare Advantage |
$5.50
|
| Rate for Payer: VA VA |
$5.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.49
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
OP
|
$71.20
|
|
|
Service Code
|
NDC 62756052269
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna Medicare |
$18.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.25
|
| Rate for Payer: BCBS Complete |
$28.48
|
| Rate for Payer: BCBS MAPPO |
$17.80
|
| Rate for Payer: BCBS Trust/PPO |
$58.53
|
| Rate for Payer: BCN Commercial |
$55.36
|
| Rate for Payer: BCN Medicare Advantage |
$17.80
|
| 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: Health Alliance Plan Medicare Advantage |
$17.80
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: Nomi Health Commercial |
$58.38
|
| Rate for Payer: PACE Senior Care Partners |
$16.91
|
| Rate for Payer: PACE SWMI |
$17.80
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: PHP Medicare Advantage |
$17.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health HMO/PPO |
$61.94
|
| Rate for Payer: Priority Health Medicare |
$17.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.70
|
| Rate for Payer: Railroad Medicare Medicare |
$17.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.66
|
| Rate for Payer: UHC Core |
$59.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.80
|
| Rate for Payer: UHC Exchange |
$17.80
|
| Rate for Payer: UHC Medicare Advantage |
$17.80
|
| Rate for Payer: VA VA |
$17.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$7.92
|
|
|
Service Code
|
NDC 63304009911
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: BCBS Trust/PPO |
$6.47
|
| 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 Commercial |
$6.73
|
| Rate for Payer: Nomi Health Commercial |
$6.49
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.15
|
| Rate for Payer: Priority Health HMO/PPO |
$6.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.31
|
| 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
|
$71.20
|
|
|
Service Code
|
NDC 62756052269
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.28 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: BCBS Trust/PPO |
$58.12
|
| 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 Commercial |
$60.52
|
| Rate for Payer: Nomi Health Commercial |
$58.38
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health HMO/PPO |
$61.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.70
|
| 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
|
OP
|
$7.92
|
|
|
Service Code
|
NDC 63304009911
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: Aetna Medicare |
$2.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.48
|
| Rate for Payer: BCBS Complete |
$3.17
|
| Rate for Payer: BCBS MAPPO |
$1.98
|
| Rate for Payer: BCBS Trust/PPO |
$6.51
|
| Rate for Payer: BCN Commercial |
$6.16
|
| Rate for Payer: BCN Medicare Advantage |
$1.98
|
| 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: Health Alliance Plan Medicare Advantage |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$7.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.73
|
| Rate for Payer: Nomi Health Commercial |
$6.49
|
| Rate for Payer: PACE Senior Care Partners |
$1.88
|
| Rate for Payer: PACE SWMI |
$1.98
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: PHP Medicare Advantage |
$1.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.15
|
| Rate for Payer: Priority Health HMO/PPO |
$6.89
|
| Rate for Payer: Priority Health Medicare |
$2.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.31
|
| Rate for Payer: Railroad Medicare Medicare |
$1.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.97
|
| Rate for Payer: UHC Core |
$6.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.98
|
| Rate for Payer: UHC Exchange |
$1.98
|
| Rate for Payer: UHC Medicare Advantage |
$1.98
|
| Rate for Payer: VA VA |
$1.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.94
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
OP
|
$71.20
|
|
|
Service Code
|
NDC 63304009919
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna Medicare |
$18.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.25
|
| Rate for Payer: BCBS Complete |
$28.48
|
| Rate for Payer: BCBS MAPPO |
$17.80
|
| Rate for Payer: BCBS Trust/PPO |
$58.53
|
| Rate for Payer: BCN Commercial |
$55.36
|
| Rate for Payer: BCN Medicare Advantage |
$17.80
|
| 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: Health Alliance Plan Medicare Advantage |
$17.80
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: Nomi Health Commercial |
$58.38
|
| Rate for Payer: PACE Senior Care Partners |
$16.91
|
| Rate for Payer: PACE SWMI |
$17.80
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: PHP Medicare Advantage |
$17.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health HMO/PPO |
$61.94
|
| Rate for Payer: Priority Health Medicare |
$17.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.70
|
| Rate for Payer: Railroad Medicare Medicare |
$17.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.66
|
| Rate for Payer: UHC Core |
$59.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.80
|
| Rate for Payer: UHC Exchange |
$17.80
|
| Rate for Payer: UHC Medicare Advantage |
$17.80
|
| Rate for Payer: VA VA |
$17.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
