|
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 |
$88.59 |
| 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 |
$88.59
|
| 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
|
$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 |
$88.59
|
| 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
|
$129.25
|
|
|
Service Code
|
NDC 65162027210
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.01 |
| Max. Negotiated Rate |
$116.33 |
| 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 |
$116.33
|
| 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
|
|
|
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 |
$116.33 |
| 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 |
$116.33
|
| 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
|
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
|
$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
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$408.90
|
|
|
Service Code
|
NDC 00591079601
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$265.79 |
| 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 |
$265.79
|
| 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
|
|
|
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
|
$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
|
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 |
$265.79
|
| 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
|
|
|
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
|
IP
|
$21.99
|
|
|
Service Code
|
NDC 65862014836
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$19.79 |
| Rate for Payer: Aetna Commercial |
$18.69
|
| Rate for Payer: BCBS Trust/PPO |
$17.95
|
| Rate for Payer: BCN Commercial |
$16.99
|
| 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: Healthscope Commercial |
$19.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.69
|
| Rate for Payer: Nomi Health Commercial |
$18.03
|
| Rate for Payer: PHP Commercial |
$18.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.29
|
| Rate for Payer: Priority Health HMO/PPO |
$19.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.35
|
| Rate for Payer: UHC Core |
$18.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.49
|
|
|
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
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 63304009919
|
| 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
|
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
|
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
|
$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 25 MG TABLET
|
Facility
|
OP
|
$71.20
|
|
|
Service Code
|
NDC 62756052069
|
| Hospital Charge Code |
15327
|
|
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 25 MG TABLET
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 62756052069
|
| Hospital Charge Code |
15327
|
|
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 25 MG TABLET
|
Facility
|
OP
|
$41.78
|
|
|
Service Code
|
NDC 00378563059
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$37.60 |
| Rate for Payer: Aetna Commercial |
$35.51
|
| Rate for Payer: Aetna Medicare |
$10.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13.06
|
| Rate for Payer: BCBS Complete |
$16.71
|
| Rate for Payer: BCBS MAPPO |
$10.45
|
| Rate for Payer: BCBS Trust/PPO |
$34.35
|
| Rate for Payer: BCN Commercial |
$32.48
|
| Rate for Payer: BCN Medicare Advantage |
$10.45
|
| 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: Health Alliance Plan Medicare Advantage |
$10.45
|
| Rate for Payer: Healthscope Commercial |
$37.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.51
|
| Rate for Payer: Nomi Health Commercial |
$34.26
|
| Rate for Payer: PACE Senior Care Partners |
$9.92
|
| Rate for Payer: PACE SWMI |
$10.45
|
| Rate for Payer: PHP Commercial |
$35.51
|
| Rate for Payer: PHP Medicare Advantage |
$10.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.16
|
| Rate for Payer: Priority Health HMO/PPO |
$36.35
|
| Rate for Payer: Priority Health Medicare |
$10.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.99
|
| Rate for Payer: Railroad Medicare Medicare |
$10.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.77
|
| Rate for Payer: UHC Core |
$34.89
|
| Rate for Payer: UHC Dual Complete DSNP |
$10.45
|
| Rate for Payer: UHC Exchange |
$10.45
|
| Rate for Payer: UHC Medicare Advantage |
$10.45
|
| Rate for Payer: VA VA |
$10.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.34
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
IP
|
$41.78
|
|
|
Service Code
|
NDC 00378563059
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.16 |
| Max. Negotiated Rate |
$37.60 |
| Rate for Payer: Aetna Commercial |
$35.51
|
| Rate for Payer: BCBS Trust/PPO |
$34.11
|
| 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 Commercial |
$35.51
|
| Rate for Payer: Nomi Health Commercial |
$34.26
|
| Rate for Payer: PHP Commercial |
$35.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.16
|
| Rate for Payer: Priority Health HMO/PPO |
$36.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.99
|
| 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
|
$21.55
|
|
|
Service Code
|
NDC 65862014636
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.01 |
| Max. Negotiated Rate |
$19.39 |
| Rate for Payer: Aetna Commercial |
$18.32
|
| Rate for Payer: BCBS Trust/PPO |
$17.59
|
| Rate for Payer: BCN Commercial |
$16.65
|
| Rate for Payer: Cash Price |
$17.24
|
| Rate for Payer: Cofinity Commercial |
$18.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.24
|
| Rate for Payer: Healthscope Commercial |
$19.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.32
|
| Rate for Payer: Nomi Health Commercial |
$17.67
|
| Rate for Payer: PHP Commercial |
$18.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.01
|
| Rate for Payer: Priority Health HMO/PPO |
$18.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.96
|
| Rate for Payer: UHC Core |
$17.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.16
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
OP
|
$21.55
|
|
|
Service Code
|
NDC 65862014636
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$19.39 |
| Rate for Payer: Aetna Commercial |
$18.32
|
| Rate for Payer: Aetna Medicare |
$5.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.73
|
| Rate for Payer: BCBS Complete |
$8.62
|
| Rate for Payer: BCBS MAPPO |
$5.39
|
| Rate for Payer: BCBS Trust/PPO |
$17.72
|
| Rate for Payer: BCN Commercial |
$16.76
|
| Rate for Payer: BCN Medicare Advantage |
$5.39
|
| Rate for Payer: Cash Price |
$17.24
|
| Rate for Payer: Cofinity Commercial |
$18.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.39
|
| Rate for Payer: Healthscope Commercial |
$19.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.32
|
| Rate for Payer: Nomi Health Commercial |
$17.67
|
| Rate for Payer: PACE Senior Care Partners |
$5.12
|
| Rate for Payer: PACE SWMI |
$5.39
|
| Rate for Payer: PHP Commercial |
$18.32
|
| Rate for Payer: PHP Medicare Advantage |
$5.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.01
|
| Rate for Payer: Priority Health HMO/PPO |
$18.75
|
| Rate for Payer: Priority Health Medicare |
$5.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.44
|
| Rate for Payer: Railroad Medicare Medicare |
$5.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.96
|
| Rate for Payer: UHC Core |
$17.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.39
|
| Rate for Payer: UHC Exchange |
$5.39
|
| Rate for Payer: UHC Medicare Advantage |
$5.39
|
| Rate for Payer: VA VA |
$5.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.16
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$20.70
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$18.63 |
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna Commercial |
$22.42
|
| Rate for Payer: Aetna Medicare |
$7.07
|
| Rate for Payer: Aetna Medicare |
$5.38
|
| Rate for Payer: Aetna Medicare |
$6.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.50
|
| Rate for Payer: BCBS Complete |
$10.55
|
| Rate for Payer: BCBS Complete |
$8.28
|
| Rate for Payer: BCBS Complete |
$10.88
|
| Rate for Payer: BCBS MAPPO |
$6.80
|
| Rate for Payer: BCBS MAPPO |
$5.17
|
| Rate for Payer: BCBS MAPPO |
$6.59
|
| Rate for Payer: BCBS Trust/PPO |
$21.69
|
| Rate for Payer: BCBS Trust/PPO |
$17.02
|
| Rate for Payer: BCBS Trust/PPO |
$22.35
|
| Rate for Payer: BCN Commercial |
$20.51
|
| Rate for Payer: BCN Commercial |
$21.14
|
| Rate for Payer: BCN Commercial |
$16.09
|
| Rate for Payer: BCN Medicare Advantage |
$5.17
|
| Rate for Payer: BCN Medicare Advantage |
$6.59
|
| Rate for Payer: BCN Medicare Advantage |
$6.80
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.17
|
| Rate for Payer: Healthscope Commercial |
$23.74
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.43
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.59
|
| Rate for Payer: Nomi Health Commercial |
$22.30
|
| Rate for Payer: Nomi Health Commercial |
$16.97
|
| Rate for Payer: Nomi Health Commercial |
$21.63
|
| Rate for Payer: PACE Senior Care Partners |
$6.46
|
| Rate for Payer: PACE Senior Care Partners |
$4.92
|
| Rate for Payer: PACE Senior Care Partners |
$6.27
|
| Rate for Payer: PACE SWMI |
$6.59
|
| Rate for Payer: PACE SWMI |
$5.17
|
| Rate for Payer: PACE SWMI |
$6.80
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$22.42
|
| Rate for Payer: PHP Commercial |
$17.59
|
| Rate for Payer: PHP Medicare Advantage |
$6.59
|
| Rate for Payer: PHP Medicare Advantage |
$6.80
|
| Rate for Payer: PHP Medicare Advantage |
$5.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.15
|
| Rate for Payer: Priority Health HMO/PPO |
$23.66
|
| Rate for Payer: Priority Health HMO/PPO |
$18.01
|
| Rate for Payer: Priority Health HMO/PPO |
$22.95
|
| Rate for Payer: Priority Health Medicare |
$5.23
|
| Rate for Payer: Priority Health Medicare |
$6.87
|
| Rate for Payer: Priority Health Medicare |
$6.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.87
|
| Rate for Payer: Railroad Medicare Medicare |
$6.59
|
| Rate for Payer: Railroad Medicare Medicare |
$6.80
|
| Rate for Payer: Railroad Medicare Medicare |
$5.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.22
|
| Rate for Payer: UHC Core |
$22.70
|
| Rate for Payer: UHC Core |
$22.03
|
| Rate for Payer: UHC Core |
$17.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.59
|
| Rate for Payer: UHC Exchange |
$6.59
|
| Rate for Payer: UHC Exchange |
$5.17
|
| Rate for Payer: UHC Exchange |
$6.80
|
| Rate for Payer: UHC Medicare Advantage |
$5.17
|
| Rate for Payer: UHC Medicare Advantage |
$6.59
|
| Rate for Payer: UHC Medicare Advantage |
$6.80
|
| Rate for Payer: VA VA |
$6.59
|
| Rate for Payer: VA VA |
$6.80
|
| Rate for Payer: VA VA |
$5.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.79
|
|
