|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$28.07
|
|
|
Service Code
|
NDC 00536126659
|
| Hospital Charge Code |
15168
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.35 |
| Max. Negotiated Rate |
$25.26 |
| Rate for Payer: Aetna American Axle |
$18.25
|
| Rate for Payer: Aetna Commercial |
$23.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.25
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Cofinity Advantage |
$19.65
|
| Rate for Payer: Cofinity Commercial |
$24.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.46
|
| Rate for Payer: Healthscope Commercial |
$25.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.05
|
| Rate for Payer: PHP Commercial |
$23.86
|
| Rate for Payer: Priority Health SBD |
$17.68
|
| Rate for Payer: UMR Bronson Commercial |
$12.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.05
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$28.07
|
|
|
Service Code
|
NDC 00536126659
|
| Hospital Charge Code |
15168
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$25.26 |
| Rate for Payer: Aetna American Axle |
$18.25
|
| Rate for Payer: Aetna Commercial |
$23.86
|
| Rate for Payer: Aetna Medicare |
$14.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.25
|
| Rate for Payer: BCBS Complete |
$11.23
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Cofinity Advantage |
$19.65
|
| Rate for Payer: Cofinity Commercial |
$24.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.46
|
| Rate for Payer: Healthscope Commercial |
$25.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.05
|
| Rate for Payer: PHP Commercial |
$23.86
|
| Rate for Payer: Priority Health SBD |
$17.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.25
|
| Rate for Payer: UHC Core |
$14.62
|
| Rate for Payer: UHC Exchange |
$11.03
|
| Rate for Payer: UMR Bronson Commercial |
$10.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.05
|
|
|
SENNOSIDES 8.8 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 09900000019
|
| Hospital Charge Code |
15168
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Aetna American Axle |
$2.60
|
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Aetna Medicare |
$2.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.60
|
| Rate for Payer: BCBS Complete |
$1.60
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cofinity Advantage |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.20
|
| Rate for Payer: Healthscope Commercial |
$3.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.00
|
| Rate for Payer: PHP Commercial |
$3.40
|
| Rate for Payer: Priority Health SBD |
$2.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.60
|
| Rate for Payer: UHC Core |
$2.08
|
| Rate for Payer: UHC Exchange |
$1.57
|
| Rate for Payer: UMR Bronson Commercial |
$1.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.00
|
|
|
SEPTIC ARTHRITIS WITH CC
|
Facility
|
IP
|
$19,677.36
|
|
|
Service Code
|
MSDRG 549
|
| Min. Negotiated Rate |
$10,154.00 |
| Max. Negotiated Rate |
$19,677.36 |
| Rate for Payer: Aetna Medicare |
$11,115.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,360.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,360.52
|
| Rate for Payer: BCBS MAPPO |
$10,688.42
|
| Rate for Payer: BCBS Trust/PPO |
$19,608.25
|
| Rate for Payer: BCN Commercial |
$19,608.25
|
| Rate for Payer: BCN Medicare Advantage |
$10,688.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,688.42
|
| Rate for Payer: Mclaren Medicare |
$10,688.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11,222.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,291.68
|
| Rate for Payer: Molina Medicare/Medicaid |
$11,757.26
|
| Rate for Payer: Nomi Health Commercial |
$15,572.88
|
| Rate for Payer: PACE Medicare |
$10,154.00
|
| Rate for Payer: PACE SWMI |
$10,688.42
|
| Rate for Payer: PHP Medicare Advantage |
$10,688.42
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$19,462.65
|
| Rate for Payer: Priority Health Medicare |
$10,688.42
|
| Rate for Payer: Priority Health Tiered Network |
$15,570.12
|
| Rate for Payer: Railroad Medicare Medicare |
$10,688.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,677.36
|
| Rate for Payer: UHC Core |
$16,462.59
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$10,688.42
|
| Rate for Payer: UHC Exchange |
$13,444.59
|
| Rate for Payer: VA VA |
$10,688.42
|
|
|
SEPTIC ARTHRITIS WITH MCC
|
Facility
|
IP
|
$34,201.20
|
|
|
Service Code
|
MSDRG 548
|
| Min. Negotiated Rate |
$15,903.48 |
| Max. Negotiated Rate |
$34,201.20 |
| Rate for Payer: Aetna Medicare |
$17,410.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,925.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,925.62
|
| Rate for Payer: BCBS MAPPO |
$16,740.50
|
| Rate for Payer: BCBS Trust/PPO |
$34,201.20
|
| Rate for Payer: BCN Commercial |
$34,201.20
|
| Rate for Payer: BCN Medicare Advantage |
$16,740.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,740.50
|
| Rate for Payer: Mclaren Medicare |
$16,740.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17,577.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,251.58
|
| Rate for Payer: Molina Medicare/Medicaid |
$18,414.55
|
| Rate for Payer: Nomi Health Commercial |
$24,908.61
|
| Rate for Payer: PACE Medicare |
$15,903.48
|
| Rate for Payer: PACE SWMI |
$16,740.50
|
| Rate for Payer: PHP Medicare Advantage |
$16,740.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$31,130.24
|
| Rate for Payer: Priority Health Medicare |
$16,740.50
|
| Rate for Payer: Priority Health Tiered Network |
$24,904.19
|
| Rate for Payer: Railroad Medicare Medicare |
$16,740.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31,473.67
|
| Rate for Payer: UHC Core |
$26,331.68
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$16,740.50
|
| Rate for Payer: UHC Exchange |
$21,504.43
|
| Rate for Payer: VA VA |
$16,740.50
|
|
|
SEPTIC ARTHRITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$17,283.15
|
|
|
Service Code
|
MSDRG 550
|
| Min. Negotiated Rate |
$7,507.65 |
| Max. Negotiated Rate |
$17,283.15 |
| Rate for Payer: Aetna Medicare |
$8,218.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,878.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,878.49
|
| Rate for Payer: BCBS MAPPO |
$7,902.79
|
| Rate for Payer: BCBS Trust/PPO |
$17,283.15
|
| Rate for Payer: BCN Commercial |
$17,283.15
|
| Rate for Payer: BCN Medicare Advantage |
$7,902.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,902.79
|
| Rate for Payer: Mclaren Medicare |
$7,902.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,297.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,088.21
|
| Rate for Payer: Molina Medicare/Medicaid |
$8,693.07
|
| Rate for Payer: Nomi Health Commercial |
$11,275.89
|
| Rate for Payer: PACE Medicare |
$7,507.65
|
| Rate for Payer: PACE SWMI |
$7,902.79
|
| Rate for Payer: PHP Medicare Advantage |
$7,902.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$14,092.36
|
| Rate for Payer: Priority Health Medicare |
$7,902.79
|
| Rate for Payer: Priority Health Tiered Network |
$11,273.89
|
| Rate for Payer: Railroad Medicare Medicare |
$7,902.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,247.83
|
| Rate for Payer: UHC Core |
$11,920.10
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,902.79
|
| Rate for Payer: UHC Exchange |
$9,734.85
|
| Rate for Payer: VA VA |
$7,902.79
|
|
|
SEPTICEMIA AND DISSEMINATED INFECTIONS
|
Facility
|
IP
|
$14,128.89
|
|
|
Service Code
|
APR-DRG 7204
|
| Min. Negotiated Rate |
$13,456.09 |
| Max. Negotiated Rate |
$14,128.89 |
| Rate for Payer: BCBS Complete |
$14,128.89
|
| Rate for Payer: Mclaren Medicaid |
$13,456.09
|
| Rate for Payer: Meridian Medicaid |
$14,128.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$13,456.09
|
| Rate for Payer: UHC Medicaid |
$13,456.09
|
| Rate for Payer: UHCCP Medicaid |
$13,456.09
|
|
|
SEPTICEMIA AND DISSEMINATED INFECTIONS
|
Facility
|
IP
|
$4,725.77
|
|
|
Service Code
|
APR-DRG 7202
|
| Min. Negotiated Rate |
$4,500.74 |
| Max. Negotiated Rate |
$4,725.77 |
| Rate for Payer: BCBS Complete |
$4,725.77
|
| Rate for Payer: Mclaren Medicaid |
$4,500.74
|
| Rate for Payer: Meridian Medicaid |
$4,725.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,500.74
|
| Rate for Payer: UHC Medicaid |
$4,500.74
|
| Rate for Payer: UHCCP Medicaid |
$4,500.74
|
|
|
SEPTICEMIA AND DISSEMINATED INFECTIONS
|
Facility
|
IP
|
$4,175.53
|
|
|
Service Code
|
APR-DRG 7201
|
| Min. Negotiated Rate |
$3,976.70 |
| Max. Negotiated Rate |
$4,175.53 |
| Rate for Payer: BCBS Complete |
$4,175.53
|
| Rate for Payer: Mclaren Medicaid |
$3,976.70
|
| Rate for Payer: Meridian Medicaid |
$4,175.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,976.70
|
| Rate for Payer: UHC Medicaid |
$3,976.70
|
| Rate for Payer: UHCCP Medicaid |
$3,976.70
|
|
|
SEPTICEMIA AND DISSEMINATED INFECTIONS
|
Facility
|
IP
|
$7,177.94
|
|
|
Service Code
|
APR-DRG 7203
|
| Min. Negotiated Rate |
$6,836.14 |
| Max. Negotiated Rate |
$7,177.94 |
| Rate for Payer: BCBS Complete |
$7,177.94
|
| Rate for Payer: Mclaren Medicaid |
$6,836.14
|
| Rate for Payer: Meridian Medicaid |
$7,177.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,836.14
|
| Rate for Payer: UHC Medicaid |
$6,836.14
|
| Rate for Payer: UHCCP Medicaid |
$6,836.14
|
|
|
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS
|
Facility
|
IP
|
$147,310.30
|
|
|
Service Code
|
MSDRG 870
|
| Min. Negotiated Rate |
$55,474.51 |
| Max. Negotiated Rate |
$147,310.30 |
| Rate for Payer: Aetna Medicare |
$60,729.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$72,992.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$72,992.77
|
| Rate for Payer: BCBS MAPPO |
$58,394.22
|
| Rate for Payer: BCBS Trust/PPO |
$147,310.30
|
| Rate for Payer: BCN Commercial |
$147,310.30
|
| Rate for Payer: BCN Medicare Advantage |
$58,394.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$58,394.22
|
| Rate for Payer: Mclaren Medicare |
$58,394.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$61,313.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67,153.35
|
| Rate for Payer: Molina Medicare/Medicaid |
$64,233.64
|
| Rate for Payer: Nomi Health Commercial |
$89,162.22
|
| Rate for Payer: PACE Medicare |
$55,474.51
|
| Rate for Payer: PACE SWMI |
$58,394.22
|
| Rate for Payer: PHP Medicare Advantage |
$58,394.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$111,433.01
|
| Rate for Payer: Priority Health Medicare |
$58,394.22
|
| Rate for Payer: Priority Health Tiered Network |
$89,146.39
|
| Rate for Payer: Railroad Medicare Medicare |
$58,394.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$112,662.34
|
| Rate for Payer: UHC Core |
$94,256.22
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$58,394.22
|
| Rate for Payer: UHC Exchange |
$76,976.72
|
| Rate for Payer: VA VA |
$58,394.22
|
|
|
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC
|
Facility
|
IP
|
$36,380.81
|
|
|
Service Code
|
MSDRG 871
|
| Min. Negotiated Rate |
$15,995.63 |
| Max. Negotiated Rate |
$36,380.81 |
| Rate for Payer: Aetna Medicare |
$17,511.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,046.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,046.89
|
| Rate for Payer: BCBS MAPPO |
$16,837.51
|
| Rate for Payer: BCBS Trust/PPO |
$36,380.81
|
| Rate for Payer: BCN Commercial |
$36,380.81
|
| Rate for Payer: BCN Medicare Advantage |
$16,837.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,837.51
|
| Rate for Payer: Mclaren Medicare |
$16,837.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17,679.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,363.14
|
| Rate for Payer: Molina Medicare/Medicaid |
$18,521.26
|
| Rate for Payer: Nomi Health Commercial |
$25,058.25
|
| Rate for Payer: PACE Medicare |
$15,995.63
|
| Rate for Payer: PACE SWMI |
$16,837.51
|
| Rate for Payer: PHP Medicare Advantage |
$16,837.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$31,317.26
|
| Rate for Payer: Priority Health Medicare |
$16,837.51
|
| Rate for Payer: Priority Health Tiered Network |
$25,053.80
|
| Rate for Payer: Railroad Medicare Medicare |
$16,837.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31,662.75
|
| Rate for Payer: UHC Core |
$26,489.87
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$16,837.51
|
| Rate for Payer: UHC Exchange |
$21,633.62
|
| Rate for Payer: VA VA |
$16,837.51
|
|
|
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC
|
Facility
|
IP
|
$16,821.97
|
|
|
Service Code
|
MSDRG 872
|
| Min. Negotiated Rate |
$8,692.99 |
| Max. Negotiated Rate |
$16,821.97 |
| Rate for Payer: Aetna Medicare |
$9,516.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,438.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,438.15
|
| Rate for Payer: BCBS MAPPO |
$9,150.52
|
| Rate for Payer: BCBS Trust/PPO |
$16,821.97
|
| Rate for Payer: BCN Commercial |
$16,821.97
|
| Rate for Payer: BCN Medicare Advantage |
$9,150.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,150.52
|
| Rate for Payer: Mclaren Medicare |
$9,150.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9,608.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,523.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$10,065.57
|
| Rate for Payer: Nomi Health Commercial |
$13,200.57
|
| Rate for Payer: PACE Medicare |
$8,692.99
|
| Rate for Payer: PACE SWMI |
$9,150.52
|
| Rate for Payer: PHP Medicare Advantage |
$9,150.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$16,497.79
|
| Rate for Payer: Priority Health Medicare |
$9,150.52
|
| Rate for Payer: Priority Health Tiered Network |
$13,198.23
|
| Rate for Payer: Railroad Medicare Medicare |
$9,150.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,679.79
|
| Rate for Payer: UHC Core |
$13,954.74
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9,150.52
|
| Rate for Payer: UHC Exchange |
$11,396.49
|
| Rate for Payer: VA VA |
$9,150.52
|
|
|
SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT
|
Facility
|
OP
|
$10,683.35
|
|
|
Service Code
|
CPT 30520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,727.75 |
| Max. Negotiated Rate |
$10,683.35 |
| Rate for Payer: Aetna Medicare |
$3,435.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,129.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,129.43
|
| Rate for Payer: BCBS Complete |
$1,814.30
|
| Rate for Payer: BCBS MAPPO |
$3,303.54
|
| Rate for Payer: BCBS Trust/PPO |
$3,987.07
|
| Rate for Payer: BCN Commercial |
$3,987.07
|
| Rate for Payer: BCN Medicare Advantage |
$3,303.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,303.54
|
| Rate for Payer: Mclaren Medicaid |
$3,303.54
|
| Rate for Payer: Mclaren Medicare |
$3,303.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,468.72
|
| Rate for Payer: Meridian Medicaid |
$3,468.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,799.07
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,633.89
|
| Rate for Payer: Nomi Health Commercial |
$9,910.62
|
| Rate for Payer: PACE Medicare |
$3,138.36
|
| Rate for Payer: PACE SWMI |
$3,303.54
|
| Rate for Payer: PHP Medicare Advantage |
$3,303.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,727.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,683.35
|
| Rate for Payer: Priority Health Medicare |
$3,303.54
|
| Rate for Payer: Priority Health Tiered Network |
$8,546.68
|
| Rate for Payer: Railroad Medicare Medicare |
$3,303.54
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,303.54
|
| Rate for Payer: UHC Medicaid |
$1,727.75
|
| Rate for Payer: UHCCP Medicaid |
$1,727.75
|
| Rate for Payer: VA VA |
$3,303.54
|
|
|
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 |
$92.39 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna American Axle |
$162.31
|
| Rate for Payer: Aetna Commercial |
$212.25
|
| Rate for Payer: Aetna Medicare |
$124.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.31
|
| Rate for Payer: BCBS Complete |
$99.88
|
| Rate for Payer: Cash Price |
$199.76
|
| Rate for Payer: Cofinity Advantage |
$174.79
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$174.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$187.28
|
| Rate for Payer: PHP Commercial |
$212.25
|
| Rate for Payer: Priority Health SBD |
$157.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$162.31
|
| Rate for Payer: UHC Core |
$130.09
|
| Rate for Payer: UHC Exchange |
$98.13
|
| Rate for Payer: UMR Bronson Commercial |
$92.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.28
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE
|
Facility
|
OP
|
$185.19
|
|
|
Service Code
|
NDC 64980040906
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.52 |
| Max. Negotiated Rate |
$166.67 |
| Rate for Payer: Aetna American Axle |
$120.37
|
| Rate for Payer: Aetna Commercial |
$157.41
|
| Rate for Payer: Aetna Medicare |
$92.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.37
|
| Rate for Payer: BCBS Complete |
$74.08
|
| Rate for Payer: Cash Price |
$148.15
|
| Rate for Payer: Cofinity Advantage |
$129.63
|
| Rate for Payer: Cofinity Commercial |
$159.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.15
|
| Rate for Payer: Healthscope Commercial |
$166.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$148.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$138.89
|
| Rate for Payer: PHP Commercial |
$157.41
|
| Rate for Payer: Priority Health SBD |
$116.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$120.37
|
| Rate for Payer: UHC Core |
$96.48
|
| Rate for Payer: UHC Exchange |
$72.78
|
| Rate for Payer: UMR Bronson Commercial |
$68.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.89
|
|
|
SERTRALINE 20 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$185.19
|
|
|
Service Code
|
NDC 64980040906
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$166.67 |
| Rate for Payer: Aetna American Axle |
$120.37
|
| Rate for Payer: Aetna Commercial |
$157.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.37
|
| Rate for Payer: Cash Price |
$148.15
|
| Rate for Payer: Cofinity Advantage |
$129.63
|
| Rate for Payer: Cofinity Commercial |
$159.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.15
|
| Rate for Payer: Healthscope Commercial |
$166.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$138.89
|
| Rate for Payer: PHP Commercial |
$157.41
|
| Rate for Payer: Priority Health SBD |
$116.67
|
| Rate for Payer: UMR Bronson Commercial |
$81.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.89
|
|
|
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 |
$109.87 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna American Axle |
$162.31
|
| Rate for Payer: Aetna Commercial |
$212.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.31
|
| Rate for Payer: Cash Price |
$199.76
|
| Rate for Payer: Cofinity Advantage |
$174.79
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$174.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$187.28
|
| Rate for Payer: PHP Commercial |
$212.25
|
| Rate for Payer: Priority Health SBD |
$157.31
|
| Rate for Payer: UMR Bronson Commercial |
$109.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.28
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$156.51
|
|
|
Service Code
|
NDC 69097083305
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.91 |
| Max. Negotiated Rate |
$140.86 |
| Rate for Payer: Aetna American Axle |
$101.73
|
| Rate for Payer: Aetna Commercial |
$133.03
|
| Rate for Payer: Aetna Medicare |
$78.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.73
|
| Rate for Payer: BCBS Complete |
$62.60
|
| Rate for Payer: Cash Price |
$125.21
|
| Rate for Payer: Cofinity Advantage |
$109.56
|
| Rate for Payer: Cofinity Commercial |
$134.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.21
|
| Rate for Payer: Healthscope Commercial |
$140.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$125.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$133.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$117.38
|
| Rate for Payer: PHP Commercial |
$133.03
|
| Rate for Payer: Priority Health SBD |
$98.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$101.73
|
| Rate for Payer: UHC Core |
$81.54
|
| Rate for Payer: UHC Exchange |
$61.51
|
| Rate for Payer: UMR Bronson Commercial |
$57.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.38
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$156.51
|
|
|
Service Code
|
NDC 69097083305
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.86 |
| Max. Negotiated Rate |
$140.86 |
| Rate for Payer: Aetna American Axle |
$101.73
|
| Rate for Payer: Aetna Commercial |
$133.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.73
|
| Rate for Payer: Cash Price |
$125.21
|
| Rate for Payer: Cofinity Advantage |
$109.56
|
| Rate for Payer: Cofinity Commercial |
$134.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.21
|
| Rate for Payer: Healthscope Commercial |
$140.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$109.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$117.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$133.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$117.38
|
| Rate for Payer: PHP Commercial |
$133.03
|
| Rate for Payer: Priority Health SBD |
$98.60
|
| Rate for Payer: UMR Bronson Commercial |
$68.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$117.38
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$59.22
|
|
|
Service Code
|
NDC 68180035109
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.91 |
| Max. Negotiated Rate |
$53.30 |
| Rate for Payer: Aetna American Axle |
$38.49
|
| Rate for Payer: Aetna Commercial |
$50.34
|
| Rate for Payer: Aetna Medicare |
$29.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.49
|
| Rate for Payer: BCBS Complete |
$23.69
|
| Rate for Payer: Cash Price |
$47.38
|
| Rate for Payer: Cofinity Advantage |
$41.45
|
| Rate for Payer: Cofinity Commercial |
$50.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.38
|
| Rate for Payer: Healthscope Commercial |
$53.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.41
|
| Rate for Payer: PHP Commercial |
$50.34
|
| Rate for Payer: Priority Health SBD |
$37.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.49
|
| Rate for Payer: UHC Core |
$30.85
|
| Rate for Payer: UHC Exchange |
$23.27
|
| Rate for Payer: UMR Bronson Commercial |
$21.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.41
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$271.70
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.55 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna American Axle |
$176.60
|
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
| Rate for Payer: UMR Bronson Commercial |
$119.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.78
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$59.22
|
|
|
Service Code
|
NDC 68180035109
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.06 |
| Max. Negotiated Rate |
$53.30 |
| Rate for Payer: Aetna American Axle |
$38.49
|
| Rate for Payer: Aetna Commercial |
$50.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.49
|
| Rate for Payer: Cash Price |
$47.38
|
| Rate for Payer: Cofinity Advantage |
$41.45
|
| Rate for Payer: Cofinity Commercial |
$50.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.38
|
| Rate for Payer: Healthscope Commercial |
$53.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.41
|
| Rate for Payer: PHP Commercial |
$50.34
|
| Rate for Payer: Priority Health SBD |
$37.31
|
| Rate for Payer: UMR Bronson Commercial |
$26.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.41
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$2.72
|
|
|
Service Code
|
NDC 60687023111
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.45 |
| Rate for Payer: Aetna American Axle |
$1.77
|
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Advantage |
$1.90
|
| Rate for Payer: Cofinity Commercial |
$2.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.04
|
| Rate for Payer: PHP Commercial |
$2.31
|
| Rate for Payer: Priority Health SBD |
$1.71
|
| Rate for Payer: UMR Bronson Commercial |
$1.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.04
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$271.70
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.53 |
| Max. Negotiated Rate |
$244.53 |
| Rate for Payer: Aetna American Axle |
$176.60
|
| Rate for Payer: Aetna Commercial |
$230.94
|
| Rate for Payer: Aetna Medicare |
$135.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.60
|
| Rate for Payer: BCBS Complete |
$108.68
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Advantage |
$190.19
|
| Rate for Payer: Cofinity Commercial |
$233.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$244.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$217.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$203.78
|
| Rate for Payer: PHP Commercial |
$230.94
|
| Rate for Payer: Priority Health SBD |
$171.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.60
|
| Rate for Payer: UHC Core |
$141.56
|
| Rate for Payer: UHC Exchange |
$106.78
|
| Rate for Payer: UMR Bronson Commercial |
$100.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.78
|
|
