|
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 Commercial |
$174.79
|
| Rate for Payer: Cofinity Commercial |
$214.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$174.79
|
| 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: PHP Commercial |
$212.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.31
|
| Rate for Payer: Priority Health SBD |
$157.31
|
| 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
|
IP
|
$217.16
|
|
|
Service Code
|
NDC 64980040906
|
| Hospital Charge Code |
28011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.55 |
| Max. Negotiated Rate |
$195.44 |
| Rate for Payer: Aetna American Axle |
$141.15
|
| Rate for Payer: Aetna Commercial |
$184.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.15
|
| Rate for Payer: Cash Price |
$173.73
|
| Rate for Payer: Cofinity Commercial |
$152.01
|
| Rate for Payer: Cofinity Commercial |
$186.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.73
|
| Rate for Payer: Healthscope Commercial |
$195.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$152.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.59
|
| Rate for Payer: PHP Commercial |
$184.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.15
|
| Rate for Payer: Priority Health SBD |
$136.81
|
| Rate for Payer: UMR Bronson Commercial |
$95.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.87
|
|
|
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 Commercial |
$41.45
|
| Rate for Payer: Cofinity Commercial |
$50.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.45
|
| 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: PHP Commercial |
$50.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.49
|
| Rate for Payer: Priority Health SBD |
$37.31
|
| Rate for Payer: UMR Bronson Commercial |
$21.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.41
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$2.68
|
|
|
Service Code
|
NDC 60687023111
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna American Axle |
$1.74
|
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: Aetna Medicare |
$1.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.74
|
| Rate for Payer: BCBS Complete |
$1.07
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Cofinity Commercial |
$2.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.14
|
| Rate for Payer: Healthscope Commercial |
$2.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.28
|
| Rate for Payer: PHP Commercial |
$2.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: Priority Health SBD |
$1.69
|
| Rate for Payer: UMR Bronson Commercial |
$0.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.01
|
|
|
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 Commercial |
$41.45
|
| Rate for Payer: Cofinity Commercial |
$50.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.45
|
| 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: PHP Commercial |
$50.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.49
|
| 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
|
$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 Commercial |
$109.56
|
| Rate for Payer: Cofinity Commercial |
$134.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.56
|
| 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: PHP Commercial |
$133.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.73
|
| 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
|
$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 Commercial |
$109.56
|
| Rate for Payer: Cofinity Commercial |
$134.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.56
|
| 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: PHP Commercial |
$133.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.73
|
| Rate for Payer: Priority Health SBD |
$98.60
|
| 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
|
$2.68
|
|
|
Service Code
|
NDC 60687023111
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna American Axle |
$1.74
|
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.74
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Cofinity Commercial |
$2.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.14
|
| Rate for Payer: Healthscope Commercial |
$2.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.28
|
| Rate for Payer: PHP Commercial |
$2.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: Priority Health SBD |
$1.69
|
| Rate for Payer: UMR Bronson Commercial |
$1.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.01
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.88 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna American Axle |
$174.13
|
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.13
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$187.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.72
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.13
|
| Rate for Payer: Priority Health SBD |
$168.78
|
| Rate for Payer: UMR Bronson Commercial |
$117.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.93
|
|
|
SERTRALINE 25 MG TABLET
|
Facility
|
OP
|
$267.90
|
|
|
Service Code
|
NDC 60687023101
|
| Hospital Charge Code |
19882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna American Axle |
$174.13
|
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna Medicare |
$133.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.13
|
| Rate for Payer: BCBS Complete |
$107.16
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$187.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.72
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.13
|
| Rate for Payer: Priority Health SBD |
$168.78
|
| Rate for Payer: UMR Bronson Commercial |
$99.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.93
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$69.80
|
|
|
Service Code
|
NDC 68180035209
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.71 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Aetna American Axle |
$45.37
|
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.37
|
| Rate for Payer: Cash Price |
$55.84
|
| Rate for Payer: Cofinity Commercial |
$48.86
|
| Rate for Payer: Cofinity Commercial |
$60.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$62.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.33
|
| Rate for Payer: PHP Commercial |
$59.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: Priority Health SBD |
$43.97
|
| Rate for Payer: UMR Bronson Commercial |
$30.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.35
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$69.80
|
|
|
Service Code
|
NDC 68180035209
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.83 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Aetna American Axle |
$45.37
|
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Aetna Medicare |
$34.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.37
|
| Rate for Payer: BCBS Complete |
$27.92
|
| Rate for Payer: Cash Price |
$55.84
|
| Rate for Payer: Cofinity Commercial |
$48.86
|
| Rate for Payer: Cofinity Commercial |
$60.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$62.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.33
|
| Rate for Payer: PHP Commercial |
$59.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: Priority Health SBD |
$43.97
|
| Rate for Payer: UMR Bronson Commercial |
$25.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.35
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$304.95
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.18 |
| Max. Negotiated Rate |
$274.45 |
| Rate for Payer: Aetna American Axle |
$198.22
|
| Rate for Payer: Aetna Commercial |
$259.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.22
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$213.47
|
| Rate for Payer: Cofinity Commercial |
$262.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$213.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$274.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.21
|
| Rate for Payer: PHP Commercial |
$259.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.22
|
| Rate for Payer: Priority Health SBD |
$192.12
|
| Rate for Payer: UMR Bronson Commercial |
$134.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.71
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.47 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna American Axle |
$146.64
|
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna Medicare |
$112.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.64
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$194.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health SBD |
$142.13
|
| Rate for Payer: UMR Bronson Commercial |
$83.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.20
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$3.05
|
|
|
Service Code
|
NDC 60687024211
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna American Axle |
$1.98
|
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Aetna Medicare |
$1.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.98
|
| Rate for Payer: BCBS Complete |
$1.22
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.13
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$2.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.59
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: Priority Health SBD |
$1.92
|
| Rate for Payer: UMR Bronson Commercial |
$1.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$1,492.95
|
|
|
Service Code
|
NDC 00049490030
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$656.90 |
| Max. Negotiated Rate |
$1,343.65 |
| Rate for Payer: Aetna American Axle |
$970.42
|
| Rate for Payer: Aetna Commercial |
$1,269.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$970.42
|
| Rate for Payer: Cash Price |
$1,194.36
|
| Rate for Payer: Cofinity Commercial |
$1,045.07
|
| Rate for Payer: Cofinity Commercial |
$1,283.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,045.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,194.36
|
| Rate for Payer: Healthscope Commercial |
$1,343.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,045.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,119.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,269.01
|
| Rate for Payer: PHP Commercial |
$1,269.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$970.42
|
| Rate for Payer: Priority Health SBD |
$940.56
|
| Rate for Payer: UMR Bronson Commercial |
$656.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,119.71
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$1,492.95
|
|
|
Service Code
|
NDC 00049490030
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$552.39 |
| Max. Negotiated Rate |
$1,343.65 |
| Rate for Payer: Aetna American Axle |
$970.42
|
| Rate for Payer: Aetna Commercial |
$1,269.01
|
| Rate for Payer: Aetna Medicare |
$746.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$970.42
|
| Rate for Payer: BCBS Complete |
$597.18
|
| Rate for Payer: Cash Price |
$1,194.36
|
| Rate for Payer: Cofinity Commercial |
$1,045.07
|
| Rate for Payer: Cofinity Commercial |
$1,283.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,045.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,194.36
|
| Rate for Payer: Healthscope Commercial |
$1,343.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,045.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,119.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,269.01
|
| Rate for Payer: PHP Commercial |
$1,269.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$970.42
|
| Rate for Payer: Priority Health SBD |
$940.56
|
| Rate for Payer: UMR Bronson Commercial |
$552.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,119.71
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.26 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna American Axle |
$146.64
|
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.64
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$194.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health SBD |
$142.13
|
| Rate for Payer: UMR Bronson Commercial |
$99.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.20
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$304.95
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.83 |
| Max. Negotiated Rate |
$274.45 |
| Rate for Payer: Aetna American Axle |
$198.22
|
| Rate for Payer: Aetna Commercial |
$259.21
|
| Rate for Payer: Aetna Medicare |
$152.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.22
|
| Rate for Payer: BCBS Complete |
$121.98
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$213.47
|
| Rate for Payer: Cofinity Commercial |
$262.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$213.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$274.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.21
|
| Rate for Payer: PHP Commercial |
$259.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.22
|
| Rate for Payer: Priority Health SBD |
$192.12
|
| Rate for Payer: UMR Bronson Commercial |
$112.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.71
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 60687024211
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna American Axle |
$1.98
|
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.98
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.13
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$2.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.59
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: Priority Health SBD |
$1.92
|
| Rate for Payer: UMR Bronson Commercial |
$1.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$210.90
|
|
|
Service Code
|
NDC 59762490004
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.03 |
| Max. Negotiated Rate |
$189.81 |
| Rate for Payer: Aetna American Axle |
$137.09
|
| Rate for Payer: Aetna Commercial |
$179.26
|
| Rate for Payer: Aetna Medicare |
$105.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.09
|
| Rate for Payer: BCBS Complete |
$84.36
|
| Rate for Payer: Cash Price |
$168.72
|
| Rate for Payer: Cofinity Commercial |
$147.63
|
| Rate for Payer: Cofinity Commercial |
$181.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.72
|
| Rate for Payer: Healthscope Commercial |
$189.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.26
|
| Rate for Payer: PHP Commercial |
$179.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.09
|
| Rate for Payer: Priority Health SBD |
$132.87
|
| Rate for Payer: UMR Bronson Commercial |
$78.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.18
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$210.90
|
|
|
Service Code
|
NDC 59762490004
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.80 |
| Max. Negotiated Rate |
$189.81 |
| Rate for Payer: Aetna American Axle |
$137.09
|
| Rate for Payer: Aetna Commercial |
$179.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.09
|
| Rate for Payer: Cash Price |
$168.72
|
| Rate for Payer: Cofinity Commercial |
$147.63
|
| Rate for Payer: Cofinity Commercial |
$181.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.72
|
| Rate for Payer: Healthscope Commercial |
$189.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.26
|
| Rate for Payer: PHP Commercial |
$179.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.09
|
| Rate for Payer: Priority Health SBD |
$132.87
|
| Rate for Payer: UMR Bronson Commercial |
$92.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.18
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$277.40
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.06 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna American Axle |
$180.31
|
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.31
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$194.18
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.31
|
| Rate for Payer: Priority Health SBD |
$174.76
|
| Rate for Payer: UMR Bronson Commercial |
$122.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.05
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$277.40
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.64 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna American Axle |
$180.31
|
| Rate for Payer: Aetna Commercial |
$235.79
|
| Rate for Payer: Aetna Medicare |
$138.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.31
|
| Rate for Payer: BCBS Complete |
$110.96
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$194.18
|
| Rate for Payer: Cofinity Commercial |
$238.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$249.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: PHP Commercial |
$235.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.31
|
| Rate for Payer: Priority Health SBD |
$174.76
|
| Rate for Payer: UMR Bronson Commercial |
$102.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.05
|
|
|
SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$8,907.47
|
|
|
Service Code
|
CPT 28315
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,696.12 |
| Max. Negotiated Rate |
$8,907.47 |
| Rate for Payer: Aetna Medicare |
$3,290.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,955.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,955.50
|
| Rate for Payer: BCBS Complete |
$1,780.92
|
| Rate for Payer: BCBS MAPPO |
$3,164.40
|
| Rate for Payer: BCN Medicare Advantage |
$3,164.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,164.40
|
| Rate for Payer: Mclaren Medicaid |
$1,696.12
|
| Rate for Payer: Mclaren Medicare |
$3,164.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,322.62
|
| Rate for Payer: Meridian Medicaid |
$1,780.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,639.06
|
| Rate for Payer: PACE Medicare |
$3,006.18
|
| Rate for Payer: PACE SWMI |
$3,164.40
|
| Rate for Payer: PHP Medicare Advantage |
$3,164.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.12
|
| Rate for Payer: Priority Health Medicare |
$3,164.40
|
| Rate for Payer: Railroad Medicare Medicare |
$3,164.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,907.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,164.40
|
| Rate for Payer: UHC Exchange |
$6,047.48
|
| Rate for Payer: UHC Medicare Advantage |
$3,164.40
|
| Rate for Payer: UHCCP Medicaid |
$1,696.12
|
| Rate for Payer: VA VA |
$3,164.40
|
|
