|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.05 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna American Axle |
$138.94
|
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.94
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Advantage |
$149.62
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$149.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health SBD |
$134.66
|
| Rate for Payer: UMR Bronson Commercial |
$94.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.31
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$2,259.36
|
|
|
Service Code
|
NDC 00013010130
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$835.96 |
| Max. Negotiated Rate |
$2,033.42 |
| Rate for Payer: Aetna American Axle |
$1,468.58
|
| Rate for Payer: Aetna Commercial |
$1,920.46
|
| Rate for Payer: Aetna Medicare |
$1,129.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,468.58
|
| Rate for Payer: BCBS Complete |
$903.74
|
| Rate for Payer: Cash Price |
$1,807.49
|
| Rate for Payer: Cofinity Advantage |
$1,581.55
|
| Rate for Payer: Cofinity Commercial |
$1,943.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,807.49
|
| Rate for Payer: Healthscope Commercial |
$2,033.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,581.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,694.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,807.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,920.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,694.52
|
| Rate for Payer: PHP Commercial |
$1,920.46
|
| Rate for Payer: Priority Health SBD |
$1,423.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,468.58
|
| Rate for Payer: UHC Core |
$1,177.13
|
| Rate for Payer: UHC Exchange |
$887.93
|
| Rate for Payer: UMR Bronson Commercial |
$835.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,694.52
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$744.96
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$327.78 |
| Max. Negotiated Rate |
$670.46 |
| Rate for Payer: Aetna American Axle |
$484.22
|
| Rate for Payer: Aetna Commercial |
$633.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$484.22
|
| Rate for Payer: Cash Price |
$595.97
|
| Rate for Payer: Cofinity Advantage |
$521.47
|
| Rate for Payer: Cofinity Commercial |
$640.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$595.97
|
| Rate for Payer: Healthscope Commercial |
$670.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$521.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$558.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$633.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$558.72
|
| Rate for Payer: PHP Commercial |
$633.22
|
| Rate for Payer: Priority Health SBD |
$469.32
|
| Rate for Payer: UMR Bronson Commercial |
$327.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$558.72
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$248.90
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.52 |
| Max. Negotiated Rate |
$224.01 |
| Rate for Payer: Aetna American Axle |
$161.78
|
| Rate for Payer: Aetna Commercial |
$211.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.78
|
| Rate for Payer: Cash Price |
$199.12
|
| Rate for Payer: Cofinity Advantage |
$174.23
|
| Rate for Payer: Cofinity Commercial |
$214.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.12
|
| Rate for Payer: Healthscope Commercial |
$224.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$174.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$186.68
|
| Rate for Payer: PHP Commercial |
$211.56
|
| Rate for Payer: Priority Health SBD |
$156.81
|
| Rate for Payer: UMR Bronson Commercial |
$109.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.68
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$769.50
|
|
|
Service Code
|
NDC 59762010406
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$338.58 |
| Max. Negotiated Rate |
$692.55 |
| Rate for Payer: Aetna American Axle |
$500.18
|
| Rate for Payer: Aetna Commercial |
$654.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$500.18
|
| Rate for Payer: Cash Price |
$615.60
|
| Rate for Payer: Cofinity Advantage |
$538.65
|
| Rate for Payer: Cofinity Commercial |
$661.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$615.60
|
| Rate for Payer: Healthscope Commercial |
$692.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$538.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$577.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$654.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$577.12
|
| Rate for Payer: PHP Commercial |
$654.08
|
| Rate for Payer: Priority Health SBD |
$484.79
|
| Rate for Payer: UMR Bronson Commercial |
$338.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$577.12
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$248.90
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.09 |
| Max. Negotiated Rate |
$224.01 |
| Rate for Payer: Aetna American Axle |
$161.78
|
| Rate for Payer: Aetna Commercial |
$211.56
|
| Rate for Payer: Aetna Medicare |
$124.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.78
|
| Rate for Payer: BCBS Complete |
$99.56
|
| Rate for Payer: Cash Price |
$199.12
|
| Rate for Payer: Cofinity Advantage |
$174.23
|
| Rate for Payer: Cofinity Commercial |
$214.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.12
|
| Rate for Payer: Healthscope Commercial |
$224.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$174.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$199.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$186.68
|
| Rate for Payer: PHP Commercial |
$211.56
|
| Rate for Payer: Priority Health SBD |
$156.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$161.78
|
| Rate for Payer: UHC Core |
$129.68
|
| Rate for Payer: UHC Exchange |
$97.82
|
| Rate for Payer: UMR Bronson Commercial |
$92.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.68
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$769.50
|
|
|
Service Code
|
NDC 59762010406
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.71 |
| Max. Negotiated Rate |
$692.55 |
| Rate for Payer: Aetna American Axle |
$500.18
|
| Rate for Payer: Aetna Commercial |
$654.08
|
| Rate for Payer: Aetna Medicare |
$384.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$500.18
|
| Rate for Payer: BCBS Complete |
$307.80
|
| Rate for Payer: Cash Price |
$615.60
|
| Rate for Payer: Cofinity Advantage |
$538.65
|
| Rate for Payer: Cofinity Commercial |
$661.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$615.60
|
| Rate for Payer: Healthscope Commercial |
$692.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$538.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$577.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$615.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$654.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$577.12
|
| Rate for Payer: PHP Commercial |
$654.08
|
| Rate for Payer: Priority Health SBD |
$484.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$500.18
|
| Rate for Payer: UHC Core |
$400.91
|
| Rate for Payer: UHC Exchange |
$302.41
|
| Rate for Payer: UMR Bronson Commercial |
$284.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$577.12
|
|
|
SULINDAC 200 MG TABLET
|
Facility
|
OP
|
$269.80
|
|
|
Service Code
|
NDC 42806001101
|
| Hospital Charge Code |
7579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.83 |
| Max. Negotiated Rate |
$242.82 |
| Rate for Payer: Aetna American Axle |
$175.37
|
| Rate for Payer: Aetna Commercial |
$229.33
|
| Rate for Payer: Aetna Medicare |
$134.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.37
|
| Rate for Payer: BCBS Complete |
$107.92
|
| Rate for Payer: Cash Price |
$215.84
|
| Rate for Payer: Cofinity Advantage |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.84
|
| Rate for Payer: Healthscope Commercial |
$242.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$215.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$202.35
|
| Rate for Payer: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.37
|
| Rate for Payer: UHC Core |
$140.57
|
| Rate for Payer: UHC Exchange |
$106.03
|
| Rate for Payer: UMR Bronson Commercial |
$99.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.35
|
|
|
SULINDAC 200 MG TABLET
|
Facility
|
IP
|
$269.80
|
|
|
Service Code
|
NDC 42806001101
|
| Hospital Charge Code |
7579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.71 |
| Max. Negotiated Rate |
$242.82 |
| Rate for Payer: Aetna American Axle |
$175.37
|
| Rate for Payer: Aetna Commercial |
$229.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.37
|
| Rate for Payer: Cash Price |
$215.84
|
| Rate for Payer: Cofinity Advantage |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.84
|
| Rate for Payer: Healthscope Commercial |
$242.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$202.35
|
| Rate for Payer: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| Rate for Payer: UMR Bronson Commercial |
$118.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.35
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY
|
Facility
|
OP
|
$318.64
|
|
|
Service Code
|
NDC 00173052300
|
| Hospital Charge Code |
20039
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.90 |
| Max. Negotiated Rate |
$286.78 |
| Rate for Payer: Aetna American Axle |
$207.12
|
| Rate for Payer: Aetna Commercial |
$270.84
|
| Rate for Payer: Aetna Medicare |
$159.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.12
|
| Rate for Payer: BCBS Complete |
$127.46
|
| Rate for Payer: Cash Price |
$254.91
|
| Rate for Payer: Cofinity Advantage |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.91
|
| Rate for Payer: Healthscope Commercial |
$286.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$254.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$238.98
|
| Rate for Payer: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$207.12
|
| Rate for Payer: UHC Core |
$166.01
|
| Rate for Payer: UHC Exchange |
$125.23
|
| Rate for Payer: UMR Bronson Commercial |
$117.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.98
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$318.64
|
|
|
Service Code
|
NDC 00173052300
|
| Hospital Charge Code |
20039
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.20 |
| Max. Negotiated Rate |
$286.78 |
| Rate for Payer: Aetna American Axle |
$207.12
|
| Rate for Payer: Aetna Commercial |
$270.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.12
|
| Rate for Payer: Cash Price |
$254.91
|
| Rate for Payer: Cofinity Advantage |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.91
|
| Rate for Payer: Healthscope Commercial |
$286.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$238.98
|
| Rate for Payer: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| Rate for Payer: UMR Bronson Commercial |
$140.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.98
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
OP
|
$95.17
|
|
|
Service Code
|
NDC 09900000878
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.21 |
| Max. Negotiated Rate |
$85.65 |
| Rate for Payer: Aetna American Axle |
$61.86
|
| Rate for Payer: Aetna Commercial |
$80.89
|
| Rate for Payer: Aetna Medicare |
$47.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.86
|
| Rate for Payer: BCBS Complete |
$38.07
|
| Rate for Payer: Cash Price |
$76.14
|
| Rate for Payer: Cofinity Advantage |
$66.62
|
| Rate for Payer: Cofinity Commercial |
$81.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.14
|
| Rate for Payer: Healthscope Commercial |
$85.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.38
|
| Rate for Payer: PHP Commercial |
$80.89
|
| Rate for Payer: Priority Health SBD |
$59.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.86
|
| Rate for Payer: UHC Core |
$49.58
|
| Rate for Payer: UHC Exchange |
$37.40
|
| Rate for Payer: UMR Bronson Commercial |
$35.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.38
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
IP
|
$95.17
|
|
|
Service Code
|
NDC 09900000878
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.87 |
| Max. Negotiated Rate |
$85.65 |
| Rate for Payer: Aetna American Axle |
$61.86
|
| Rate for Payer: Aetna Commercial |
$80.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.86
|
| Rate for Payer: Cash Price |
$76.14
|
| Rate for Payer: Cofinity Advantage |
$66.62
|
| Rate for Payer: Cofinity Commercial |
$81.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.14
|
| Rate for Payer: Healthscope Commercial |
$85.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.38
|
| Rate for Payer: PHP Commercial |
$80.89
|
| Rate for Payer: Priority Health SBD |
$59.96
|
| Rate for Payer: UMR Bronson Commercial |
$41.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.38
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
IP
|
$1,065.01
|
|
|
Service Code
|
NDC 00173073500
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$468.60 |
| Max. Negotiated Rate |
$958.51 |
| Rate for Payer: Aetna American Axle |
$692.26
|
| Rate for Payer: Aetna Commercial |
$905.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$692.26
|
| Rate for Payer: Cash Price |
$852.01
|
| Rate for Payer: Cofinity Advantage |
$745.51
|
| Rate for Payer: Cofinity Commercial |
$915.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$852.01
|
| Rate for Payer: Healthscope Commercial |
$958.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$745.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$798.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$905.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$798.76
|
| Rate for Payer: PHP Commercial |
$905.26
|
| Rate for Payer: Priority Health SBD |
$670.96
|
| Rate for Payer: UMR Bronson Commercial |
$468.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$798.76
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
OP
|
$1,065.01
|
|
|
Service Code
|
NDC 00173073500
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$394.05 |
| Max. Negotiated Rate |
$958.51 |
| Rate for Payer: Aetna American Axle |
$692.26
|
| Rate for Payer: Aetna Commercial |
$905.26
|
| Rate for Payer: Aetna Medicare |
$532.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$692.26
|
| Rate for Payer: BCBS Complete |
$426.00
|
| Rate for Payer: Cash Price |
$852.01
|
| Rate for Payer: Cofinity Advantage |
$745.51
|
| Rate for Payer: Cofinity Commercial |
$915.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$852.01
|
| Rate for Payer: Healthscope Commercial |
$958.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$745.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$798.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$852.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$905.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$798.76
|
| Rate for Payer: PHP Commercial |
$905.26
|
| Rate for Payer: Priority Health SBD |
$670.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$692.26
|
| Rate for Payer: UHC Core |
$554.87
|
| Rate for Payer: UHC Exchange |
$418.55
|
| Rate for Payer: UMR Bronson Commercial |
$394.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$798.76
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$2,321.48
|
|
|
Service Code
|
NDC 00173073601
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$858.95 |
| Max. Negotiated Rate |
$2,089.33 |
| Rate for Payer: Aetna American Axle |
$1,508.96
|
| Rate for Payer: Aetna Commercial |
$1,973.26
|
| Rate for Payer: Aetna Medicare |
$1,160.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,508.96
|
| Rate for Payer: BCBS Complete |
$928.59
|
| Rate for Payer: Cash Price |
$1,857.18
|
| Rate for Payer: Cofinity Advantage |
$1,625.04
|
| Rate for Payer: Cofinity Commercial |
$1,996.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,857.18
|
| Rate for Payer: Healthscope Commercial |
$2,089.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,625.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,741.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,857.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,973.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,741.11
|
| Rate for Payer: PHP Commercial |
$1,973.26
|
| Rate for Payer: Priority Health SBD |
$1,462.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,508.96
|
| Rate for Payer: UHC Core |
$1,209.49
|
| Rate for Payer: UHC Exchange |
$912.34
|
| Rate for Payer: UMR Bronson Commercial |
$858.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,741.11
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$284.78
|
|
|
Service Code
|
NDC 55111029236
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.37 |
| Max. Negotiated Rate |
$256.30 |
| Rate for Payer: Aetna American Axle |
$185.11
|
| Rate for Payer: Aetna Commercial |
$242.06
|
| Rate for Payer: Aetna Medicare |
$142.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.11
|
| Rate for Payer: BCBS Complete |
$113.91
|
| Rate for Payer: Cash Price |
$227.82
|
| Rate for Payer: Cofinity Advantage |
$199.35
|
| Rate for Payer: Cofinity Commercial |
$244.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.82
|
| Rate for Payer: Healthscope Commercial |
$256.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$227.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$213.59
|
| Rate for Payer: PHP Commercial |
$242.06
|
| Rate for Payer: Priority Health SBD |
$179.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$185.11
|
| Rate for Payer: UHC Core |
$148.37
|
| Rate for Payer: UHC Exchange |
$111.92
|
| Rate for Payer: UMR Bronson Commercial |
$105.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.59
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$284.78
|
|
|
Service Code
|
NDC 55111029236
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$256.30 |
| Rate for Payer: Aetna American Axle |
$185.11
|
| Rate for Payer: Aetna Commercial |
$242.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.11
|
| Rate for Payer: Cash Price |
$227.82
|
| Rate for Payer: Cofinity Advantage |
$199.35
|
| Rate for Payer: Cofinity Commercial |
$244.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.82
|
| Rate for Payer: Healthscope Commercial |
$256.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$213.59
|
| Rate for Payer: PHP Commercial |
$242.06
|
| Rate for Payer: Priority Health SBD |
$179.41
|
| Rate for Payer: UMR Bronson Commercial |
$125.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.59
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 09900000877
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Advantage |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.91
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$1.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.91
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$2,321.48
|
|
|
Service Code
|
NDC 00173073601
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,021.45 |
| Max. Negotiated Rate |
$2,089.33 |
| Rate for Payer: Aetna American Axle |
$1,508.96
|
| Rate for Payer: Aetna Commercial |
$1,973.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,508.96
|
| Rate for Payer: Cash Price |
$1,857.18
|
| Rate for Payer: Cofinity Advantage |
$1,625.04
|
| Rate for Payer: Cofinity Commercial |
$1,996.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,857.18
|
| Rate for Payer: Healthscope Commercial |
$2,089.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,625.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,741.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,973.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,741.11
|
| Rate for Payer: PHP Commercial |
$1,973.26
|
| Rate for Payer: Priority Health SBD |
$1,462.53
|
| Rate for Payer: UMR Bronson Commercial |
$1,021.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,741.11
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
OP
|
$2.55
|
|
|
Service Code
|
NDC 09900000877
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: BCBS Complete |
$1.02
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cofinity Advantage |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.91
|
| Rate for Payer: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.66
|
| Rate for Payer: UHC Core |
$1.33
|
| Rate for Payer: UHC Exchange |
$1.00
|
| Rate for Payer: UMR Bronson Commercial |
$0.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.91
|
|
|
SUMATRIPTAN 5 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$318.64
|
|
|
Service Code
|
NDC 00173052400
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.20 |
| Max. Negotiated Rate |
$286.78 |
| Rate for Payer: Aetna American Axle |
$207.12
|
| Rate for Payer: Aetna Commercial |
$270.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.12
|
| Rate for Payer: Cash Price |
$254.91
|
| Rate for Payer: Cofinity Advantage |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.91
|
| Rate for Payer: Healthscope Commercial |
$286.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$238.98
|
| Rate for Payer: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| Rate for Payer: UMR Bronson Commercial |
$140.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.98
|
|
|
SUMATRIPTAN 5 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$71.55
|
|
|
Service Code
|
NDC 45802061900
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.48 |
| Max. Negotiated Rate |
$64.39 |
| Rate for Payer: Aetna American Axle |
$46.51
|
| Rate for Payer: Aetna Commercial |
$60.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.51
|
| Rate for Payer: Cash Price |
$57.24
|
| Rate for Payer: Cofinity Advantage |
$50.09
|
| Rate for Payer: Cofinity Commercial |
$61.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.24
|
| Rate for Payer: Healthscope Commercial |
$64.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.66
|
| Rate for Payer: PHP Commercial |
$60.82
|
| Rate for Payer: Priority Health SBD |
$45.08
|
| Rate for Payer: UMR Bronson Commercial |
$31.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.66
|
|
|
SUMATRIPTAN 5 MG/ACTUATION NASAL SPRAY
|
Facility
|
OP
|
$169.31
|
|
|
Service Code
|
NDC 66993008169
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.64 |
| Max. Negotiated Rate |
$152.38 |
| Rate for Payer: Aetna American Axle |
$110.05
|
| Rate for Payer: Aetna Commercial |
$143.91
|
| Rate for Payer: Aetna Medicare |
$84.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.05
|
| Rate for Payer: BCBS Complete |
$67.72
|
| Rate for Payer: Cash Price |
$135.45
|
| Rate for Payer: Cofinity Advantage |
$118.52
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.45
|
| Rate for Payer: Healthscope Commercial |
$152.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.98
|
| Rate for Payer: PHP Commercial |
$143.91
|
| Rate for Payer: Priority Health SBD |
$106.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$110.05
|
| Rate for Payer: UHC Core |
$88.21
|
| Rate for Payer: UHC Exchange |
$66.54
|
| Rate for Payer: UMR Bronson Commercial |
$62.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.98
|
|
|
SUMATRIPTAN 5 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$169.31
|
|
|
Service Code
|
NDC 66993008169
|
| Hospital Charge Code |
20038
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.50 |
| Max. Negotiated Rate |
$152.38 |
| Rate for Payer: Aetna American Axle |
$110.05
|
| Rate for Payer: Aetna Commercial |
$143.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.05
|
| Rate for Payer: Cash Price |
$135.45
|
| Rate for Payer: Cofinity Advantage |
$118.52
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.45
|
| Rate for Payer: Healthscope Commercial |
$152.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.98
|
| Rate for Payer: PHP Commercial |
$143.91
|
| Rate for Payer: Priority Health SBD |
$106.67
|
| Rate for Payer: UMR Bronson Commercial |
$74.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.98
|
|
