|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.12 |
| Max. Negotiated Rate |
$380.70 |
| Rate for Payer: Aetna American Axle |
$274.95
|
| Rate for Payer: Aetna Commercial |
$359.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.95
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$296.10
|
| Rate for Payer: Cofinity Commercial |
$363.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$296.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$380.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.55
|
| Rate for Payer: PHP Commercial |
$359.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.95
|
| Rate for Payer: Priority Health SBD |
$266.49
|
| Rate for Payer: UMR Bronson Commercial |
$186.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.25
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$725.76
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.53 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Aetna American Axle |
$471.74
|
| Rate for Payer: Aetna Commercial |
$616.90
|
| Rate for Payer: Aetna Medicare |
$362.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$471.74
|
| Rate for Payer: BCBS Complete |
$290.30
|
| Rate for Payer: Cash Price |
$580.61
|
| Rate for Payer: Cofinity Commercial |
$508.03
|
| Rate for Payer: Cofinity Commercial |
$624.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$508.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$580.61
|
| Rate for Payer: Healthscope Commercial |
$653.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$508.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$544.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$616.90
|
| Rate for Payer: PHP Commercial |
$616.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$471.74
|
| Rate for Payer: Priority Health SBD |
$457.23
|
| Rate for Payer: UMR Bronson Commercial |
$268.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$544.32
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$408.90
|
|
|
Service Code
|
NDC 00591079601
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.92 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna American Axle |
$265.78
|
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.78
|
| Rate for Payer: Cash Price |
$327.12
|
| Rate for Payer: Cofinity Commercial |
$286.23
|
| Rate for Payer: Cofinity Commercial |
$351.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$286.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.12
|
| Rate for Payer: Healthscope Commercial |
$368.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$286.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$306.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$347.56
|
| Rate for Payer: PHP Commercial |
$347.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.78
|
| Rate for Payer: Priority Health SBD |
$257.61
|
| Rate for Payer: UMR Bronson Commercial |
$179.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$306.68
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$423.00
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.51 |
| Max. Negotiated Rate |
$380.70 |
| Rate for Payer: Aetna American Axle |
$274.95
|
| Rate for Payer: Aetna Commercial |
$359.55
|
| Rate for Payer: Aetna Medicare |
$211.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.95
|
| Rate for Payer: BCBS Complete |
$169.20
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$296.10
|
| Rate for Payer: Cofinity Commercial |
$363.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$296.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$380.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.55
|
| Rate for Payer: PHP Commercial |
$359.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.95
|
| Rate for Payer: Priority Health SBD |
$266.49
|
| Rate for Payer: UMR Bronson Commercial |
$156.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.25
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$408.90
|
|
|
Service Code
|
NDC 00591079601
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.29 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna American Axle |
$265.78
|
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: Aetna Medicare |
$204.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.78
|
| Rate for Payer: BCBS Complete |
$163.56
|
| Rate for Payer: Cash Price |
$327.12
|
| Rate for Payer: Cofinity Commercial |
$286.23
|
| Rate for Payer: Cofinity Commercial |
$351.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$286.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.12
|
| Rate for Payer: Healthscope Commercial |
$368.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$286.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$306.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$347.56
|
| Rate for Payer: PHP Commercial |
$347.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.78
|
| Rate for Payer: Priority Health SBD |
$257.61
|
| Rate for Payer: UMR Bronson Commercial |
$151.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$306.68
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$725.76
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$319.33 |
| Max. Negotiated Rate |
$653.18 |
| Rate for Payer: Aetna American Axle |
$471.74
|
| Rate for Payer: Aetna Commercial |
$616.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$471.74
|
| Rate for Payer: Cash Price |
$580.61
|
| Rate for Payer: Cofinity Commercial |
$508.03
|
| Rate for Payer: Cofinity Commercial |
$624.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$508.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$580.61
|
| Rate for Payer: Healthscope Commercial |
$653.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$508.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$544.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$616.90
|
| Rate for Payer: PHP Commercial |
$616.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$471.74
|
| Rate for Payer: Priority Health SBD |
$457.23
|
| Rate for Payer: UMR Bronson Commercial |
$319.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$544.32
|
|
|
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 Commercial |
$1,581.55
|
| Rate for Payer: Cofinity Commercial |
$1,943.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,581.55
|
| 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: Multiplan/Beech St/PHCS Commercial |
$1,920.46
|
| Rate for Payer: PHP Commercial |
$1,920.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,468.58
|
| Rate for Payer: Priority Health SBD |
$1,423.40
|
| Rate for Payer: UMR Bronson Commercial |
$835.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,694.52
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$205.20
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.29 |
| Max. Negotiated Rate |
$184.68 |
| Rate for Payer: Aetna American Axle |
$133.38
|
| Rate for Payer: Aetna Commercial |
$174.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$133.38
|
| Rate for Payer: Cash Price |
$164.16
|
| Rate for Payer: Cofinity Commercial |
$143.64
|
| Rate for Payer: Cofinity Commercial |
$176.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$143.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.16
|
| Rate for Payer: Healthscope Commercial |
$184.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.42
|
| Rate for Payer: PHP Commercial |
$174.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.38
|
| Rate for Payer: Priority Health SBD |
$129.28
|
| Rate for Payer: UMR Bronson Commercial |
$90.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.90
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$595.65
|
|
|
Service Code
|
NDC 59762010406
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.39 |
| Max. Negotiated Rate |
$536.08 |
| Rate for Payer: Aetna American Axle |
$387.17
|
| Rate for Payer: Aetna Commercial |
$506.30
|
| Rate for Payer: Aetna Medicare |
$297.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.17
|
| Rate for Payer: BCBS Complete |
$238.26
|
| Rate for Payer: Cash Price |
$476.52
|
| Rate for Payer: Cofinity Commercial |
$416.96
|
| Rate for Payer: Cofinity Commercial |
$512.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.52
|
| Rate for Payer: Healthscope Commercial |
$536.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.30
|
| Rate for Payer: PHP Commercial |
$506.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$387.17
|
| Rate for Payer: Priority Health SBD |
$375.26
|
| Rate for Payer: UMR Bronson Commercial |
$220.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.74
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$205.20
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.92 |
| Max. Negotiated Rate |
$184.68 |
| Rate for Payer: Aetna American Axle |
$133.38
|
| Rate for Payer: Aetna Commercial |
$174.42
|
| Rate for Payer: Aetna Medicare |
$102.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$133.38
|
| Rate for Payer: BCBS Complete |
$82.08
|
| Rate for Payer: Cash Price |
$164.16
|
| Rate for Payer: Cofinity Commercial |
$143.64
|
| Rate for Payer: Cofinity Commercial |
$176.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$143.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.16
|
| Rate for Payer: Healthscope Commercial |
$184.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$143.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.42
|
| Rate for Payer: PHP Commercial |
$174.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.38
|
| Rate for Payer: Priority Health SBD |
$129.28
|
| Rate for Payer: UMR Bronson Commercial |
$75.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.90
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$595.65
|
|
|
Service Code
|
NDC 59762010406
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.09 |
| Max. Negotiated Rate |
$536.08 |
| Rate for Payer: Aetna American Axle |
$387.17
|
| Rate for Payer: Aetna Commercial |
$506.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.17
|
| Rate for Payer: Cash Price |
$476.52
|
| Rate for Payer: Cofinity Commercial |
$416.96
|
| Rate for Payer: Cofinity Commercial |
$512.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.52
|
| Rate for Payer: Healthscope Commercial |
$536.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.30
|
| Rate for Payer: PHP Commercial |
$506.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$387.17
|
| Rate for Payer: Priority Health SBD |
$375.26
|
| Rate for Payer: UMR Bronson Commercial |
$262.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.74
|
|
|
SULFUR HEXAFLUORIDE MICROSPHERES 25 MG INTRAVENOUS SUSPENSION
|
Facility
|
OP
|
$24.91
|
|
|
Service Code
|
HCPCS Q9950
|
| Hospital Charge Code |
175536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$24.91 |
| Rate for Payer: BCBS Trust/PPO |
$24.91
|
| Rate for Payer: BCN Commercial |
$24.91
|
|
|
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 Commercial |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$188.86
|
| 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: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.37
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| 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 Commercial |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$188.86
|
| 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: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.37
|
| 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 Commercial |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.05
|
| 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: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.12
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| 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 Commercial |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.05
|
| 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: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.12
|
| 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
|
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 Commercial |
$745.51
|
| Rate for Payer: Cofinity Commercial |
$915.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$745.51
|
| 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: PHP Commercial |
$905.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$692.26
|
| 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 Commercial |
$745.51
|
| Rate for Payer: Cofinity Commercial |
$915.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$745.51
|
| 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: PHP Commercial |
$905.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$692.26
|
| Rate for Payer: Priority Health SBD |
$670.96
|
| Rate for Payer: UMR Bronson Commercial |
$394.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$798.76
|
|
|
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 Commercial |
$66.62
|
| Rate for Payer: Cofinity Commercial |
$81.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.62
|
| 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: PHP Commercial |
$80.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.86
|
| 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
|
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 |
$47.58
|
| 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 Commercial |
$66.62
|
| Rate for Payer: Cofinity Commercial |
$81.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.62
|
| 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: PHP Commercial |
$80.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.86
|
| Rate for Payer: Priority Health SBD |
$59.96
|
| Rate for Payer: UMR Bronson Commercial |
$35.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.38
|
|
|
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 Commercial |
$1,625.04
|
| Rate for Payer: Cofinity Commercial |
$1,996.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,625.04
|
| 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: PHP Commercial |
$1,973.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,508.96
|
| 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
|
$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 Commercial |
$199.35
|
| Rate for Payer: Cofinity Commercial |
$244.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.35
|
| 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 |
$213.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.06
|
| Rate for Payer: PHP Commercial |
$242.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.11
|
| Rate for Payer: Priority Health SBD |
$179.41
|
| Rate for Payer: UMR Bronson Commercial |
$105.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.58
|
|
|
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 |
$2.30 |
| 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 Commercial |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| 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: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| 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
|
OP
|
$2.55
|
|
|
Service Code
|
NDC 09900000877
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| 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 Commercial |
$1.78
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.04
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| 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: PHP Commercial |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$0.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.91
|
|
|
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 Commercial |
$1,625.04
|
| Rate for Payer: Cofinity Commercial |
$1,996.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,625.04
|
| 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: PHP Commercial |
$1,973.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,508.96
|
| Rate for Payer: Priority Health SBD |
$1,462.53
|
| Rate for Payer: UMR Bronson Commercial |
$858.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,741.11
|
|
