|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$277.40
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.31 |
| Max. Negotiated Rate |
$277.40 |
| Rate for Payer: Aetna Commercial |
$249.66
|
| Rate for Payer: ASR ASR |
$269.08
|
| Rate for Payer: ASR Commercial |
$269.08
|
| Rate for Payer: BCBS Trust/PPO |
$226.05
|
| Rate for Payer: BCN Commercial |
$215.07
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$260.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$277.40
|
| Rate for Payer: Healthscope Whirlpool |
$269.08
|
| Rate for Payer: Mclaren Commercial |
$249.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Nomi Health Commercial |
$227.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.11
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$31.73
|
|
|
Service Code
|
NDC 68180035206
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.69 |
| Max. Negotiated Rate |
$31.73 |
| Rate for Payer: Aetna Commercial |
$28.56
|
| Rate for Payer: Aetna Medicare |
$15.86
|
| Rate for Payer: ASR ASR |
$30.78
|
| Rate for Payer: ASR Commercial |
$30.78
|
| Rate for Payer: BCBS Complete |
$12.69
|
| Rate for Payer: BCBS Trust/PPO |
$25.98
|
| Rate for Payer: BCN Commercial |
$24.60
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Cofinity Commercial |
$29.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.38
|
| Rate for Payer: Healthscope Commercial |
$31.73
|
| Rate for Payer: Healthscope Whirlpool |
$30.78
|
| Rate for Payer: Mclaren Commercial |
$28.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.97
|
| Rate for Payer: Nomi Health Commercial |
$26.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.80
|
| Rate for Payer: Priority Health Narrow Network |
$22.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.92
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$304.95
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.98 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$274.46
|
| Rate for Payer: Aetna Medicare |
$152.48
|
| Rate for Payer: ASR ASR |
$295.80
|
| Rate for Payer: ASR Commercial |
$295.80
|
| Rate for Payer: BCBS Complete |
$121.98
|
| Rate for Payer: BCBS Trust/PPO |
$249.72
|
| Rate for Payer: BCN Commercial |
$236.43
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$286.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$304.95
|
| Rate for Payer: Healthscope Whirlpool |
$295.80
|
| Rate for Payer: Mclaren Commercial |
$274.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.21
|
| Rate for Payer: Nomi Health Commercial |
$250.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$267.20
|
| Rate for Payer: Priority Health Narrow Network |
$213.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$268.36
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.64 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: ASR Commercial |
$218.83
|
| Rate for Payer: BCBS Trust/PPO |
$183.84
|
| Rate for Payer: BCN Commercial |
$174.91
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$225.60
|
| Rate for Payer: Healthscope Whirlpool |
$218.83
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$277.40
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.96 |
| Max. Negotiated Rate |
$277.40 |
| Rate for Payer: Aetna Commercial |
$249.66
|
| Rate for Payer: Aetna Medicare |
$138.70
|
| Rate for Payer: ASR ASR |
$269.08
|
| Rate for Payer: ASR Commercial |
$269.08
|
| Rate for Payer: BCBS Complete |
$110.96
|
| Rate for Payer: BCBS Trust/PPO |
$227.16
|
| Rate for Payer: BCN Commercial |
$215.07
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$260.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$277.40
|
| Rate for Payer: Healthscope Whirlpool |
$269.08
|
| Rate for Payer: Mclaren Commercial |
$249.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Nomi Health Commercial |
$227.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$243.06
|
| Rate for Payer: Priority Health Narrow Network |
$194.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.11
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$4,976.87
|
|
|
Service Code
|
NDC 00049490041
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,990.75 |
| Max. Negotiated Rate |
$4,976.87 |
| Rate for Payer: Aetna Commercial |
$4,479.18
|
| Rate for Payer: Aetna Medicare |
$2,488.44
|
| Rate for Payer: ASR ASR |
$4,827.56
|
| Rate for Payer: ASR Commercial |
$4,827.56
|
| Rate for Payer: BCBS Complete |
$1,990.75
|
| Rate for Payer: BCBS Trust/PPO |
$4,075.56
|
| Rate for Payer: BCN Commercial |
$3,858.57
|
| Rate for Payer: Cash Price |
$3,981.50
|
| Rate for Payer: Cofinity Commercial |
$4,678.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,981.50
|
| Rate for Payer: Healthscope Commercial |
$4,976.87
|
| Rate for Payer: Healthscope Whirlpool |
$4,827.56
|
| Rate for Payer: Mclaren Commercial |
$4,479.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,230.34
|
| Rate for Payer: Nomi Health Commercial |
$4,081.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,234.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,360.73
|
| Rate for Payer: Priority Health Narrow Network |
$3,488.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,379.65
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.24 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: Aetna Medicare |
$112.80
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: ASR Commercial |
$218.83
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: BCBS Trust/PPO |
$184.74
|
| Rate for Payer: BCN Commercial |
$174.91
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$225.60
|
| Rate for Payer: Healthscope Whirlpool |
$218.83
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$197.67
|
| Rate for Payer: Priority Health Narrow Network |
$158.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$304.95
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.22 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$274.46
|
| Rate for Payer: ASR ASR |
$295.80
|
| Rate for Payer: ASR Commercial |
$295.80
|
| Rate for Payer: BCBS Trust/PPO |
$248.50
|
| Rate for Payer: BCN Commercial |
$236.43
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$286.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$304.95
|
| Rate for Payer: Healthscope Whirlpool |
$295.80
|
| Rate for Payer: Mclaren Commercial |
$274.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.21
|
| Rate for Payer: Nomi Health Commercial |
$250.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$268.36
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: Aetna Medicare |
$2.58
|
| Rate for Payer: ASR ASR |
$5.01
|
| Rate for Payer: ASR Commercial |
$5.01
|
| Rate for Payer: BCBS Complete |
$2.06
|
| Rate for Payer: BCBS Trust/PPO |
$4.23
|
| Rate for Payer: BCN Commercial |
$4.00
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$4.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$5.16
|
| Rate for Payer: Healthscope Whirlpool |
$5.01
|
| Rate for Payer: Mclaren Commercial |
$4.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Nomi Health Commercial |
$4.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.52
|
| Rate for Payer: Priority Health Narrow Network |
$3.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.54
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$81.90
|
|
|
Service Code
|
NDC 12165010003
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.24 |
| Max. Negotiated Rate |
$81.90 |
| Rate for Payer: Aetna Commercial |
$73.71
|
| Rate for Payer: ASR ASR |
$79.44
|
| Rate for Payer: ASR Commercial |
$79.44
|
| Rate for Payer: BCBS Trust/PPO |
$66.74
|
| Rate for Payer: BCN Commercial |
$63.50
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$76.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$81.90
|
| Rate for Payer: Healthscope Whirlpool |
$79.44
|
| Rate for Payer: Mclaren Commercial |
$73.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: Nomi Health Commercial |
$67.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.07
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$81.90
|
|
|
Service Code
|
NDC 12165010003
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$81.90 |
| Rate for Payer: Aetna Commercial |
$73.71
|
| Rate for Payer: Aetna Medicare |
$40.95
|
| Rate for Payer: ASR ASR |
$79.44
|
| Rate for Payer: ASR Commercial |
$79.44
|
| Rate for Payer: BCBS Complete |
$32.76
|
| Rate for Payer: BCBS Trust/PPO |
$67.07
|
| Rate for Payer: BCN Commercial |
$63.50
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$76.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$81.90
|
| Rate for Payer: Healthscope Whirlpool |
$79.44
|
| Rate for Payer: Mclaren Commercial |
$73.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.62
|
| Rate for Payer: Nomi Health Commercial |
$67.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$71.76
|
| Rate for Payer: Priority Health Narrow Network |
$57.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.07
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: ASR ASR |
$5.01
|
| Rate for Payer: ASR Commercial |
$5.01
|
| Rate for Payer: BCBS Trust/PPO |
$4.20
|
| Rate for Payer: BCN Commercial |
$4.00
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$4.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$5.16
|
| Rate for Payer: Healthscope Whirlpool |
$5.01
|
| Rate for Payer: Mclaren Commercial |
$4.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Nomi Health Commercial |
$4.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.54
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$15.07
|
|
|
Service Code
|
NDC 67877012425
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$15.07 |
| Rate for Payer: Aetna Commercial |
$13.56
|
| Rate for Payer: Aetna Medicare |
$7.54
|
| Rate for Payer: ASR ASR |
$14.62
|
| Rate for Payer: ASR Commercial |
$14.62
|
| Rate for Payer: BCBS Complete |
$6.03
|
| Rate for Payer: BCBS Trust/PPO |
$12.34
|
| Rate for Payer: BCN Commercial |
$11.68
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.07
|
| Rate for Payer: Healthscope Whirlpool |
$14.62
|
| Rate for Payer: Mclaren Commercial |
$13.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.81
|
| Rate for Payer: Nomi Health Commercial |
$12.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.20
|
| Rate for Payer: Priority Health Narrow Network |
$10.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.26
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$15.07
|
|
|
Service Code
|
NDC 67877012425
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$15.07 |
| Rate for Payer: Aetna Commercial |
$13.56
|
| Rate for Payer: ASR ASR |
$14.62
|
| Rate for Payer: ASR Commercial |
$14.62
|
| Rate for Payer: BCBS Trust/PPO |
$12.28
|
| Rate for Payer: BCN Commercial |
$11.68
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.07
|
| Rate for Payer: Healthscope Whirlpool |
$14.62
|
| Rate for Payer: Mclaren Commercial |
$13.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.81
|
| Rate for Payer: Nomi Health Commercial |
$12.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.26
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$26.32
|
|
|
Service Code
|
NDC 43598021025
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.11 |
| Max. Negotiated Rate |
$26.32 |
| Rate for Payer: Aetna Commercial |
$23.69
|
| Rate for Payer: ASR ASR |
$25.53
|
| Rate for Payer: ASR Commercial |
$25.53
|
| Rate for Payer: BCBS Trust/PPO |
$21.45
|
| Rate for Payer: BCN Commercial |
$20.41
|
| Rate for Payer: Cash Price |
$21.06
|
| Rate for Payer: Cofinity Commercial |
$24.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.06
|
| Rate for Payer: Healthscope Commercial |
$26.32
|
| Rate for Payer: Healthscope Whirlpool |
$25.53
|
| Rate for Payer: Mclaren Commercial |
$23.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.37
|
| Rate for Payer: Nomi Health Commercial |
$21.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.16
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$26.32
|
|
|
Service Code
|
NDC 43598021025
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$26.32 |
| Rate for Payer: Aetna Commercial |
$23.69
|
| Rate for Payer: Aetna Medicare |
$13.16
|
| Rate for Payer: ASR ASR |
$25.53
|
| Rate for Payer: ASR Commercial |
$25.53
|
| Rate for Payer: BCBS Complete |
$10.53
|
| Rate for Payer: BCBS Trust/PPO |
$21.55
|
| Rate for Payer: BCN Commercial |
$20.41
|
| Rate for Payer: Cash Price |
$21.06
|
| Rate for Payer: Cofinity Commercial |
$24.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.06
|
| Rate for Payer: Healthscope Commercial |
$26.32
|
| Rate for Payer: Healthscope Whirlpool |
$25.53
|
| Rate for Payer: Mclaren Commercial |
$23.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.37
|
| Rate for Payer: Nomi Health Commercial |
$21.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.06
|
| Rate for Payer: Priority Health Narrow Network |
$18.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.16
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$30.94
|
|
|
Service Code
|
NDC 61570013120
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: Aetna Medicare |
$15.47
|
| Rate for Payer: ASR ASR |
$30.01
|
| Rate for Payer: ASR Commercial |
$30.01
|
| Rate for Payer: BCBS Complete |
$12.38
|
| Rate for Payer: BCBS Trust/PPO |
$25.34
|
| Rate for Payer: BCN Commercial |
$23.99
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$29.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.75
|
| Rate for Payer: Healthscope Commercial |
$30.94
|
| Rate for Payer: Healthscope Whirlpool |
$30.01
|
| Rate for Payer: Mclaren Commercial |
$27.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.30
|
| Rate for Payer: Nomi Health Commercial |
$25.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.11
|
| Rate for Payer: Priority Health Narrow Network |
$21.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.23
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$30.94
|
|
|
Service Code
|
NDC 61570013120
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.11 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: ASR ASR |
$30.01
|
| Rate for Payer: ASR Commercial |
$30.01
|
| Rate for Payer: BCBS Trust/PPO |
$25.21
|
| Rate for Payer: BCN Commercial |
$23.99
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$29.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.75
|
| Rate for Payer: Healthscope Commercial |
$30.94
|
| Rate for Payer: Healthscope Whirlpool |
$30.01
|
| Rate for Payer: Mclaren Commercial |
$27.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.30
|
| Rate for Payer: Nomi Health Commercial |
$25.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.23
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
NDC 77333081225
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Aetna Medicare |
$1.75
|
| Rate for Payer: ASR ASR |
$3.40
|
| Rate for Payer: ASR Commercial |
$3.40
|
| Rate for Payer: BCBS Complete |
$1.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.87
|
| Rate for Payer: BCN Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.50
|
| Rate for Payer: Healthscope Whirlpool |
$3.40
|
| Rate for Payer: Mclaren Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.07
|
| Rate for Payer: Priority Health Narrow Network |
$2.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.08
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$54.05
|
|
|
Service Code
|
NDC 00904720660
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.13 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna Commercial |
$48.64
|
| Rate for Payer: ASR ASR |
$52.43
|
| Rate for Payer: ASR Commercial |
$52.43
|
| Rate for Payer: BCBS Trust/PPO |
$44.05
|
| Rate for Payer: BCN Commercial |
$41.90
|
| Rate for Payer: Cash Price |
$43.24
|
| Rate for Payer: Cofinity Commercial |
$50.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.24
|
| Rate for Payer: Healthscope Commercial |
$54.05
|
| Rate for Payer: Healthscope Whirlpool |
$52.43
|
| Rate for Payer: Mclaren Commercial |
$48.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.94
|
| Rate for Payer: Nomi Health Commercial |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.56
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$54.05
|
|
|
Service Code
|
NDC 00904720660
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.62 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna Commercial |
$48.64
|
| Rate for Payer: Aetna Medicare |
$27.02
|
| Rate for Payer: ASR ASR |
$52.43
|
| Rate for Payer: ASR Commercial |
$52.43
|
| Rate for Payer: BCBS Complete |
$21.62
|
| Rate for Payer: BCBS Trust/PPO |
$44.26
|
| Rate for Payer: BCN Commercial |
$41.90
|
| Rate for Payer: Cash Price |
$43.24
|
| Rate for Payer: Cofinity Commercial |
$50.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.24
|
| Rate for Payer: Healthscope Commercial |
$54.05
|
| Rate for Payer: Healthscope Whirlpool |
$52.43
|
| Rate for Payer: Mclaren Commercial |
$48.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.94
|
| Rate for Payer: Nomi Health Commercial |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$47.36
|
| Rate for Payer: Priority Health Narrow Network |
$37.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.56
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$350.15
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.06 |
| Max. Negotiated Rate |
$350.15 |
| Rate for Payer: Aetna Commercial |
$315.14
|
| Rate for Payer: Aetna Medicare |
$175.08
|
| Rate for Payer: ASR ASR |
$339.65
|
| Rate for Payer: ASR Commercial |
$339.65
|
| Rate for Payer: BCBS Complete |
$140.06
|
| Rate for Payer: BCBS Trust/PPO |
$286.74
|
| Rate for Payer: BCN Commercial |
$271.47
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$329.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$350.15
|
| Rate for Payer: Healthscope Whirlpool |
$339.65
|
| Rate for Payer: Mclaren Commercial |
$315.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: Nomi Health Commercial |
$287.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$306.80
|
| Rate for Payer: Priority Health Narrow Network |
$245.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.13
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
NDC 77333081225
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: ASR ASR |
$3.40
|
| Rate for Payer: ASR Commercial |
$3.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.85
|
| Rate for Payer: BCN Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.50
|
| Rate for Payer: Healthscope Whirlpool |
$3.40
|
| Rate for Payer: Mclaren Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.08
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$227.60 |
| Max. Negotiated Rate |
$350.15 |
| Rate for Payer: Aetna Commercial |
$315.14
|
| Rate for Payer: ASR ASR |
$339.65
|
| Rate for Payer: ASR Commercial |
$339.65
|
| Rate for Payer: BCBS Trust/PPO |
$285.34
|
| Rate for Payer: BCN Commercial |
$271.47
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$329.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$350.15
|
| Rate for Payer: Healthscope Whirlpool |
$339.65
|
| Rate for Payer: Mclaren Commercial |
$315.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: Nomi Health Commercial |
$287.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.13
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM
|
Facility
|
OP
|
$606.75
|
|
|
Service Code
|
CPT 12016
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$146.70 |
| Max. Negotiated Rate |
$606.75 |
| Rate for Payer: Aetna Medicare |
$391.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$489.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$489.31
|
| Rate for Payer: BCBS Complete |
$220.31
|
| Rate for Payer: BCBS MAPPO |
$391.45
|
| Rate for Payer: BCN Medicare Advantage |
$391.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$391.45
|
| Rate for Payer: Humana Choice PPO Medicare |
$391.45
|
| Rate for Payer: Mclaren Medicaid |
$209.82
|
| Rate for Payer: Mclaren Medicare |
$391.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$411.02
|
| Rate for Payer: Meridian Medicaid |
$220.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$450.17
|
| Rate for Payer: PACE Medicare |
$371.88
|
| Rate for Payer: PACE SWMI |
$391.45
|
| Rate for Payer: PHP Commercial |
$430.60
|
| Rate for Payer: PHP Medicaid |
$209.82
|
| Rate for Payer: PHP Medicare Advantage |
$391.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$209.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$183.37
|
| Rate for Payer: Priority Health Medicare |
$391.45
|
| Rate for Payer: Priority Health Narrow Network |
$146.70
|
| Rate for Payer: Railroad Medicare Medicare |
$391.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$391.45
|
| Rate for Payer: UHC Exchange |
$606.75
|
| Rate for Payer: UHC Medicare Advantage |
$391.45
|
| Rate for Payer: UHCCP DNSP |
$391.45
|
| Rate for Payer: UHCCP Medicaid |
$209.82
|
| Rate for Payer: VA VA |
$391.45
|
|
