|
SUBMUCOSAL INJECTABLE COMPOSITION (ELEVIEW)
|
Facility
|
IP
|
$287.55
|
|
|
Service Code
|
NDC 05391530190
|
| Hospital Charge Code |
200133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$181.16 |
| Max. Negotiated Rate |
$258.80 |
| Rate for Payer: Aetna Commercial |
$244.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.91
|
| Rate for Payer: Cash Price |
$230.04
|
| Rate for Payer: Cofinity Advantage |
$201.28
|
| Rate for Payer: Cofinity Commercial |
$247.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$230.04
|
| Rate for Payer: Healthscope Commercial |
$258.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$244.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$215.66
|
| Rate for Payer: PHP Commercial |
$244.42
|
| Rate for Payer: Priority Health SBD |
$181.16
|
|
|
SUBMUCOSAL INJECTABLE COMPOSITION (ELEVIEW)
|
Facility
|
OP
|
$287.55
|
|
|
Service Code
|
NDC 05391530190
|
| Hospital Charge Code |
200133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.01 |
| Max. Negotiated Rate |
$258.80 |
| Rate for Payer: Aetna Commercial |
$244.42
|
| Rate for Payer: Aetna Medicare |
$143.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.91
|
| Rate for Payer: BCBS Complete |
$115.02
|
| Rate for Payer: Cash Price |
$230.04
|
| Rate for Payer: Cofinity Advantage |
$201.28
|
| Rate for Payer: Cofinity Commercial |
$247.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$230.04
|
| Rate for Payer: Healthscope Commercial |
$258.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$230.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$244.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$215.66
|
| Rate for Payer: PHP Commercial |
$244.42
|
| Rate for Payer: Priority Health SBD |
$181.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$186.91
|
| Rate for Payer: UHC Core |
$149.81
|
| Rate for Payer: UHC Exchange |
$113.01
|
|
|
SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD
|
Facility
|
OP
|
$10,683.35
|
|
|
Service Code
|
CPT 30140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,256.18 |
| Max. Negotiated Rate |
$10,683.35 |
| Rate for Payer: Aetna Medicare |
$3,435.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,129.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,129.43
|
| Rate for Payer: BCBS Complete |
$1,814.30
|
| Rate for Payer: BCBS MAPPO |
$3,303.54
|
| Rate for Payer: BCBS Trust/PPO |
$1,256.18
|
| Rate for Payer: BCN Commercial |
$1,256.18
|
| Rate for Payer: BCN Medicare Advantage |
$3,303.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,303.54
|
| Rate for Payer: Mclaren Medicaid |
$1,727.75
|
| Rate for Payer: Mclaren Medicare |
$3,303.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,468.72
|
| Rate for Payer: Meridian Medicaid |
$3,468.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,799.07
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,633.89
|
| Rate for Payer: Nomi Health Commercial |
$9,910.62
|
| Rate for Payer: PACE Medicare |
$3,138.36
|
| Rate for Payer: PACE SWMI |
$3,303.54
|
| Rate for Payer: PHP Medicare Advantage |
$3,303.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,727.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,683.35
|
| Rate for Payer: Priority Health Medicare |
$3,303.54
|
| Rate for Payer: Priority Health Tiered Network |
$8,546.68
|
| Rate for Payer: Railroad Medicare Medicare |
$3,303.54
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,303.54
|
| Rate for Payer: UHC Medicaid |
$1,727.75
|
| Rate for Payer: UHCCP Medicaid |
$1,727.75
|
| Rate for Payer: VA VA |
$3,303.54
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$26.97
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
163722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.99 |
| Max. Negotiated Rate |
$24.27 |
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna Commercial |
$20.13
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.39
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cofinity Advantage |
$18.88
|
| Rate for Payer: Cofinity Advantage |
$16.58
|
| Rate for Payer: Cofinity Advantage |
$20.26
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.15
|
| Rate for Payer: Healthscope Commercial |
$21.31
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.23
|
| Rate for Payer: PHP Commercial |
$20.13
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: Priority Health SBD |
$18.23
|
| Rate for Payer: Priority Health SBD |
$14.92
|
| Rate for Payer: Priority Health SBD |
$16.99
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION (CODE)
|
Facility
|
OP
|
$23.68
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
163722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: Aetna Commercial |
$20.13
|
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna Medicare |
$11.84
|
| Rate for Payer: Aetna Medicare |
$13.48
|
| Rate for Payer: Aetna Medicare |
$14.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: BCBS Complete |
$11.58
|
| Rate for Payer: BCBS Complete |
$9.47
|
| Rate for Payer: BCBS Complete |
$10.79
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cofinity Advantage |
$18.88
|
| Rate for Payer: Cofinity Advantage |
$16.58
|
| Rate for Payer: Cofinity Advantage |
$20.26
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$21.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.70
|
| Rate for Payer: PHP Commercial |
$20.13
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: Priority Health SBD |
$14.92
|
| Rate for Payer: Priority Health SBD |
$18.23
|
| Rate for Payer: Priority Health SBD |
$16.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$23.68
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: Aetna Commercial |
$20.13
|
| Rate for Payer: Aetna Commercial |
$23.34
|
| Rate for Payer: Aetna Commercial |
$17.25
|
| Rate for Payer: Aetna Commercial |
$18.37
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna Commercial |
$44.34
|
| Rate for Payer: Aetna Commercial |
$15.74
|
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna Medicare |
$26.08
|
| Rate for Payer: Aetna Medicare |
$10.15
|
| Rate for Payer: Aetna Medicare |
$9.26
|
| Rate for Payer: Aetna Medicare |
$11.84
|
| Rate for Payer: Aetna Medicare |
$13.73
|
| Rate for Payer: Aetna Medicare |
$12.91
|
| Rate for Payer: Aetna Medicare |
$13.48
|
| Rate for Payer: Aetna Medicare |
$14.47
|
| Rate for Payer: Aetna Medicare |
$10.80
|
| Rate for Payer: Aetna Medicare |
$11.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.20
|
| Rate for Payer: BCBS Complete |
$20.86
|
| Rate for Payer: BCBS Complete |
$11.58
|
| Rate for Payer: BCBS Complete |
$8.12
|
| Rate for Payer: BCBS Complete |
$7.41
|
| Rate for Payer: BCBS Complete |
$8.64
|
| Rate for Payer: BCBS Complete |
$10.33
|
| Rate for Payer: BCBS Complete |
$10.79
|
| Rate for Payer: BCBS Complete |
$9.47
|
| Rate for Payer: BCBS Complete |
$10.98
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: Cash Price |
$17.65
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$21.97
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$41.73
|
| Rate for Payer: Cash Price |
$41.73
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$17.65
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: Cash Price |
$14.82
|
| Rate for Payer: Cash Price |
$14.82
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$21.97
|
| Rate for Payer: Cofinity Advantage |
$16.58
|
| Rate for Payer: Cofinity Advantage |
$19.22
|
| Rate for Payer: Cofinity Advantage |
$36.51
|
| Rate for Payer: Cofinity Advantage |
$15.44
|
| Rate for Payer: Cofinity Advantage |
$12.96
|
| Rate for Payer: Cofinity Advantage |
$15.13
|
| Rate for Payer: Cofinity Advantage |
$14.21
|
| Rate for Payer: Cofinity Advantage |
$18.88
|
| Rate for Payer: Cofinity Advantage |
$18.08
|
| Rate for Payer: Cofinity Advantage |
$20.26
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$18.58
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$44.86
|
| Rate for Payer: Cofinity Commercial |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$17.46
|
| Rate for Payer: Cofinity Commercial |
$18.97
|
| Rate for Payer: Cofinity Commercial |
$23.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.82
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Healthscope Commercial |
$16.67
|
| Rate for Payer: Healthscope Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$19.45
|
| Rate for Payer: Healthscope Commercial |
$19.85
|
| Rate for Payer: Healthscope Commercial |
$21.31
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$24.71
|
| Rate for Payer: Healthscope Commercial |
$46.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.59
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: PHP Commercial |
$23.34
|
| Rate for Payer: PHP Commercial |
$18.37
|
| Rate for Payer: PHP Commercial |
$15.74
|
| Rate for Payer: PHP Commercial |
$44.34
|
| Rate for Payer: PHP Commercial |
$20.13
|
| Rate for Payer: PHP Commercial |
$18.75
|
| Rate for Payer: PHP Commercial |
$17.25
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: Priority Health SBD |
$16.27
|
| Rate for Payer: Priority Health SBD |
$14.92
|
| Rate for Payer: Priority Health SBD |
$16.99
|
| Rate for Payer: Priority Health SBD |
$13.90
|
| Rate for Payer: Priority Health SBD |
$17.30
|
| Rate for Payer: Priority Health SBD |
$13.61
|
| Rate for Payer: Priority Health SBD |
$12.79
|
| Rate for Payer: Priority Health SBD |
$11.67
|
| Rate for Payer: Priority Health SBD |
$18.23
|
| Rate for Payer: Priority Health SBD |
$32.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Core |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
| Rate for Payer: UHC Exchange |
$2.56
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$25.83
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.27 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna Commercial |
$17.25
|
| Rate for Payer: Aetna Commercial |
$15.74
|
| Rate for Payer: Aetna Commercial |
$18.37
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna Commercial |
$23.34
|
| Rate for Payer: Aetna Commercial |
$20.13
|
| Rate for Payer: Aetna Commercial |
$44.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cash Price |
$21.97
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: Cash Price |
$17.65
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$14.82
|
| Rate for Payer: Cash Price |
$41.73
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cofinity Advantage |
$15.13
|
| Rate for Payer: Cofinity Advantage |
$19.22
|
| Rate for Payer: Cofinity Advantage |
$15.44
|
| Rate for Payer: Cofinity Advantage |
$18.88
|
| Rate for Payer: Cofinity Advantage |
$20.26
|
| Rate for Payer: Cofinity Advantage |
$12.96
|
| Rate for Payer: Cofinity Advantage |
$18.08
|
| Rate for Payer: Cofinity Advantage |
$36.51
|
| Rate for Payer: Cofinity Advantage |
$14.21
|
| Rate for Payer: Cofinity Advantage |
$16.58
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$18.58
|
| Rate for Payer: Cofinity Commercial |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$17.46
|
| Rate for Payer: Cofinity Commercial |
$44.86
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$23.62
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Cofinity Commercial |
$18.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.24
|
| Rate for Payer: Healthscope Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$21.31
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: Healthscope Commercial |
$16.67
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Healthscope Commercial |
$24.71
|
| Rate for Payer: Healthscope Commercial |
$46.94
|
| Rate for Payer: Healthscope Commercial |
$19.45
|
| Rate for Payer: Healthscope Commercial |
$19.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.21
|
| Rate for Payer: PHP Commercial |
$44.34
|
| Rate for Payer: PHP Commercial |
$23.34
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: PHP Commercial |
$15.74
|
| Rate for Payer: PHP Commercial |
$18.37
|
| Rate for Payer: PHP Commercial |
$20.13
|
| Rate for Payer: PHP Commercial |
$17.25
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: PHP Commercial |
$18.75
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: Priority Health SBD |
$16.27
|
| Rate for Payer: Priority Health SBD |
$13.61
|
| Rate for Payer: Priority Health SBD |
$13.90
|
| Rate for Payer: Priority Health SBD |
$17.30
|
| Rate for Payer: Priority Health SBD |
$14.92
|
| Rate for Payer: Priority Health SBD |
$11.67
|
| Rate for Payer: Priority Health SBD |
$32.86
|
| Rate for Payer: Priority Health SBD |
$16.99
|
| Rate for Payer: Priority Health SBD |
$18.23
|
| Rate for Payer: Priority Health SBD |
$12.79
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$25.35
|
|
|
Service Code
|
NDC 69339020919
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$22.82 |
| Rate for Payer: Aetna Commercial |
$21.55
|
| Rate for Payer: Aetna Medicare |
$12.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.48
|
| Rate for Payer: BCBS Complete |
$10.14
|
| Rate for Payer: Cash Price |
$20.28
|
| Rate for Payer: Cofinity Advantage |
$17.75
|
| Rate for Payer: Cofinity Commercial |
$21.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.28
|
| Rate for Payer: Healthscope Commercial |
$22.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.01
|
| Rate for Payer: PHP Commercial |
$21.55
|
| Rate for Payer: Priority Health SBD |
$15.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.48
|
| Rate for Payer: UHC Core |
$13.21
|
| Rate for Payer: UHC Exchange |
$9.96
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.40
|
|
|
Service Code
|
NDC 00121097400
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$22.86 |
| Rate for Payer: Aetna Commercial |
$21.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.51
|
| Rate for Payer: Cash Price |
$20.32
|
| Rate for Payer: Cofinity Advantage |
$17.78
|
| Rate for Payer: Cofinity Commercial |
$21.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.32
|
| Rate for Payer: Healthscope Commercial |
$22.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.05
|
| Rate for Payer: PHP Commercial |
$21.59
|
| Rate for Payer: Priority Health SBD |
$16.00
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$34.18
|
|
|
Service Code
|
NDC 69339014817
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$30.76 |
| Rate for Payer: Aetna Commercial |
$29.05
|
| Rate for Payer: Aetna Medicare |
$17.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.22
|
| Rate for Payer: BCBS Complete |
$13.67
|
| Rate for Payer: Cash Price |
$27.34
|
| Rate for Payer: Cofinity Advantage |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$29.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.34
|
| Rate for Payer: Healthscope Commercial |
$30.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.64
|
| Rate for Payer: PHP Commercial |
$29.05
|
| Rate for Payer: Priority Health SBD |
$21.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.22
|
| Rate for Payer: UHC Core |
$17.81
|
| Rate for Payer: UHC Exchange |
$13.43
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$34.18
|
|
|
Service Code
|
NDC 69339014817
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.53 |
| Max. Negotiated Rate |
$30.76 |
| Rate for Payer: Aetna Commercial |
$29.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.22
|
| Rate for Payer: Cash Price |
$27.34
|
| Rate for Payer: Cofinity Advantage |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$29.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.34
|
| Rate for Payer: Healthscope Commercial |
$30.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.64
|
| Rate for Payer: PHP Commercial |
$29.05
|
| Rate for Payer: Priority Health SBD |
$21.53
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$25.40
|
|
|
Service Code
|
NDC 00121097400
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$22.86 |
| Rate for Payer: Aetna Commercial |
$21.59
|
| Rate for Payer: Aetna Medicare |
$12.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.51
|
| Rate for Payer: BCBS Complete |
$10.16
|
| Rate for Payer: Cash Price |
$20.32
|
| Rate for Payer: Cofinity Advantage |
$17.78
|
| Rate for Payer: Cofinity Commercial |
$21.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.32
|
| Rate for Payer: Healthscope Commercial |
$22.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.05
|
| Rate for Payer: PHP Commercial |
$21.59
|
| Rate for Payer: Priority Health SBD |
$16.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.51
|
| Rate for Payer: UHC Core |
$13.23
|
| Rate for Payer: UHC Exchange |
$9.98
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$34.20
|
|
|
Service Code
|
NDC 81033014910
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.55 |
| Max. Negotiated Rate |
$30.78 |
| Rate for Payer: Aetna Commercial |
$29.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.23
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cofinity Advantage |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$29.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.36
|
| Rate for Payer: Healthscope Commercial |
$30.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.65
|
| Rate for Payer: PHP Commercial |
$29.07
|
| Rate for Payer: Priority Health SBD |
$21.55
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$25.40
|
|
|
Service Code
|
NDC 00121097410
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$22.86 |
| Rate for Payer: Aetna Commercial |
$21.59
|
| Rate for Payer: Aetna Medicare |
$12.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.51
|
| Rate for Payer: BCBS Complete |
$10.16
|
| Rate for Payer: Cash Price |
$20.32
|
| Rate for Payer: Cofinity Advantage |
$17.78
|
| Rate for Payer: Cofinity Commercial |
$21.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.32
|
| Rate for Payer: Healthscope Commercial |
$22.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.05
|
| Rate for Payer: PHP Commercial |
$21.59
|
| Rate for Payer: Priority Health SBD |
$16.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.51
|
| Rate for Payer: UHC Core |
$13.23
|
| Rate for Payer: UHC Exchange |
$9.98
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$34.18
|
|
|
Service Code
|
NDC 69339014801
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.53 |
| Max. Negotiated Rate |
$30.76 |
| Rate for Payer: Aetna Commercial |
$29.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.22
|
| Rate for Payer: Cash Price |
$27.34
|
| Rate for Payer: Cofinity Advantage |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$29.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.34
|
| Rate for Payer: Healthscope Commercial |
$30.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.64
|
| Rate for Payer: PHP Commercial |
$29.05
|
| Rate for Payer: Priority Health SBD |
$21.53
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$25.25
|
|
|
Service Code
|
NDC 81033014952
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$22.73 |
| Rate for Payer: Aetna Commercial |
$21.46
|
| Rate for Payer: Aetna Medicare |
$12.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.41
|
| Rate for Payer: BCBS Complete |
$10.10
|
| Rate for Payer: Cash Price |
$20.20
|
| Rate for Payer: Cofinity Advantage |
$17.68
|
| Rate for Payer: Cofinity Commercial |
$21.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.20
|
| Rate for Payer: Healthscope Commercial |
$22.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.94
|
| Rate for Payer: PHP Commercial |
$21.46
|
| Rate for Payer: Priority Health SBD |
$15.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.41
|
| Rate for Payer: UHC Core |
$13.16
|
| Rate for Payer: UHC Exchange |
$9.92
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$36.63
|
|
|
Service Code
|
NDC 50268073211
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna Medicare |
$18.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.81
|
| Rate for Payer: BCBS Complete |
$14.65
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cofinity Advantage |
$25.64
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.30
|
| Rate for Payer: Healthscope Commercial |
$32.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$27.47
|
| Rate for Payer: PHP Commercial |
$31.14
|
| Rate for Payer: Priority Health SBD |
$23.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.81
|
| Rate for Payer: UHC Core |
$19.08
|
| Rate for Payer: UHC Exchange |
$14.40
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$33.17
|
|
|
Service Code
|
NDC 60687073842
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.90 |
| Max. Negotiated Rate |
$29.85 |
| Rate for Payer: Aetna Commercial |
$28.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.56
|
| Rate for Payer: Cash Price |
$26.54
|
| Rate for Payer: Cofinity Advantage |
$23.22
|
| Rate for Payer: Cofinity Commercial |
$28.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.54
|
| Rate for Payer: Healthscope Commercial |
$29.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.88
|
| Rate for Payer: PHP Commercial |
$28.19
|
| Rate for Payer: Priority Health SBD |
$20.90
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$30.15
|
|
|
Service Code
|
NDC 00904747066
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Aetna Commercial |
$25.63
|
| Rate for Payer: Aetna Medicare |
$15.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.60
|
| Rate for Payer: BCBS Complete |
$12.06
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cofinity Advantage |
$21.11
|
| Rate for Payer: Cofinity Commercial |
$25.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.12
|
| Rate for Payer: Healthscope Commercial |
$27.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.61
|
| Rate for Payer: PHP Commercial |
$25.63
|
| Rate for Payer: Priority Health SBD |
$18.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.60
|
| Rate for Payer: UHC Core |
$15.71
|
| Rate for Payer: UHC Exchange |
$11.85
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$45.51
|
|
|
Service Code
|
NDC 00904747072
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.89 |
| Max. Negotiated Rate |
$40.96 |
| Rate for Payer: Aetna Commercial |
$38.68
|
| Rate for Payer: Aetna Medicare |
$22.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.58
|
| Rate for Payer: BCBS Complete |
$18.20
|
| Rate for Payer: Cash Price |
$36.41
|
| Rate for Payer: Cofinity Advantage |
$31.86
|
| Rate for Payer: Cofinity Commercial |
$39.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.41
|
| Rate for Payer: Healthscope Commercial |
$40.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$36.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.13
|
| Rate for Payer: PHP Commercial |
$38.68
|
| Rate for Payer: Priority Health SBD |
$28.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.58
|
| Rate for Payer: UHC Core |
$23.71
|
| Rate for Payer: UHC Exchange |
$17.89
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.35
|
|
|
Service Code
|
NDC 69339020919
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.97 |
| Max. Negotiated Rate |
$22.82 |
| Rate for Payer: Aetna Commercial |
$21.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.48
|
| Rate for Payer: Cash Price |
$20.28
|
| Rate for Payer: Cofinity Advantage |
$17.75
|
| Rate for Payer: Cofinity Commercial |
$21.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.28
|
| Rate for Payer: Healthscope Commercial |
$22.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.01
|
| Rate for Payer: PHP Commercial |
$21.55
|
| Rate for Payer: Priority Health SBD |
$15.97
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$30.15
|
|
|
Service Code
|
NDC 00904747066
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.99 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Aetna Commercial |
$25.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.60
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cofinity Advantage |
$21.11
|
| Rate for Payer: Cofinity Commercial |
$25.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.12
|
| Rate for Payer: Healthscope Commercial |
$27.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.61
|
| Rate for Payer: PHP Commercial |
$25.63
|
| Rate for Payer: Priority Health SBD |
$18.99
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$27.99
|
|
|
Service Code
|
NDC 60687073856
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.63 |
| Max. Negotiated Rate |
$25.19 |
| Rate for Payer: Aetna Commercial |
$23.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.19
|
| Rate for Payer: Cash Price |
$22.39
|
| Rate for Payer: Cofinity Advantage |
$19.59
|
| Rate for Payer: Cofinity Commercial |
$24.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$25.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.99
|
| Rate for Payer: PHP Commercial |
$23.79
|
| Rate for Payer: Priority Health SBD |
$17.63
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$45.51
|
|
|
Service Code
|
NDC 00904747072
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.67 |
| Max. Negotiated Rate |
$40.96 |
| Rate for Payer: Aetna Commercial |
$38.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.58
|
| Rate for Payer: Cash Price |
$36.41
|
| Rate for Payer: Cofinity Advantage |
$31.86
|
| Rate for Payer: Cofinity Commercial |
$39.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.41
|
| Rate for Payer: Healthscope Commercial |
$40.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.13
|
| Rate for Payer: PHP Commercial |
$38.68
|
| Rate for Payer: Priority Health SBD |
$28.67
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$27.99
|
|
|
Service Code
|
NDC 60687073856
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$25.19 |
| Rate for Payer: Aetna Commercial |
$23.79
|
| Rate for Payer: Aetna Medicare |
$13.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.19
|
| Rate for Payer: BCBS Complete |
$11.20
|
| Rate for Payer: Cash Price |
$22.39
|
| Rate for Payer: Cofinity Advantage |
$19.59
|
| Rate for Payer: Cofinity Commercial |
$24.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$25.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.99
|
| Rate for Payer: PHP Commercial |
$23.79
|
| Rate for Payer: Priority Health SBD |
$17.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.19
|
| Rate for Payer: UHC Core |
$14.58
|
| Rate for Payer: UHC Exchange |
$11.00
|
|
