|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.16
|
|
|
Service Code
|
NDC 69339020901
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$22.64 |
| Rate for Payer: Aetna Commercial |
$21.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.35
|
| Rate for Payer: Cash Price |
$20.13
|
| Rate for Payer: Cofinity Advantage |
$17.61
|
| Rate for Payer: Cofinity Commercial |
$21.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.13
|
| Rate for Payer: Healthscope Commercial |
$22.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.87
|
| Rate for Payer: PHP Commercial |
$21.39
|
| Rate for Payer: Priority Health SBD |
$15.85
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.25
|
|
|
Service Code
|
NDC 81033014952
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$22.73 |
| Rate for Payer: Aetna Commercial |
$21.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.41
|
| 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: 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
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$36.63
|
|
|
Service Code
|
NDC 50268073211
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.08 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.81
|
| 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: 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
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$25.16
|
|
|
Service Code
|
NDC 69339020901
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$22.64 |
| Rate for Payer: Aetna Commercial |
$21.39
|
| Rate for Payer: Aetna Medicare |
$12.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.35
|
| Rate for Payer: BCBS Complete |
$10.06
|
| Rate for Payer: Cash Price |
$20.13
|
| Rate for Payer: Cofinity Advantage |
$17.61
|
| Rate for Payer: Cofinity Commercial |
$21.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.13
|
| Rate for Payer: Healthscope Commercial |
$22.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.87
|
| Rate for Payer: PHP Commercial |
$21.39
|
| Rate for Payer: Priority Health SBD |
$15.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.35
|
| Rate for Payer: UHC Core |
$13.11
|
| Rate for Payer: UHC Exchange |
$9.89
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$33.17
|
|
|
Service Code
|
NDC 60687073842
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.04 |
| Max. Negotiated Rate |
$29.85 |
| Rate for Payer: Aetna Commercial |
$28.19
|
| Rate for Payer: Aetna Medicare |
$16.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.56
|
| Rate for Payer: BCBS Complete |
$13.27
|
| 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: MI Amish Medical Board Commercial |
$26.54
|
| 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
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.56
|
| Rate for Payer: UHC Core |
$17.28
|
| Rate for Payer: UHC Exchange |
$13.04
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$34.18
|
|
|
Service Code
|
NDC 69339014801
|
| 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
|
$25.40
|
|
|
Service Code
|
NDC 00121097410
|
| 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
|
$36.63
|
|
|
Service Code
|
NDC 50268073212
|
| 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
|
OP
|
$34.20
|
|
|
Service Code
|
NDC 81033014910
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$30.78 |
| Rate for Payer: Aetna Commercial |
$29.07
|
| Rate for Payer: Aetna Medicare |
$17.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.23
|
| Rate for Payer: BCBS Complete |
$13.68
|
| 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: MI Amish Medical Board Commercial |
$27.36
|
| 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
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.23
|
| Rate for Payer: UHC Core |
$17.82
|
| Rate for Payer: UHC Exchange |
$13.44
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$36.63
|
|
|
Service Code
|
NDC 50268073212
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.08 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.81
|
| 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: 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
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$1,868.25
|
|
|
Service Code
|
NDC 00093221005
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$734.22 |
| Max. Negotiated Rate |
$1,681.42 |
| Rate for Payer: Aetna Commercial |
$1,588.01
|
| Rate for Payer: Aetna Medicare |
$934.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,214.36
|
| Rate for Payer: BCBS Complete |
$747.30
|
| Rate for Payer: Cash Price |
$1,494.60
|
| Rate for Payer: Cofinity Advantage |
$1,307.78
|
| Rate for Payer: Cofinity Commercial |
$1,606.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,494.60
|
| Rate for Payer: Healthscope Commercial |
$1,681.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,494.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,588.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,401.19
|
| Rate for Payer: PHP Commercial |
$1,588.01
|
| Rate for Payer: Priority Health SBD |
$1,177.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,214.36
|
| Rate for Payer: UHC Core |
$973.36
|
| Rate for Payer: UHC Exchange |
$734.22
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$1,868.25
|
|
|
Service Code
|
NDC 00093221005
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,177.00 |
| Max. Negotiated Rate |
$1,681.42 |
| Rate for Payer: Aetna Commercial |
$1,588.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,214.36
|
| Rate for Payer: Cash Price |
$1,494.60
|
| Rate for Payer: Cofinity Advantage |
$1,307.78
|
| Rate for Payer: Cofinity Commercial |
$1,606.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,494.60
|
| Rate for Payer: Healthscope Commercial |
$1,681.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,588.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,401.19
|
| Rate for Payer: PHP Commercial |
$1,588.01
|
| Rate for Payer: Priority Health SBD |
$1,177.00
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$237.50
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.62 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$201.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.38
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cofinity Advantage |
$166.25
|
| Rate for Payer: Cofinity Commercial |
$204.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.00
|
| Rate for Payer: Healthscope Commercial |
$213.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.12
|
| Rate for Payer: PHP Commercial |
$201.88
|
| Rate for Payer: Priority Health SBD |
$149.62
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$237.50
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.34 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$201.88
|
| Rate for Payer: Aetna Medicare |
$118.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.38
|
| Rate for Payer: BCBS Complete |
$95.00
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cofinity Advantage |
$166.25
|
| Rate for Payer: Cofinity Commercial |
$204.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.00
|
| Rate for Payer: Healthscope Commercial |
$213.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.12
|
| Rate for Payer: PHP Commercial |
$201.88
|
| Rate for Payer: Priority Health SBD |
$149.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.38
|
| Rate for Payer: UHC Core |
$123.74
|
| Rate for Payer: UHC Exchange |
$93.34
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$383.05
|
|
|
Service Code
|
NDC 59762040101
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.32 |
| Max. Negotiated Rate |
$344.75 |
| Rate for Payer: Aetna Commercial |
$325.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.98
|
| Rate for Payer: Cash Price |
$306.44
|
| Rate for Payer: Cofinity Advantage |
$268.13
|
| Rate for Payer: Cofinity Commercial |
$329.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.44
|
| Rate for Payer: Healthscope Commercial |
$344.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$287.29
|
| Rate for Payer: PHP Commercial |
$325.59
|
| Rate for Payer: Priority Health SBD |
$241.32
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$310.65
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.09 |
| Max. Negotiated Rate |
$279.58 |
| Rate for Payer: Aetna Commercial |
$264.05
|
| Rate for Payer: Aetna Medicare |
$155.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.92
|
| Rate for Payer: BCBS Complete |
$124.26
|
| Rate for Payer: Cash Price |
$248.52
|
| Rate for Payer: Cofinity Advantage |
$217.46
|
| Rate for Payer: Cofinity Commercial |
$267.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.52
|
| Rate for Payer: Healthscope Commercial |
$279.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$248.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.99
|
| Rate for Payer: PHP Commercial |
$264.05
|
| Rate for Payer: Priority Health SBD |
$195.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$201.92
|
| Rate for Payer: UHC Core |
$161.85
|
| Rate for Payer: UHC Exchange |
$122.09
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$383.05
|
|
|
Service Code
|
NDC 59762040101
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.54 |
| Max. Negotiated Rate |
$344.75 |
| Rate for Payer: Aetna Commercial |
$325.59
|
| Rate for Payer: Aetna Medicare |
$191.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.98
|
| Rate for Payer: BCBS Complete |
$153.22
|
| Rate for Payer: Cash Price |
$306.44
|
| Rate for Payer: Cofinity Advantage |
$268.13
|
| Rate for Payer: Cofinity Commercial |
$329.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.44
|
| Rate for Payer: Healthscope Commercial |
$344.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$306.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$287.29
|
| Rate for Payer: PHP Commercial |
$325.59
|
| Rate for Payer: Priority Health SBD |
$241.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.98
|
| Rate for Payer: UHC Core |
$199.57
|
| Rate for Payer: UHC Exchange |
$150.54
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$310.65
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.71 |
| Max. Negotiated Rate |
$279.58 |
| Rate for Payer: Aetna Commercial |
$264.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.92
|
| Rate for Payer: Cash Price |
$248.52
|
| Rate for Payer: Cofinity Advantage |
$217.46
|
| Rate for Payer: Cofinity Commercial |
$267.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.52
|
| Rate for Payer: Healthscope Commercial |
$279.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.99
|
| Rate for Payer: PHP Commercial |
$264.05
|
| Rate for Payer: Priority Health SBD |
$195.71
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$471.91
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$185.46 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna Medicare |
$235.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.74
|
| Rate for Payer: BCBS Complete |
$188.76
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Advantage |
$330.34
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$377.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health SBD |
$297.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$306.74
|
| Rate for Payer: UHC Core |
$245.87
|
| Rate for Payer: UHC Exchange |
$185.46
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$471.91
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$185.46 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna Medicare |
$235.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.74
|
| Rate for Payer: BCBS Complete |
$188.76
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Advantage |
$330.34
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$377.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health SBD |
$297.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$306.74
|
| Rate for Payer: UHC Core |
$245.87
|
| Rate for Payer: UHC Exchange |
$185.46
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$471.91
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$297.30 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.74
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Advantage |
$330.34
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health SBD |
$297.30
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$471.91
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$297.30 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.74
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Advantage |
$330.34
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health SBD |
$297.30
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$142.44
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.98 |
| Max. Negotiated Rate |
$128.20 |
| Rate for Payer: Aetna Commercial |
$121.07
|
| Rate for Payer: Aetna Medicare |
$71.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.59
|
| Rate for Payer: BCBS Complete |
$56.98
|
| Rate for Payer: Cash Price |
$113.95
|
| Rate for Payer: Cofinity Advantage |
$99.71
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.95
|
| Rate for Payer: Healthscope Commercial |
$128.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.83
|
| Rate for Payer: PHP Commercial |
$121.07
|
| Rate for Payer: Priority Health SBD |
$89.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$92.59
|
| Rate for Payer: UHC Core |
$74.21
|
| Rate for Payer: UHC Exchange |
$55.98
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$142.44
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.74 |
| Max. Negotiated Rate |
$128.20 |
| Rate for Payer: Aetna Commercial |
$121.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.59
|
| Rate for Payer: Cash Price |
$113.95
|
| Rate for Payer: Cofinity Advantage |
$99.71
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.95
|
| Rate for Payer: Healthscope Commercial |
$128.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.83
|
| Rate for Payer: PHP Commercial |
$121.07
|
| Rate for Payer: Priority Health SBD |
$89.74
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.03
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$46.83 |
| Rate for Payer: Aetna Commercial |
$44.23
|
| Rate for Payer: Aetna Medicare |
$26.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.82
|
| Rate for Payer: BCBS Complete |
$20.81
|
| Rate for Payer: Cash Price |
$41.62
|
| Rate for Payer: Cofinity Advantage |
$36.42
|
| Rate for Payer: Cofinity Commercial |
$44.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.62
|
| Rate for Payer: Healthscope Commercial |
$46.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.02
|
| Rate for Payer: PHP Commercial |
$44.23
|
| Rate for Payer: Priority Health SBD |
$32.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.82
|
| Rate for Payer: UHC Core |
$27.11
|
| Rate for Payer: UHC Exchange |
$20.45
|
|
