|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.03
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.78 |
| Max. Negotiated Rate |
$46.83 |
| Rate for Payer: Aetna Commercial |
$44.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.82
|
| 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: 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
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$12.88
|
|
|
Service Code
|
NDC 50383082421
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.37
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cofinity Advantage |
$9.02
|
| Rate for Payer: Cofinity Commercial |
$11.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.30
|
| Rate for Payer: Healthscope Commercial |
$11.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.66
|
| Rate for Payer: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health SBD |
$8.11
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$12.88
|
|
|
Service Code
|
NDC 50383082421
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.95
|
| Rate for Payer: Aetna Medicare |
$6.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.37
|
| Rate for Payer: BCBS Complete |
$5.15
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cofinity Advantage |
$9.02
|
| Rate for Payer: Cofinity Commercial |
$11.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.30
|
| Rate for Payer: Healthscope Commercial |
$11.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.66
|
| Rate for Payer: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health SBD |
$8.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.37
|
| Rate for Payer: UHC Core |
$6.71
|
| Rate for Payer: UHC Exchange |
$5.06
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.03
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.78 |
| Max. Negotiated Rate |
$46.83 |
| Rate for Payer: Aetna Commercial |
$44.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.82
|
| 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: 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
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.03
|
|
|
Service Code
|
NDC 00121085340
|
| 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
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$12.88
|
|
|
Service Code
|
NDC 50383082420
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.37
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cofinity Advantage |
$9.02
|
| Rate for Payer: Cofinity Commercial |
$11.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.30
|
| Rate for Payer: Healthscope Commercial |
$11.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.66
|
| Rate for Payer: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health SBD |
$8.11
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$12.88
|
|
|
Service Code
|
NDC 50383082420
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.95
|
| Rate for Payer: Aetna Medicare |
$6.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.37
|
| Rate for Payer: BCBS Complete |
$5.15
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cofinity Advantage |
$9.02
|
| Rate for Payer: Cofinity Commercial |
$11.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.30
|
| Rate for Payer: Healthscope Commercial |
$11.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.66
|
| Rate for Payer: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health SBD |
$8.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.37
|
| Rate for Payer: UHC Core |
$6.71
|
| Rate for Payer: UHC Exchange |
$5.06
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$51.89
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.69 |
| Max. Negotiated Rate |
$46.70 |
| Rate for Payer: Aetna Commercial |
$44.11
|
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cash Price |
$41.51
|
| Rate for Payer: Cofinity Advantage |
$36.32
|
| Rate for Payer: Cofinity Advantage |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Cofinity Commercial |
$44.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$46.70
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.92
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: PHP Commercial |
$44.11
|
| Rate for Payer: Priority Health SBD |
$32.69
|
| Rate for Payer: Priority Health SBD |
$16.51
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$51.89
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$46.70 |
| Rate for Payer: Aetna Commercial |
$44.11
|
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna Medicare |
$13.10
|
| Rate for Payer: Aetna Medicare |
$25.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: BCBS Complete |
$10.48
|
| Rate for Payer: BCBS Complete |
$20.76
|
| Rate for Payer: BCBS Trust/PPO |
$0.07
|
| Rate for Payer: BCBS Trust/PPO |
$0.07
|
| Rate for Payer: BCN Commercial |
$0.07
|
| Rate for Payer: BCN Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$41.51
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cash Price |
$41.51
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Advantage |
$36.32
|
| Rate for Payer: Cofinity Advantage |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$44.63
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.51
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Healthscope Commercial |
$46.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.65
|
| Rate for Payer: PHP Commercial |
$44.11
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health SBD |
$32.69
|
| Rate for Payer: Priority Health SBD |
$16.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$401.85
|
|
|
Service Code
|
NDC 60687061401
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.17 |
| Max. Negotiated Rate |
$361.67 |
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.20
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Advantage |
$281.30
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.39
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health SBD |
$253.17
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 65862042001
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.35 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Advantage |
$97.06
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.99
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health SBD |
$87.35
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$4.02
|
|
|
Service Code
|
NDC 60687061411
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Aetna Medicare |
$2.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.61
|
| Rate for Payer: BCBS Complete |
$1.61
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Advantage |
$2.81
|
| Rate for Payer: Cofinity Commercial |
$3.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$3.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: PHP Commercial |
$3.42
|
| Rate for Payer: Priority Health SBD |
$2.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.61
|
| Rate for Payer: UHC Core |
$2.09
|
| Rate for Payer: UHC Exchange |
$1.58
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$364.25
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.15 |
| Max. Negotiated Rate |
$327.82 |
| Rate for Payer: Aetna Commercial |
$309.61
|
| Rate for Payer: Aetna Medicare |
$182.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$236.76
|
| Rate for Payer: BCBS Complete |
$145.70
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Advantage |
$254.97
|
| Rate for Payer: Cofinity Commercial |
$313.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Healthscope Commercial |
$327.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$291.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$309.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.19
|
| Rate for Payer: PHP Commercial |
$309.61
|
| Rate for Payer: Priority Health SBD |
$229.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$236.76
|
| Rate for Payer: UHC Core |
$189.77
|
| Rate for Payer: UHC Exchange |
$143.15
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$364.25
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$229.48 |
| Max. Negotiated Rate |
$327.82 |
| Rate for Payer: Aetna Commercial |
$309.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$236.76
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Advantage |
$254.97
|
| Rate for Payer: Cofinity Commercial |
$313.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Healthscope Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$309.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.19
|
| Rate for Payer: PHP Commercial |
$309.61
|
| Rate for Payer: Priority Health SBD |
$229.48
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$4.02
|
|
|
Service Code
|
NDC 60687061411
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.61
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Advantage |
$2.81
|
| Rate for Payer: Cofinity Commercial |
$3.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$3.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: PHP Commercial |
$3.42
|
| Rate for Payer: Priority Health SBD |
$2.53
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$138.65
|
|
|
Service Code
|
NDC 65862042001
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.49 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna Medicare |
$69.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: BCBS Complete |
$55.46
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Advantage |
$97.06
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$110.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.99
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.12
|
| Rate for Payer: UHC Core |
$72.24
|
| Rate for Payer: UHC Exchange |
$54.49
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$401.85
|
|
|
Service Code
|
NDC 60687061401
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.93 |
| Max. Negotiated Rate |
$361.67 |
| Rate for Payer: Aetna Commercial |
$341.57
|
| Rate for Payer: Aetna Medicare |
$200.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.20
|
| Rate for Payer: BCBS Complete |
$160.74
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Advantage |
$281.30
|
| Rate for Payer: Cofinity Commercial |
$345.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$361.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$321.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.39
|
| Rate for Payer: PHP Commercial |
$341.57
|
| Rate for Payer: Priority Health SBD |
$253.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.20
|
| Rate for Payer: UHC Core |
$209.36
|
| Rate for Payer: UHC Exchange |
$157.93
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$892.80
|
|
|
Service Code
|
NDC 62135096001
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$350.87 |
| Max. Negotiated Rate |
$803.52 |
| Rate for Payer: Aetna Commercial |
$758.88
|
| Rate for Payer: Aetna Medicare |
$446.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$580.32
|
| Rate for Payer: BCBS Complete |
$357.12
|
| Rate for Payer: Cash Price |
$714.24
|
| Rate for Payer: Cofinity Advantage |
$624.96
|
| Rate for Payer: Cofinity Commercial |
$767.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$714.24
|
| Rate for Payer: Healthscope Commercial |
$803.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$714.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$758.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$669.60
|
| Rate for Payer: PHP Commercial |
$758.88
|
| Rate for Payer: Priority Health SBD |
$562.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$580.32
|
| Rate for Payer: UHC Core |
$465.15
|
| Rate for Payer: UHC Exchange |
$350.87
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$744.96
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$292.77 |
| Max. Negotiated Rate |
$670.46 |
| Rate for Payer: Aetna Commercial |
$633.22
|
| Rate for Payer: Aetna Medicare |
$372.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$484.22
|
| Rate for Payer: BCBS Complete |
$297.98
|
| Rate for Payer: Cash Price |
$595.97
|
| Rate for Payer: Cofinity Advantage |
$521.47
|
| Rate for Payer: Cofinity Commercial |
$640.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$595.97
|
| Rate for Payer: Healthscope Commercial |
$670.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$595.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$633.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$558.72
|
| Rate for Payer: PHP Commercial |
$633.22
|
| Rate for Payer: Priority Health SBD |
$469.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$484.22
|
| Rate for Payer: UHC Core |
$388.12
|
| Rate for Payer: UHC Exchange |
$292.77
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$892.80
|
|
|
Service Code
|
NDC 62135096001
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$562.46 |
| Max. Negotiated Rate |
$803.52 |
| Rate for Payer: Aetna Commercial |
$758.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$580.32
|
| Rate for Payer: Cash Price |
$714.24
|
| Rate for Payer: Cofinity Advantage |
$624.96
|
| Rate for Payer: Cofinity Commercial |
$767.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$714.24
|
| Rate for Payer: Healthscope Commercial |
$803.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$758.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$669.60
|
| Rate for Payer: PHP Commercial |
$758.88
|
| Rate for Payer: Priority Health SBD |
$562.46
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$744.96
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$469.32 |
| Max. Negotiated Rate |
$670.46 |
| Rate for Payer: Aetna Commercial |
$633.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$484.22
|
| Rate for Payer: Cash Price |
$595.97
|
| Rate for Payer: Cofinity Advantage |
$521.47
|
| Rate for Payer: Cofinity Commercial |
$640.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$595.97
|
| Rate for Payer: Healthscope Commercial |
$670.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$633.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$558.72
|
| Rate for Payer: PHP Commercial |
$633.22
|
| Rate for Payer: Priority Health SBD |
$469.32
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna Medicare |
$106.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.94
|
| Rate for Payer: BCBS Complete |
$85.50
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Advantage |
$149.62
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$171.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health SBD |
$134.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$138.94
|
| Rate for Payer: UHC Core |
$111.36
|
| Rate for Payer: UHC Exchange |
$84.00
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.66 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.94
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Advantage |
$149.62
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health SBD |
$134.66
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$7.92
|
|
|
Service Code
|
NDC 55111029209
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.15
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cofinity Advantage |
$5.54
|
| Rate for Payer: Cofinity Commercial |
$6.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.34
|
| Rate for Payer: Healthscope Commercial |
$7.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.94
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: Priority Health SBD |
$4.99
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 62756052169
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.86 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.28
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Advantage |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.40
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health SBD |
$44.86
|
|
