|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$449.46
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$179.78 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna Medicare |
$224.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.15
|
| Rate for Payer: BCBS Complete |
$179.78
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$314.62
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health SBD |
$283.16
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$449.46
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$283.16 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.15
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$314.62
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health SBD |
$283.16
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$449.46
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$179.78 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna Medicare |
$224.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.15
|
| Rate for Payer: BCBS Complete |
$179.78
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$314.62
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health SBD |
$283.16
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$449.46
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$283.16 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.15
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$314.62
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health SBD |
$283.16
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$139.71
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.02 |
| Max. Negotiated Rate |
$125.74 |
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.81
|
| Rate for Payer: Cash Price |
$111.77
|
| Rate for Payer: Cofinity Commercial |
$120.15
|
| Rate for Payer: Cofinity Commercial |
$97.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.77
|
| Rate for Payer: Healthscope Commercial |
$125.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.75
|
| Rate for Payer: PHP Commercial |
$118.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.81
|
| Rate for Payer: Priority Health SBD |
$88.02
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$139.71
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.88 |
| Max. Negotiated Rate |
$125.74 |
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna Medicare |
$69.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.81
|
| Rate for Payer: BCBS Complete |
$55.88
|
| Rate for Payer: Cash Price |
$111.77
|
| Rate for Payer: Cofinity Commercial |
$120.15
|
| Rate for Payer: Cofinity Commercial |
$97.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.77
|
| Rate for Payer: Healthscope Commercial |
$125.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.75
|
| Rate for Payer: PHP Commercial |
$118.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.81
|
| Rate for Payer: Priority Health SBD |
$88.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.69
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.08 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna Medicare |
$26.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.25
|
| Rate for Payer: BCBS Complete |
$21.08
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$36.88
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health SBD |
$33.19
|
|
|
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 Commercial |
$11.08
|
| Rate for Payer: Cofinity Commercial |
$9.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.02
|
| 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: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.37
|
| 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 |
$5.15 |
| 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 Commercial |
$11.08
|
| Rate for Payer: Cofinity Commercial |
$9.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.02
|
| 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: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.37
|
| Rate for Payer: Priority Health SBD |
$8.11
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.69
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.19 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.25
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$36.88
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health SBD |
$33.19
|
|
|
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 |
$5.15 |
| 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 Commercial |
$11.08
|
| Rate for Payer: Cofinity Commercial |
$9.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.02
|
| 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: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.37
|
| Rate for Payer: Priority Health SBD |
$8.11
|
|
|
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 Commercial |
$11.08
|
| Rate for Payer: Cofinity Commercial |
$9.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.02
|
| 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: PHP Commercial |
$10.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.37
|
| Rate for Payer: Priority Health SBD |
$8.11
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.69
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.08 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna Medicare |
$26.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.25
|
| Rate for Payer: BCBS Complete |
$21.08
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$36.88
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health SBD |
$33.19
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.69
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.19 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.25
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$36.88
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health SBD |
$33.19
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.20
|
|
|
Service Code
|
NDC 70069036210
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Commercial |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.03
|
| Rate for Payer: Priority Health SBD |
$16.51
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.20
|
|
|
Service Code
|
NDC 70069036201
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Commercial |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.03
|
| Rate for Payer: Priority Health SBD |
$16.51
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.20
|
|
|
Service Code
|
NDC 70069036201
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna Medicare |
$13.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: BCBS Complete |
$10.48
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Commercial |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.03
|
| Rate for Payer: Priority Health SBD |
$16.51
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.63
|
|
|
Service Code
|
NDC 00703951493
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.37 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Aetna Commercial |
$16.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.76
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Cofinity Commercial |
$16.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$17.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.69
|
| Rate for Payer: PHP Commercial |
$16.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.76
|
| Rate for Payer: Priority Health SBD |
$12.37
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.63
|
|
|
Service Code
|
NDC 00703951491
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.37 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Aetna Commercial |
$16.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.76
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Cofinity Commercial |
$16.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$17.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.69
|
| Rate for Payer: PHP Commercial |
$16.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.76
|
| Rate for Payer: Priority Health SBD |
$12.37
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.63
|
|
|
Service Code
|
NDC 00703951491
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Aetna Commercial |
$16.69
|
| Rate for Payer: Aetna Medicare |
$9.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.76
|
| Rate for Payer: BCBS Complete |
$7.85
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Cofinity Commercial |
$16.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$17.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.69
|
| Rate for Payer: PHP Commercial |
$16.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.76
|
| Rate for Payer: Priority Health SBD |
$12.37
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.20
|
|
|
Service Code
|
NDC 70069036210
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna Medicare |
$13.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: BCBS Complete |
$10.48
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Commercial |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.03
|
| Rate for Payer: Priority Health SBD |
$16.51
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.63
|
|
|
Service Code
|
NDC 00703951493
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Aetna Commercial |
$16.69
|
| Rate for Payer: Aetna Medicare |
$9.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.76
|
| Rate for Payer: BCBS Complete |
$7.85
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Cofinity Commercial |
$16.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$17.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.69
|
| Rate for Payer: PHP Commercial |
$16.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.76
|
| Rate for Payer: Priority Health SBD |
$12.37
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.58 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health SBD |
$183.58
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.56 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna Medicare |
$145.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health SBD |
$183.58
|
|
|
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 Commercial |
$624.96
|
| Rate for Payer: Cofinity Commercial |
$767.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$624.96
|
| 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: PHP Commercial |
$758.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$580.32
|
| Rate for Payer: Priority Health SBD |
$562.46
|
|
