|
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS
|
Facility
|
OP
|
$9,692.51
|
|
|
Service Code
|
CPT 37765
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,652.95 |
| Max. Negotiated Rate |
$9,692.51 |
| Rate for Payer: Aetna Medicare |
$3,207.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,854.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,854.82
|
| Rate for Payer: BCBS Complete |
$1,735.60
|
| Rate for Payer: BCBS MAPPO |
$3,083.86
|
| Rate for Payer: BCBS Trust/PPO |
$1,917.56
|
| Rate for Payer: BCN Commercial |
$1,917.56
|
| Rate for Payer: BCN Medicare Advantage |
$3,083.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,083.86
|
| Rate for Payer: Mclaren Medicaid |
$1,652.95
|
| Rate for Payer: Mclaren Medicare |
$3,083.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,238.05
|
| Rate for Payer: Meridian Medicaid |
$1,735.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,546.44
|
| Rate for Payer: Nomi Health Commercial |
$6,476.11
|
| Rate for Payer: PACE Medicare |
$2,929.67
|
| Rate for Payer: PACE SWMI |
$3,083.86
|
| Rate for Payer: PHP Medicare Advantage |
$3,083.86
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,652.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,692.51
|
| Rate for Payer: Priority Health Medicare |
$3,083.86
|
| Rate for Payer: Priority Health Narrow Network |
$7,754.01
|
| Rate for Payer: Railroad Medicare Medicare |
$3,083.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,680.76
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,083.86
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,083.86
|
| Rate for Payer: UHCCP Medicaid |
$1,736.21
|
| Rate for Payer: VA VA |
$3,083.86
|
|
|
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS
|
Facility
|
OP
|
$9,692.51
|
|
|
Service Code
|
CPT 37766
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$287.52 |
| Max. Negotiated Rate |
$9,692.51 |
| Rate for Payer: Aetna Medicare |
$3,207.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,854.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,854.82
|
| Rate for Payer: BCBS Complete |
$1,735.60
|
| Rate for Payer: BCBS MAPPO |
$3,083.86
|
| Rate for Payer: BCBS Trust/PPO |
$287.52
|
| Rate for Payer: BCN Commercial |
$287.52
|
| Rate for Payer: BCN Medicare Advantage |
$3,083.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,083.86
|
| Rate for Payer: Mclaren Medicaid |
$1,652.95
|
| Rate for Payer: Mclaren Medicare |
$3,083.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,238.05
|
| Rate for Payer: Meridian Medicaid |
$1,735.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,546.44
|
| Rate for Payer: Nomi Health Commercial |
$6,476.11
|
| Rate for Payer: PACE Medicare |
$2,929.67
|
| Rate for Payer: PACE SWMI |
$3,083.86
|
| Rate for Payer: PHP Medicare Advantage |
$3,083.86
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,652.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,692.51
|
| Rate for Payer: Priority Health Medicare |
$3,083.86
|
| Rate for Payer: Priority Health Narrow Network |
$7,754.01
|
| Rate for Payer: Railroad Medicare Medicare |
$3,083.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$352.88
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,083.86
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,083.86
|
| Rate for Payer: UHCCP Medicaid |
$1,736.21
|
| Rate for Payer: VA VA |
$3,083.86
|
|
|
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
CPT 61782
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$182.96 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: BCBS Trust/PPO |
$367.65
|
| Rate for Payer: BCN Commercial |
$367.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$182.96
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$940.00
|
|
|
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
CPT 61783
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$252.15 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: BCBS Trust/PPO |
$495.26
|
| Rate for Payer: BCN Commercial |
$495.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.15
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$940.00
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
OP
|
$443.75
|
|
|
Service Code
|
NDC 62327033303
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.50 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna Medicare |
$221.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: BCBS Complete |
$177.50
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.00
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.44
|
| Rate for Payer: Priority Health SBD |
$279.56
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
IP
|
$443.75
|
|
|
Service Code
|
NDC 62327033303
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$279.56 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.00
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.44
|
| Rate for Payer: Priority Health SBD |
$279.56
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
IP
|
$443.75
|
|
|
Service Code
|
NDC 62327033343
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$279.56 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.00
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.44
|
| Rate for Payer: Priority Health SBD |
$279.56
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
OP
|
$443.75
|
|
|
Service Code
|
NDC 62327033343
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.50 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna Medicare |
$221.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: BCBS Complete |
$177.50
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.00
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.44
|
| Rate for Payer: Priority Health SBD |
$279.56
|
|
|
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 Commercial |
$201.28
|
| Rate for Payer: Cofinity Commercial |
$247.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$201.28
|
| 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: PHP Commercial |
$244.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.91
|
| Rate for Payer: Priority Health SBD |
$181.16
|
|
|
SUBMUCOSAL INJECTABLE COMPOSITION (ELEVIEW)
|
Facility
|
IP
|
$287.55
|
|
|
Service Code
|
NDC 09900001087
|
| 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 Commercial |
$201.28
|
| Rate for Payer: Cofinity Commercial |
$247.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$201.28
|
| 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: PHP Commercial |
$244.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.91
|
| Rate for Payer: Priority Health SBD |
$181.16
|
|
|
SUBMUCOSAL INJECTABLE COMPOSITION (ELEVIEW)
|
Facility
|
OP
|
$287.55
|
|
|
Service Code
|
NDC 09900001087
|
| Hospital Charge Code |
200133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$115.02 |
| 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 Commercial |
$201.28
|
| Rate for Payer: Cofinity Commercial |
$247.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$201.28
|
| 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: PHP Commercial |
$244.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.91
|
| 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 |
$115.02 |
| 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 Commercial |
$201.28
|
| Rate for Payer: Cofinity Commercial |
$247.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$201.28
|
| 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: PHP Commercial |
$244.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.91
|
| Rate for Payer: Priority Health SBD |
$181.16
|
|
|
SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD
|
Facility
|
OP
|
$9,986.81
|
|
|
Service Code
|
CPT 30140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$188.57 |
| Max. Negotiated Rate |
$9,986.81 |
| Rate for Payer: Aetna Medicare |
$3,304.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,971.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,971.88
|
| Rate for Payer: BCBS Complete |
$1,788.30
|
| Rate for Payer: BCBS MAPPO |
$3,177.50
|
| Rate for Payer: BCBS Trust/PPO |
$980.72
|
| Rate for Payer: BCN Commercial |
$980.72
|
| Rate for Payer: BCN Medicare Advantage |
$3,177.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,177.50
|
| Rate for Payer: Mclaren Medicaid |
$1,703.14
|
| Rate for Payer: Mclaren Medicare |
$3,177.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,336.38
|
| Rate for Payer: Meridian Medicaid |
$1,788.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,654.12
|
| Rate for Payer: Nomi Health Commercial |
$6,672.75
|
| Rate for Payer: PACE Medicare |
$3,018.62
|
| Rate for Payer: PACE SWMI |
$3,177.50
|
| Rate for Payer: PHP Medicare Advantage |
$3,177.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,986.81
|
| Rate for Payer: Priority Health Medicare |
$3,177.50
|
| Rate for Payer: Priority Health Narrow Network |
$7,989.45
|
| Rate for Payer: Railroad Medicare Medicare |
$3,177.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.57
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,177.50
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,177.50
|
| Rate for Payer: UHCCP Medicaid |
$1,788.93
|
| Rate for Payer: VA VA |
$3,177.50
|
|
|
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 |
$24.60
|
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.58
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cofinity Commercial |
$55.54
|
| Rate for Payer: Cofinity Commercial |
$18.88
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$20.26
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.48
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Healthscope Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.45
|
| Rate for Payer: PHP Commercial |
$67.45
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.81
|
| Rate for Payer: Priority Health SBD |
$49.99
|
| Rate for Payer: Priority Health SBD |
$16.99
|
| Rate for Payer: Priority Health SBD |
$18.23
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION (CODE)
|
Facility
|
OP
|
$79.35
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
163722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$71.42 |
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna Medicare |
$13.48
|
| Rate for Payer: Aetna Medicare |
$14.47
|
| Rate for Payer: Aetna Medicare |
$39.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.58
|
| Rate for Payer: BCBS Complete |
$11.58
|
| Rate for Payer: BCBS Complete |
$10.79
|
| Rate for Payer: BCBS Complete |
$31.74
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cofinity Commercial |
$20.26
|
| Rate for Payer: Cofinity Commercial |
$18.88
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$55.54
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.88
|
| 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 |
$63.48
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$71.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.45
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: PHP Commercial |
$67.45
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.53
|
| Rate for Payer: Priority Health SBD |
$16.99
|
| Rate for Payer: Priority Health SBD |
$49.99
|
| Rate for Payer: Priority Health SBD |
$18.23
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$22.06
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$19.85 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Commercial |
$15.74
|
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna Commercial |
$23.34
|
| Rate for Payer: Aetna Commercial |
$18.37
|
| Rate for Payer: Aetna Commercial |
$44.34
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna Commercial |
$17.26
|
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.34
|
| Rate for Payer: Cash Price |
$17.65
|
| Rate for Payer: Cash Price |
$41.73
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: Cash Price |
$14.82
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$21.97
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$19.22
|
| Rate for Payer: Cofinity Commercial |
$23.62
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$14.21
|
| Rate for Payer: Cofinity Commercial |
$17.46
|
| Rate for Payer: Cofinity Commercial |
$15.13
|
| Rate for Payer: Cofinity Commercial |
$18.58
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.97
|
| Rate for Payer: Cofinity Commercial |
$18.08
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Cofinity Commercial |
$18.88
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$55.54
|
| Rate for Payer: Cofinity Commercial |
$20.26
|
| Rate for Payer: Cofinity Commercial |
$44.86
|
| Rate for Payer: Cofinity Commercial |
$36.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.65
|
| Rate for Payer: Healthscope Commercial |
$24.71
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: Healthscope Commercial |
$19.45
|
| Rate for Payer: Healthscope Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$19.85
|
| Rate for Payer: Healthscope Commercial |
$16.67
|
| Rate for Payer: Healthscope Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$46.94
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.34
|
| 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 |
$18.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.26
|
| 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 |
$67.45
|
| Rate for Payer: PHP Commercial |
$23.34
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: PHP Commercial |
$44.34
|
| Rate for Payer: PHP Commercial |
$17.26
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: PHP Commercial |
$18.75
|
| Rate for Payer: PHP Commercial |
$18.37
|
| Rate for Payer: PHP Commercial |
$15.74
|
| Rate for Payer: PHP Commercial |
$67.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.20
|
| Rate for Payer: Priority Health SBD |
$12.79
|
| Rate for Payer: Priority Health SBD |
$13.61
|
| Rate for Payer: Priority Health SBD |
$13.90
|
| Rate for Payer: Priority Health SBD |
$49.99
|
| 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 |
$17.30
|
| Rate for Payer: Priority Health SBD |
$16.27
|
| Rate for Payer: Priority Health SBD |
$11.67
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$79.35
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$71.42 |
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna Commercial |
$18.37
|
| Rate for Payer: Aetna Commercial |
$15.74
|
| Rate for Payer: Aetna Commercial |
$17.26
|
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna Commercial |
$23.34
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna Commercial |
$44.34
|
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Medicare |
$26.08
|
| Rate for Payer: Aetna Medicare |
$10.80
|
| Rate for Payer: Aetna Medicare |
$13.48
|
| Rate for Payer: Aetna Medicare |
$14.47
|
| Rate for Payer: Aetna Medicare |
$39.68
|
| Rate for Payer: Aetna Medicare |
$9.26
|
| Rate for Payer: Aetna Medicare |
$11.03
|
| Rate for Payer: Aetna Medicare |
$10.15
|
| Rate for Payer: Aetna Medicare |
$12.92
|
| Rate for Payer: Aetna Medicare |
$13.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| 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) |
$12.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: BCBS Complete |
$8.64
|
| Rate for Payer: BCBS Complete |
$11.58
|
| Rate for Payer: BCBS Complete |
$7.41
|
| Rate for Payer: BCBS Complete |
$10.98
|
| Rate for Payer: BCBS Complete |
$8.12
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: BCBS Complete |
$10.79
|
| Rate for Payer: BCBS Complete |
$10.33
|
| Rate for Payer: BCBS Complete |
$31.74
|
| Rate for Payer: BCBS Complete |
$20.86
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$21.97
|
| Rate for Payer: Cash Price |
$21.97
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: Cash Price |
$14.82
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cash Price |
$41.73
|
| Rate for Payer: Cash Price |
$17.65
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cash Price |
$17.65
|
| 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: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$18.97
|
| Rate for Payer: Cofinity Commercial |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$55.54
|
| Rate for Payer: Cofinity Commercial |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$20.26
|
| Rate for Payer: Cofinity Commercial |
$19.22
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$14.21
|
| Rate for Payer: Cofinity Commercial |
$17.46
|
| Rate for Payer: Cofinity Commercial |
$44.86
|
| Rate for Payer: Cofinity Commercial |
$36.51
|
| Rate for Payer: Cofinity Commercial |
$15.13
|
| Rate for Payer: Cofinity Commercial |
$18.58
|
| Rate for Payer: Cofinity Commercial |
$23.62
|
| Rate for Payer: Cofinity Commercial |
$18.08
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$18.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.82
|
| 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 |
$63.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.66
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: Healthscope Commercial |
$19.85
|
| Rate for Payer: Healthscope Commercial |
$19.45
|
| Rate for Payer: Healthscope Commercial |
$16.67
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$24.71
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Healthscope Commercial |
$46.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.96
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: PHP Commercial |
$17.26
|
| Rate for Payer: PHP Commercial |
$23.34
|
| Rate for Payer: PHP Commercial |
$67.45
|
| Rate for Payer: PHP Commercial |
$18.37
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: PHP Commercial |
$15.74
|
| Rate for Payer: PHP Commercial |
$44.34
|
| Rate for Payer: PHP Commercial |
$18.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.79
|
| Rate for Payer: Priority Health SBD |
$11.67
|
| Rate for Payer: Priority Health SBD |
$32.86
|
| Rate for Payer: Priority Health SBD |
$18.23
|
| Rate for Payer: Priority Health SBD |
$49.99
|
| Rate for Payer: Priority Health SBD |
$13.90
|
| Rate for Payer: Priority Health SBD |
$13.61
|
| Rate for Payer: Priority Health SBD |
$16.99
|
| Rate for Payer: Priority Health SBD |
$12.79
|
| Rate for Payer: Priority Health SBD |
$16.27
|
| Rate for Payer: Priority Health SBD |
$17.30
|
|
|
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 Commercial |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$29.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.93
|
| 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: PHP Commercial |
$29.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.22
|
| Rate for Payer: Priority Health SBD |
$21.53
|
|
|
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 |
$14.65 |
| 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 Commercial |
$25.64
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.64
|
| 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: PHP Commercial |
$31.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.81
|
| Rate for Payer: Priority Health SBD |
$23.08
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$46.36
|
|
|
Service Code
|
NDC 00904747072
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.54 |
| Max. Negotiated Rate |
$41.72 |
| Rate for Payer: Aetna Commercial |
$39.41
|
| Rate for Payer: Aetna Medicare |
$23.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.13
|
| Rate for Payer: BCBS Complete |
$18.54
|
| Rate for Payer: Cash Price |
$37.09
|
| Rate for Payer: Cofinity Commercial |
$32.45
|
| Rate for Payer: Cofinity Commercial |
$39.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.09
|
| Rate for Payer: Healthscope Commercial |
$41.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.41
|
| Rate for Payer: PHP Commercial |
$39.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.13
|
| Rate for Payer: Priority Health SBD |
$29.21
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$46.23
|
|
|
Service Code
|
NDC 66689079050
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$41.61 |
| Rate for Payer: Aetna Commercial |
$39.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.05
|
| Rate for Payer: Cash Price |
$36.98
|
| Rate for Payer: Cofinity Commercial |
$32.36
|
| Rate for Payer: Cofinity Commercial |
$39.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.98
|
| Rate for Payer: Healthscope Commercial |
$41.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.30
|
| Rate for Payer: PHP Commercial |
$39.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.05
|
| Rate for Payer: Priority Health SBD |
$29.12
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$29.91
|
|
|
Service Code
|
NDC 00904747066
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$26.92 |
| Rate for Payer: Aetna Commercial |
$25.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.44
|
| Rate for Payer: Cash Price |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$20.94
|
| Rate for Payer: Cofinity Commercial |
$25.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.93
|
| Rate for Payer: Healthscope Commercial |
$26.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.42
|
| Rate for Payer: PHP Commercial |
$25.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.44
|
| Rate for Payer: Priority Health SBD |
$18.84
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$46.36
|
|
|
Service Code
|
NDC 00904747072
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$41.72 |
| Rate for Payer: Aetna Commercial |
$39.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.13
|
| Rate for Payer: Cash Price |
$37.09
|
| Rate for Payer: Cofinity Commercial |
$32.45
|
| Rate for Payer: Cofinity Commercial |
$39.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.09
|
| Rate for Payer: Healthscope Commercial |
$41.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.41
|
| Rate for Payer: PHP Commercial |
$39.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.13
|
| Rate for Payer: Priority Health SBD |
$29.21
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$46.23
|
|
|
Service Code
|
NDC 66689079050
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.49 |
| Max. Negotiated Rate |
$41.61 |
| Rate for Payer: Aetna Commercial |
$39.30
|
| Rate for Payer: Aetna Medicare |
$23.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.05
|
| Rate for Payer: BCBS Complete |
$18.49
|
| Rate for Payer: Cash Price |
$36.98
|
| Rate for Payer: Cofinity Commercial |
$32.36
|
| Rate for Payer: Cofinity Commercial |
$39.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.98
|
| Rate for Payer: Healthscope Commercial |
$41.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.30
|
| Rate for Payer: PHP Commercial |
$39.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.05
|
| Rate for Payer: Priority Health SBD |
$29.12
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$32.88
|
|
|
Service Code
|
NDC 60687073842
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.71 |
| Max. Negotiated Rate |
$29.59 |
| Rate for Payer: Aetna Commercial |
$27.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.37
|
| Rate for Payer: Cash Price |
$26.30
|
| Rate for Payer: Cofinity Commercial |
$23.02
|
| Rate for Payer: Cofinity Commercial |
$28.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.30
|
| Rate for Payer: Healthscope Commercial |
$29.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.95
|
| Rate for Payer: PHP Commercial |
$27.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.37
|
| Rate for Payer: Priority Health SBD |
$20.71
|
|
