|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$42.29
|
|
|
Service Code
|
NDC 68094004361
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.43 |
| Max. Negotiated Rate |
$38.06 |
| Rate for Payer: Aetna Commercial |
$35.95
|
| Rate for Payer: BCBS Trust/PPO |
$34.93
|
| Rate for Payer: BCN Commercial |
$34.93
|
| Rate for Payer: Cash Price |
$33.83
|
| Rate for Payer: Cofinity Commercial |
$36.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.83
|
| Rate for Payer: Healthscope Commercial |
$38.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.95
|
| Rate for Payer: Nomi Health Commercial |
$34.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.72
|
| Rate for Payer: PHP Commercial |
$35.95
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$36.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$29.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.22
|
| Rate for Payer: UHC Core |
$35.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.72
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$25.30
|
|
|
Service Code
|
NDC 00121097440
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$22.77 |
| Rate for Payer: Aetna Commercial |
$21.50
|
| Rate for Payer: Aetna Medicare |
$6.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.91
|
| Rate for Payer: BCBS Complete |
$4.68
|
| Rate for Payer: BCBS MAPPO |
$6.33
|
| Rate for Payer: BCBS Trust/PPO |
$20.80
|
| Rate for Payer: BCN Commercial |
$20.80
|
| Rate for Payer: BCN Medicare Advantage |
$6.33
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Cofinity Commercial |
$21.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.33
|
| Rate for Payer: Healthscope Commercial |
$22.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.98
|
| Rate for Payer: Mclaren Medicaid |
$4.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.64
|
| Rate for Payer: Meridian Medicaid |
$4.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.27
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.50
|
| Rate for Payer: Nomi Health Commercial |
$20.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.98
|
| Rate for Payer: PACE Senior Care Partners |
$6.01
|
| Rate for Payer: PACE SWMI |
$6.33
|
| Rate for Payer: PHP Commercial |
$21.50
|
| Rate for Payer: PHP Medicare Advantage |
$6.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$22.01
|
| Rate for Payer: Priority Health Medicare |
$6.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.61
|
| Rate for Payer: Railroad Medicare Medicare |
$6.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.26
|
| Rate for Payer: UHC Core |
$21.13
|
| Rate for Payer: UHC Exchange |
$6.33
|
| Rate for Payer: UHC Medicaid |
$4.46
|
| Rate for Payer: UHC Medicare Advantage |
$6.33
|
| Rate for Payer: UHCCP Medicaid |
$4.46
|
| Rate for Payer: VA VA |
$6.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.98
|
|
|
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 |
$17.68 |
| Max. Negotiated Rate |
$22.86 |
| Rate for Payer: Aetna Commercial |
$21.59
|
| Rate for Payer: BCBS Trust/PPO |
$20.98
|
| Rate for Payer: BCN Commercial |
$20.98
|
| Rate for Payer: Cash Price |
$20.32
|
| 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: Lakeland Regional Health Systems Commercial |
$19.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.59
|
| Rate for Payer: Nomi Health Commercial |
$20.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.05
|
| Rate for Payer: PHP Commercial |
$21.59
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$22.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.35
|
| Rate for Payer: UHC Core |
$21.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.05
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.30
|
|
|
Service Code
|
NDC 00121097440
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.61 |
| Max. Negotiated Rate |
$22.77 |
| Rate for Payer: Aetna Commercial |
$21.50
|
| Rate for Payer: BCBS Trust/PPO |
$20.90
|
| Rate for Payer: BCN Commercial |
$20.90
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Cofinity Commercial |
$21.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.24
|
| Rate for Payer: Healthscope Commercial |
$22.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.50
|
| Rate for Payer: Nomi Health Commercial |
$20.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.98
|
| Rate for Payer: PHP Commercial |
$21.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$22.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.26
|
| Rate for Payer: UHC Core |
$21.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.98
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$30.15
|
|
|
Service Code
|
NDC 00904747066
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.32 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Aetna Commercial |
$25.63
|
| Rate for Payer: Aetna Medicare |
$7.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.42
|
| Rate for Payer: BCBS Complete |
$5.58
|
| Rate for Payer: BCBS MAPPO |
$7.54
|
| Rate for Payer: BCBS Trust/PPO |
$24.79
|
| Rate for Payer: BCN Commercial |
$24.79
|
| Rate for Payer: BCN Medicare Advantage |
$7.54
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cofinity Commercial |
$25.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.54
|
| Rate for Payer: Healthscope Commercial |
$27.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.61
|
| Rate for Payer: Mclaren Medicaid |
$5.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.91
|
| Rate for Payer: Meridian Medicaid |
$5.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.67
|
| Rate for Payer: Molina Medicare/Medicaid |
$8.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.63
|
| Rate for Payer: Nomi Health Commercial |
$24.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.61
|
| Rate for Payer: PACE Senior Care Partners |
$7.16
|
| Rate for Payer: PACE SWMI |
$7.54
|
| Rate for Payer: PHP Commercial |
$25.63
|
| Rate for Payer: PHP Medicare Advantage |
$7.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$5.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$26.23
|
| Rate for Payer: Priority Health Medicare |
$7.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.98
|
| Rate for Payer: Railroad Medicare Medicare |
$7.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.53
|
| Rate for Payer: UHC Core |
$25.18
|
| Rate for Payer: UHC Exchange |
$7.54
|
| Rate for Payer: UHC Medicaid |
$5.32
|
| Rate for Payer: UHC Medicare Advantage |
$7.54
|
| Rate for Payer: UHCCP Medicaid |
$5.32
|
| Rate for Payer: VA VA |
$7.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.61
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$45.51
|
|
|
Service Code
|
NDC 00904747072
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.02 |
| Max. Negotiated Rate |
$40.96 |
| Rate for Payer: Aetna Commercial |
$38.68
|
| Rate for Payer: Aetna Medicare |
$11.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14.22
|
| Rate for Payer: BCBS Complete |
$8.42
|
| Rate for Payer: BCBS MAPPO |
$11.38
|
| Rate for Payer: BCBS Trust/PPO |
$37.41
|
| Rate for Payer: BCN Commercial |
$37.41
|
| Rate for Payer: BCN Medicare Advantage |
$11.38
|
| Rate for Payer: Cash Price |
$36.41
|
| Rate for Payer: Cofinity Commercial |
$39.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11.38
|
| Rate for Payer: Healthscope Commercial |
$40.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.13
|
| Rate for Payer: Mclaren Medicaid |
$8.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11.95
|
| Rate for Payer: Meridian Medicaid |
$8.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.08
|
| Rate for Payer: Molina Medicare/Medicaid |
$12.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.68
|
| Rate for Payer: Nomi Health Commercial |
$37.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.13
|
| Rate for Payer: PACE Senior Care Partners |
$10.81
|
| Rate for Payer: PACE SWMI |
$11.38
|
| Rate for Payer: PHP Commercial |
$38.68
|
| Rate for Payer: PHP Medicare Advantage |
$11.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.02
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$39.59
|
| Rate for Payer: Priority Health Medicare |
$11.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$31.67
|
| Rate for Payer: Railroad Medicare Medicare |
$11.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.05
|
| Rate for Payer: UHC Core |
$38.00
|
| Rate for Payer: UHC Exchange |
$11.38
|
| Rate for Payer: UHC Medicaid |
$8.02
|
| Rate for Payer: UHC Medicare Advantage |
$11.38
|
| Rate for Payer: UHCCP Medicaid |
$8.02
|
| Rate for Payer: VA VA |
$11.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.13
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$42.29
|
|
|
Service Code
|
NDC 68094004359
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.43 |
| Max. Negotiated Rate |
$38.06 |
| Rate for Payer: Aetna Commercial |
$35.95
|
| Rate for Payer: BCBS Trust/PPO |
$34.93
|
| Rate for Payer: BCN Commercial |
$34.93
|
| Rate for Payer: Cash Price |
$33.83
|
| Rate for Payer: Cofinity Commercial |
$36.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.83
|
| Rate for Payer: Healthscope Commercial |
$38.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.95
|
| Rate for Payer: Nomi Health Commercial |
$34.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.72
|
| Rate for Payer: PHP Commercial |
$35.95
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$36.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$29.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.22
|
| Rate for Payer: UHC Core |
$35.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.72
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$2.86
|
|
|
Service Code
|
NDC 60687069511
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.57 |
| Rate for Payer: Aetna Commercial |
$2.43
|
| Rate for Payer: BCBS Trust/PPO |
$2.36
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.29
|
| Rate for Payer: Healthscope Commercial |
$2.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.43
|
| Rate for Payer: Nomi Health Commercial |
$2.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.15
|
| Rate for Payer: PHP Commercial |
$2.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.52
|
| Rate for Payer: UHC Core |
$2.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.15
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$285.95
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.02 |
| Max. Negotiated Rate |
$257.36 |
| Rate for Payer: Aetna Commercial |
$243.06
|
| Rate for Payer: BCBS Trust/PPO |
$236.17
|
| Rate for Payer: BCN Commercial |
$236.17
|
| Rate for Payer: Cash Price |
$228.76
|
| Rate for Payer: Cofinity Commercial |
$245.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.76
|
| Rate for Payer: Healthscope Commercial |
$257.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$214.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.06
|
| Rate for Payer: Nomi Health Commercial |
$234.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$214.46
|
| Rate for Payer: PHP Commercial |
$243.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$248.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$251.64
|
| Rate for Payer: UHC Core |
$238.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$214.46
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$237.50
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.30 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$201.88
|
| Rate for Payer: BCBS Trust/PPO |
$196.15
|
| Rate for Payer: BCN Commercial |
$196.15
|
| Rate for Payer: Cash Price |
$190.00
|
| 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: Lakeland Regional Health Systems Commercial |
$178.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.88
|
| Rate for Payer: Nomi Health Commercial |
$194.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.12
|
| Rate for Payer: PHP Commercial |
$201.88
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$206.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$165.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.00
|
| Rate for Payer: UHC Core |
$198.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.12
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$3.11
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna Commercial |
$2.64
|
| Rate for Payer: Aetna Medicare |
$0.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.97
|
| Rate for Payer: BCBS Complete |
$0.58
|
| Rate for Payer: BCBS MAPPO |
$0.78
|
| Rate for Payer: BCBS Trust/PPO |
$2.56
|
| Rate for Payer: BCN Commercial |
$2.56
|
| Rate for Payer: BCN Medicare Advantage |
$0.78
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.78
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.33
|
| Rate for Payer: Mclaren Medicaid |
$0.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.82
|
| Rate for Payer: Meridian Medicaid |
$0.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.89
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: Nomi Health Commercial |
$2.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.33
|
| Rate for Payer: PACE Senior Care Partners |
$0.74
|
| Rate for Payer: PACE SWMI |
$0.78
|
| Rate for Payer: PHP Commercial |
$2.64
|
| Rate for Payer: PHP Medicare Advantage |
$0.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.71
|
| Rate for Payer: Priority Health Medicare |
$0.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.16
|
| Rate for Payer: Railroad Medicare Medicare |
$0.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.74
|
| Rate for Payer: UHC Core |
$2.60
|
| Rate for Payer: UHC Exchange |
$0.78
|
| Rate for Payer: UHC Medicaid |
$0.55
|
| Rate for Payer: UHC Medicare Advantage |
$0.78
|
| Rate for Payer: UHCCP Medicaid |
$0.55
|
| Rate for Payer: VA VA |
$0.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.33
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$2.86
|
|
|
Service Code
|
NDC 60687069511
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.57 |
| Rate for Payer: Aetna Commercial |
$2.43
|
| Rate for Payer: Aetna Medicare |
$0.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.89
|
| Rate for Payer: BCBS Complete |
$0.53
|
| Rate for Payer: BCBS MAPPO |
$0.72
|
| Rate for Payer: BCBS Trust/PPO |
$2.35
|
| Rate for Payer: BCN Commercial |
$2.35
|
| Rate for Payer: BCN Medicare Advantage |
$0.72
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.72
|
| Rate for Payer: Healthscope Commercial |
$2.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.15
|
| Rate for Payer: Mclaren Medicaid |
$0.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.75
|
| Rate for Payer: Meridian Medicaid |
$0.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.82
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.43
|
| Rate for Payer: Nomi Health Commercial |
$2.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.15
|
| Rate for Payer: PACE Senior Care Partners |
$0.68
|
| Rate for Payer: PACE SWMI |
$0.72
|
| Rate for Payer: PHP Commercial |
$2.43
|
| Rate for Payer: PHP Medicare Advantage |
$0.72
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.49
|
| Rate for Payer: Priority Health Medicare |
$0.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.99
|
| Rate for Payer: Railroad Medicare Medicare |
$0.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.52
|
| Rate for Payer: UHC Core |
$2.39
|
| Rate for Payer: UHC Exchange |
$0.72
|
| Rate for Payer: UHC Medicaid |
$0.50
|
| Rate for Payer: UHC Medicare Advantage |
$0.72
|
| Rate for Payer: UHCCP Medicaid |
$0.50
|
| Rate for Payer: VA VA |
$0.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.15
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$310.65
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$216.21 |
| Max. Negotiated Rate |
$279.58 |
| Rate for Payer: Aetna Commercial |
$264.05
|
| Rate for Payer: BCBS Trust/PPO |
$256.57
|
| Rate for Payer: BCN Commercial |
$256.57
|
| Rate for Payer: Cash Price |
$248.52
|
| 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: Lakeland Regional Health Systems Commercial |
$232.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.05
|
| Rate for Payer: Nomi Health Commercial |
$254.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.99
|
| Rate for Payer: PHP Commercial |
$264.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$270.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$216.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.37
|
| Rate for Payer: UHC Core |
$259.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.99
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$237.50
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.87 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$201.88
|
| Rate for Payer: Aetna Medicare |
$61.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$74.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$74.22
|
| Rate for Payer: BCBS Complete |
$43.96
|
| Rate for Payer: BCBS MAPPO |
$59.38
|
| Rate for Payer: BCBS Trust/PPO |
$195.25
|
| Rate for Payer: BCN Commercial |
$195.25
|
| Rate for Payer: BCN Medicare Advantage |
$59.38
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cofinity Commercial |
$204.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$59.38
|
| Rate for Payer: Healthscope Commercial |
$213.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.12
|
| Rate for Payer: Mclaren Medicaid |
$41.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$62.34
|
| Rate for Payer: Meridian Medicaid |
$43.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.28
|
| Rate for Payer: Molina Medicare/Medicaid |
$65.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.88
|
| Rate for Payer: Nomi Health Commercial |
$194.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.12
|
| Rate for Payer: PACE Senior Care Partners |
$56.41
|
| Rate for Payer: PACE SWMI |
$59.38
|
| Rate for Payer: PHP Commercial |
$201.88
|
| Rate for Payer: PHP Medicare Advantage |
$59.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$41.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$206.62
|
| Rate for Payer: Priority Health Medicare |
$59.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$165.30
|
| Rate for Payer: Railroad Medicare Medicare |
$59.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.00
|
| Rate for Payer: UHC Core |
$198.31
|
| Rate for Payer: UHC Exchange |
$59.38
|
| Rate for Payer: UHC Medicaid |
$41.87
|
| Rate for Payer: UHC Medicare Advantage |
$59.38
|
| Rate for Payer: UHCCP Medicaid |
$41.87
|
| Rate for Payer: VA VA |
$59.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.12
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$3.11
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna Commercial |
$2.64
|
| Rate for Payer: BCBS Trust/PPO |
$2.57
|
| Rate for Payer: BCN Commercial |
$2.57
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: Nomi Health Commercial |
$2.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.33
|
| Rate for Payer: PHP Commercial |
$2.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.74
|
| Rate for Payer: UHC Core |
$2.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.33
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$285.95
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.41 |
| Max. Negotiated Rate |
$257.36 |
| Rate for Payer: Aetna Commercial |
$243.06
|
| Rate for Payer: Aetna Medicare |
$74.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$89.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$89.36
|
| Rate for Payer: BCBS Complete |
$52.93
|
| Rate for Payer: BCBS MAPPO |
$71.49
|
| Rate for Payer: BCBS Trust/PPO |
$235.08
|
| Rate for Payer: BCN Commercial |
$235.08
|
| Rate for Payer: BCN Medicare Advantage |
$71.49
|
| Rate for Payer: Cash Price |
$228.76
|
| Rate for Payer: Cofinity Commercial |
$245.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$71.49
|
| Rate for Payer: Healthscope Commercial |
$257.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$214.46
|
| Rate for Payer: Mclaren Medicaid |
$50.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$75.06
|
| Rate for Payer: Meridian Medicaid |
$52.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.21
|
| Rate for Payer: Molina Medicare/Medicaid |
$78.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.06
|
| Rate for Payer: Nomi Health Commercial |
$234.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$214.46
|
| Rate for Payer: PACE Senior Care Partners |
$67.91
|
| Rate for Payer: PACE SWMI |
$71.49
|
| Rate for Payer: PHP Commercial |
$243.06
|
| Rate for Payer: PHP Medicare Advantage |
$71.49
|
| Rate for Payer: Priority Health Choice Medicaid |
$50.41
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$248.78
|
| Rate for Payer: Priority Health Medicare |
$72.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.02
|
| Rate for Payer: Railroad Medicare Medicare |
$71.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$251.64
|
| Rate for Payer: UHC Core |
$238.77
|
| Rate for Payer: UHC Exchange |
$71.49
|
| Rate for Payer: UHC Medicaid |
$50.41
|
| Rate for Payer: UHC Medicare Advantage |
$71.49
|
| Rate for Payer: UHCCP Medicaid |
$50.41
|
| Rate for Payer: VA VA |
$71.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$214.46
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$310.65
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.77 |
| Max. Negotiated Rate |
$279.58 |
| Rate for Payer: Aetna Commercial |
$264.05
|
| Rate for Payer: Aetna Medicare |
$80.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$97.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$97.08
|
| Rate for Payer: BCBS Complete |
$57.50
|
| Rate for Payer: BCBS MAPPO |
$77.66
|
| Rate for Payer: BCBS Trust/PPO |
$255.39
|
| Rate for Payer: BCN Commercial |
$255.39
|
| Rate for Payer: BCN Medicare Advantage |
$77.66
|
| Rate for Payer: Cash Price |
$248.52
|
| Rate for Payer: Cofinity Commercial |
$267.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$77.66
|
| Rate for Payer: Healthscope Commercial |
$279.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.99
|
| Rate for Payer: Mclaren Medicaid |
$54.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$81.55
|
| Rate for Payer: Meridian Medicaid |
$57.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$89.31
|
| Rate for Payer: Molina Medicare/Medicaid |
$85.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.05
|
| Rate for Payer: Nomi Health Commercial |
$254.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.99
|
| Rate for Payer: PACE Senior Care Partners |
$73.78
|
| Rate for Payer: PACE SWMI |
$77.66
|
| Rate for Payer: PHP Commercial |
$264.05
|
| Rate for Payer: PHP Medicare Advantage |
$77.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$54.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$270.27
|
| Rate for Payer: Priority Health Medicare |
$78.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$216.21
|
| Rate for Payer: Railroad Medicare Medicare |
$77.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.37
|
| Rate for Payer: UHC Core |
$259.39
|
| Rate for Payer: UHC Exchange |
$77.66
|
| Rate for Payer: UHC Medicaid |
$54.77
|
| Rate for Payer: UHC Medicare Advantage |
$77.66
|
| Rate for Payer: UHCCP Medicaid |
$54.77
|
| Rate for Payer: VA VA |
$77.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.99
|
|
|
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 |
$83.20 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna Medicare |
$122.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.47
|
| Rate for Payer: BCBS Complete |
$87.35
|
| Rate for Payer: BCBS MAPPO |
$117.98
|
| Rate for Payer: BCBS Trust/PPO |
$387.96
|
| Rate for Payer: BCN Commercial |
$387.96
|
| Rate for Payer: BCN Medicare Advantage |
$117.98
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.98
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.93
|
| Rate for Payer: Mclaren Medicaid |
$83.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$123.88
|
| Rate for Payer: Meridian Medicaid |
$87.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.67
|
| Rate for Payer: Molina Medicare/Medicaid |
$129.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Nomi Health Commercial |
$386.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PACE Senior Care Partners |
$112.08
|
| Rate for Payer: PACE SWMI |
$117.98
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: PHP Medicare Advantage |
$117.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$83.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$410.56
|
| Rate for Payer: Priority Health Medicare |
$119.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$328.45
|
| Rate for Payer: Railroad Medicare Medicare |
$117.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$415.28
|
| Rate for Payer: UHC Core |
$394.04
|
| Rate for Payer: UHC Exchange |
$117.98
|
| Rate for Payer: UHC Medicaid |
$83.20
|
| Rate for Payer: UHC Medicare Advantage |
$117.98
|
| Rate for Payer: UHCCP Medicaid |
$83.20
|
| Rate for Payer: VA VA |
$117.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.93
|
|
|
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 |
$328.45 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: BCBS Trust/PPO |
$389.75
|
| Rate for Payer: BCN Commercial |
$389.75
|
| Rate for Payer: Cash Price |
$377.53
|
| 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: Lakeland Regional Health Systems Commercial |
$353.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Nomi Health Commercial |
$386.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$410.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$328.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$415.28
|
| Rate for Payer: UHC Core |
$394.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.93
|
|
|
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 |
$83.20 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna Medicare |
$122.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.47
|
| Rate for Payer: BCBS Complete |
$87.35
|
| Rate for Payer: BCBS MAPPO |
$117.98
|
| Rate for Payer: BCBS Trust/PPO |
$387.96
|
| Rate for Payer: BCN Commercial |
$387.96
|
| Rate for Payer: BCN Medicare Advantage |
$117.98
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.98
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.93
|
| Rate for Payer: Mclaren Medicaid |
$83.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$123.88
|
| Rate for Payer: Meridian Medicaid |
$87.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.67
|
| Rate for Payer: Molina Medicare/Medicaid |
$129.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Nomi Health Commercial |
$386.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PACE Senior Care Partners |
$112.08
|
| Rate for Payer: PACE SWMI |
$117.98
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: PHP Medicare Advantage |
$117.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$83.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$410.56
|
| Rate for Payer: Priority Health Medicare |
$119.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$328.45
|
| Rate for Payer: Railroad Medicare Medicare |
$117.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$415.28
|
| Rate for Payer: UHC Core |
$394.04
|
| Rate for Payer: UHC Exchange |
$117.98
|
| Rate for Payer: UHC Medicaid |
$83.20
|
| Rate for Payer: UHC Medicare Advantage |
$117.98
|
| Rate for Payer: UHCCP Medicaid |
$83.20
|
| Rate for Payer: VA VA |
$117.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.93
|
|
|
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 |
$328.45 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: BCBS Trust/PPO |
$389.75
|
| Rate for Payer: BCN Commercial |
$389.75
|
| Rate for Payer: Cash Price |
$377.53
|
| 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: Lakeland Regional Health Systems Commercial |
$353.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Nomi Health Commercial |
$386.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$410.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$328.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$415.28
|
| Rate for Payer: UHC Core |
$394.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.93
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$142.44
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.14 |
| Max. Negotiated Rate |
$128.20 |
| Rate for Payer: Aetna Commercial |
$121.07
|
| Rate for Payer: BCBS Trust/PPO |
$117.64
|
| Rate for Payer: BCN Commercial |
$117.64
|
| Rate for Payer: Cash Price |
$113.95
|
| 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: Lakeland Regional Health Systems Commercial |
$106.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.07
|
| Rate for Payer: Nomi Health Commercial |
$116.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.83
|
| Rate for Payer: PHP Commercial |
$121.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$123.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.35
|
| Rate for Payer: UHC Core |
$118.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.83
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$142.44
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.11 |
| Max. Negotiated Rate |
$128.20 |
| Rate for Payer: Aetna Commercial |
$121.07
|
| Rate for Payer: Aetna Medicare |
$37.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$44.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$44.51
|
| Rate for Payer: BCBS Complete |
$26.37
|
| Rate for Payer: BCBS MAPPO |
$35.61
|
| Rate for Payer: BCBS Trust/PPO |
$117.10
|
| Rate for Payer: BCN Commercial |
$117.10
|
| Rate for Payer: BCN Medicare Advantage |
$35.61
|
| Rate for Payer: Cash Price |
$113.95
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$35.61
|
| Rate for Payer: Healthscope Commercial |
$128.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.83
|
| Rate for Payer: Mclaren Medicaid |
$25.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$37.39
|
| Rate for Payer: Meridian Medicaid |
$26.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.95
|
| Rate for Payer: Molina Medicare/Medicaid |
$39.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.07
|
| Rate for Payer: Nomi Health Commercial |
$116.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.83
|
| Rate for Payer: PACE Senior Care Partners |
$33.83
|
| Rate for Payer: PACE SWMI |
$35.61
|
| Rate for Payer: PHP Commercial |
$121.07
|
| Rate for Payer: PHP Medicare Advantage |
$35.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$25.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$123.92
|
| Rate for Payer: Priority Health Medicare |
$35.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.14
|
| Rate for Payer: Railroad Medicare Medicare |
$35.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.35
|
| Rate for Payer: UHC Core |
$118.94
|
| Rate for Payer: UHC Exchange |
$35.61
|
| Rate for Payer: UHC Medicaid |
$25.11
|
| Rate for Payer: UHC Medicare Advantage |
$35.61
|
| Rate for Payer: UHCCP Medicaid |
$25.11
|
| Rate for Payer: VA VA |
$35.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.83
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$47.29
|
|
|
Service Code
|
NDC 81033001240
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.91 |
| Max. Negotiated Rate |
$42.56 |
| Rate for Payer: Aetna Commercial |
$40.20
|
| Rate for Payer: BCBS Trust/PPO |
$39.06
|
| Rate for Payer: BCN Commercial |
$39.06
|
| Rate for Payer: Cash Price |
$37.83
|
| Rate for Payer: Cofinity Commercial |
$40.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.83
|
| Rate for Payer: Healthscope Commercial |
$42.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.20
|
| Rate for Payer: Nomi Health Commercial |
$38.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.47
|
| Rate for Payer: PHP Commercial |
$40.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$41.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$41.62
|
| Rate for Payer: UHC Core |
$39.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.47
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$47.29
|
|
|
Service Code
|
NDC 81033001220
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$42.56 |
| Rate for Payer: Aetna Commercial |
$40.20
|
| Rate for Payer: Aetna Medicare |
$12.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14.78
|
| Rate for Payer: BCBS Complete |
$8.75
|
| Rate for Payer: BCBS MAPPO |
$11.82
|
| Rate for Payer: BCBS Trust/PPO |
$38.88
|
| Rate for Payer: BCN Commercial |
$38.88
|
| Rate for Payer: BCN Medicare Advantage |
$11.82
|
| Rate for Payer: Cash Price |
$37.83
|
| Rate for Payer: Cofinity Commercial |
$40.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11.82
|
| Rate for Payer: Healthscope Commercial |
$42.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.47
|
| Rate for Payer: Mclaren Medicaid |
$8.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.41
|
| Rate for Payer: Meridian Medicaid |
$8.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.20
|
| Rate for Payer: Nomi Health Commercial |
$38.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.47
|
| Rate for Payer: PACE Senior Care Partners |
$11.23
|
| Rate for Payer: PACE SWMI |
$11.82
|
| Rate for Payer: PHP Commercial |
$40.20
|
| Rate for Payer: PHP Medicare Advantage |
$11.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$41.14
|
| Rate for Payer: Priority Health Medicare |
$11.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.91
|
| Rate for Payer: Railroad Medicare Medicare |
$11.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$41.62
|
| Rate for Payer: UHC Core |
$39.49
|
| Rate for Payer: UHC Exchange |
$11.82
|
| Rate for Payer: UHC Medicaid |
$8.34
|
| Rate for Payer: UHC Medicare Advantage |
$11.82
|
| Rate for Payer: UHCCP Medicaid |
$8.34
|
| Rate for Payer: VA VA |
$11.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.47
|
|
