|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$13.84
|
|
|
Service Code
|
NDC 09900000414
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$12.46 |
| Rate for Payer: Aetna Commercial |
$11.76
|
| Rate for Payer: BCBS Trust/PPO |
$11.43
|
| Rate for Payer: BCN Commercial |
$11.43
|
| Rate for Payer: Cash Price |
$11.07
|
| Rate for Payer: Cofinity Commercial |
$11.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.07
|
| Rate for Payer: Healthscope Commercial |
$12.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.76
|
| Rate for Payer: Nomi Health Commercial |
$11.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.38
|
| Rate for Payer: PHP Commercial |
$11.76
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$12.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.18
|
| Rate for Payer: UHC Core |
$11.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.38
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$13.84
|
|
|
Service Code
|
NDC 09900000414
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$12.46 |
| Rate for Payer: Aetna Commercial |
$11.76
|
| Rate for Payer: Aetna Medicare |
$3.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.33
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.33
|
| Rate for Payer: BCBS Complete |
$2.56
|
| Rate for Payer: BCBS MAPPO |
$3.46
|
| Rate for Payer: BCBS Trust/PPO |
$11.38
|
| Rate for Payer: BCN Commercial |
$11.38
|
| Rate for Payer: BCN Medicare Advantage |
$3.46
|
| Rate for Payer: Cash Price |
$11.07
|
| Rate for Payer: Cofinity Commercial |
$11.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.46
|
| Rate for Payer: Healthscope Commercial |
$12.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.38
|
| Rate for Payer: Mclaren Medicaid |
$2.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.63
|
| Rate for Payer: Meridian Medicaid |
$2.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.98
|
| Rate for Payer: Molina Medicare/Medicaid |
$3.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.76
|
| Rate for Payer: Nomi Health Commercial |
$11.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.38
|
| Rate for Payer: PACE Senior Care Partners |
$3.29
|
| Rate for Payer: PACE SWMI |
$3.46
|
| Rate for Payer: PHP Commercial |
$11.76
|
| Rate for Payer: PHP Medicare Advantage |
$3.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$12.04
|
| Rate for Payer: Priority Health Medicare |
$3.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.63
|
| Rate for Payer: Railroad Medicare Medicare |
$3.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.18
|
| Rate for Payer: UHC Core |
$11.56
|
| Rate for Payer: UHC Exchange |
$3.46
|
| Rate for Payer: UHC Medicaid |
$2.44
|
| Rate for Payer: UHC Medicare Advantage |
$3.46
|
| Rate for Payer: UHCCP Medicaid |
$2.44
|
| Rate for Payer: VA VA |
$3.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.38
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.03
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$46.83 |
| Rate for Payer: Aetna Commercial |
$44.23
|
| Rate for Payer: Aetna Medicare |
$13.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.26
|
| Rate for Payer: BCBS Complete |
$9.63
|
| Rate for Payer: BCBS MAPPO |
$13.01
|
| Rate for Payer: BCBS Trust/PPO |
$42.77
|
| Rate for Payer: BCN Commercial |
$42.77
|
| Rate for Payer: BCN Medicare Advantage |
$13.01
|
| Rate for Payer: Cash Price |
$41.62
|
| Rate for Payer: Cofinity Commercial |
$44.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.01
|
| Rate for Payer: Healthscope Commercial |
$46.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.02
|
| Rate for Payer: Mclaren Medicaid |
$9.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.66
|
| Rate for Payer: Meridian Medicaid |
$9.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.96
|
| Rate for Payer: Molina Medicare/Medicaid |
$14.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.23
|
| Rate for Payer: Nomi Health Commercial |
$42.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.02
|
| Rate for Payer: PACE Senior Care Partners |
$12.36
|
| Rate for Payer: PACE SWMI |
$13.01
|
| Rate for Payer: PHP Commercial |
$44.23
|
| Rate for Payer: PHP Medicare Advantage |
$13.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$45.27
|
| Rate for Payer: Priority Health Medicare |
$13.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.21
|
| Rate for Payer: Railroad Medicare Medicare |
$13.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.79
|
| Rate for Payer: UHC Core |
$43.45
|
| Rate for Payer: UHC Exchange |
$13.01
|
| Rate for Payer: UHC Medicaid |
$9.17
|
| Rate for Payer: UHC Medicare Advantage |
$13.01
|
| Rate for Payer: UHCCP Medicaid |
$9.17
|
| Rate for Payer: VA VA |
$13.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$47.29
|
|
|
Service Code
|
NDC 81033001240
|
| 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
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$47.29
|
|
|
Service Code
|
NDC 81033001220
|
| 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
|
IP
|
$52.03
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.21 |
| Max. Negotiated Rate |
$46.83 |
| Rate for Payer: Aetna Commercial |
$44.23
|
| Rate for Payer: BCBS Trust/PPO |
$42.97
|
| Rate for Payer: BCN Commercial |
$42.97
|
| Rate for Payer: Cash Price |
$41.62
|
| Rate for Payer: Cofinity Commercial |
$44.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.62
|
| Rate for Payer: Healthscope Commercial |
$46.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.23
|
| Rate for Payer: Nomi Health Commercial |
$42.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.02
|
| Rate for Payer: PHP Commercial |
$44.23
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$45.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.79
|
| Rate for Payer: UHC Core |
$43.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$148.76
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: Aetna Medicare |
$38.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.49
|
| Rate for Payer: BCBS Complete |
$27.54
|
| Rate for Payer: BCBS MAPPO |
$37.19
|
| Rate for Payer: BCBS Trust/PPO |
$122.30
|
| Rate for Payer: BCN Commercial |
$122.30
|
| Rate for Payer: BCN Medicare Advantage |
$37.19
|
| Rate for Payer: Cash Price |
$119.01
|
| Rate for Payer: Cofinity Commercial |
$127.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.19
|
| Rate for Payer: Healthscope Commercial |
$133.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.57
|
| Rate for Payer: Mclaren Medicaid |
$26.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.05
|
| Rate for Payer: Meridian Medicaid |
$27.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.77
|
| Rate for Payer: Molina Medicare/Medicaid |
$40.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.45
|
| Rate for Payer: Nomi Health Commercial |
$121.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.57
|
| Rate for Payer: PACE Senior Care Partners |
$35.33
|
| Rate for Payer: PACE SWMI |
$37.19
|
| Rate for Payer: PHP Commercial |
$126.45
|
| Rate for Payer: PHP Medicare Advantage |
$37.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.23
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$129.42
|
| Rate for Payer: Priority Health Medicare |
$37.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$103.54
|
| Rate for Payer: Railroad Medicare Medicare |
$37.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.91
|
| Rate for Payer: UHC Core |
$124.21
|
| Rate for Payer: UHC Exchange |
$37.19
|
| Rate for Payer: UHC Medicaid |
$26.23
|
| Rate for Payer: UHC Medicare Advantage |
$37.19
|
| Rate for Payer: UHCCP Medicaid |
$26.23
|
| Rate for Payer: VA VA |
$37.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.57
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.03
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.21 |
| Max. Negotiated Rate |
$46.83 |
| Rate for Payer: Aetna Commercial |
$44.23
|
| Rate for Payer: BCBS Trust/PPO |
$42.97
|
| Rate for Payer: BCN Commercial |
$42.97
|
| Rate for Payer: Cash Price |
$41.62
|
| Rate for Payer: Cofinity Commercial |
$44.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.62
|
| Rate for Payer: Healthscope Commercial |
$46.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.23
|
| Rate for Payer: Nomi Health Commercial |
$42.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.02
|
| Rate for Payer: PHP Commercial |
$44.23
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$45.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.79
|
| Rate for Payer: UHC Core |
$43.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.03
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$46.83 |
| Rate for Payer: Aetna Commercial |
$44.23
|
| Rate for Payer: Aetna Medicare |
$13.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.26
|
| Rate for Payer: BCBS Complete |
$9.63
|
| Rate for Payer: BCBS MAPPO |
$13.01
|
| Rate for Payer: BCBS Trust/PPO |
$42.77
|
| Rate for Payer: BCN Commercial |
$42.77
|
| Rate for Payer: BCN Medicare Advantage |
$13.01
|
| Rate for Payer: Cash Price |
$41.62
|
| Rate for Payer: Cofinity Commercial |
$44.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.01
|
| Rate for Payer: Healthscope Commercial |
$46.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.02
|
| Rate for Payer: Mclaren Medicaid |
$9.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.66
|
| Rate for Payer: Meridian Medicaid |
$9.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.96
|
| Rate for Payer: Molina Medicare/Medicaid |
$14.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.23
|
| Rate for Payer: Nomi Health Commercial |
$42.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.02
|
| Rate for Payer: PACE Senior Care Partners |
$12.36
|
| Rate for Payer: PACE SWMI |
$13.01
|
| Rate for Payer: PHP Commercial |
$44.23
|
| Rate for Payer: PHP Medicare Advantage |
$13.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$45.27
|
| Rate for Payer: Priority Health Medicare |
$13.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.21
|
| Rate for Payer: Railroad Medicare Medicare |
$13.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.79
|
| Rate for Payer: UHC Core |
$43.45
|
| Rate for Payer: UHC Exchange |
$13.01
|
| Rate for Payer: UHC Medicaid |
$9.17
|
| Rate for Payer: UHC Medicare Advantage |
$13.01
|
| Rate for Payer: UHCCP Medicaid |
$9.17
|
| Rate for Payer: VA VA |
$13.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$148.76
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.54 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: BCBS Trust/PPO |
$122.86
|
| Rate for Payer: BCN Commercial |
$122.86
|
| Rate for Payer: Cash Price |
$119.01
|
| Rate for Payer: Cofinity Commercial |
$127.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.01
|
| Rate for Payer: Healthscope Commercial |
$133.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.45
|
| Rate for Payer: Nomi Health Commercial |
$121.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.57
|
| Rate for Payer: PHP Commercial |
$126.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$129.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$103.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.91
|
| Rate for Payer: UHC Core |
$124.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.57
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$44.46
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$40.01 |
| Rate for Payer: Aetna Commercial |
$37.79
|
| Rate for Payer: BCBS Trust/PPO |
$36.72
|
| Rate for Payer: BCN Commercial |
$36.72
|
| Rate for Payer: Cash Price |
$35.57
|
| Rate for Payer: Cofinity Commercial |
$38.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.57
|
| Rate for Payer: Healthscope Commercial |
$40.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.79
|
| Rate for Payer: Nomi Health Commercial |
$36.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.34
|
| Rate for Payer: PHP Commercial |
$37.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$38.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$30.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.12
|
| Rate for Payer: UHC Core |
$37.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.34
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$44.46
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$40.01 |
| Rate for Payer: Aetna Commercial |
$37.79
|
| Rate for Payer: Aetna Medicare |
$11.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13.89
|
| Rate for Payer: BCBS Complete |
$8.23
|
| Rate for Payer: BCBS MAPPO |
$11.12
|
| Rate for Payer: BCBS Trust/PPO |
$36.55
|
| Rate for Payer: BCN Commercial |
$36.55
|
| Rate for Payer: BCN Medicare Advantage |
$11.12
|
| Rate for Payer: Cash Price |
$35.57
|
| Rate for Payer: Cofinity Commercial |
$38.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11.12
|
| Rate for Payer: Healthscope Commercial |
$40.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.34
|
| Rate for Payer: Mclaren Medicaid |
$7.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11.67
|
| Rate for Payer: Meridian Medicaid |
$8.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.78
|
| Rate for Payer: Molina Medicare/Medicaid |
$12.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.79
|
| Rate for Payer: Nomi Health Commercial |
$36.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.34
|
| Rate for Payer: PACE Senior Care Partners |
$10.56
|
| Rate for Payer: PACE SWMI |
$11.12
|
| Rate for Payer: PHP Commercial |
$37.79
|
| Rate for Payer: PHP Medicare Advantage |
$11.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$38.68
|
| Rate for Payer: Priority Health Medicare |
$11.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$30.94
|
| Rate for Payer: Railroad Medicare Medicare |
$11.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.12
|
| Rate for Payer: UHC Core |
$37.12
|
| Rate for Payer: UHC Exchange |
$11.12
|
| Rate for Payer: UHC Medicaid |
$7.84
|
| Rate for Payer: UHC Medicare Advantage |
$11.12
|
| Rate for Payer: UHCCP Medicaid |
$7.84
|
| Rate for Payer: VA VA |
$11.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.34
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$101.05
|
|
|
Service Code
|
NDC 53746027101
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.82 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna Medicare |
$26.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.58
|
| Rate for Payer: BCBS Complete |
$18.70
|
| Rate for Payer: BCBS MAPPO |
$25.26
|
| Rate for Payer: BCBS Trust/PPO |
$83.07
|
| Rate for Payer: BCN Commercial |
$83.07
|
| Rate for Payer: BCN Medicare Advantage |
$25.26
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25.26
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Mclaren Medicaid |
$17.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26.53
|
| Rate for Payer: Meridian Medicaid |
$18.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.05
|
| Rate for Payer: Molina Medicare/Medicaid |
$27.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: Nomi Health Commercial |
$82.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.79
|
| Rate for Payer: PACE Senior Care Partners |
$24.00
|
| Rate for Payer: PACE SWMI |
$25.26
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: PHP Medicare Advantage |
$25.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$17.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$87.91
|
| Rate for Payer: Priority Health Medicare |
$25.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.33
|
| Rate for Payer: Railroad Medicare Medicare |
$25.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.92
|
| Rate for Payer: UHC Core |
$84.38
|
| Rate for Payer: UHC Exchange |
$25.26
|
| Rate for Payer: UHC Medicaid |
$17.82
|
| Rate for Payer: UHC Medicare Advantage |
$25.26
|
| Rate for Payer: UHCCP Medicaid |
$17.82
|
| Rate for Payer: VA VA |
$25.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
NDC 53746027101
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.33 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: BCBS Trust/PPO |
$83.46
|
| Rate for Payer: BCN Commercial |
$83.46
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: Nomi Health Commercial |
$82.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.79
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$87.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.92
|
| Rate for Payer: UHC Core |
$84.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$136.30
|
|
|
Service Code
|
NDC 53746027201
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.03 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna Medicare |
$35.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42.59
|
| Rate for Payer: BCBS Complete |
$25.23
|
| Rate for Payer: BCBS MAPPO |
$34.08
|
| Rate for Payer: BCBS Trust/PPO |
$112.05
|
| Rate for Payer: BCN Commercial |
$112.05
|
| Rate for Payer: BCN Medicare Advantage |
$34.08
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34.08
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Mclaren Medicaid |
$24.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$35.78
|
| Rate for Payer: Meridian Medicaid |
$25.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.19
|
| Rate for Payer: Molina Medicare/Medicaid |
$37.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: Nomi Health Commercial |
$111.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$102.22
|
| Rate for Payer: PACE Senior Care Partners |
$32.37
|
| Rate for Payer: PACE SWMI |
$34.08
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: PHP Medicare Advantage |
$34.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$24.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$118.58
|
| Rate for Payer: Priority Health Medicare |
$34.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$94.86
|
| Rate for Payer: Railroad Medicare Medicare |
$34.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.94
|
| Rate for Payer: UHC Core |
$113.81
|
| Rate for Payer: UHC Exchange |
$34.08
|
| Rate for Payer: UHC Medicaid |
$24.03
|
| Rate for Payer: UHC Medicare Advantage |
$34.08
|
| Rate for Payer: UHCCP Medicaid |
$24.03
|
| Rate for Payer: VA VA |
$34.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 65162027210
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$304.22 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: BCBS Trust/PPO |
$361.00
|
| Rate for Payer: BCN Commercial |
$361.00
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Nomi Health Commercial |
$358.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$327.82
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$380.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$304.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$384.65
|
| Rate for Payer: UHC Core |
$364.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$437.10
|
|
|
Service Code
|
NDC 65162027210
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.06 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna Medicare |
$113.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$136.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$136.59
|
| Rate for Payer: BCBS Complete |
$80.91
|
| Rate for Payer: BCBS MAPPO |
$109.28
|
| Rate for Payer: BCBS Trust/PPO |
$359.34
|
| Rate for Payer: BCN Commercial |
$359.34
|
| Rate for Payer: BCN Medicare Advantage |
$109.28
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$109.28
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.82
|
| Rate for Payer: Mclaren Medicaid |
$77.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$114.74
|
| Rate for Payer: Meridian Medicaid |
$80.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$125.67
|
| Rate for Payer: Molina Medicare/Medicaid |
$120.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Nomi Health Commercial |
$358.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$327.82
|
| Rate for Payer: PACE Senior Care Partners |
$103.81
|
| Rate for Payer: PACE SWMI |
$109.28
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: PHP Medicare Advantage |
$109.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$77.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$380.28
|
| Rate for Payer: Priority Health Medicare |
$110.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$304.22
|
| Rate for Payer: Railroad Medicare Medicare |
$109.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$384.65
|
| Rate for Payer: UHC Core |
$364.98
|
| Rate for Payer: UHC Exchange |
$109.28
|
| Rate for Payer: UHC Medicaid |
$77.06
|
| Rate for Payer: UHC Medicare Advantage |
$109.28
|
| Rate for Payer: UHCCP Medicaid |
$77.06
|
| Rate for Payer: VA VA |
$109.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$136.30
|
|
|
Service Code
|
NDC 53746027201
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.86 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: BCBS Trust/PPO |
$112.57
|
| Rate for Payer: BCN Commercial |
$112.57
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: Nomi Health Commercial |
$111.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$102.22
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$118.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$94.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.94
|
| Rate for Payer: UHC Core |
$113.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$364.25
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.22 |
| Max. Negotiated Rate |
$327.82 |
| Rate for Payer: Aetna Commercial |
$309.61
|
| Rate for Payer: Aetna Medicare |
$94.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$113.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$113.83
|
| Rate for Payer: BCBS Complete |
$67.42
|
| Rate for Payer: BCBS MAPPO |
$91.06
|
| Rate for Payer: BCBS Trust/PPO |
$299.45
|
| Rate for Payer: BCN Commercial |
$299.45
|
| Rate for Payer: BCN Medicare Advantage |
$91.06
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Commercial |
$313.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.06
|
| Rate for Payer: Healthscope Commercial |
$327.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$273.19
|
| Rate for Payer: Mclaren Medicaid |
$64.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$95.62
|
| Rate for Payer: Meridian Medicaid |
$67.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.72
|
| Rate for Payer: Molina Medicare/Medicaid |
$100.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$309.61
|
| Rate for Payer: Nomi Health Commercial |
$298.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.19
|
| Rate for Payer: PACE Senior Care Partners |
$86.51
|
| Rate for Payer: PACE SWMI |
$91.06
|
| Rate for Payer: PHP Commercial |
$309.61
|
| Rate for Payer: PHP Medicare Advantage |
$91.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$316.90
|
| Rate for Payer: Priority Health Medicare |
$91.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$253.52
|
| Rate for Payer: Railroad Medicare Medicare |
$91.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$320.54
|
| Rate for Payer: UHC Core |
$304.15
|
| Rate for Payer: UHC Exchange |
$91.06
|
| Rate for Payer: UHC Medicaid |
$64.22
|
| Rate for Payer: UHC Medicare Advantage |
$91.06
|
| Rate for Payer: UHCCP Medicaid |
$64.22
|
| Rate for Payer: VA VA |
$91.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$273.19
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$364.25
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.52 |
| Max. Negotiated Rate |
$327.82 |
| Rate for Payer: Aetna Commercial |
$309.61
|
| Rate for Payer: BCBS Trust/PPO |
$300.83
|
| Rate for Payer: BCN Commercial |
$300.83
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Commercial |
$313.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Healthscope Commercial |
$327.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$273.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$309.61
|
| Rate for Payer: Nomi Health Commercial |
$298.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.19
|
| Rate for Payer: PHP Commercial |
$309.61
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$316.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$253.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$320.54
|
| Rate for Payer: UHC Core |
$304.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$273.19
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.77 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: BCBS Trust/PPO |
$176.54
|
| Rate for Payer: BCN Commercial |
$176.54
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$185.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$148.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.10
|
| Rate for Payer: UHC Core |
$178.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.31
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$744.96
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.34 |
| Max. Negotiated Rate |
$670.46 |
| Rate for Payer: Aetna Commercial |
$633.22
|
| Rate for Payer: Aetna Medicare |
$193.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$232.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$232.80
|
| Rate for Payer: BCBS Complete |
$137.89
|
| Rate for Payer: BCBS MAPPO |
$186.24
|
| Rate for Payer: BCBS Trust/PPO |
$612.43
|
| Rate for Payer: BCN Commercial |
$612.43
|
| Rate for Payer: BCN Medicare Advantage |
$186.24
|
| Rate for Payer: Cash Price |
$595.97
|
| Rate for Payer: Cofinity Commercial |
$640.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$595.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$186.24
|
| Rate for Payer: Healthscope Commercial |
$670.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$558.72
|
| Rate for Payer: Mclaren Medicaid |
$131.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$195.55
|
| Rate for Payer: Meridian Medicaid |
$137.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$214.18
|
| Rate for Payer: Molina Medicare/Medicaid |
$204.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$633.22
|
| Rate for Payer: Nomi Health Commercial |
$610.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$558.72
|
| Rate for Payer: PACE Senior Care Partners |
$176.93
|
| Rate for Payer: PACE SWMI |
$186.24
|
| Rate for Payer: PHP Commercial |
$633.22
|
| Rate for Payer: PHP Medicare Advantage |
$186.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$131.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$648.12
|
| Rate for Payer: Priority Health Medicare |
$188.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$518.49
|
| Rate for Payer: Railroad Medicare Medicare |
$186.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$655.56
|
| Rate for Payer: UHC Core |
$622.04
|
| Rate for Payer: UHC Exchange |
$186.24
|
| Rate for Payer: UHC Medicaid |
$131.34
|
| Rate for Payer: UHC Medicare Advantage |
$186.24
|
| Rate for Payer: UHCCP Medicaid |
$131.34
|
| Rate for Payer: VA VA |
$186.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$558.72
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.68 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna Medicare |
$55.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66.80
|
| Rate for Payer: BCBS Complete |
$39.57
|
| Rate for Payer: BCBS MAPPO |
$53.44
|
| Rate for Payer: BCBS Trust/PPO |
$175.72
|
| Rate for Payer: BCN Commercial |
$175.72
|
| Rate for Payer: BCN Medicare Advantage |
$53.44
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$53.44
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: Mclaren Medicaid |
$37.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$56.11
|
| Rate for Payer: Meridian Medicaid |
$39.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61.45
|
| Rate for Payer: Molina Medicare/Medicaid |
$58.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: PACE Senior Care Partners |
$50.77
|
| Rate for Payer: PACE SWMI |
$53.44
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: PHP Medicare Advantage |
$53.44
|
| Rate for Payer: Priority Health Choice Medicaid |
$37.68
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$185.96
|
| Rate for Payer: Priority Health Medicare |
$53.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$148.77
|
| Rate for Payer: Railroad Medicare Medicare |
$53.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.10
|
| Rate for Payer: UHC Core |
$178.48
|
| Rate for Payer: UHC Exchange |
$53.44
|
| Rate for Payer: UHC Medicaid |
$37.68
|
| Rate for Payer: UHC Medicare Advantage |
$53.44
|
| Rate for Payer: UHCCP Medicaid |
$37.68
|
| Rate for Payer: VA VA |
$53.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.31
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$744.96
|
|
|
Service Code
|
NDC 00013010110
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$518.49 |
| Max. Negotiated Rate |
$670.46 |
| Rate for Payer: Aetna Commercial |
$633.22
|
| Rate for Payer: BCBS Trust/PPO |
$615.26
|
| Rate for Payer: BCN Commercial |
$615.26
|
| Rate for Payer: Cash Price |
$595.97
|
| Rate for Payer: Cofinity Commercial |
$640.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$595.97
|
| Rate for Payer: Healthscope Commercial |
$670.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$558.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$633.22
|
| Rate for Payer: Nomi Health Commercial |
$610.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$558.72
|
| Rate for Payer: PHP Commercial |
$633.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$648.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$518.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$655.56
|
| Rate for Payer: UHC Core |
$622.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$558.72
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 62756052269
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.56 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: BCBS Trust/PPO |
$58.80
|
| Rate for Payer: BCN Commercial |
$58.80
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: Nomi Health Commercial |
$58.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.40
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$61.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$49.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.66
|
| Rate for Payer: UHC Core |
$59.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.40
|
|
