|
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 |
$11.01 |
| Max. Negotiated Rate |
$41.72 |
| Rate for Payer: Aetna Commercial |
$39.41
|
| Rate for Payer: Aetna Medicare |
$12.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14.49
|
| Rate for Payer: BCBS Complete |
$18.54
|
| Rate for Payer: BCBS MAPPO |
$11.59
|
| Rate for Payer: BCBS Trust/PPO |
$38.11
|
| Rate for Payer: BCN Commercial |
$36.04
|
| Rate for Payer: BCN Medicare Advantage |
$11.59
|
| Rate for Payer: Cash Price |
$37.09
|
| Rate for Payer: Cofinity Commercial |
$39.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11.59
|
| Rate for Payer: Healthscope Commercial |
$41.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.41
|
| Rate for Payer: Nomi Health Commercial |
$38.02
|
| Rate for Payer: PACE Senior Care Partners |
$11.01
|
| Rate for Payer: PACE SWMI |
$11.59
|
| Rate for Payer: PHP Commercial |
$39.41
|
| Rate for Payer: PHP Medicare Advantage |
$11.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.13
|
| Rate for Payer: Priority Health HMO/PPO |
$40.33
|
| Rate for Payer: Priority Health Medicare |
$11.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$31.06
|
| Rate for Payer: Railroad Medicare Medicare |
$11.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.80
|
| Rate for Payer: UHC Core |
$38.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$11.59
|
| Rate for Payer: UHC Exchange |
$11.59
|
| Rate for Payer: UHC Medicare Advantage |
$11.59
|
| Rate for Payer: VA VA |
$11.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.77
|
|
|
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 |
$30.13 |
| Max. Negotiated Rate |
$41.72 |
| Rate for Payer: Aetna Commercial |
$39.41
|
| Rate for Payer: BCBS Trust/PPO |
$37.84
|
| Rate for Payer: BCN Commercial |
$35.83
|
| Rate for Payer: Cash Price |
$37.09
|
| Rate for Payer: Cofinity Commercial |
$39.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.09
|
| Rate for Payer: Healthscope Commercial |
$41.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.41
|
| Rate for Payer: Nomi Health Commercial |
$38.02
|
| Rate for Payer: PHP Commercial |
$39.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.13
|
| Rate for Payer: Priority Health HMO/PPO |
$40.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$31.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.80
|
| Rate for Payer: UHC Core |
$38.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.77
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.49
|
|
|
Service Code
|
NDC 60687073823
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$22.94 |
| Rate for Payer: Aetna Commercial |
$21.67
|
| Rate for Payer: BCBS Trust/PPO |
$20.81
|
| Rate for Payer: BCN Commercial |
$19.70
|
| Rate for Payer: Cash Price |
$20.39
|
| Rate for Payer: Cofinity Commercial |
$21.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.39
|
| Rate for Payer: Healthscope Commercial |
$22.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.67
|
| Rate for Payer: Nomi Health Commercial |
$20.90
|
| Rate for Payer: PHP Commercial |
$21.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.57
|
| Rate for Payer: Priority Health HMO/PPO |
$22.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.43
|
| Rate for Payer: UHC Core |
$21.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.12
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$234.65
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.52 |
| Max. Negotiated Rate |
$211.19 |
| Rate for Payer: Aetna Commercial |
$199.45
|
| Rate for Payer: BCBS Trust/PPO |
$191.54
|
| Rate for Payer: BCN Commercial |
$181.34
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$201.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$211.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$199.45
|
| Rate for Payer: Nomi Health Commercial |
$192.41
|
| Rate for Payer: PHP Commercial |
$199.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.52
|
| Rate for Payer: Priority Health HMO/PPO |
$204.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$157.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$206.49
|
| Rate for Payer: UHC Core |
$195.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.99
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$314.45
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.39 |
| Max. Negotiated Rate |
$283.00 |
| Rate for Payer: Aetna Commercial |
$267.28
|
| Rate for Payer: BCBS Trust/PPO |
$256.69
|
| Rate for Payer: BCN Commercial |
$243.01
|
| Rate for Payer: Cash Price |
$251.56
|
| Rate for Payer: Cofinity Commercial |
$270.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$251.56
|
| Rate for Payer: Healthscope Commercial |
$283.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$267.28
|
| Rate for Payer: Nomi Health Commercial |
$257.85
|
| Rate for Payer: PHP Commercial |
$267.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.39
|
| Rate for Payer: Priority Health HMO/PPO |
$273.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$210.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$276.72
|
| Rate for Payer: UHC Core |
$262.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.84
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$314.45
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.68 |
| Max. Negotiated Rate |
$283.00 |
| Rate for Payer: Aetna Commercial |
$267.28
|
| Rate for Payer: Aetna Medicare |
$81.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$98.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$98.27
|
| Rate for Payer: BCBS Complete |
$125.78
|
| Rate for Payer: BCBS MAPPO |
$78.61
|
| Rate for Payer: BCBS Trust/PPO |
$258.51
|
| Rate for Payer: BCN Commercial |
$244.48
|
| Rate for Payer: BCN Medicare Advantage |
$78.61
|
| Rate for Payer: Cash Price |
$251.56
|
| Rate for Payer: Cofinity Commercial |
$270.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$251.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.61
|
| Rate for Payer: Healthscope Commercial |
$283.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$90.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$267.28
|
| Rate for Payer: Nomi Health Commercial |
$257.85
|
| Rate for Payer: PACE Senior Care Partners |
$74.68
|
| Rate for Payer: PACE SWMI |
$78.61
|
| Rate for Payer: PHP Commercial |
$267.28
|
| Rate for Payer: PHP Medicare Advantage |
$78.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.39
|
| Rate for Payer: Priority Health HMO/PPO |
$273.57
|
| Rate for Payer: Priority Health Medicare |
$79.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$210.68
|
| Rate for Payer: Railroad Medicare Medicare |
$78.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$276.72
|
| Rate for Payer: UHC Core |
$262.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.61
|
| Rate for Payer: UHC Exchange |
$78.61
|
| Rate for Payer: UHC Medicare Advantage |
$78.61
|
| Rate for Payer: VA VA |
$78.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.84
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$3.15
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna Commercial |
$2.68
|
| Rate for Payer: Aetna Medicare |
$0.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.98
|
| Rate for Payer: BCBS Complete |
$1.26
|
| Rate for Payer: BCBS MAPPO |
$0.79
|
| Rate for Payer: BCBS Trust/PPO |
$2.59
|
| Rate for Payer: BCN Commercial |
$2.45
|
| Rate for Payer: BCN Medicare Advantage |
$0.79
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.79
|
| Rate for Payer: Healthscope Commercial |
$2.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.68
|
| Rate for Payer: Nomi Health Commercial |
$2.58
|
| Rate for Payer: PACE Senior Care Partners |
$0.75
|
| Rate for Payer: PACE SWMI |
$0.79
|
| Rate for Payer: PHP Commercial |
$2.68
|
| Rate for Payer: PHP Medicare Advantage |
$0.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.05
|
| Rate for Payer: Priority Health HMO/PPO |
$2.74
|
| Rate for Payer: Priority Health Medicare |
$0.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.11
|
| Rate for Payer: Railroad Medicare Medicare |
$0.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.77
|
| Rate for Payer: UHC Core |
$2.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.79
|
| Rate for Payer: UHC Exchange |
$0.79
|
| Rate for Payer: UHC Medicare Advantage |
$0.79
|
| Rate for Payer: VA VA |
$0.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.36
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$3.15
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna Commercial |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$2.57
|
| Rate for Payer: BCN Commercial |
$2.43
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.52
|
| Rate for Payer: Healthscope Commercial |
$2.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.68
|
| Rate for Payer: Nomi Health Commercial |
$2.58
|
| Rate for Payer: PHP Commercial |
$2.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.05
|
| Rate for Payer: Priority Health HMO/PPO |
$2.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.77
|
| Rate for Payer: UHC Core |
$2.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.36
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$234.65
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.73 |
| Max. Negotiated Rate |
$211.19 |
| Rate for Payer: Aetna Commercial |
$199.45
|
| Rate for Payer: Aetna Medicare |
$61.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$73.33
|
| Rate for Payer: Amish Plain Church Group Commercial |
$73.33
|
| Rate for Payer: BCBS Complete |
$93.86
|
| Rate for Payer: BCBS MAPPO |
$58.66
|
| Rate for Payer: BCBS Trust/PPO |
$192.91
|
| Rate for Payer: BCN Commercial |
$182.44
|
| Rate for Payer: BCN Medicare Advantage |
$58.66
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$201.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$58.66
|
| Rate for Payer: Healthscope Commercial |
$211.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$61.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$199.45
|
| Rate for Payer: Nomi Health Commercial |
$192.41
|
| Rate for Payer: PACE Senior Care Partners |
$55.73
|
| Rate for Payer: PACE SWMI |
$58.66
|
| Rate for Payer: PHP Commercial |
$199.45
|
| Rate for Payer: PHP Medicare Advantage |
$58.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.52
|
| Rate for Payer: Priority Health HMO/PPO |
$204.15
|
| Rate for Payer: Priority Health Medicare |
$59.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$157.22
|
| Rate for Payer: Railroad Medicare Medicare |
$58.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$206.49
|
| Rate for Payer: UHC Core |
$195.93
|
| Rate for Payer: UHC Dual Complete DSNP |
$58.66
|
| Rate for Payer: UHC Exchange |
$58.66
|
| Rate for Payer: UHC Medicare Advantage |
$58.66
|
| Rate for Payer: VA VA |
$58.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.99
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$449.46
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$292.15 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: BCBS Trust/PPO |
$366.89
|
| Rate for Payer: BCN Commercial |
$347.34
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: Nomi Health Commercial |
$368.56
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health HMO/PPO |
$391.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$301.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$395.52
|
| Rate for Payer: UHC Core |
$375.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.10
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$449.46
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.75 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna Medicare |
$116.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$140.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$140.46
|
| Rate for Payer: BCBS Complete |
$179.78
|
| Rate for Payer: BCBS MAPPO |
$112.36
|
| Rate for Payer: BCBS Trust/PPO |
$369.50
|
| Rate for Payer: BCN Commercial |
$349.46
|
| Rate for Payer: BCN Medicare Advantage |
$112.36
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$112.36
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$117.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$129.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: Nomi Health Commercial |
$368.56
|
| Rate for Payer: PACE Senior Care Partners |
$106.75
|
| Rate for Payer: PACE SWMI |
$112.36
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: PHP Medicare Advantage |
$112.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health HMO/PPO |
$391.03
|
| Rate for Payer: Priority Health Medicare |
$113.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$301.14
|
| Rate for Payer: Railroad Medicare Medicare |
$112.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$395.52
|
| Rate for Payer: UHC Core |
$375.30
|
| Rate for Payer: UHC Dual Complete DSNP |
$112.36
|
| Rate for Payer: UHC Exchange |
$112.36
|
| Rate for Payer: UHC Medicare Advantage |
$112.36
|
| Rate for Payer: VA VA |
$112.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.10
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$449.46
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$292.15 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: BCBS Trust/PPO |
$366.89
|
| Rate for Payer: BCN Commercial |
$347.34
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: Nomi Health Commercial |
$368.56
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health HMO/PPO |
$391.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$301.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$395.52
|
| Rate for Payer: UHC Core |
$375.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.10
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$449.46
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.75 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna Medicare |
$116.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$140.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$140.46
|
| Rate for Payer: BCBS Complete |
$179.78
|
| Rate for Payer: BCBS MAPPO |
$112.36
|
| Rate for Payer: BCBS Trust/PPO |
$369.50
|
| Rate for Payer: BCN Commercial |
$349.46
|
| Rate for Payer: BCN Medicare Advantage |
$112.36
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$112.36
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$117.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$129.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: Nomi Health Commercial |
$368.56
|
| Rate for Payer: PACE Senior Care Partners |
$106.75
|
| Rate for Payer: PACE SWMI |
$112.36
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: PHP Medicare Advantage |
$112.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health HMO/PPO |
$391.03
|
| Rate for Payer: Priority Health Medicare |
$113.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$301.14
|
| Rate for Payer: Railroad Medicare Medicare |
$112.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$395.52
|
| Rate for Payer: UHC Core |
$375.30
|
| Rate for Payer: UHC Dual Complete DSNP |
$112.36
|
| Rate for Payer: UHC Exchange |
$112.36
|
| Rate for Payer: UHC Medicare Advantage |
$112.36
|
| Rate for Payer: VA VA |
$112.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.10
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$139.71
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.81 |
| Max. Negotiated Rate |
$125.74 |
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: BCBS Trust/PPO |
$114.05
|
| Rate for Payer: BCN Commercial |
$107.97
|
| Rate for Payer: Cash Price |
$111.77
|
| Rate for Payer: Cofinity Commercial |
$120.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.77
|
| Rate for Payer: Healthscope Commercial |
$125.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.75
|
| Rate for Payer: Nomi Health Commercial |
$114.56
|
| Rate for Payer: PHP Commercial |
$118.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.81
|
| Rate for Payer: Priority Health HMO/PPO |
$121.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$93.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.94
|
| Rate for Payer: UHC Core |
$116.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.78
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$139.71
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.18 |
| Max. Negotiated Rate |
$125.74 |
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna Medicare |
$36.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$43.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$43.66
|
| Rate for Payer: BCBS Complete |
$55.88
|
| Rate for Payer: BCBS MAPPO |
$34.93
|
| Rate for Payer: BCBS Trust/PPO |
$114.86
|
| Rate for Payer: BCN Commercial |
$108.62
|
| Rate for Payer: BCN Medicare Advantage |
$34.93
|
| Rate for Payer: Cash Price |
$111.77
|
| Rate for Payer: Cofinity Commercial |
$120.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34.93
|
| Rate for Payer: Healthscope Commercial |
$125.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$36.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.75
|
| Rate for Payer: Nomi Health Commercial |
$114.56
|
| Rate for Payer: PACE Senior Care Partners |
$33.18
|
| Rate for Payer: PACE SWMI |
$34.93
|
| Rate for Payer: PHP Commercial |
$118.75
|
| Rate for Payer: PHP Medicare Advantage |
$34.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.81
|
| Rate for Payer: Priority Health HMO/PPO |
$121.55
|
| Rate for Payer: Priority Health Medicare |
$35.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$93.61
|
| Rate for Payer: Railroad Medicare Medicare |
$34.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.94
|
| Rate for Payer: UHC Core |
$116.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$34.93
|
| Rate for Payer: UHC Exchange |
$34.93
|
| Rate for Payer: UHC Medicare Advantage |
$34.93
|
| Rate for Payer: VA VA |
$34.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.78
|
|
|
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 |
$96.69 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: BCBS Trust/PPO |
$121.43
|
| Rate for Payer: BCN Commercial |
$114.96
|
| 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: PHP Commercial |
$126.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.69
|
| Rate for Payer: Priority Health HMO/PPO |
$129.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.67
|
| 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 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 |
$35.33 |
| 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 |
$59.50
|
| Rate for Payer: BCBS MAPPO |
$37.19
|
| Rate for Payer: BCBS Trust/PPO |
$122.30
|
| Rate for Payer: BCN Commercial |
$115.66
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.45
|
| Rate for Payer: Nomi Health Commercial |
$121.98
|
| 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 Cigna Priority Health |
$96.69
|
| Rate for Payer: Priority Health HMO/PPO |
$129.42
|
| Rate for Payer: Priority Health Medicare |
$37.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.67
|
| 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 Dual Complete DSNP |
$37.19
|
| Rate for Payer: UHC Exchange |
$37.19
|
| Rate for Payer: UHC Medicare Advantage |
$37.19
|
| 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
|
$52.69
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: BCBS Trust/PPO |
$43.01
|
| Rate for Payer: BCN Commercial |
$40.72
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO |
$45.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.37
|
| Rate for Payer: UHC Core |
$44.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.52
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.69
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna Medicare |
$13.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.47
|
| Rate for Payer: BCBS Complete |
$21.08
|
| Rate for Payer: BCBS MAPPO |
$13.17
|
| Rate for Payer: BCBS Trust/PPO |
$43.32
|
| Rate for Payer: BCN Commercial |
$40.97
|
| Rate for Payer: BCN Medicare Advantage |
$13.17
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.17
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: PACE Senior Care Partners |
$12.51
|
| Rate for Payer: PACE SWMI |
$13.17
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: PHP Medicare Advantage |
$13.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO |
$45.84
|
| Rate for Payer: Priority Health Medicare |
$13.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.30
|
| Rate for Payer: Railroad Medicare Medicare |
$13.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.37
|
| Rate for Payer: UHC Core |
$44.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.17
|
| Rate for Payer: UHC Exchange |
$13.17
|
| Rate for Payer: UHC Medicare Advantage |
$13.17
|
| Rate for Payer: VA VA |
$13.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.52
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.69
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: Aetna Medicare |
$13.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.47
|
| Rate for Payer: BCBS Complete |
$21.08
|
| Rate for Payer: BCBS MAPPO |
$13.17
|
| Rate for Payer: BCBS Trust/PPO |
$43.32
|
| Rate for Payer: BCN Commercial |
$40.97
|
| Rate for Payer: BCN Medicare Advantage |
$13.17
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.17
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: PACE Senior Care Partners |
$12.51
|
| Rate for Payer: PACE SWMI |
$13.17
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: PHP Medicare Advantage |
$13.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO |
$45.84
|
| Rate for Payer: Priority Health Medicare |
$13.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.30
|
| Rate for Payer: Railroad Medicare Medicare |
$13.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.37
|
| Rate for Payer: UHC Core |
$44.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.17
|
| Rate for Payer: UHC Exchange |
$13.17
|
| Rate for Payer: UHC Medicare Advantage |
$13.17
|
| Rate for Payer: VA VA |
$13.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.52
|
|
|
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 |
$9.00 |
| Max. Negotiated Rate |
$12.46 |
| Rate for Payer: Aetna Commercial |
$11.76
|
| Rate for Payer: BCBS Trust/PPO |
$11.30
|
| Rate for Payer: BCN Commercial |
$10.70
|
| 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: PHP Commercial |
$11.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.00
|
| Rate for Payer: Priority Health HMO/PPO |
$12.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.27
|
| 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
|
IP
|
$52.69
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$47.42 |
| Rate for Payer: Aetna Commercial |
$44.79
|
| Rate for Payer: BCBS Trust/PPO |
$43.01
|
| Rate for Payer: BCN Commercial |
$40.72
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$45.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$47.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: PHP Commercial |
$44.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO |
$45.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.37
|
| Rate for Payer: UHC Core |
$44.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.52
|
|
|
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 |
$3.29 |
| 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 |
$5.54
|
| Rate for Payer: BCBS MAPPO |
$3.46
|
| Rate for Payer: BCBS Trust/PPO |
$11.38
|
| Rate for Payer: BCN Commercial |
$10.76
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.76
|
| Rate for Payer: Nomi Health Commercial |
$11.35
|
| 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 Cigna Priority Health |
$9.00
|
| Rate for Payer: Priority Health HMO/PPO |
$12.04
|
| Rate for Payer: Priority Health Medicare |
$3.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.27
|
| 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 Dual Complete DSNP |
$3.46
|
| Rate for Payer: UHC Exchange |
$3.46
|
| Rate for Payer: UHC Medicare Advantage |
$3.46
|
| Rate for Payer: VA VA |
$3.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.38
|
|
|
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 |
$24.00 |
| 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 |
$40.42
|
| Rate for Payer: BCBS MAPPO |
$25.26
|
| Rate for Payer: BCBS Trust/PPO |
$83.07
|
| Rate for Payer: BCN Commercial |
$78.57
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: Nomi Health Commercial |
$82.86
|
| 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 Cigna Priority Health |
$65.68
|
| Rate for Payer: Priority Health HMO/PPO |
$87.91
|
| Rate for Payer: Priority Health Medicare |
$25.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.70
|
| 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 Dual Complete DSNP |
$25.26
|
| Rate for Payer: UHC Exchange |
$25.26
|
| Rate for Payer: UHC Medicare Advantage |
$25.26
|
| 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 |
$65.68 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: BCBS Trust/PPO |
$82.49
|
| Rate for Payer: BCN Commercial |
$78.09
|
| 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: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.68
|
| Rate for Payer: Priority Health HMO/PPO |
$87.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.70
|
| 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
|
|
