|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$29.48
|
|
|
Service Code
|
NDC 0121-0974-10
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.97 |
| Max. Negotiated Rate |
$26.53 |
| Rate for Payer: Aetna American Axle |
$19.16
|
| Rate for Payer: Aetna Commercial |
$25.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.16
|
| Rate for Payer: Cash Price |
$23.58
|
| Rate for Payer: Cofinity Commercial |
$20.64
|
| Rate for Payer: Cofinity Commercial |
$25.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.58
|
| Rate for Payer: Healthscope Commercial |
$26.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.06
|
| Rate for Payer: PHP Commercial |
$25.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.64
|
| Rate for Payer: Priority Health SBD |
$18.57
|
| Rate for Payer: UMR Bronson Commercial |
$12.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.11
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.06
|
|
|
Service Code
|
NDC 0904-7269-66
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$22.55 |
| Rate for Payer: Aetna American Axle |
$16.29
|
| Rate for Payer: Aetna Commercial |
$21.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.29
|
| Rate for Payer: Cash Price |
$20.05
|
| Rate for Payer: Cofinity Commercial |
$17.54
|
| Rate for Payer: Cofinity Commercial |
$21.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.05
|
| Rate for Payer: Healthscope Commercial |
$22.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.30
|
| Rate for Payer: PHP Commercial |
$21.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.54
|
| Rate for Payer: Priority Health SBD |
$15.79
|
| Rate for Payer: UMR Bronson Commercial |
$11.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.80
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$40.28
|
|
|
Service Code
|
NDC 68094-043-59
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$36.25 |
| Rate for Payer: Aetna American Axle |
$26.18
|
| Rate for Payer: Aetna Commercial |
$34.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.18
|
| Rate for Payer: Cash Price |
$32.22
|
| Rate for Payer: Cofinity Commercial |
$28.20
|
| Rate for Payer: Cofinity Commercial |
$34.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.22
|
| Rate for Payer: Healthscope Commercial |
$36.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$28.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.24
|
| Rate for Payer: PHP Commercial |
$34.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.20
|
| Rate for Payer: Priority Health SBD |
$25.38
|
| Rate for Payer: UMR Bronson Commercial |
$17.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.21
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.06
|
|
|
Service Code
|
NDC 0904-7269-18
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$22.55 |
| Rate for Payer: Aetna American Axle |
$16.29
|
| Rate for Payer: Aetna Commercial |
$21.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.29
|
| Rate for Payer: Cash Price |
$20.05
|
| Rate for Payer: Cofinity Commercial |
$17.54
|
| Rate for Payer: Cofinity Commercial |
$21.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.05
|
| Rate for Payer: Healthscope Commercial |
$22.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.30
|
| Rate for Payer: PHP Commercial |
$21.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.54
|
| Rate for Payer: Priority Health SBD |
$15.79
|
| Rate for Payer: UMR Bronson Commercial |
$11.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.80
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$29.91
|
|
|
Service Code
|
NDC 60687-738-42
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$26.92 |
| Rate for Payer: Aetna American Axle |
$19.44
|
| Rate for Payer: Aetna Commercial |
$25.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.44
|
| Rate for Payer: Cash Price |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$20.94
|
| Rate for Payer: Cofinity Commercial |
$25.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.93
|
| Rate for Payer: Healthscope Commercial |
$26.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.42
|
| Rate for Payer: PHP Commercial |
$25.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.94
|
| Rate for Payer: Priority Health SBD |
$18.84
|
| Rate for Payer: UMR Bronson Commercial |
$13.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.43
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$35.48
|
|
|
Service Code
|
NDC 0121-0974-94
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.61 |
| Max. Negotiated Rate |
$31.93 |
| Rate for Payer: Aetna American Axle |
$23.06
|
| Rate for Payer: Aetna Commercial |
$30.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.06
|
| Rate for Payer: Cash Price |
$28.38
|
| Rate for Payer: Cofinity Commercial |
$24.84
|
| Rate for Payer: Cofinity Commercial |
$30.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.38
|
| Rate for Payer: Healthscope Commercial |
$31.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.16
|
| Rate for Payer: PHP Commercial |
$30.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.84
|
| Rate for Payer: Priority Health SBD |
$22.35
|
| Rate for Payer: UMR Bronson Commercial |
$15.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.61
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$39.48
|
|
|
Service Code
|
NDC 9900-0008-04
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.37 |
| Max. Negotiated Rate |
$35.53 |
| Rate for Payer: Aetna American Axle |
$25.66
|
| Rate for Payer: Aetna Commercial |
$33.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.66
|
| Rate for Payer: Cash Price |
$31.58
|
| Rate for Payer: Cofinity Commercial |
$27.64
|
| Rate for Payer: Cofinity Commercial |
$33.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.58
|
| Rate for Payer: Healthscope Commercial |
$35.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.56
|
| Rate for Payer: PHP Commercial |
$33.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.64
|
| Rate for Payer: Priority Health SBD |
$24.87
|
| Rate for Payer: UMR Bronson Commercial |
$17.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.61
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$31.54
|
|
|
Service Code
|
NDC 0121-0747-40
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$28.39 |
| Rate for Payer: Aetna American Axle |
$20.50
|
| Rate for Payer: Aetna Commercial |
$26.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.50
|
| Rate for Payer: Cash Price |
$25.23
|
| Rate for Payer: Cofinity Commercial |
$22.08
|
| Rate for Payer: Cofinity Commercial |
$27.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.23
|
| Rate for Payer: Healthscope Commercial |
$28.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.81
|
| Rate for Payer: PHP Commercial |
$26.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.08
|
| Rate for Payer: Priority Health SBD |
$19.87
|
| Rate for Payer: UMR Bronson Commercial |
$13.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.66
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$27.03
|
|
|
Service Code
|
NDC 0121-0974-40
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.89 |
| Max. Negotiated Rate |
$24.33 |
| Rate for Payer: Aetna American Axle |
$17.57
|
| Rate for Payer: Aetna Commercial |
$22.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.57
|
| Rate for Payer: Cash Price |
$21.62
|
| Rate for Payer: Cofinity Commercial |
$18.92
|
| Rate for Payer: Cofinity Commercial |
$23.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.62
|
| Rate for Payer: Healthscope Commercial |
$24.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.98
|
| Rate for Payer: PHP Commercial |
$22.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.92
|
| Rate for Payer: Priority Health SBD |
$17.03
|
| Rate for Payer: UMR Bronson Commercial |
$11.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.27
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$33.75
|
|
|
Service Code
|
NDC 0121-0747-10
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$30.38 |
| Rate for Payer: Aetna American Axle |
$21.94
|
| Rate for Payer: Aetna Commercial |
$28.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.94
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cofinity Commercial |
$23.62
|
| Rate for Payer: Cofinity Commercial |
$29.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.00
|
| Rate for Payer: Healthscope Commercial |
$30.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.69
|
| Rate for Payer: PHP Commercial |
$28.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.62
|
| Rate for Payer: Priority Health SBD |
$21.26
|
| Rate for Payer: UMR Bronson Commercial |
$14.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.31
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,191.46
|
|
|
Service Code
|
NDC 58914-170-14
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$524.24 |
| Max. Negotiated Rate |
$1,072.31 |
| Rate for Payer: Aetna American Axle |
$774.45
|
| Rate for Payer: Aetna Commercial |
$1,012.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$774.45
|
| Rate for Payer: Cash Price |
$953.17
|
| Rate for Payer: Cofinity Commercial |
$1,024.66
|
| Rate for Payer: Cofinity Commercial |
$834.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$953.17
|
| Rate for Payer: Healthscope Commercial |
$1,072.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$834.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$893.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,012.74
|
| Rate for Payer: PHP Commercial |
$1,012.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$834.02
|
| Rate for Payer: Priority Health SBD |
$750.62
|
| Rate for Payer: UMR Bronson Commercial |
$524.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$893.60
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$279.30
|
|
|
Service Code
|
NDC 51079-753-20
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.89 |
| Max. Negotiated Rate |
$251.37 |
| Rate for Payer: Aetna American Axle |
$181.54
|
| Rate for Payer: Aetna Commercial |
$237.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.54
|
| Rate for Payer: Cash Price |
$223.44
|
| Rate for Payer: Cofinity Commercial |
$195.51
|
| Rate for Payer: Cofinity Commercial |
$240.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.44
|
| Rate for Payer: Healthscope Commercial |
$251.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$195.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$209.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$237.40
|
| Rate for Payer: PHP Commercial |
$237.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.51
|
| Rate for Payer: Priority Health SBD |
$175.96
|
| Rate for Payer: UMR Bronson Commercial |
$122.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$209.48
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$226.10
|
|
|
Service Code
|
NDC 63739-943-10
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.48 |
| Max. Negotiated Rate |
$203.49 |
| Rate for Payer: Aetna American Axle |
$146.96
|
| Rate for Payer: Aetna Commercial |
$192.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.96
|
| Rate for Payer: Cash Price |
$180.88
|
| Rate for Payer: Cofinity Commercial |
$158.27
|
| Rate for Payer: Cofinity Commercial |
$194.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.88
|
| Rate for Payer: Healthscope Commercial |
$203.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$158.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$192.18
|
| Rate for Payer: PHP Commercial |
$192.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.27
|
| Rate for Payer: Priority Health SBD |
$142.44
|
| Rate for Payer: UMR Bronson Commercial |
$99.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.58
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$1,238.76
|
|
|
Service Code
|
NDC 62135-436-90
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$545.05 |
| Max. Negotiated Rate |
$1,114.88 |
| Rate for Payer: Aetna American Axle |
$805.19
|
| Rate for Payer: Aetna Commercial |
$1,052.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$805.19
|
| Rate for Payer: Cash Price |
$991.01
|
| Rate for Payer: Cofinity Commercial |
$1,065.33
|
| Rate for Payer: Cofinity Commercial |
$867.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$991.01
|
| Rate for Payer: Healthscope Commercial |
$1,114.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$867.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$929.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,052.95
|
| Rate for Payer: PHP Commercial |
$1,052.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$867.13
|
| Rate for Payer: Priority Health SBD |
$780.42
|
| Rate for Payer: UMR Bronson Commercial |
$545.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$929.07
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 0093-2210-01
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.92 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.92
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UMR Bronson Commercial |
$104.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 51079-753-01
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna American Axle |
$1.82
|
| Rate for Payer: Aetna Commercial |
$2.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.82
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$1.96
|
| Rate for Payer: Cofinity Commercial |
$2.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.24
|
| Rate for Payer: Healthscope Commercial |
$2.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.38
|
| Rate for Payer: PHP Commercial |
$2.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.96
|
| Rate for Payer: Priority Health SBD |
$1.76
|
| Rate for Payer: UMR Bronson Commercial |
$1.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.10
|
|
|
SUCTION ASSISTED LIPECTOMY; TRUNK
|
Facility
|
OP
|
$10,039.01
|
|
|
Service Code
|
CPT 15877
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,744.36 |
| Max. Negotiated Rate |
$10,039.01 |
| Rate for Payer: Aetna Medicare |
$3,316.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,986.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,986.20
|
| Rate for Payer: BCBS Complete |
$1,831.74
|
| Rate for Payer: BCBS MAPPO |
$3,188.96
|
| Rate for Payer: BCBS Trust/PPO |
$2,344.98
|
| Rate for Payer: BCN Medicare Advantage |
$3,188.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,188.96
|
| Rate for Payer: Mclaren Medicaid |
$1,744.36
|
| Rate for Payer: Mclaren Medicare |
$3,188.96
|
| Rate for Payer: Meridian Medicaid |
$1,831.74
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,348.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,667.30
|
| Rate for Payer: PACE Medicare |
$3,029.51
|
| Rate for Payer: PACE SWMI |
$3,188.96
|
| Rate for Payer: PHP Medicare Advantage |
$3,188.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,744.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,039.01
|
| Rate for Payer: Priority Health Medicare |
$3,188.96
|
| Rate for Payer: Priority Health Narrow Network |
$8,031.21
|
| Rate for Payer: Railroad Medicare Medicare |
$3,188.96
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,188.96
|
| Rate for Payer: UHC Medicare Advantage |
$3,284.63
|
| Rate for Payer: VA VA |
$3,188.96
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$428.08
|
|
|
Service Code
|
NDC 0006-5423-12
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$188.36 |
| Max. Negotiated Rate |
$385.27 |
| Rate for Payer: Aetna American Axle |
$278.25
|
| Rate for Payer: Aetna Commercial |
$363.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.25
|
| Rate for Payer: Cash Price |
$342.46
|
| Rate for Payer: Cofinity Commercial |
$299.66
|
| Rate for Payer: Cofinity Commercial |
$368.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.46
|
| Rate for Payer: Healthscope Commercial |
$385.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$363.87
|
| Rate for Payer: PHP Commercial |
$363.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.66
|
| Rate for Payer: Priority Health SBD |
$269.69
|
| Rate for Payer: UMR Bronson Commercial |
$188.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.06
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$250.92
|
|
|
Service Code
|
NDC 9900-0018-19
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.40 |
| Max. Negotiated Rate |
$225.83 |
| Rate for Payer: Aetna American Axle |
$163.10
|
| Rate for Payer: Aetna Commercial |
$213.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.10
|
| Rate for Payer: Cash Price |
$200.74
|
| Rate for Payer: Cofinity Commercial |
$175.64
|
| Rate for Payer: Cofinity Commercial |
$215.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.74
|
| Rate for Payer: Healthscope Commercial |
$225.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.28
|
| Rate for Payer: PHP Commercial |
$213.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.64
|
| Rate for Payer: Priority Health SBD |
$158.08
|
| Rate for Payer: UMR Bronson Commercial |
$110.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.19
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$784.11
|
|
|
Service Code
|
NDC 0006-5425-05
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$345.01 |
| Max. Negotiated Rate |
$705.70 |
| Rate for Payer: Aetna American Axle |
$509.67
|
| Rate for Payer: Aetna Commercial |
$666.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$509.67
|
| Rate for Payer: Cash Price |
$627.29
|
| Rate for Payer: Cofinity Commercial |
$548.88
|
| Rate for Payer: Cofinity Commercial |
$674.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$627.29
|
| Rate for Payer: Healthscope Commercial |
$705.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$548.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$588.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$666.49
|
| Rate for Payer: PHP Commercial |
$666.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$548.88
|
| Rate for Payer: Priority Health SBD |
$493.99
|
| Rate for Payer: UMR Bronson Commercial |
$345.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$588.08
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$982.90
|
|
|
Service Code
|
NDC 0006-5425-15
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$432.48 |
| Max. Negotiated Rate |
$884.61 |
| Rate for Payer: Aetna American Axle |
$638.88
|
| Rate for Payer: Aetna Commercial |
$835.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$638.88
|
| Rate for Payer: Cash Price |
$786.32
|
| Rate for Payer: Cofinity Commercial |
$688.03
|
| Rate for Payer: Cofinity Commercial |
$845.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$786.32
|
| Rate for Payer: Healthscope Commercial |
$884.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$688.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$737.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$835.46
|
| Rate for Payer: PHP Commercial |
$835.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$688.03
|
| Rate for Payer: Priority Health SBD |
$619.23
|
| Rate for Payer: UMR Bronson Commercial |
$432.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$737.18
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$428.08
|
|
|
Service Code
|
NDC 0006-5423-02
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$188.36 |
| Max. Negotiated Rate |
$385.27 |
| Rate for Payer: Aetna American Axle |
$278.25
|
| Rate for Payer: Aetna Commercial |
$363.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.25
|
| Rate for Payer: Cash Price |
$342.46
|
| Rate for Payer: Cofinity Commercial |
$299.66
|
| Rate for Payer: Cofinity Commercial |
$368.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.46
|
| Rate for Payer: Healthscope Commercial |
$385.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$363.87
|
| Rate for Payer: PHP Commercial |
$363.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.66
|
| Rate for Payer: Priority Health SBD |
$269.69
|
| Rate for Payer: UMR Bronson Commercial |
$188.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.06
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$120.07
|
|
|
Service Code
|
NDC 24208-670-04
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.83 |
| Max. Negotiated Rate |
$108.06 |
| Rate for Payer: Aetna American Axle |
$78.05
|
| Rate for Payer: Aetna Commercial |
$102.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.05
|
| Rate for Payer: Cash Price |
$96.06
|
| Rate for Payer: Cofinity Commercial |
$103.26
|
| Rate for Payer: Cofinity Commercial |
$84.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.06
|
| Rate for Payer: Healthscope Commercial |
$108.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$84.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$102.06
|
| Rate for Payer: PHP Commercial |
$102.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.05
|
| Rate for Payer: Priority Health SBD |
$75.64
|
| Rate for Payer: UMR Bronson Commercial |
$52.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.05
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$145.38
|
|
|
Service Code
|
NDC 61314-701-01
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.97 |
| Max. Negotiated Rate |
$130.84 |
| Rate for Payer: Aetna American Axle |
$94.50
|
| Rate for Payer: Aetna Commercial |
$123.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.50
|
| Rate for Payer: Cash Price |
$116.30
|
| Rate for Payer: Cofinity Commercial |
$101.77
|
| Rate for Payer: Cofinity Commercial |
$125.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.30
|
| Rate for Payer: Healthscope Commercial |
$130.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$123.57
|
| Rate for Payer: PHP Commercial |
$123.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.77
|
| Rate for Payer: Priority Health SBD |
$91.59
|
| Rate for Payer: UMR Bronson Commercial |
$63.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.04
|
|
|
SULFADIAZINE 500 MG TABLET
|
Facility
|
IP
|
$3,309.36
|
|
|
Service Code
|
NDC 42806-757-60
|
| Hospital Charge Code |
7554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,456.12 |
| Max. Negotiated Rate |
$2,978.42 |
| Rate for Payer: Aetna American Axle |
$2,151.08
|
| Rate for Payer: Aetna Commercial |
$2,812.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,151.08
|
| Rate for Payer: Cash Price |
$2,647.49
|
| Rate for Payer: Cofinity Commercial |
$2,316.55
|
| Rate for Payer: Cofinity Commercial |
$2,846.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,647.49
|
| Rate for Payer: Healthscope Commercial |
$2,978.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,316.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,482.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,812.96
|
| Rate for Payer: PHP Commercial |
$2,812.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,316.55
|
| Rate for Payer: Priority Health SBD |
$2,084.90
|
| Rate for Payer: UMR Bronson Commercial |
$1,456.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,482.02
|
|
