|
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
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$120.76
|
|
|
Service Code
|
NDC 70954-258-10
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.13 |
| Max. Negotiated Rate |
$108.68 |
| Rate for Payer: Aetna American Axle |
$78.49
|
| Rate for Payer: Aetna Commercial |
$102.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.49
|
| Rate for Payer: Cash Price |
$96.61
|
| Rate for Payer: Cofinity Commercial |
$103.85
|
| Rate for Payer: Cofinity Commercial |
$84.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.61
|
| Rate for Payer: Healthscope Commercial |
$108.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$84.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$102.65
|
| Rate for Payer: PHP Commercial |
$102.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.53
|
| Rate for Payer: Priority Health SBD |
$76.08
|
| Rate for Payer: UMR Bronson Commercial |
$53.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.57
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$308.02
|
|
|
Service Code
|
NDC 50383-823-16
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.53 |
| Max. Negotiated Rate |
$277.22 |
| Rate for Payer: Aetna American Axle |
$200.21
|
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.21
|
| Rate for Payer: Cash Price |
$246.42
|
| Rate for Payer: Cofinity Commercial |
$215.61
|
| Rate for Payer: Cofinity Commercial |
$264.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.42
|
| Rate for Payer: Healthscope Commercial |
$277.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$261.82
|
| Rate for Payer: PHP Commercial |
$261.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.61
|
| Rate for Payer: Priority Health SBD |
$194.05
|
| Rate for Payer: UMR Bronson Commercial |
$135.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$308.02
|
|
|
Service Code
|
NDC 50383-824-16
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.53 |
| Max. Negotiated Rate |
$277.22 |
| Rate for Payer: Aetna American Axle |
$200.21
|
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.21
|
| Rate for Payer: Cash Price |
$246.42
|
| Rate for Payer: Cofinity Commercial |
$215.61
|
| Rate for Payer: Cofinity Commercial |
$264.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.42
|
| Rate for Payer: Healthscope Commercial |
$277.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$261.82
|
| Rate for Payer: PHP Commercial |
$261.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.61
|
| Rate for Payer: Priority Health SBD |
$194.05
|
| Rate for Payer: UMR Bronson Commercial |
$135.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$148.76
|
|
|
Service Code
|
NDC 65862-496-47
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna American Axle |
$96.69
|
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.69
|
| Rate for Payer: Cash Price |
$119.01
|
| Rate for Payer: Cofinity Commercial |
$104.13
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$104.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$126.45
|
| Rate for Payer: PHP Commercial |
$126.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.13
|
| Rate for Payer: Priority Health SBD |
$93.72
|
| Rate for Payer: UMR Bronson Commercial |
$65.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.57
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.44
|
|
|
Service Code
|
NDC 0703-9503-03
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$22.90 |
| Rate for Payer: Aetna American Axle |
$16.54
|
| Rate for Payer: Aetna Commercial |
$21.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.54
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cofinity Commercial |
$17.81
|
| Rate for Payer: Cofinity Commercial |
$21.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.35
|
| Rate for Payer: Healthscope Commercial |
$22.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.62
|
| Rate for Payer: PHP Commercial |
$21.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.81
|
| Rate for Payer: Priority Health SBD |
$16.03
|
| Rate for Payer: UMR Bronson Commercial |
$11.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.08
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$418.30
|
|
|
Service Code
|
NDC 53489-145-01
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.05 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.90
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.90
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$355.56
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.81
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$184.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.72
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$131.60
|
|
|
Service Code
|
NDC 65862-419-01
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.90 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna American Axle |
$85.54
|
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$92.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.12
|
| Rate for Payer: Priority Health SBD |
$82.91
|
| Rate for Payer: UMR Bronson Commercial |
$57.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 65162-271-10
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.02
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$46.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
NDC 53746-271-01
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.46 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna American Axle |
$65.68
|
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$70.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.89
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.74
|
| Rate for Payer: Priority Health SBD |
$63.66
|
| Rate for Payer: UMR Bronson Commercial |
$44.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$286.70
|
|
|
Service Code
|
NDC 0904-2725-61
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.15 |
| Max. Negotiated Rate |
$258.03 |
| Rate for Payer: Aetna American Axle |
$186.36
|
| Rate for Payer: Aetna Commercial |
$243.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.36
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$200.69
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.36
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$200.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$243.70
|
| Rate for Payer: PHP Commercial |
$243.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.69
|
| Rate for Payer: Priority Health SBD |
$180.62
|
| Rate for Payer: UMR Bronson Commercial |
$126.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.02
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 60687-531-01
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.94
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UMR Bronson Commercial |
$177.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$298.45
|
|
|
Service Code
|
NDC 63739-228-10
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.32 |
| Max. Negotiated Rate |
$268.60 |
| Rate for Payer: Aetna American Axle |
$193.99
|
| Rate for Payer: Aetna Commercial |
$253.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$193.99
|
| Rate for Payer: Cash Price |
$238.76
|
| Rate for Payer: Cofinity Commercial |
$208.92
|
| Rate for Payer: Cofinity Commercial |
$256.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$238.76
|
| Rate for Payer: Healthscope Commercial |
$268.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$208.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$223.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$253.68
|
| Rate for Payer: PHP Commercial |
$253.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.92
|
| Rate for Payer: Priority Health SBD |
$188.02
|
| Rate for Payer: UMR Bronson Commercial |
$131.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$223.84
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$4.05
|
|
|
Service Code
|
NDC 60687-531-11
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna American Axle |
$2.63
|
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.63
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cofinity Commercial |
$2.84
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.24
|
| Rate for Payer: Healthscope Commercial |
$3.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.84
|
| Rate for Payer: Priority Health SBD |
$2.55
|
| Rate for Payer: UMR Bronson Commercial |
$1.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.04
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 59762-5000-5
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.94
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UMR Bronson Commercial |
$177.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$2,259.36
|
|
|
Service Code
|
NDC 0013-0101-30
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$994.12 |
| Max. Negotiated Rate |
$2,033.42 |
| Rate for Payer: Aetna American Axle |
$1,468.58
|
| Rate for Payer: Aetna Commercial |
$1,920.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,468.58
|
| Rate for Payer: Cash Price |
$1,807.49
|
| Rate for Payer: Cofinity Commercial |
$1,581.55
|
| Rate for Payer: Cofinity Commercial |
$1,943.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,807.49
|
| Rate for Payer: Healthscope Commercial |
$2,033.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,581.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,694.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,920.46
|
| Rate for Payer: PHP Commercial |
$1,920.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,581.55
|
| Rate for Payer: Priority Health SBD |
$1,423.40
|
| Rate for Payer: UMR Bronson Commercial |
$994.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,694.52
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$753.12
|
|
|
Service Code
|
NDC 0013-0101-10
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.37 |
| Max. Negotiated Rate |
$677.81 |
| Rate for Payer: Aetna American Axle |
$489.53
|
| Rate for Payer: Aetna Commercial |
$640.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$489.53
|
| Rate for Payer: Cash Price |
$602.50
|
| Rate for Payer: Cofinity Commercial |
$527.18
|
| Rate for Payer: Cofinity Commercial |
$647.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.50
|
| Rate for Payer: Healthscope Commercial |
$677.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$527.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$564.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$640.15
|
| Rate for Payer: PHP Commercial |
$640.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$527.18
|
| Rate for Payer: Priority Health SBD |
$474.47
|
| Rate for Payer: UMR Bronson Commercial |
$331.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$564.84
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$408.90
|
|
|
Service Code
|
NDC 0591-0796-01
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.92 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna American Axle |
$265.78
|
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.78
|
| Rate for Payer: Cash Price |
$327.12
|
| Rate for Payer: Cofinity Commercial |
$286.23
|
| Rate for Payer: Cofinity Commercial |
$351.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.12
|
| Rate for Payer: Healthscope Commercial |
$368.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$286.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$306.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$347.56
|
| Rate for Payer: PHP Commercial |
$347.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.23
|
| Rate for Payer: Priority Health SBD |
$257.61
|
| Rate for Payer: UMR Bronson Commercial |
$179.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$306.68
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$655.50
|
|
|
Service Code
|
NDC 59762-0104-6
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$288.42 |
| Max. Negotiated Rate |
$589.95 |
| Rate for Payer: Aetna American Axle |
$426.08
|
| Rate for Payer: Aetna Commercial |
$557.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$426.08
|
| Rate for Payer: Cash Price |
$524.40
|
| Rate for Payer: Cofinity Commercial |
$458.85
|
| Rate for Payer: Cofinity Commercial |
$563.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$524.40
|
| Rate for Payer: Healthscope Commercial |
$589.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$491.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$557.18
|
| Rate for Payer: PHP Commercial |
$557.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$458.85
|
| Rate for Payer: Priority Health SBD |
$412.96
|
| Rate for Payer: UMR Bronson Commercial |
$288.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$491.62
|
|
|
SULFASALAZINE 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$397.15
|
|
|
Service Code
|
NDC 59762-0104-5
|
| Hospital Charge Code |
7563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.75 |
| Max. Negotiated Rate |
$357.44 |
| Rate for Payer: Aetna American Axle |
$258.15
|
| Rate for Payer: Aetna Commercial |
$337.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.15
|
| Rate for Payer: Cash Price |
$317.72
|
| Rate for Payer: Cofinity Commercial |
$278.00
|
| Rate for Payer: Cofinity Commercial |
$341.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$317.72
|
| Rate for Payer: Healthscope Commercial |
$357.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$278.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$337.58
|
| Rate for Payer: PHP Commercial |
$337.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health SBD |
$250.20
|
| Rate for Payer: UMR Bronson Commercial |
$174.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.86
|
|
|
SULINDAC 200 MG TABLET
|
Facility
|
IP
|
$269.80
|
|
|
Service Code
|
NDC 42806-011-01
|
| Hospital Charge Code |
7579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.71 |
| Max. Negotiated Rate |
$242.82 |
| Rate for Payer: Aetna American Axle |
$175.37
|
| Rate for Payer: Aetna Commercial |
$229.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.37
|
| Rate for Payer: Cash Price |
$215.84
|
| Rate for Payer: Cofinity Commercial |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.84
|
| Rate for Payer: Healthscope Commercial |
$242.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$229.33
|
| Rate for Payer: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.86
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| Rate for Payer: UMR Bronson Commercial |
$118.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.35
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$318.64
|
|
|
Service Code
|
NDC 0173-0523-00
|
| Hospital Charge Code |
20039
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.20 |
| Max. Negotiated Rate |
$286.78 |
| Rate for Payer: Aetna American Axle |
$207.12
|
| Rate for Payer: Aetna Commercial |
$270.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.12
|
| Rate for Payer: Cash Price |
$254.91
|
| Rate for Payer: Cofinity Commercial |
$223.05
|
| Rate for Payer: Cofinity Commercial |
$274.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.91
|
| Rate for Payer: Healthscope Commercial |
$286.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$270.84
|
| Rate for Payer: PHP Commercial |
$270.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.05
|
| Rate for Payer: Priority Health SBD |
$200.74
|
| Rate for Payer: UMR Bronson Commercial |
$140.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.98
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$169.31
|
|
|
Service Code
|
NDC 0781-6523-86
|
| Hospital Charge Code |
20039
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.50 |
| Max. Negotiated Rate |
$152.38 |
| Rate for Payer: Aetna American Axle |
$110.05
|
| Rate for Payer: Aetna Commercial |
$143.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.05
|
| Rate for Payer: Cash Price |
$135.45
|
| Rate for Payer: Cofinity Commercial |
$118.52
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.45
|
| Rate for Payer: Healthscope Commercial |
$152.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$143.91
|
| Rate for Payer: PHP Commercial |
$143.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.52
|
| Rate for Payer: Priority Health SBD |
$106.67
|
| Rate for Payer: UMR Bronson Commercial |
$74.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.98
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY
|
Facility
|
IP
|
$169.31
|
|
|
Service Code
|
NDC 0781-6523-06
|
| Hospital Charge Code |
20039
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.50 |
| Max. Negotiated Rate |
$152.38 |
| Rate for Payer: Aetna American Axle |
$110.05
|
| Rate for Payer: Aetna Commercial |
$143.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.05
|
| Rate for Payer: Cash Price |
$135.45
|
| Rate for Payer: Cofinity Commercial |
$118.52
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.45
|
| Rate for Payer: Healthscope Commercial |
$152.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$118.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$143.91
|
| Rate for Payer: PHP Commercial |
$143.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.52
|
| Rate for Payer: Priority Health SBD |
$106.67
|
| Rate for Payer: UMR Bronson Commercial |
$74.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.98
|
|
|
SUMATRIPTAN 25 MG TABLET
|
Facility
|
IP
|
$1,065.01
|
|
|
Service Code
|
NDC 0173-0735-00
|
| Hospital Charge Code |
15327
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$468.60 |
| Max. Negotiated Rate |
$958.51 |
| Rate for Payer: Aetna American Axle |
$692.26
|
| Rate for Payer: Aetna Commercial |
$905.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$692.26
|
| Rate for Payer: Cash Price |
$852.01
|
| Rate for Payer: Cofinity Commercial |
$745.51
|
| Rate for Payer: Cofinity Commercial |
$915.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$852.01
|
| Rate for Payer: Healthscope Commercial |
$958.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$745.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$798.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$905.26
|
| Rate for Payer: PHP Commercial |
$905.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$745.51
|
| Rate for Payer: Priority Health SBD |
$670.96
|
| Rate for Payer: UMR Bronson Commercial |
$468.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$798.76
|
|
