|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna American Axle |
$3.35
|
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: Aetna Medicare |
$2.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.35
|
| Rate for Payer: BCBS Complete |
$2.06
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Advantage |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$4.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$4.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.87
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health SBD |
$3.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.35
|
| Rate for Payer: UHC Core |
$2.69
|
| Rate for Payer: UHC Exchange |
$2.03
|
| Rate for Payer: UMR Bronson Commercial |
$1.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.87
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$940.45
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$413.80 |
| Max. Negotiated Rate |
$846.40 |
| Rate for Payer: Aetna American Axle |
$611.29
|
| Rate for Payer: Aetna Commercial |
$799.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$611.29
|
| Rate for Payer: Cash Price |
$752.36
|
| Rate for Payer: Cofinity Advantage |
$658.32
|
| Rate for Payer: Cofinity Commercial |
$808.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$752.36
|
| Rate for Payer: Healthscope Commercial |
$846.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$658.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$705.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$799.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$705.34
|
| Rate for Payer: PHP Commercial |
$799.38
|
| Rate for Payer: Priority Health SBD |
$592.48
|
| Rate for Payer: UMR Bronson Commercial |
$413.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$705.34
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna American Axle |
$3.35
|
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.35
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Advantage |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$4.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$4.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.87
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health SBD |
$3.25
|
| Rate for Payer: UMR Bronson Commercial |
$2.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.87
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$940.45
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$347.97 |
| Max. Negotiated Rate |
$846.40 |
| Rate for Payer: Aetna American Axle |
$611.29
|
| Rate for Payer: Aetna Commercial |
$799.38
|
| Rate for Payer: Aetna Medicare |
$470.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$611.29
|
| Rate for Payer: BCBS Complete |
$376.18
|
| Rate for Payer: Cash Price |
$752.36
|
| Rate for Payer: Cofinity Advantage |
$658.32
|
| Rate for Payer: Cofinity Commercial |
$808.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$752.36
|
| Rate for Payer: Healthscope Commercial |
$846.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$658.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$705.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$752.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$799.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$705.34
|
| Rate for Payer: PHP Commercial |
$799.38
|
| Rate for Payer: Priority Health SBD |
$592.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$611.29
|
| Rate for Payer: UHC Core |
$489.97
|
| Rate for Payer: UHC Exchange |
$369.60
|
| Rate for Payer: UMR Bronson Commercial |
$347.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$705.34
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$148.40
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.91 |
| Max. Negotiated Rate |
$133.56 |
| Rate for Payer: Aetna American Axle |
$96.46
|
| Rate for Payer: Aetna Commercial |
$126.14
|
| Rate for Payer: Aetna Medicare |
$74.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.46
|
| Rate for Payer: BCBS Complete |
$59.36
|
| Rate for Payer: Cash Price |
$118.72
|
| Rate for Payer: Cofinity Advantage |
$103.88
|
| Rate for Payer: Cofinity Commercial |
$127.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.72
|
| Rate for Payer: Healthscope Commercial |
$133.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$118.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.30
|
| Rate for Payer: PHP Commercial |
$126.14
|
| Rate for Payer: Priority Health SBD |
$93.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$96.46
|
| Rate for Payer: UHC Core |
$77.32
|
| Rate for Payer: UHC Exchange |
$58.32
|
| Rate for Payer: UMR Bronson Commercial |
$54.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.30
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$29.23
|
|
|
Service Code
|
NDC 61570013150
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna American Axle |
$19.00
|
| Rate for Payer: Aetna Commercial |
$24.85
|
| Rate for Payer: Aetna Medicare |
$14.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.00
|
| Rate for Payer: BCBS Complete |
$11.69
|
| Rate for Payer: Cash Price |
$23.38
|
| Rate for Payer: Cofinity Advantage |
$20.46
|
| Rate for Payer: Cofinity Commercial |
$25.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.38
|
| Rate for Payer: Healthscope Commercial |
$26.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.92
|
| Rate for Payer: PHP Commercial |
$24.85
|
| Rate for Payer: Priority Health SBD |
$18.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.00
|
| Rate for Payer: UHC Core |
$15.23
|
| Rate for Payer: UHC Exchange |
$11.49
|
| Rate for Payer: UMR Bronson Commercial |
$10.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.92
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$148.40
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.30 |
| Max. Negotiated Rate |
$133.56 |
| Rate for Payer: Aetna American Axle |
$96.46
|
| Rate for Payer: Aetna Commercial |
$126.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.46
|
| Rate for Payer: Cash Price |
$118.72
|
| Rate for Payer: Cofinity Advantage |
$103.88
|
| Rate for Payer: Cofinity Commercial |
$127.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.72
|
| Rate for Payer: Healthscope Commercial |
$133.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.30
|
| Rate for Payer: PHP Commercial |
$126.14
|
| Rate for Payer: Priority Health SBD |
$93.49
|
| Rate for Payer: UMR Bronson Commercial |
$65.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.30
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$134.40
|
|
|
Service Code
|
NDC 67877012440
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.14 |
| Max. Negotiated Rate |
$120.96 |
| Rate for Payer: Aetna American Axle |
$87.36
|
| Rate for Payer: Aetna Commercial |
$114.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.36
|
| Rate for Payer: Cash Price |
$107.52
|
| Rate for Payer: Cofinity Advantage |
$94.08
|
| Rate for Payer: Cofinity Commercial |
$115.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.52
|
| Rate for Payer: Healthscope Commercial |
$120.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.80
|
| Rate for Payer: PHP Commercial |
$114.24
|
| Rate for Payer: Priority Health SBD |
$84.67
|
| Rate for Payer: UMR Bronson Commercial |
$59.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.80
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$29.23
|
|
|
Service Code
|
NDC 61570013150
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.86 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna American Axle |
$19.00
|
| Rate for Payer: Aetna Commercial |
$24.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.00
|
| Rate for Payer: Cash Price |
$23.38
|
| Rate for Payer: Cofinity Advantage |
$20.46
|
| Rate for Payer: Cofinity Commercial |
$25.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.38
|
| Rate for Payer: Healthscope Commercial |
$26.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.92
|
| Rate for Payer: PHP Commercial |
$24.85
|
| Rate for Payer: Priority Health SBD |
$18.41
|
| Rate for Payer: UMR Bronson Commercial |
$12.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.92
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$32.38
|
|
|
Service Code
|
NDC 67877012450
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$29.14 |
| Rate for Payer: Aetna American Axle |
$21.05
|
| Rate for Payer: Aetna Commercial |
$27.52
|
| Rate for Payer: Aetna Medicare |
$16.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.05
|
| Rate for Payer: BCBS Complete |
$12.95
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cofinity Advantage |
$22.67
|
| Rate for Payer: Cofinity Commercial |
$27.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.90
|
| Rate for Payer: Healthscope Commercial |
$29.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.29
|
| Rate for Payer: PHP Commercial |
$27.52
|
| Rate for Payer: Priority Health SBD |
$20.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.05
|
| Rate for Payer: UHC Core |
$16.87
|
| Rate for Payer: UHC Exchange |
$12.73
|
| Rate for Payer: UMR Bronson Commercial |
$11.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.29
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$32.38
|
|
|
Service Code
|
NDC 67877012450
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$29.14 |
| Rate for Payer: Aetna American Axle |
$21.05
|
| Rate for Payer: Aetna Commercial |
$27.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.05
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cofinity Advantage |
$22.67
|
| Rate for Payer: Cofinity Commercial |
$27.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.90
|
| Rate for Payer: Healthscope Commercial |
$29.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.29
|
| Rate for Payer: PHP Commercial |
$27.52
|
| Rate for Payer: Priority Health SBD |
$20.40
|
| Rate for Payer: UMR Bronson Commercial |
$14.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.29
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$134.40
|
|
|
Service Code
|
NDC 67877012440
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.73 |
| Max. Negotiated Rate |
$120.96 |
| Rate for Payer: Aetna American Axle |
$87.36
|
| Rate for Payer: Aetna Commercial |
$114.24
|
| Rate for Payer: Aetna Medicare |
$67.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.36
|
| Rate for Payer: BCBS Complete |
$53.76
|
| Rate for Payer: Cash Price |
$107.52
|
| Rate for Payer: Cofinity Advantage |
$94.08
|
| Rate for Payer: Cofinity Commercial |
$115.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.52
|
| Rate for Payer: Healthscope Commercial |
$120.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$107.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.80
|
| Rate for Payer: PHP Commercial |
$114.24
|
| Rate for Payer: Priority Health SBD |
$84.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.36
|
| Rate for Payer: UHC Core |
$70.02
|
| Rate for Payer: UHC Exchange |
$52.82
|
| Rate for Payer: UMR Bronson Commercial |
$49.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.80
|
|
|
SIMETHICONE 125 MG CHEWABLE TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 00536122308
|
| Hospital Charge Code |
7226
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.17 |
| 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 Advantage |
$74.03
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$79.31
|
| Rate for Payer: PHP Commercial |
$89.89
|
| 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
|
|
|
SIMETHICONE 125 MG CHEWABLE TABLET
|
Facility
|
OP
|
$105.75
|
|
|
Service Code
|
NDC 00536122308
|
| Hospital Charge Code |
7226
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$95.17 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna Medicare |
$52.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: BCBS Complete |
$42.30
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Advantage |
$74.03
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$84.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$79.31
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.74
|
| Rate for Payer: UHC Core |
$55.10
|
| Rate for Payer: UHC Exchange |
$41.56
|
| Rate for Payer: UMR Bronson Commercial |
$39.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 62372063015
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna American Axle |
$16.15
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Advantage |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.63
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: UMR Bronson Commercial |
$10.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.63
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$24.64
|
|
|
Service Code
|
NDC 19903001023
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna American Axle |
$16.02
|
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna Medicare |
$12.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.02
|
| Rate for Payer: BCBS Complete |
$9.86
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Advantage |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.48
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.02
|
| Rate for Payer: UHC Core |
$12.84
|
| Rate for Payer: UHC Exchange |
$9.68
|
| Rate for Payer: UMR Bronson Commercial |
$9.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$15.39
|
|
|
Service Code
|
NDC 70000005101
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.69 |
| Max. Negotiated Rate |
$13.85 |
| Rate for Payer: Aetna American Axle |
$10.00
|
| Rate for Payer: Aetna Commercial |
$13.08
|
| Rate for Payer: Aetna Medicare |
$7.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.00
|
| Rate for Payer: BCBS Complete |
$6.16
|
| Rate for Payer: Cash Price |
$12.31
|
| Rate for Payer: Cofinity Advantage |
$10.77
|
| Rate for Payer: Cofinity Commercial |
$13.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.31
|
| Rate for Payer: Healthscope Commercial |
$13.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.54
|
| Rate for Payer: PHP Commercial |
$13.08
|
| Rate for Payer: Priority Health SBD |
$9.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.00
|
| Rate for Payer: UHC Core |
$8.02
|
| Rate for Payer: UHC Exchange |
$6.05
|
| Rate for Payer: UMR Bronson Commercial |
$5.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.54
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.64
|
|
|
Service Code
|
NDC 19903001023
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna American Axle |
$16.02
|
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.02
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Advantage |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.48
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| Rate for Payer: UMR Bronson Commercial |
$10.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$9.86
|
|
|
Service Code
|
NDC 96295013553
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$8.87 |
| Rate for Payer: Aetna American Axle |
$6.41
|
| Rate for Payer: Aetna Commercial |
$8.38
|
| Rate for Payer: Aetna Medicare |
$4.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.41
|
| Rate for Payer: BCBS Complete |
$3.94
|
| Rate for Payer: Cash Price |
$7.89
|
| Rate for Payer: Cofinity Advantage |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$8.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.89
|
| Rate for Payer: Healthscope Commercial |
$8.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.39
|
| Rate for Payer: PHP Commercial |
$8.38
|
| Rate for Payer: Priority Health SBD |
$6.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.41
|
| Rate for Payer: UHC Core |
$5.14
|
| Rate for Payer: UHC Exchange |
$3.87
|
| Rate for Payer: UMR Bronson Commercial |
$3.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.39
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$15.39
|
|
|
Service Code
|
NDC 70000005101
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$13.85 |
| Rate for Payer: Aetna American Axle |
$10.00
|
| Rate for Payer: Aetna Commercial |
$13.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.00
|
| Rate for Payer: Cash Price |
$12.31
|
| Rate for Payer: Cofinity Advantage |
$10.77
|
| Rate for Payer: Cofinity Commercial |
$13.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.31
|
| Rate for Payer: Healthscope Commercial |
$13.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.54
|
| Rate for Payer: PHP Commercial |
$13.08
|
| Rate for Payer: Priority Health SBD |
$9.70
|
| Rate for Payer: UMR Bronson Commercial |
$6.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.54
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.64
|
|
|
Service Code
|
NDC 19903001021
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna American Axle |
$16.02
|
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.02
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Advantage |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.48
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| Rate for Payer: UMR Bronson Commercial |
$10.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 62372063015
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna American Axle |
$16.15
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Advantage |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.63
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.15
|
| Rate for Payer: UHC Core |
$12.94
|
| Rate for Payer: UHC Exchange |
$9.76
|
| Rate for Payer: UMR Bronson Commercial |
$9.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.63
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
OP
|
$24.64
|
|
|
Service Code
|
NDC 19903001021
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna American Axle |
$16.02
|
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: Aetna Medicare |
$12.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.02
|
| Rate for Payer: BCBS Complete |
$9.86
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Advantage |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.48
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.02
|
| Rate for Payer: UHC Core |
$12.84
|
| Rate for Payer: UHC Exchange |
$9.68
|
| Rate for Payer: UMR Bronson Commercial |
$9.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$9.86
|
|
|
Service Code
|
NDC 96295013553
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$8.87 |
| Rate for Payer: Aetna American Axle |
$6.41
|
| Rate for Payer: Aetna Commercial |
$8.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.41
|
| Rate for Payer: Cash Price |
$7.89
|
| Rate for Payer: Cofinity Advantage |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$8.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.89
|
| Rate for Payer: Healthscope Commercial |
$8.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.39
|
| Rate for Payer: PHP Commercial |
$8.38
|
| Rate for Payer: Priority Health SBD |
$6.21
|
| Rate for Payer: UMR Bronson Commercial |
$4.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.39
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$56.40
|
|
|
Service Code
|
NDC 57896079101
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.82 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna American Axle |
$36.66
|
| Rate for Payer: Aetna Commercial |
$47.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.66
|
| Rate for Payer: Cash Price |
$45.12
|
| Rate for Payer: Cofinity Advantage |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.12
|
| Rate for Payer: Healthscope Commercial |
$50.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.30
|
| Rate for Payer: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health SBD |
$35.53
|
| Rate for Payer: UMR Bronson Commercial |
$24.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
