|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 61570013150
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.62 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna American Axle |
$18.66
|
| Rate for Payer: Aetna Commercial |
$24.39
|
| Rate for Payer: Aetna Medicare |
$14.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.66
|
| Rate for Payer: BCBS Complete |
$11.48
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$20.09
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Healthscope Commercial |
$25.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.39
|
| Rate for Payer: PHP Commercial |
$24.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health SBD |
$18.08
|
| Rate for Payer: UMR Bronson Commercial |
$10.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.52
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$141.40
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.32 |
| Max. Negotiated Rate |
$127.26 |
| Rate for Payer: Aetna American Axle |
$91.91
|
| Rate for Payer: Aetna Commercial |
$120.19
|
| Rate for Payer: Aetna Medicare |
$70.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.91
|
| Rate for Payer: BCBS Complete |
$56.56
|
| Rate for Payer: Cash Price |
$113.12
|
| Rate for Payer: Cofinity Commercial |
$121.60
|
| Rate for Payer: Cofinity Commercial |
$98.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.12
|
| Rate for Payer: Healthscope Commercial |
$127.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.19
|
| Rate for Payer: PHP Commercial |
$120.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.91
|
| Rate for Payer: Priority Health SBD |
$89.08
|
| Rate for Payer: UMR Bronson Commercial |
$52.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.05
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$141.40
|
|
|
Service Code
|
NDC 61570013140
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.22 |
| Max. Negotiated Rate |
$127.26 |
| Rate for Payer: Aetna American Axle |
$91.91
|
| Rate for Payer: Aetna Commercial |
$120.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.91
|
| Rate for Payer: Cash Price |
$113.12
|
| Rate for Payer: Cofinity Commercial |
$121.60
|
| Rate for Payer: Cofinity Commercial |
$98.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.12
|
| Rate for Payer: Healthscope Commercial |
$127.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.19
|
| Rate for Payer: PHP Commercial |
$120.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.91
|
| Rate for Payer: Priority Health SBD |
$89.08
|
| Rate for Payer: UMR Bronson Commercial |
$62.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.05
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$88.20
|
|
|
Service Code
|
NDC 67877012440
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.81 |
| Max. Negotiated Rate |
$79.38 |
| Rate for Payer: Aetna American Axle |
$57.33
|
| Rate for Payer: Aetna Commercial |
$74.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.33
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$61.74
|
| Rate for Payer: Cofinity Commercial |
$75.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$79.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: PHP Commercial |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: Priority Health SBD |
$55.57
|
| Rate for Payer: UMR Bronson Commercial |
$38.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.15
|
|
|
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 Commercial |
$74.03
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.03
|
| 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: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$39.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
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 Commercial |
$74.03
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.03
|
| 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: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| 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 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 Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| 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: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| 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
|
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 Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.25
|
| 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: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| 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
|
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 Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.25
|
| 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: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| 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 Commercial |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$8.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.90
|
| 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: PHP Commercial |
$8.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.41
|
| Rate for Payer: Priority Health SBD |
$6.21
|
| 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
|
$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 Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| 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: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| 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 Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.25
|
| 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: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| 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 Commercial |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$8.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.90
|
| 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: PHP Commercial |
$8.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.41
|
| 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 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 Commercial |
$10.77
|
| Rate for Payer: Cofinity Commercial |
$13.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.77
|
| 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: PHP Commercial |
$13.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.00
|
| 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
|
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 Commercial |
$10.77
|
| Rate for Payer: Cofinity Commercial |
$13.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.77
|
| 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: PHP Commercial |
$13.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.00
|
| Rate for Payer: Priority Health SBD |
$9.70
|
| 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
|
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 Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.25
|
| 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: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| Rate for Payer: Priority Health SBD |
$15.52
|
| Rate for Payer: UMR Bronson Commercial |
$9.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$70.50
|
|
|
Service Code
|
NDC 69618003301
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.09 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.83
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna Medicare |
$35.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.83
|
| Rate for Payer: BCBS Complete |
$28.20
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.92
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.83
|
| Rate for Payer: Priority Health SBD |
$44.41
|
| Rate for Payer: UMR Bronson Commercial |
$26.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$72.85
|
|
|
Service Code
|
NDC 09629513606
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna American Axle |
$47.35
|
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna Medicare |
$36.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: BCBS Complete |
$29.14
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Commercial |
$50.99
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.92
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.35
|
| Rate for Payer: Priority Health SBD |
$45.90
|
| Rate for Payer: UMR Bronson Commercial |
$26.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.64
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$72.85
|
|
|
Service Code
|
NDC 09629513606
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.05 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna American Axle |
$47.35
|
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Commercial |
$50.99
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.92
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.35
|
| Rate for Payer: Priority Health SBD |
$45.90
|
| Rate for Payer: UMR Bronson Commercial |
$32.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.64
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$54.05
|
|
|
Service Code
|
NDC 00904720660
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.78 |
| Max. Negotiated Rate |
$48.65 |
| Rate for Payer: Aetna American Axle |
$35.13
|
| Rate for Payer: Aetna Commercial |
$45.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.13
|
| Rate for Payer: Cash Price |
$43.24
|
| Rate for Payer: Cofinity Commercial |
$37.84
|
| Rate for Payer: Cofinity Commercial |
$46.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.24
|
| Rate for Payer: Healthscope Commercial |
$48.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.94
|
| Rate for Payer: PHP Commercial |
$45.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.13
|
| Rate for Payer: Priority Health SBD |
$34.05
|
| Rate for Payer: UMR Bronson Commercial |
$23.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.54
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$54.05
|
|
|
Service Code
|
NDC 00904720660
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$48.65 |
| Rate for Payer: Aetna American Axle |
$35.13
|
| Rate for Payer: Aetna Commercial |
$45.94
|
| Rate for Payer: Aetna Medicare |
$27.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.13
|
| Rate for Payer: BCBS Complete |
$21.62
|
| Rate for Payer: Cash Price |
$43.24
|
| Rate for Payer: Cofinity Commercial |
$37.84
|
| Rate for Payer: Cofinity Commercial |
$46.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.24
|
| Rate for Payer: Healthscope Commercial |
$48.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.94
|
| Rate for Payer: PHP Commercial |
$45.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.13
|
| Rate for Payer: Priority Health SBD |
$34.05
|
| Rate for Payer: UMR Bronson Commercial |
$20.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.54
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 70000043401
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$34.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$70.50
|
|
|
Service Code
|
NDC 69618003301
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.83
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.83
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.92
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.83
|
| Rate for Payer: Priority Health SBD |
$44.41
|
| Rate for Payer: UMR Bronson Commercial |
$31.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
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 Commercial |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.48
|
| 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: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.66
|
| 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
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 70000043401
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.69 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna Medicare |
$38.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: BCBS Complete |
$31.02
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$28.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
