|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$3.11
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna American Axle |
$2.02
|
| Rate for Payer: Aetna Commercial |
$2.64
|
| Rate for Payer: Aetna Medicare |
$1.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.02
|
| Rate for Payer: BCBS Complete |
$1.24
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cofinity Advantage |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.33
|
| Rate for Payer: PHP Commercial |
$2.64
|
| Rate for Payer: Priority Health SBD |
$1.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.02
|
| Rate for Payer: UHC Core |
$1.62
|
| Rate for Payer: UHC Exchange |
$1.22
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.33
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$1,238.76
|
|
|
Service Code
|
NDC 62135043690
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$545.05 |
| Max. Negotiated Rate |
$1,114.88 |
| Rate for Payer: Aetna American Axle |
$805.19
|
| Rate for Payer: Aetna Commercial |
$1,052.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$805.19
|
| Rate for Payer: Cash Price |
$991.01
|
| Rate for Payer: Cofinity Advantage |
$867.13
|
| Rate for Payer: Cofinity Commercial |
$1,065.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$991.01
|
| Rate for Payer: Healthscope Commercial |
$1,114.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$867.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$929.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,052.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$929.07
|
| Rate for Payer: PHP Commercial |
$1,052.95
|
| Rate for Payer: Priority Health SBD |
$780.42
|
| Rate for Payer: UMR Bronson Commercial |
$545.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$929.07
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$1,238.76
|
|
|
Service Code
|
NDC 62135043690
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$458.34 |
| Max. Negotiated Rate |
$1,114.88 |
| Rate for Payer: Aetna American Axle |
$805.19
|
| Rate for Payer: Aetna Commercial |
$1,052.95
|
| Rate for Payer: Aetna Medicare |
$619.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$805.19
|
| Rate for Payer: BCBS Complete |
$495.50
|
| Rate for Payer: Cash Price |
$991.01
|
| Rate for Payer: Cofinity Advantage |
$867.13
|
| Rate for Payer: Cofinity Commercial |
$1,065.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$991.01
|
| Rate for Payer: Healthscope Commercial |
$1,114.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$867.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$929.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$991.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,052.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$929.07
|
| Rate for Payer: PHP Commercial |
$1,052.95
|
| Rate for Payer: Priority Health SBD |
$780.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$805.19
|
| Rate for Payer: UHC Core |
$645.39
|
| Rate for Payer: UHC Exchange |
$486.83
|
| Rate for Payer: UMR Bronson Commercial |
$458.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$929.07
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$471.91
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$174.61 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna American Axle |
$306.74
|
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna Medicare |
$235.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.74
|
| Rate for Payer: BCBS Complete |
$188.76
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Advantage |
$330.34
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$330.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$377.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health SBD |
$297.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$306.74
|
| Rate for Payer: UHC Core |
$245.87
|
| Rate for Payer: UHC Exchange |
$185.46
|
| Rate for Payer: UMR Bronson Commercial |
$174.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.93
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$864.32
|
|
|
Service Code
|
NDC 00006542505
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$380.30 |
| Max. Negotiated Rate |
$777.89 |
| Rate for Payer: Aetna American Axle |
$561.81
|
| Rate for Payer: Aetna Commercial |
$734.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$561.81
|
| Rate for Payer: Cash Price |
$691.46
|
| Rate for Payer: Cofinity Advantage |
$605.02
|
| Rate for Payer: Cofinity Commercial |
$743.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$691.46
|
| Rate for Payer: Healthscope Commercial |
$777.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$605.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$648.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$734.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$648.24
|
| Rate for Payer: PHP Commercial |
$734.67
|
| Rate for Payer: Priority Health SBD |
$544.52
|
| Rate for Payer: UMR Bronson Commercial |
$380.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$648.24
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$864.32
|
|
|
Service Code
|
NDC 00006542505
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$319.80 |
| Max. Negotiated Rate |
$777.89 |
| Rate for Payer: Aetna American Axle |
$561.81
|
| Rate for Payer: Aetna Commercial |
$734.67
|
| Rate for Payer: Aetna Medicare |
$432.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$561.81
|
| Rate for Payer: BCBS Complete |
$345.73
|
| Rate for Payer: Cash Price |
$691.46
|
| Rate for Payer: Cofinity Advantage |
$605.02
|
| Rate for Payer: Cofinity Commercial |
$743.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$691.46
|
| Rate for Payer: Healthscope Commercial |
$777.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$605.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$648.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$691.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$734.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$648.24
|
| Rate for Payer: PHP Commercial |
$734.67
|
| Rate for Payer: Priority Health SBD |
$544.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$561.81
|
| Rate for Payer: UHC Core |
$450.31
|
| Rate for Payer: UHC Exchange |
$339.68
|
| Rate for Payer: UMR Bronson Commercial |
$319.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$648.24
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,083.45
|
|
|
Service Code
|
NDC 00006542515
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$400.88 |
| Max. Negotiated Rate |
$975.11 |
| Rate for Payer: Aetna American Axle |
$704.24
|
| Rate for Payer: Aetna Commercial |
$920.93
|
| Rate for Payer: Aetna Medicare |
$541.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.24
|
| Rate for Payer: BCBS Complete |
$433.38
|
| Rate for Payer: Cash Price |
$866.76
|
| Rate for Payer: Cofinity Advantage |
$758.41
|
| Rate for Payer: Cofinity Commercial |
$931.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$866.76
|
| Rate for Payer: Healthscope Commercial |
$975.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$758.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$812.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$866.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$920.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.59
|
| Rate for Payer: PHP Commercial |
$920.93
|
| Rate for Payer: Priority Health SBD |
$682.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$704.24
|
| Rate for Payer: UHC Core |
$564.48
|
| Rate for Payer: UHC Exchange |
$425.80
|
| Rate for Payer: UMR Bronson Commercial |
$400.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$812.59
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,083.45
|
|
|
Service Code
|
NDC 00006542515
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$476.72 |
| Max. Negotiated Rate |
$975.11 |
| Rate for Payer: Aetna American Axle |
$704.24
|
| Rate for Payer: Aetna Commercial |
$920.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.24
|
| Rate for Payer: Cash Price |
$866.76
|
| Rate for Payer: Cofinity Advantage |
$758.41
|
| Rate for Payer: Cofinity Commercial |
$931.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$866.76
|
| Rate for Payer: Healthscope Commercial |
$975.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$758.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$812.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$920.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.59
|
| Rate for Payer: PHP Commercial |
$920.93
|
| Rate for Payer: Priority Health SBD |
$682.57
|
| Rate for Payer: UMR Bronson Commercial |
$476.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$812.59
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$471.91
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$207.64 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna American Axle |
$306.74
|
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.74
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Advantage |
$330.34
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$330.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health SBD |
$297.30
|
| Rate for Payer: UMR Bronson Commercial |
$207.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.93
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$471.91
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$174.61 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna American Axle |
$306.74
|
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna Medicare |
$235.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.74
|
| Rate for Payer: BCBS Complete |
$188.76
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Advantage |
$330.34
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$330.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$377.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health SBD |
$297.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$306.74
|
| Rate for Payer: UHC Core |
$245.87
|
| Rate for Payer: UHC Exchange |
$185.46
|
| Rate for Payer: UMR Bronson Commercial |
$174.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.93
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$471.91
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$207.64 |
| Max. Negotiated Rate |
$424.72 |
| Rate for Payer: Aetna American Axle |
$306.74
|
| Rate for Payer: Aetna Commercial |
$401.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$306.74
|
| Rate for Payer: Cash Price |
$377.53
|
| Rate for Payer: Cofinity Advantage |
$330.34
|
| Rate for Payer: Cofinity Commercial |
$405.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.53
|
| Rate for Payer: Healthscope Commercial |
$424.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$330.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$353.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: PHP Commercial |
$401.12
|
| Rate for Payer: Priority Health SBD |
$297.30
|
| Rate for Payer: UMR Bronson Commercial |
$207.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$353.93
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$250.92
|
|
|
Service Code
|
NDC 09900001819
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.84 |
| Max. Negotiated Rate |
$225.83 |
| Rate for Payer: Aetna American Axle |
$163.10
|
| Rate for Payer: Aetna Commercial |
$213.28
|
| Rate for Payer: Aetna Medicare |
$125.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.10
|
| Rate for Payer: BCBS Complete |
$100.37
|
| Rate for Payer: Cash Price |
$200.74
|
| Rate for Payer: Cofinity Advantage |
$175.64
|
| Rate for Payer: Cofinity Commercial |
$215.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.74
|
| Rate for Payer: Healthscope Commercial |
$225.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$200.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.19
|
| Rate for Payer: PHP Commercial |
$213.28
|
| Rate for Payer: Priority Health SBD |
$158.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.10
|
| Rate for Payer: UHC Core |
$130.73
|
| Rate for Payer: UHC Exchange |
$98.61
|
| Rate for Payer: UMR Bronson Commercial |
$92.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.19
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$250.92
|
|
|
Service Code
|
NDC 09900001819
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.40 |
| Max. Negotiated Rate |
$225.83 |
| Rate for Payer: Aetna American Axle |
$163.10
|
| Rate for Payer: Aetna Commercial |
$213.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.10
|
| Rate for Payer: Cash Price |
$200.74
|
| Rate for Payer: Cofinity Advantage |
$175.64
|
| Rate for Payer: Cofinity Commercial |
$215.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.74
|
| Rate for Payer: Healthscope Commercial |
$225.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.19
|
| Rate for Payer: PHP Commercial |
$213.28
|
| Rate for Payer: Priority Health SBD |
$158.08
|
| Rate for Payer: UMR Bronson Commercial |
$110.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.19
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$142.44
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.67 |
| Max. Negotiated Rate |
$128.20 |
| Rate for Payer: Aetna American Axle |
$92.59
|
| Rate for Payer: Aetna Commercial |
$121.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.59
|
| Rate for Payer: Cash Price |
$113.95
|
| Rate for Payer: Cofinity Advantage |
$99.71
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.95
|
| Rate for Payer: Healthscope Commercial |
$128.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.83
|
| Rate for Payer: PHP Commercial |
$121.07
|
| Rate for Payer: Priority Health SBD |
$89.74
|
| Rate for Payer: UMR Bronson Commercial |
$62.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.83
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$142.44
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$128.20 |
| Rate for Payer: Aetna American Axle |
$92.59
|
| Rate for Payer: Aetna Commercial |
$121.07
|
| Rate for Payer: Aetna Medicare |
$71.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.59
|
| Rate for Payer: BCBS Complete |
$56.98
|
| Rate for Payer: Cash Price |
$113.95
|
| Rate for Payer: Cofinity Advantage |
$99.71
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.95
|
| Rate for Payer: Healthscope Commercial |
$128.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.83
|
| Rate for Payer: PHP Commercial |
$121.07
|
| Rate for Payer: Priority Health SBD |
$89.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$92.59
|
| Rate for Payer: UHC Core |
$74.21
|
| Rate for Payer: UHC Exchange |
$55.98
|
| Rate for Payer: UMR Bronson Commercial |
$52.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.83
|
|
|
SULFADIAZINE 500 MG TABLET
|
Facility
|
IP
|
$3,309.36
|
|
|
Service Code
|
NDC 42806075760
|
| 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 Advantage |
$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 Commercial |
$2,812.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,482.02
|
| Rate for Payer: PHP Commercial |
$2,812.96
|
| 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
|
|
|
SULFADIAZINE 500 MG TABLET
|
Facility
|
OP
|
$3,309.36
|
|
|
Service Code
|
NDC 42806075760
|
| Hospital Charge Code |
7554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,224.46 |
| 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 Medicare |
$1,654.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,151.08
|
| Rate for Payer: BCBS Complete |
$1,323.74
|
| Rate for Payer: Cash Price |
$2,647.49
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$2,647.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,812.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,482.02
|
| Rate for Payer: PHP Commercial |
$2,812.96
|
| Rate for Payer: Priority Health SBD |
$2,084.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,151.08
|
| Rate for Payer: UHC Core |
$1,724.18
|
| Rate for Payer: UHC Exchange |
$1,300.58
|
| Rate for Payer: UMR Bronson Commercial |
$1,224.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,482.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$148.76
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna American Axle |
$96.69
|
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: Aetna Medicare |
$74.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.69
|
| Rate for Payer: BCBS Complete |
$59.50
|
| Rate for Payer: Cash Price |
$119.01
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$119.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.57
|
| Rate for Payer: PHP Commercial |
$126.45
|
| Rate for Payer: Priority Health SBD |
$93.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$96.69
|
| Rate for Payer: UHC Core |
$77.50
|
| Rate for Payer: UHC Exchange |
$58.46
|
| Rate for Payer: UMR Bronson Commercial |
$55.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.57
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$308.02
|
|
|
Service Code
|
NDC 50383082316
|
| 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 Advantage |
$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 |
$231.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$231.01
|
| Rate for Payer: PHP Commercial |
$261.82
|
| 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 |
$231.01
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$126.01
|
|
|
Service Code
|
NDC 70954025810
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.62 |
| Max. Negotiated Rate |
$113.41 |
| Rate for Payer: Aetna American Axle |
$81.91
|
| Rate for Payer: Aetna Commercial |
$107.11
|
| Rate for Payer: Aetna Medicare |
$63.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.91
|
| Rate for Payer: BCBS Complete |
$50.40
|
| Rate for Payer: Cash Price |
$100.81
|
| Rate for Payer: Cofinity Advantage |
$88.21
|
| Rate for Payer: Cofinity Commercial |
$108.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.81
|
| Rate for Payer: Healthscope Commercial |
$113.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$100.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.51
|
| Rate for Payer: PHP Commercial |
$107.11
|
| Rate for Payer: Priority Health SBD |
$79.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$81.91
|
| Rate for Payer: UHC Core |
$65.65
|
| Rate for Payer: UHC Exchange |
$49.52
|
| Rate for Payer: UMR Bronson Commercial |
$46.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.51
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$308.02
|
|
|
Service Code
|
NDC 50383082416
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.97 |
| Max. Negotiated Rate |
$277.22 |
| Rate for Payer: Aetna American Axle |
$200.21
|
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna Medicare |
$154.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.21
|
| Rate for Payer: BCBS Complete |
$123.21
|
| Rate for Payer: Cash Price |
$246.42
|
| Rate for Payer: Cofinity Advantage |
$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 |
$231.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$246.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$231.01
|
| Rate for Payer: PHP Commercial |
$261.82
|
| Rate for Payer: Priority Health SBD |
$194.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$200.21
|
| Rate for Payer: UHC Core |
$160.48
|
| Rate for Payer: UHC Exchange |
$121.05
|
| Rate for Payer: UMR Bronson Commercial |
$113.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.01
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$308.02
|
|
|
Service Code
|
NDC 50383082416
|
| 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 Advantage |
$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 |
$231.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$231.01
|
| Rate for Payer: PHP Commercial |
$261.82
|
| 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 |
$231.01
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$126.01
|
|
|
Service Code
|
NDC 70954025810
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.44 |
| Max. Negotiated Rate |
$113.41 |
| Rate for Payer: Aetna American Axle |
$81.91
|
| Rate for Payer: Aetna Commercial |
$107.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.91
|
| Rate for Payer: Cash Price |
$100.81
|
| Rate for Payer: Cofinity Advantage |
$88.21
|
| Rate for Payer: Cofinity Commercial |
$108.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.81
|
| Rate for Payer: Healthscope Commercial |
$113.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.51
|
| Rate for Payer: PHP Commercial |
$107.11
|
| Rate for Payer: Priority Health SBD |
$79.39
|
| Rate for Payer: UMR Bronson Commercial |
$55.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.51
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$308.02
|
|
|
Service Code
|
NDC 50383082316
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.97 |
| Max. Negotiated Rate |
$277.22 |
| Rate for Payer: Aetna American Axle |
$200.21
|
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna Medicare |
$154.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.21
|
| Rate for Payer: BCBS Complete |
$123.21
|
| Rate for Payer: Cash Price |
$246.42
|
| Rate for Payer: Cofinity Advantage |
$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 |
$231.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$246.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$231.01
|
| Rate for Payer: PHP Commercial |
$261.82
|
| Rate for Payer: Priority Health SBD |
$194.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$200.21
|
| Rate for Payer: UHC Core |
$160.48
|
| Rate for Payer: UHC Exchange |
$121.05
|
| Rate for Payer: UMR Bronson Commercial |
$113.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.01
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$148.76
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$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 Advantage |
$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 Commercial |
$126.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.57
|
| Rate for Payer: PHP Commercial |
$126.45
|
| 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
|
|
