|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.44
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$22.90 |
| Rate for Payer: Aetna American Axle |
$16.54
|
| Rate for Payer: Aetna American Axle |
$17.03
|
| Rate for Payer: Aetna Commercial |
$21.62
|
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Advantage |
$18.34
|
| Rate for Payer: Cofinity Advantage |
$17.81
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Cofinity Commercial |
$21.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$22.90
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.65
|
| Rate for Payer: PHP Commercial |
$21.62
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health SBD |
$16.51
|
| Rate for Payer: Priority Health SBD |
$16.03
|
| Rate for Payer: UMR Bronson Commercial |
$11.19
|
| Rate for Payer: UMR Bronson Commercial |
$11.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.65
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$25.44
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$22.90 |
| Rate for Payer: Aetna American Axle |
$16.54
|
| Rate for Payer: Aetna American Axle |
$17.03
|
| Rate for Payer: Aetna Commercial |
$21.62
|
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna Medicare |
$12.72
|
| Rate for Payer: Aetna Medicare |
$13.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: BCBS Complete |
$10.48
|
| Rate for Payer: BCBS Complete |
$10.18
|
| Rate for Payer: BCBS Trust/PPO |
$0.10
|
| Rate for Payer: BCBS Trust/PPO |
$0.10
|
| Rate for Payer: BCN Commercial |
$0.10
|
| Rate for Payer: BCN Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Advantage |
$17.81
|
| Rate for Payer: Cofinity Advantage |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$21.88
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$22.90
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.08
|
| Rate for Payer: PHP Commercial |
$21.62
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health SBD |
$16.03
|
| Rate for Payer: Priority Health SBD |
$16.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
| Rate for Payer: UMR Bronson Commercial |
$9.41
|
| Rate for Payer: UMR Bronson Commercial |
$9.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.65
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$164.50
|
|
|
Service Code
|
NDC 57237023201
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.38 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna American Axle |
$106.92
|
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.92
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Advantage |
$115.15
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.60
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$123.38
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: Priority Health SBD |
$103.64
|
| Rate for Payer: UMR Bronson Commercial |
$72.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.38
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
NDC 53746027101
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.46 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna American Axle |
$65.68
|
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Advantage |
$70.73
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.79
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health SBD |
$63.66
|
| Rate for Payer: UMR Bronson Commercial |
$44.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$406.55
|
|
|
Service Code
|
NDC 65162027110
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.88 |
| Max. Negotiated Rate |
$365.89 |
| Rate for Payer: Aetna American Axle |
$264.26
|
| Rate for Payer: Aetna Commercial |
$345.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.26
|
| Rate for Payer: Cash Price |
$325.24
|
| Rate for Payer: Cofinity Advantage |
$284.58
|
| Rate for Payer: Cofinity Commercial |
$349.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.24
|
| Rate for Payer: Healthscope Commercial |
$365.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$304.91
|
| Rate for Payer: PHP Commercial |
$345.57
|
| Rate for Payer: Priority Health SBD |
$256.13
|
| Rate for Payer: UMR Bronson Commercial |
$178.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.91
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$131.60
|
|
|
Service Code
|
NDC 65862041901
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna American Axle |
$85.54
|
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna Medicare |
$65.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: BCBS Complete |
$52.64
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Advantage |
$92.12
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.70
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health SBD |
$82.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$85.54
|
| Rate for Payer: UHC Core |
$68.56
|
| Rate for Payer: UHC Exchange |
$51.72
|
| Rate for Payer: UMR Bronson Commercial |
$48.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$418.30
|
|
|
Service Code
|
NDC 53489014501
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.05 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.89
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.89
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Advantage |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$313.73
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$184.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.73
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$131.60
|
|
|
Service Code
|
NDC 65862041901
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.90 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna American Axle |
$85.54
|
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Advantage |
$92.12
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.70
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health SBD |
$82.91
|
| Rate for Payer: UMR Bronson Commercial |
$57.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$406.55
|
|
|
Service Code
|
NDC 65162027110
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.42 |
| Max. Negotiated Rate |
$365.89 |
| Rate for Payer: Aetna American Axle |
$264.26
|
| Rate for Payer: Aetna Commercial |
$345.57
|
| Rate for Payer: Aetna Medicare |
$203.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.26
|
| Rate for Payer: BCBS Complete |
$162.62
|
| Rate for Payer: Cash Price |
$325.24
|
| Rate for Payer: Cofinity Advantage |
$284.58
|
| Rate for Payer: Cofinity Commercial |
$349.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.24
|
| Rate for Payer: Healthscope Commercial |
$365.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$325.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$304.91
|
| Rate for Payer: PHP Commercial |
$345.57
|
| Rate for Payer: Priority Health SBD |
$256.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$264.26
|
| Rate for Payer: UHC Core |
$211.81
|
| Rate for Payer: UHC Exchange |
$159.77
|
| Rate for Payer: UMR Bronson Commercial |
$150.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.91
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$164.50
|
|
|
Service Code
|
NDC 57237023201
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.87 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna American Axle |
$106.92
|
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: Aetna Medicare |
$82.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.92
|
| Rate for Payer: BCBS Complete |
$65.80
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Advantage |
$115.15
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.60
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$131.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$123.38
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: Priority Health SBD |
$103.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.92
|
| Rate for Payer: UHC Core |
$85.70
|
| Rate for Payer: UHC Exchange |
$64.65
|
| Rate for Payer: UMR Bronson Commercial |
$60.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.38
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$101.05
|
|
|
Service Code
|
NDC 53746027101
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.39 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna American Axle |
$65.68
|
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna Medicare |
$50.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: BCBS Complete |
$40.42
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Advantage |
$70.73
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$80.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.79
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health SBD |
$63.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.68
|
| Rate for Payer: UHC Core |
$52.65
|
| Rate for Payer: UHC Exchange |
$39.71
|
| Rate for Payer: UMR Bronson Commercial |
$37.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$418.30
|
|
|
Service Code
|
NDC 53489014501
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.77 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.89
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna Medicare |
$209.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.89
|
| Rate for Payer: BCBS Complete |
$167.32
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Advantage |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$334.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$313.73
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$271.89
|
| Rate for Payer: UHC Core |
$217.93
|
| Rate for Payer: UHC Exchange |
$164.39
|
| Rate for Payer: UMR Bronson Commercial |
$154.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.73
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 65862042001
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.01 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Advantage |
$97.06
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.99
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UMR Bronson Commercial |
$61.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$171.55
|
|
|
Service Code
|
NDC 57237023301
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.47 |
| Max. Negotiated Rate |
$154.40 |
| Rate for Payer: Aetna American Axle |
$111.51
|
| Rate for Payer: Aetna Commercial |
$145.82
|
| Rate for Payer: Aetna Medicare |
$85.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$111.51
|
| Rate for Payer: BCBS Complete |
$68.62
|
| Rate for Payer: Cash Price |
$137.24
|
| Rate for Payer: Cofinity Advantage |
$120.08
|
| Rate for Payer: Cofinity Commercial |
$147.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$137.24
|
| Rate for Payer: Healthscope Commercial |
$154.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$120.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$128.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$137.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$145.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$128.66
|
| Rate for Payer: PHP Commercial |
$145.82
|
| Rate for Payer: Priority Health SBD |
$108.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$111.51
|
| Rate for Payer: UHC Core |
$89.38
|
| Rate for Payer: UHC Exchange |
$67.42
|
| Rate for Payer: UMR Bronson Commercial |
$63.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$128.66
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$138.65
|
|
|
Service Code
|
NDC 65862042001
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.30 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna Medicare |
$69.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: BCBS Complete |
$55.46
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Advantage |
$97.06
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$110.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.99
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.12
|
| Rate for Payer: UHC Core |
$72.24
|
| Rate for Payer: UHC Exchange |
$54.49
|
| Rate for Payer: UMR Bronson Commercial |
$51.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$364.25
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.27 |
| Max. Negotiated Rate |
$327.82 |
| Rate for Payer: Aetna American Axle |
$236.76
|
| Rate for Payer: Aetna Commercial |
$309.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$236.76
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Advantage |
$254.97
|
| Rate for Payer: Cofinity Commercial |
$313.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Healthscope Commercial |
$327.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$254.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$273.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$309.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.19
|
| Rate for Payer: PHP Commercial |
$309.61
|
| Rate for Payer: Priority Health SBD |
$229.48
|
| Rate for Payer: UMR Bronson Commercial |
$160.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$273.19
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$4.05
|
|
|
Service Code
|
NDC 60687053111
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Aetna American Axle |
$2.63
|
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Aetna Medicare |
$2.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.63
|
| Rate for Payer: BCBS Complete |
$1.62
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cofinity Advantage |
$2.83
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.24
|
| Rate for Payer: Healthscope Commercial |
$3.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.04
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: Priority Health SBD |
$2.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.63
|
| Rate for Payer: UHC Core |
$2.11
|
| Rate for Payer: UHC Exchange |
$1.59
|
| Rate for Payer: UMR Bronson Commercial |
$1.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.04
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 60687053101
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Advantage |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.15
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UMR Bronson Commercial |
$177.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$404.20
|
|
|
Service Code
|
NDC 60687053101
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.55 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna Medicare |
$202.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: BCBS Complete |
$161.68
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Advantage |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$323.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.15
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$262.73
|
| Rate for Payer: UHC Core |
$210.59
|
| Rate for Payer: UHC Exchange |
$158.85
|
| Rate for Payer: UMR Bronson Commercial |
$149.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$4.05
|
|
|
Service Code
|
NDC 60687053111
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Aetna American Axle |
$2.63
|
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.63
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cofinity Advantage |
$2.83
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.24
|
| Rate for Payer: Healthscope Commercial |
$3.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.04
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: Priority Health SBD |
$2.55
|
| Rate for Payer: UMR Bronson Commercial |
$1.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.04
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$364.25
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.77 |
| Max. Negotiated Rate |
$327.82 |
| Rate for Payer: Aetna American Axle |
$236.76
|
| Rate for Payer: Aetna Commercial |
$309.61
|
| Rate for Payer: Aetna Medicare |
$182.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$236.76
|
| Rate for Payer: BCBS Complete |
$145.70
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Advantage |
$254.97
|
| Rate for Payer: Cofinity Commercial |
$313.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Healthscope Commercial |
$327.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$254.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$273.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$291.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$309.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.19
|
| Rate for Payer: PHP Commercial |
$309.61
|
| Rate for Payer: Priority Health SBD |
$229.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$236.76
|
| Rate for Payer: UHC Core |
$189.77
|
| Rate for Payer: UHC Exchange |
$143.15
|
| Rate for Payer: UMR Bronson Commercial |
$134.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$273.19
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$171.55
|
|
|
Service Code
|
NDC 57237023301
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.48 |
| Max. Negotiated Rate |
$154.40 |
| Rate for Payer: Aetna American Axle |
$111.51
|
| Rate for Payer: Aetna Commercial |
$145.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$111.51
|
| Rate for Payer: Cash Price |
$137.24
|
| Rate for Payer: Cofinity Advantage |
$120.08
|
| Rate for Payer: Cofinity Commercial |
$147.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$137.24
|
| Rate for Payer: Healthscope Commercial |
$154.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$120.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$128.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$145.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$128.66
|
| Rate for Payer: PHP Commercial |
$145.82
|
| Rate for Payer: Priority Health SBD |
$108.08
|
| Rate for Payer: UMR Bronson Commercial |
$75.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$128.66
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$2,259.36
|
|
|
Service Code
|
NDC 00013010130
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$994.12 |
| Max. Negotiated Rate |
$2,033.42 |
| Rate for Payer: Aetna American Axle |
$1,468.58
|
| Rate for Payer: Aetna Commercial |
$1,920.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,468.58
|
| Rate for Payer: Cash Price |
$1,807.49
|
| Rate for Payer: Cofinity Advantage |
$1,581.55
|
| Rate for Payer: Cofinity Commercial |
$1,943.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,807.49
|
| Rate for Payer: Healthscope Commercial |
$2,033.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,581.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,694.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,920.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,694.52
|
| Rate for Payer: PHP Commercial |
$1,920.46
|
| Rate for Payer: Priority Health SBD |
$1,423.40
|
| Rate for Payer: UMR Bronson Commercial |
$994.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,694.52
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.09 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna American Axle |
$138.94
|
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna Medicare |
$106.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.94
|
| Rate for Payer: BCBS Complete |
$85.50
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Advantage |
$149.62
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$149.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$171.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health SBD |
$134.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$138.94
|
| Rate for Payer: UHC Core |
$111.36
|
| Rate for Payer: UHC Exchange |
$84.00
|
| Rate for Payer: UMR Bronson Commercial |
$79.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.31
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.05 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna American Axle |
$138.94
|
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.94
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Advantage |
$149.62
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$149.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health SBD |
$134.66
|
| Rate for Payer: UMR Bronson Commercial |
$94.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.31
|
|
