|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$21.14
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$19.03 |
| Rate for Payer: Aetna American Axle |
$13.74
|
| Rate for Payer: Aetna American Axle |
$20.80
|
| Rate for Payer: Aetna American Axle |
$18.51
|
| Rate for Payer: Aetna American Axle |
$14.05
|
| Rate for Payer: Aetna American Axle |
$17.53
|
| Rate for Payer: Aetna American Axle |
$51.58
|
| Rate for Payer: Aetna Commercial |
$17.97
|
| Rate for Payer: Aetna Commercial |
$18.37
|
| Rate for Payer: Aetna Commercial |
$24.21
|
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna Commercial |
$27.20
|
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.80
|
| Rate for Payer: Cash Price |
$25.60
|
| Rate for Payer: Cash Price |
$22.78
|
| Rate for Payer: Cash Price |
$16.91
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cofinity Commercial |
$27.52
|
| Rate for Payer: Cofinity Commercial |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$24.49
|
| Rate for Payer: Cofinity Commercial |
$19.94
|
| Rate for Payer: Cofinity Commercial |
$18.88
|
| Rate for Payer: Cofinity Commercial |
$15.13
|
| Rate for Payer: Cofinity Commercial |
$18.58
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$18.18
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$55.55
|
| Rate for Payer: Cofinity Commercial |
$22.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.48
|
| Rate for Payer: Healthscope Commercial |
$25.63
|
| Rate for Payer: Healthscope Commercial |
$71.42
|
| Rate for Payer: Healthscope Commercial |
$28.80
|
| Rate for Payer: Healthscope Commercial |
$19.45
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$19.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: PHP Commercial |
$17.97
|
| Rate for Payer: PHP Commercial |
$18.37
|
| Rate for Payer: PHP Commercial |
$24.21
|
| Rate for Payer: PHP Commercial |
$27.20
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: PHP Commercial |
$67.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.58
|
| Rate for Payer: Priority Health SBD |
$20.16
|
| Rate for Payer: Priority Health SBD |
$17.94
|
| Rate for Payer: Priority Health SBD |
$13.32
|
| Rate for Payer: Priority Health SBD |
$13.61
|
| Rate for Payer: Priority Health SBD |
$16.99
|
| Rate for Payer: Priority Health SBD |
$49.99
|
| Rate for Payer: UMR Bronson Commercial |
$34.91
|
| Rate for Payer: UMR Bronson Commercial |
$9.51
|
| Rate for Payer: UMR Bronson Commercial |
$11.87
|
| Rate for Payer: UMR Bronson Commercial |
$14.08
|
| Rate for Payer: UMR Bronson Commercial |
$12.53
|
| Rate for Payer: UMR Bronson Commercial |
$9.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.86
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$31.54
|
|
|
Service Code
|
NDC 00121074740
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$28.39 |
| Rate for Payer: Aetna American Axle |
$20.50
|
| Rate for Payer: Aetna Commercial |
$26.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.50
|
| Rate for Payer: Cash Price |
$25.23
|
| Rate for Payer: Cofinity Commercial |
$22.08
|
| Rate for Payer: Cofinity Commercial |
$27.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.23
|
| Rate for Payer: Healthscope Commercial |
$28.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.81
|
| Rate for Payer: PHP Commercial |
$26.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.50
|
| Rate for Payer: Priority Health SBD |
$19.87
|
| Rate for Payer: UMR Bronson Commercial |
$13.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.66
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$46.47
|
|
|
Service Code
|
NDC 66689079001
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$41.82 |
| Rate for Payer: Aetna American Axle |
$30.21
|
| Rate for Payer: Aetna Commercial |
$39.50
|
| Rate for Payer: Aetna Medicare |
$23.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.21
|
| Rate for Payer: BCBS Complete |
$18.59
|
| Rate for Payer: Cash Price |
$37.18
|
| Rate for Payer: Cofinity Commercial |
$32.53
|
| Rate for Payer: Cofinity Commercial |
$39.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.18
|
| Rate for Payer: Healthscope Commercial |
$41.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.50
|
| Rate for Payer: PHP Commercial |
$39.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.21
|
| Rate for Payer: Priority Health SBD |
$29.28
|
| Rate for Payer: UMR Bronson Commercial |
$17.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.85
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$1,191.46
|
|
|
Service Code
|
NDC 58914017014
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$440.84 |
| Max. Negotiated Rate |
$1,072.31 |
| Rate for Payer: Aetna American Axle |
$774.45
|
| Rate for Payer: Aetna Commercial |
$1,012.74
|
| Rate for Payer: Aetna Medicare |
$595.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$774.45
|
| Rate for Payer: BCBS Complete |
$476.58
|
| Rate for Payer: Cash Price |
$953.17
|
| Rate for Payer: Cofinity Commercial |
$1,024.66
|
| Rate for Payer: Cofinity Commercial |
$834.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$834.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$953.17
|
| Rate for Payer: Healthscope Commercial |
$1,072.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$834.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$893.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,012.74
|
| Rate for Payer: PHP Commercial |
$1,012.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$774.45
|
| Rate for Payer: Priority Health SBD |
$750.62
|
| Rate for Payer: UMR Bronson Commercial |
$440.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$893.60
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$33.75
|
|
|
Service Code
|
NDC 00121074710
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$30.38 |
| Rate for Payer: Aetna American Axle |
$21.94
|
| Rate for Payer: Aetna Commercial |
$28.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.94
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cofinity Commercial |
$23.62
|
| Rate for Payer: Cofinity Commercial |
$29.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.00
|
| Rate for Payer: Healthscope Commercial |
$30.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.69
|
| Rate for Payer: PHP Commercial |
$28.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.94
|
| Rate for Payer: Priority Health SBD |
$21.26
|
| Rate for Payer: UMR Bronson Commercial |
$14.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.31
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$39.48
|
|
|
Service Code
|
NDC 09900000804
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.61 |
| Max. Negotiated Rate |
$35.53 |
| Rate for Payer: Aetna American Axle |
$25.66
|
| Rate for Payer: Aetna Commercial |
$33.56
|
| Rate for Payer: Aetna Medicare |
$19.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.66
|
| Rate for Payer: BCBS Complete |
$15.79
|
| Rate for Payer: Cash Price |
$31.58
|
| Rate for Payer: Cofinity Commercial |
$27.64
|
| Rate for Payer: Cofinity Commercial |
$33.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.58
|
| Rate for Payer: Healthscope Commercial |
$35.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.56
|
| Rate for Payer: PHP Commercial |
$33.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.66
|
| Rate for Payer: Priority Health SBD |
$24.87
|
| Rate for Payer: UMR Bronson Commercial |
$14.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.61
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$25.83
|
|
|
Service Code
|
NDC 00121097410
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.37 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna American Axle |
$16.79
|
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cofinity Commercial |
$18.08
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.66
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.96
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.79
|
| Rate for Payer: Priority Health SBD |
$16.27
|
| Rate for Payer: UMR Bronson Commercial |
$11.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.37
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$32.88
|
|
|
Service Code
|
NDC 60687073808
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$29.59 |
| Rate for Payer: Aetna American Axle |
$21.37
|
| Rate for Payer: Aetna Commercial |
$27.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.37
|
| Rate for Payer: Cash Price |
$26.30
|
| Rate for Payer: Cofinity Commercial |
$23.02
|
| Rate for Payer: Cofinity Commercial |
$28.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.30
|
| Rate for Payer: Healthscope Commercial |
$29.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.95
|
| Rate for Payer: PHP Commercial |
$27.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.37
|
| Rate for Payer: Priority Health SBD |
$20.71
|
| Rate for Payer: UMR Bronson Commercial |
$14.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.66
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$44.16
|
|
|
Service Code
|
NDC 00121097450
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.34 |
| Max. Negotiated Rate |
$39.74 |
| Rate for Payer: Aetna American Axle |
$28.70
|
| Rate for Payer: Aetna Commercial |
$37.54
|
| Rate for Payer: Aetna Medicare |
$22.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.70
|
| Rate for Payer: BCBS Complete |
$17.66
|
| Rate for Payer: Cash Price |
$35.33
|
| Rate for Payer: Cofinity Commercial |
$30.91
|
| Rate for Payer: Cofinity Commercial |
$37.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.33
|
| Rate for Payer: Healthscope Commercial |
$39.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.54
|
| Rate for Payer: PHP Commercial |
$37.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.70
|
| Rate for Payer: Priority Health SBD |
$27.82
|
| Rate for Payer: UMR Bronson Commercial |
$16.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.12
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$42.29
|
|
|
Service Code
|
NDC 68094004359
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$38.06 |
| Rate for Payer: Aetna American Axle |
$27.49
|
| Rate for Payer: Aetna Commercial |
$35.95
|
| Rate for Payer: Aetna Medicare |
$21.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.49
|
| Rate for Payer: BCBS Complete |
$16.92
|
| Rate for Payer: Cash Price |
$33.83
|
| Rate for Payer: Cofinity Commercial |
$29.60
|
| Rate for Payer: Cofinity Commercial |
$36.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.83
|
| Rate for Payer: Healthscope Commercial |
$38.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.95
|
| Rate for Payer: PHP Commercial |
$35.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.49
|
| Rate for Payer: Priority Health SBD |
$26.64
|
| Rate for Payer: UMR Bronson Commercial |
$15.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.72
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$46.47
|
|
|
Service Code
|
NDC 66689079001
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$41.82 |
| Rate for Payer: Aetna American Axle |
$30.21
|
| Rate for Payer: Aetna Commercial |
$39.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.21
|
| Rate for Payer: Cash Price |
$37.18
|
| Rate for Payer: Cofinity Commercial |
$32.53
|
| Rate for Payer: Cofinity Commercial |
$39.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.18
|
| Rate for Payer: Healthscope Commercial |
$41.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.50
|
| Rate for Payer: PHP Commercial |
$39.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.21
|
| Rate for Payer: Priority Health SBD |
$29.28
|
| Rate for Payer: UMR Bronson Commercial |
$20.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.85
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$29.91
|
|
|
Service Code
|
NDC 00904747066
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$26.92 |
| Rate for Payer: Aetna American Axle |
$19.44
|
| Rate for Payer: Aetna Commercial |
$25.42
|
| Rate for Payer: Aetna Medicare |
$14.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.44
|
| Rate for Payer: BCBS Complete |
$11.96
|
| Rate for Payer: Cash Price |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$20.94
|
| Rate for Payer: Cofinity Commercial |
$25.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.93
|
| Rate for Payer: Healthscope Commercial |
$26.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.42
|
| Rate for Payer: PHP Commercial |
$25.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.44
|
| Rate for Payer: Priority Health SBD |
$18.84
|
| Rate for Payer: UMR Bronson Commercial |
$11.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.43
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$42.29
|
|
|
Service Code
|
NDC 68094004359
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.61 |
| Max. Negotiated Rate |
$38.06 |
| Rate for Payer: Aetna American Axle |
$27.49
|
| Rate for Payer: Aetna Commercial |
$35.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.49
|
| Rate for Payer: Cash Price |
$33.83
|
| Rate for Payer: Cofinity Commercial |
$29.60
|
| Rate for Payer: Cofinity Commercial |
$36.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.83
|
| Rate for Payer: Healthscope Commercial |
$38.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.95
|
| Rate for Payer: PHP Commercial |
$35.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.49
|
| Rate for Payer: Priority Health SBD |
$26.64
|
| Rate for Payer: UMR Bronson Commercial |
$18.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.72
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$46.36
|
|
|
Service Code
|
NDC 00904747072
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$41.72 |
| Rate for Payer: Aetna American Axle |
$30.13
|
| Rate for Payer: Aetna Commercial |
$39.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.13
|
| Rate for Payer: Cash Price |
$37.09
|
| Rate for Payer: Cofinity Commercial |
$32.45
|
| Rate for Payer: Cofinity Commercial |
$39.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.09
|
| Rate for Payer: Healthscope Commercial |
$41.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.41
|
| Rate for Payer: PHP Commercial |
$39.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.13
|
| Rate for Payer: Priority Health SBD |
$29.21
|
| Rate for Payer: UMR Bronson Commercial |
$20.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.77
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$46.36
|
|
|
Service Code
|
NDC 00904747072
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$41.72 |
| Rate for Payer: Aetna American Axle |
$30.13
|
| Rate for Payer: Aetna Commercial |
$39.41
|
| Rate for Payer: Aetna Medicare |
$23.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.13
|
| Rate for Payer: BCBS Complete |
$18.54
|
| Rate for Payer: Cash Price |
$37.09
|
| Rate for Payer: Cofinity Commercial |
$32.45
|
| Rate for Payer: Cofinity Commercial |
$39.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$32.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.09
|
| Rate for Payer: Healthscope Commercial |
$41.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.41
|
| Rate for Payer: PHP Commercial |
$39.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.13
|
| Rate for Payer: Priority Health SBD |
$29.21
|
| Rate for Payer: UMR Bronson Commercial |
$17.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.77
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$39.48
|
|
|
Service Code
|
NDC 09900000804
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.37 |
| Max. Negotiated Rate |
$35.53 |
| Rate for Payer: Aetna American Axle |
$25.66
|
| Rate for Payer: Aetna Commercial |
$33.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.66
|
| Rate for Payer: Cash Price |
$31.58
|
| Rate for Payer: Cofinity Commercial |
$27.64
|
| Rate for Payer: Cofinity Commercial |
$33.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.58
|
| Rate for Payer: Healthscope Commercial |
$35.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.56
|
| Rate for Payer: PHP Commercial |
$33.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.66
|
| Rate for Payer: Priority Health SBD |
$24.87
|
| Rate for Payer: UMR Bronson Commercial |
$17.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.61
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$42.68
|
|
|
Service Code
|
NDC 68094004362
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.79 |
| Max. Negotiated Rate |
$38.41 |
| Rate for Payer: Aetna American Axle |
$27.74
|
| Rate for Payer: Aetna Commercial |
$36.28
|
| Rate for Payer: Aetna Medicare |
$21.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.74
|
| Rate for Payer: BCBS Complete |
$17.07
|
| Rate for Payer: Cash Price |
$34.14
|
| Rate for Payer: Cofinity Commercial |
$29.88
|
| Rate for Payer: Cofinity Commercial |
$36.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.14
|
| Rate for Payer: Healthscope Commercial |
$38.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.28
|
| Rate for Payer: PHP Commercial |
$36.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.74
|
| Rate for Payer: Priority Health SBD |
$26.89
|
| Rate for Payer: UMR Bronson Commercial |
$15.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.01
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$33.75
|
|
|
Service Code
|
NDC 00121074710
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$30.38 |
| Rate for Payer: Aetna American Axle |
$21.94
|
| Rate for Payer: Aetna Commercial |
$28.69
|
| Rate for Payer: Aetna Medicare |
$16.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.94
|
| Rate for Payer: BCBS Complete |
$13.50
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cofinity Commercial |
$23.62
|
| Rate for Payer: Cofinity Commercial |
$29.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.00
|
| Rate for Payer: Healthscope Commercial |
$30.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.69
|
| Rate for Payer: PHP Commercial |
$28.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.94
|
| Rate for Payer: Priority Health SBD |
$21.26
|
| Rate for Payer: UMR Bronson Commercial |
$12.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.31
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$42.68
|
|
|
Service Code
|
NDC 68094004362
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$38.41 |
| Rate for Payer: Aetna American Axle |
$27.74
|
| Rate for Payer: Aetna Commercial |
$36.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.74
|
| Rate for Payer: Cash Price |
$34.14
|
| Rate for Payer: Cofinity Commercial |
$29.88
|
| Rate for Payer: Cofinity Commercial |
$36.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.14
|
| Rate for Payer: Healthscope Commercial |
$38.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$29.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.28
|
| Rate for Payer: PHP Commercial |
$36.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.74
|
| Rate for Payer: Priority Health SBD |
$26.89
|
| Rate for Payer: UMR Bronson Commercial |
$18.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.01
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$29.91
|
|
|
Service Code
|
NDC 00904747066
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$26.92 |
| Rate for Payer: Aetna American Axle |
$19.44
|
| Rate for Payer: Aetna Commercial |
$25.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.44
|
| Rate for Payer: Cash Price |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$20.94
|
| Rate for Payer: Cofinity Commercial |
$25.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.93
|
| Rate for Payer: Healthscope Commercial |
$26.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.42
|
| Rate for Payer: PHP Commercial |
$25.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.44
|
| Rate for Payer: Priority Health SBD |
$18.84
|
| Rate for Payer: UMR Bronson Commercial |
$13.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.43
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$813.96
|
|
|
Service Code
|
NDC 82182010614
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$301.17 |
| Max. Negotiated Rate |
$732.56 |
| Rate for Payer: Aetna American Axle |
$529.07
|
| Rate for Payer: Aetna Commercial |
$691.87
|
| Rate for Payer: Aetna Medicare |
$406.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$529.07
|
| Rate for Payer: BCBS Complete |
$325.58
|
| Rate for Payer: Cash Price |
$651.17
|
| Rate for Payer: Cofinity Commercial |
$569.77
|
| Rate for Payer: Cofinity Commercial |
$700.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$569.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$651.17
|
| Rate for Payer: Healthscope Commercial |
$732.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$569.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$610.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$691.87
|
| Rate for Payer: PHP Commercial |
$691.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$529.07
|
| Rate for Payer: Priority Health SBD |
$512.79
|
| Rate for Payer: UMR Bronson Commercial |
$301.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$610.47
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,191.46
|
|
|
Service Code
|
NDC 58914017014
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$524.24 |
| Max. Negotiated Rate |
$1,072.31 |
| Rate for Payer: Aetna American Axle |
$774.45
|
| Rate for Payer: Aetna Commercial |
$1,012.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$774.45
|
| Rate for Payer: Cash Price |
$953.17
|
| Rate for Payer: Cofinity Commercial |
$1,024.66
|
| Rate for Payer: Cofinity Commercial |
$834.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$834.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$953.17
|
| Rate for Payer: Healthscope Commercial |
$1,072.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$834.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$893.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,012.74
|
| Rate for Payer: PHP Commercial |
$1,012.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$774.45
|
| Rate for Payer: Priority Health SBD |
$750.62
|
| Rate for Payer: UMR Bronson Commercial |
$524.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$893.60
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$25.59
|
|
|
Service Code
|
NDC 00904726918
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.47 |
| Max. Negotiated Rate |
$23.03 |
| Rate for Payer: Aetna American Axle |
$16.63
|
| Rate for Payer: Aetna Commercial |
$21.75
|
| Rate for Payer: Aetna Medicare |
$12.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.63
|
| Rate for Payer: BCBS Complete |
$10.24
|
| Rate for Payer: Cash Price |
$20.47
|
| Rate for Payer: Cofinity Commercial |
$17.91
|
| Rate for Payer: Cofinity Commercial |
$22.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.47
|
| Rate for Payer: Healthscope Commercial |
$23.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.75
|
| Rate for Payer: PHP Commercial |
$21.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.63
|
| Rate for Payer: Priority Health SBD |
$16.12
|
| Rate for Payer: UMR Bronson Commercial |
$9.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.19
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$32.88
|
|
|
Service Code
|
NDC 60687073842
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$29.59 |
| Rate for Payer: Aetna American Axle |
$21.37
|
| Rate for Payer: Aetna Commercial |
$27.95
|
| Rate for Payer: Aetna Medicare |
$16.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.37
|
| Rate for Payer: BCBS Complete |
$13.15
|
| Rate for Payer: Cash Price |
$26.30
|
| Rate for Payer: Cofinity Commercial |
$23.02
|
| Rate for Payer: Cofinity Commercial |
$28.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.30
|
| Rate for Payer: Healthscope Commercial |
$29.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.95
|
| Rate for Payer: PHP Commercial |
$27.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.37
|
| Rate for Payer: Priority Health SBD |
$20.71
|
| Rate for Payer: UMR Bronson Commercial |
$12.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.66
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$34.80
|
|
|
Service Code
|
NDC 00121097494
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.31 |
| Max. Negotiated Rate |
$31.32 |
| Rate for Payer: Aetna American Axle |
$22.62
|
| Rate for Payer: Aetna Commercial |
$29.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.62
|
| Rate for Payer: Cash Price |
$27.84
|
| Rate for Payer: Cofinity Commercial |
$24.36
|
| Rate for Payer: Cofinity Commercial |
$29.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.84
|
| Rate for Payer: Healthscope Commercial |
$31.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.58
|
| Rate for Payer: PHP Commercial |
$29.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.62
|
| Rate for Payer: Priority Health SBD |
$21.92
|
| Rate for Payer: UMR Bronson Commercial |
$15.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.10
|
|
