|
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
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$34.80
|
|
|
Service Code
|
NDC 00121097494
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.88 |
| Max. Negotiated Rate |
$31.32 |
| Rate for Payer: Aetna American Axle |
$22.62
|
| Rate for Payer: Aetna Commercial |
$29.58
|
| Rate for Payer: Aetna Medicare |
$17.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.62
|
| Rate for Payer: BCBS Complete |
$13.92
|
| 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 |
$12.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.10
|
|
|
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
|
IP
|
$25.59
|
|
|
Service Code
|
NDC 00904726918
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$23.03 |
| Rate for Payer: Aetna American Axle |
$16.63
|
| Rate for Payer: Aetna Commercial |
$21.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.63
|
| 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 |
$11.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.19
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$25.83
|
|
|
Service Code
|
NDC 00121097410
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna American Axle |
$16.79
|
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna Medicare |
$12.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: BCBS Complete |
$10.33
|
| 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 |
$9.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.37
|
|
|
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
|
$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
|
$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
|
$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
|
$32.88
|
|
|
Service Code
|
NDC 60687073808
|
| 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
|
$32.88
|
|
|
Service Code
|
NDC 60687073842
|
| 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
|
$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
|
$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 00904726966
|
| 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 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 Commercial |
$1,065.33
|
| Rate for Payer: Cofinity Commercial |
$867.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$867.13
|
| 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: PHP Commercial |
$1,052.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$805.19
|
| Rate for Payer: Priority Health SBD |
$780.42
|
| Rate for Payer: UMR Bronson Commercial |
$458.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$929.07
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$3.15
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna American Axle |
$2.05
|
| Rate for Payer: Aetna Commercial |
$2.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.05
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.52
|
| Rate for Payer: Healthscope Commercial |
$2.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.68
|
| Rate for Payer: PHP Commercial |
$2.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.05
|
| Rate for Payer: Priority Health SBD |
$1.98
|
| Rate for Payer: UMR Bronson Commercial |
$1.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.36
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$234.65
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.82 |
| Max. Negotiated Rate |
$211.19 |
| Rate for Payer: Aetna American Axle |
$152.52
|
| Rate for Payer: Aetna Commercial |
$199.45
|
| Rate for Payer: Aetna Medicare |
$117.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$152.52
|
| Rate for Payer: BCBS Complete |
$93.86
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$164.25
|
| Rate for Payer: Cofinity Commercial |
$201.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$211.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$199.45
|
| Rate for Payer: PHP Commercial |
$199.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.52
|
| Rate for Payer: Priority Health SBD |
$147.83
|
| Rate for Payer: UMR Bronson Commercial |
$86.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.99
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$234.65
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.25 |
| Max. Negotiated Rate |
$211.19 |
| Rate for Payer: Aetna American Axle |
$152.52
|
| Rate for Payer: Aetna Commercial |
$199.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$152.52
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$164.25
|
| Rate for Payer: Cofinity Commercial |
$201.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$211.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$199.45
|
| Rate for Payer: PHP Commercial |
$199.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.52
|
| Rate for Payer: Priority Health SBD |
$147.83
|
| Rate for Payer: UMR Bronson Commercial |
$103.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.99
|
|
|
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 Commercial |
$1,065.33
|
| Rate for Payer: Cofinity Commercial |
$867.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$867.13
|
| 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: PHP Commercial |
$1,052.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$805.19
|
| 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
|
$314.45
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.35 |
| Max. Negotiated Rate |
$283.00 |
| Rate for Payer: Aetna American Axle |
$204.39
|
| Rate for Payer: Aetna Commercial |
$267.28
|
| Rate for Payer: Aetna Medicare |
$157.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$204.39
|
| Rate for Payer: BCBS Complete |
$125.78
|
| Rate for Payer: Cash Price |
$251.56
|
| Rate for Payer: Cofinity Commercial |
$220.12
|
| Rate for Payer: Cofinity Commercial |
$270.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$220.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$251.56
|
| Rate for Payer: Healthscope Commercial |
$283.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$220.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$267.28
|
| Rate for Payer: PHP Commercial |
$267.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.39
|
| Rate for Payer: Priority Health SBD |
$198.10
|
| Rate for Payer: UMR Bronson Commercial |
$116.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.84
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$314.45
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.36 |
| Max. Negotiated Rate |
$283.00 |
| Rate for Payer: Aetna American Axle |
$204.39
|
| Rate for Payer: Aetna Commercial |
$267.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$204.39
|
| Rate for Payer: Cash Price |
$251.56
|
| Rate for Payer: Cofinity Commercial |
$220.12
|
| Rate for Payer: Cofinity Commercial |
$270.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$220.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$251.56
|
| Rate for Payer: Healthscope Commercial |
$283.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$220.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$267.28
|
| Rate for Payer: PHP Commercial |
$267.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.39
|
| Rate for Payer: Priority Health SBD |
$198.10
|
| Rate for Payer: UMR Bronson Commercial |
$138.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.84
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$3.15
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna American Axle |
$2.05
|
| Rate for Payer: Aetna Commercial |
$2.68
|
| Rate for Payer: Aetna Medicare |
$1.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.05
|
| Rate for Payer: BCBS Complete |
$1.26
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.52
|
| Rate for Payer: Healthscope Commercial |
$2.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.68
|
| Rate for Payer: PHP Commercial |
$2.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.05
|
| Rate for Payer: Priority Health SBD |
$1.98
|
| Rate for Payer: UMR Bronson Commercial |
$1.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.36
|
|
|
SUCTION ASSISTED LIPECTOMY; HEAD AND NECK
|
Facility
|
OP
|
$10,050.52
|
|
|
Service Code
|
CPT 15876
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,913.77 |
| Max. Negotiated Rate |
$10,050.52 |
| Rate for Payer: Aetna Medicare |
$3,713.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,463.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,463.09
|
| Rate for Payer: BCBS Complete |
$2,009.46
|
| Rate for Payer: BCBS MAPPO |
$3,570.47
|
| Rate for Payer: BCN Medicare Advantage |
$3,570.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,570.47
|
| Rate for Payer: Mclaren Medicaid |
$1,913.77
|
| Rate for Payer: Mclaren Medicare |
$3,570.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,748.99
|
| Rate for Payer: Meridian Medicaid |
$2,009.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,106.04
|
| Rate for Payer: PACE Medicare |
$3,391.95
|
| Rate for Payer: PACE SWMI |
$3,570.47
|
| Rate for Payer: PHP Medicare Advantage |
$3,570.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,913.77
|
| Rate for Payer: Priority Health Medicare |
$3,570.47
|
| Rate for Payer: Railroad Medicare Medicare |
$3,570.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,050.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,570.47
|
| Rate for Payer: UHC Exchange |
$6,823.53
|
| Rate for Payer: UHC Medicare Advantage |
$3,570.47
|
| Rate for Payer: UHCCP Medicaid |
$1,913.77
|
| Rate for Payer: VA VA |
$3,570.47
|
|
|
SUCTION ASSISTED LIPECTOMY; TRUNK
|
Facility
|
OP
|
$10,050.52
|
|
|
Service Code
|
CPT 15877
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,913.77 |
| Max. Negotiated Rate |
$10,050.52 |
| Rate for Payer: Aetna Medicare |
$3,713.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,463.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,463.09
|
| Rate for Payer: BCBS Complete |
$2,009.46
|
| Rate for Payer: BCBS MAPPO |
$3,570.47
|
| Rate for Payer: BCN Medicare Advantage |
$3,570.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,570.47
|
| Rate for Payer: Mclaren Medicaid |
$1,913.77
|
| Rate for Payer: Mclaren Medicare |
$3,570.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,748.99
|
| Rate for Payer: Meridian Medicaid |
$2,009.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,106.04
|
| Rate for Payer: PACE Medicare |
$3,391.95
|
| Rate for Payer: PACE SWMI |
$3,570.47
|
| Rate for Payer: PHP Medicare Advantage |
$3,570.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,913.77
|
| Rate for Payer: Priority Health Medicare |
$3,570.47
|
| Rate for Payer: Railroad Medicare Medicare |
$3,570.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,050.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,570.47
|
| Rate for Payer: UHC Exchange |
$6,823.53
|
| Rate for Payer: UHC Medicare Advantage |
$3,570.47
|
| Rate for Payer: UHCCP Medicaid |
$1,913.77
|
| Rate for Payer: VA VA |
$3,570.47
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$823.21
|
|
|
Service Code
|
NDC 00006542505
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$362.21 |
| Max. Negotiated Rate |
$740.89 |
| Rate for Payer: Aetna American Axle |
$535.09
|
| Rate for Payer: Aetna Commercial |
$699.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$535.09
|
| Rate for Payer: Cash Price |
$658.57
|
| Rate for Payer: Cofinity Commercial |
$576.25
|
| Rate for Payer: Cofinity Commercial |
$707.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$576.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$658.57
|
| Rate for Payer: Healthscope Commercial |
$740.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$576.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$617.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$699.73
|
| Rate for Payer: PHP Commercial |
$699.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$535.09
|
| Rate for Payer: Priority Health SBD |
$518.62
|
| Rate for Payer: UMR Bronson Commercial |
$362.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$617.41
|
|
