|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$26.26
|
|
|
Service Code
|
NDC 00121097440
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$23.63 |
| Rate for Payer: Aetna American Axle |
$17.07
|
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.07
|
| Rate for Payer: Cash Price |
$21.01
|
| Rate for Payer: Cofinity Commercial |
$18.38
|
| Rate for Payer: Cofinity Commercial |
$22.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.01
|
| Rate for Payer: Healthscope Commercial |
$23.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.32
|
| Rate for Payer: PHP Commercial |
$22.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.07
|
| Rate for Payer: Priority Health SBD |
$16.54
|
| Rate for Payer: UMR Bronson Commercial |
$11.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.70
|
|
|
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
|
$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 |
$12.80
|
| 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
|
$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
|
$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
|
OP
|
$26.26
|
|
|
Service Code
|
NDC 00121097440
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.72 |
| Max. Negotiated Rate |
$23.63 |
| Rate for Payer: Aetna American Axle |
$17.07
|
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: Aetna Medicare |
$13.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.07
|
| Rate for Payer: BCBS Complete |
$10.50
|
| Rate for Payer: Cash Price |
$21.01
|
| Rate for Payer: Cofinity Commercial |
$18.38
|
| Rate for Payer: Cofinity Commercial |
$22.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.01
|
| Rate for Payer: Healthscope Commercial |
$23.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.32
|
| Rate for Payer: PHP Commercial |
$22.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.07
|
| Rate for Payer: Priority Health SBD |
$16.54
|
| Rate for Payer: UMR Bronson Commercial |
$9.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.70
|
|
|
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
|
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 |
$12.92
|
| 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
|
$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
|
$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
|
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
|
$31.54
|
|
|
Service Code
|
NDC 00121074740
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$28.39 |
| Rate for Payer: Aetna American Axle |
$20.50
|
| Rate for Payer: Aetna Commercial |
$26.81
|
| Rate for Payer: Aetna Medicare |
$15.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.50
|
| Rate for Payer: BCBS Complete |
$12.62
|
| 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 |
$11.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.66
|
|
|
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
|
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
|
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
|
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
|
$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
|
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
|
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
|
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
|
$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 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 |
$211.18 |
| Rate for Payer: Aetna American Axle |
$152.52
|
| Rate for Payer: Aetna Commercial |
$199.45
|
| Rate for Payer: Aetna Medicare |
$117.32
|
| 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 |
$164.26
|
| Rate for Payer: Cofinity Commercial |
$201.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$164.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$211.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.26
|
| 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
|
$3.15
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.84 |
| 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 |
$2.20
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.52
|
| Rate for Payer: Healthscope Commercial |
$2.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.20
|
| 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
|
$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
|
|
