|
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 |
$2.84 |
| Rate for Payer: Aetna American Axle |
$2.05
|
| Rate for Payer: Aetna Commercial |
$2.68
|
| Rate for Payer: Aetna Medicare |
$1.58
|
| 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 |
$2.20
|
| 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 |
$1.17
|
| 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
|
|
|
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 |
$211.18 |
| 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 |
$164.26
|
| 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 |
$103.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.99
|
|
|
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
|
|
|
SUCTION ASSISTED LIPECTOMY; HEAD AND NECK
|
Facility
|
OP
|
$11,273.70
|
|
|
Service Code
|
CPT 15876
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,922.61 |
| Max. Negotiated Rate |
$11,273.70 |
| Rate for Payer: Aetna Medicare |
$3,730.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,483.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,483.69
|
| Rate for Payer: BCBS Complete |
$2,018.74
|
| Rate for Payer: BCBS MAPPO |
$3,586.95
|
| Rate for Payer: BCBS Trust/PPO |
$2,108.09
|
| Rate for Payer: BCN Commercial |
$2,108.09
|
| Rate for Payer: BCN Medicare Advantage |
$3,586.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,586.95
|
| Rate for Payer: Mclaren Medicaid |
$1,922.61
|
| Rate for Payer: Mclaren Medicare |
$3,586.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,766.30
|
| Rate for Payer: Meridian Medicaid |
$2,018.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,124.99
|
| Rate for Payer: Nomi Health Commercial |
$7,532.60
|
| Rate for Payer: PACE Medicare |
$3,407.60
|
| Rate for Payer: PACE SWMI |
$3,586.95
|
| Rate for Payer: PHP Medicare Advantage |
$3,586.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,922.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,273.70
|
| Rate for Payer: Priority Health Medicare |
$3,586.95
|
| Rate for Payer: Priority Health Narrow Network |
$9,018.96
|
| Rate for Payer: Railroad Medicare Medicare |
$3,586.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,096.91
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,586.95
|
| Rate for Payer: UHC Exchange |
$6,855.02
|
| Rate for Payer: UHC Medicare Advantage |
$3,586.95
|
| Rate for Payer: UHCCP Medicaid |
$1,922.61
|
| Rate for Payer: VA VA |
$3,586.95
|
|
|
SUCTION ASSISTED LIPECTOMY; TRUNK
|
Facility
|
OP
|
$11,273.70
|
|
|
Service Code
|
CPT 15877
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,922.61 |
| Max. Negotiated Rate |
$11,273.70 |
| Rate for Payer: Aetna Medicare |
$3,730.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,483.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,483.69
|
| Rate for Payer: BCBS Complete |
$2,018.74
|
| Rate for Payer: BCBS MAPPO |
$3,586.95
|
| Rate for Payer: BCBS Trust/PPO |
$2,459.44
|
| Rate for Payer: BCN Commercial |
$2,459.44
|
| Rate for Payer: BCN Medicare Advantage |
$3,586.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,586.95
|
| Rate for Payer: Mclaren Medicaid |
$1,922.61
|
| Rate for Payer: Mclaren Medicare |
$3,586.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,766.30
|
| Rate for Payer: Meridian Medicaid |
$2,018.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,124.99
|
| Rate for Payer: Nomi Health Commercial |
$7,532.60
|
| Rate for Payer: PACE Medicare |
$3,407.60
|
| Rate for Payer: PACE SWMI |
$3,586.95
|
| Rate for Payer: PHP Medicare Advantage |
$3,586.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,922.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,273.70
|
| Rate for Payer: Priority Health Medicare |
$3,586.95
|
| Rate for Payer: Priority Health Narrow Network |
$9,018.96
|
| Rate for Payer: Railroad Medicare Medicare |
$3,586.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,096.91
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,586.95
|
| Rate for Payer: UHC Exchange |
$6,855.02
|
| Rate for Payer: UHC Medicare Advantage |
$3,586.95
|
| Rate for Payer: UHCCP Medicaid |
$1,922.61
|
| Rate for Payer: VA VA |
$3,586.95
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$449.46
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$166.30 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna American Axle |
$292.15
|
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna Medicare |
$224.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.15
|
| Rate for Payer: BCBS Complete |
$179.78
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$314.62
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health SBD |
$283.16
|
| Rate for Payer: UMR Bronson Commercial |
$166.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.10
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$250.92
|
|
|
Service Code
|
NDC 09900001819
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.40 |
| Max. Negotiated Rate |
$225.83 |
| Rate for Payer: Aetna American Axle |
$163.10
|
| Rate for Payer: Aetna Commercial |
$213.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.10
|
| Rate for Payer: Cash Price |
$200.74
|
| Rate for Payer: Cofinity Commercial |
$175.64
|
| Rate for Payer: Cofinity Commercial |
$215.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.74
|
| Rate for Payer: Healthscope Commercial |
$225.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.28
|
| Rate for Payer: PHP Commercial |
$213.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.10
|
| Rate for Payer: Priority Health SBD |
$158.08
|
| Rate for Payer: UMR Bronson Commercial |
$110.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.19
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$250.92
|
|
|
Service Code
|
NDC 09900001819
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.84 |
| Max. Negotiated Rate |
$225.83 |
| Rate for Payer: Aetna American Axle |
$163.10
|
| Rate for Payer: Aetna Commercial |
$213.28
|
| Rate for Payer: Aetna Medicare |
$125.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.10
|
| Rate for Payer: BCBS Complete |
$100.37
|
| Rate for Payer: Cash Price |
$200.74
|
| Rate for Payer: Cofinity Commercial |
$175.64
|
| Rate for Payer: Cofinity Commercial |
$215.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.74
|
| Rate for Payer: Healthscope Commercial |
$225.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.28
|
| Rate for Payer: PHP Commercial |
$213.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.10
|
| Rate for Payer: Priority Health SBD |
$158.08
|
| Rate for Payer: UMR Bronson Commercial |
$92.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.19
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$449.46
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$197.76 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna American Axle |
$292.15
|
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.15
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$314.62
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health SBD |
$283.16
|
| Rate for Payer: UMR Bronson Commercial |
$197.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.10
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$449.46
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$197.76 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna American Axle |
$292.15
|
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.15
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$314.62
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health SBD |
$283.16
|
| Rate for Payer: UMR Bronson Commercial |
$197.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.10
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,031.92
|
|
|
Service Code
|
NDC 00006542515
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$381.81 |
| Max. Negotiated Rate |
$928.73 |
| Rate for Payer: Aetna American Axle |
$670.75
|
| Rate for Payer: Aetna Commercial |
$877.13
|
| Rate for Payer: Aetna Medicare |
$515.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$670.75
|
| Rate for Payer: BCBS Complete |
$412.77
|
| Rate for Payer: Cash Price |
$825.54
|
| Rate for Payer: Cofinity Commercial |
$722.34
|
| Rate for Payer: Cofinity Commercial |
$887.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$722.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$825.54
|
| Rate for Payer: Healthscope Commercial |
$928.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$722.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$773.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$877.13
|
| Rate for Payer: PHP Commercial |
$877.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$670.75
|
| Rate for Payer: Priority Health SBD |
$650.11
|
| Rate for Payer: UMR Bronson Commercial |
$381.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$773.94
|
|
|
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
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$449.46
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$166.30 |
| Max. Negotiated Rate |
$404.51 |
| Rate for Payer: Aetna American Axle |
$292.15
|
| Rate for Payer: Aetna Commercial |
$382.04
|
| Rate for Payer: Aetna Medicare |
$224.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.15
|
| Rate for Payer: BCBS Complete |
$179.78
|
| Rate for Payer: Cash Price |
$359.57
|
| Rate for Payer: Cofinity Commercial |
$314.62
|
| Rate for Payer: Cofinity Commercial |
$386.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$314.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.57
|
| Rate for Payer: Healthscope Commercial |
$404.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.04
|
| Rate for Payer: PHP Commercial |
$382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.15
|
| Rate for Payer: Priority Health SBD |
$283.16
|
| Rate for Payer: UMR Bronson Commercial |
$166.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.10
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,031.92
|
|
|
Service Code
|
NDC 00006542515
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$454.04 |
| Max. Negotiated Rate |
$928.73 |
| Rate for Payer: Aetna American Axle |
$670.75
|
| Rate for Payer: Aetna Commercial |
$877.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$670.75
|
| Rate for Payer: Cash Price |
$825.54
|
| Rate for Payer: Cofinity Commercial |
$722.34
|
| Rate for Payer: Cofinity Commercial |
$887.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$722.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$825.54
|
| Rate for Payer: Healthscope Commercial |
$928.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$722.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$773.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$877.13
|
| Rate for Payer: PHP Commercial |
$877.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$670.75
|
| Rate for Payer: Priority Health SBD |
$650.11
|
| Rate for Payer: UMR Bronson Commercial |
$454.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$773.94
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$823.21
|
|
|
Service Code
|
NDC 00006542505
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$304.59 |
| Max. Negotiated Rate |
$740.89 |
| Rate for Payer: Aetna American Axle |
$535.09
|
| Rate for Payer: Aetna Commercial |
$699.73
|
| Rate for Payer: Aetna Medicare |
$411.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$535.09
|
| Rate for Payer: BCBS Complete |
$329.28
|
| 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 |
$304.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$617.41
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$145.38
|
|
|
Service Code
|
NDC 61314070101
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.79 |
| Max. Negotiated Rate |
$130.84 |
| Rate for Payer: Aetna American Axle |
$94.50
|
| Rate for Payer: Aetna Commercial |
$123.57
|
| Rate for Payer: Aetna Medicare |
$72.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.50
|
| Rate for Payer: BCBS Complete |
$58.15
|
| Rate for Payer: Cash Price |
$116.30
|
| Rate for Payer: Cofinity Commercial |
$101.77
|
| Rate for Payer: Cofinity Commercial |
$125.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.30
|
| Rate for Payer: Healthscope Commercial |
$130.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.57
|
| Rate for Payer: PHP Commercial |
$123.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.50
|
| Rate for Payer: Priority Health SBD |
$91.59
|
| Rate for Payer: UMR Bronson Commercial |
$53.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.04
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$139.71
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.69 |
| Max. Negotiated Rate |
$125.74 |
| Rate for Payer: Aetna American Axle |
$90.81
|
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna Medicare |
$69.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.81
|
| Rate for Payer: BCBS Complete |
$55.88
|
| Rate for Payer: Cash Price |
$111.77
|
| Rate for Payer: Cofinity Commercial |
$120.15
|
| Rate for Payer: Cofinity Commercial |
$97.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.77
|
| Rate for Payer: Healthscope Commercial |
$125.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.75
|
| Rate for Payer: PHP Commercial |
$118.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.81
|
| Rate for Payer: Priority Health SBD |
$88.02
|
| Rate for Payer: UMR Bronson Commercial |
$51.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.78
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$145.38
|
|
|
Service Code
|
NDC 61314070101
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.97 |
| Max. Negotiated Rate |
$130.84 |
| Rate for Payer: Aetna American Axle |
$94.50
|
| Rate for Payer: Aetna Commercial |
$123.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.50
|
| Rate for Payer: Cash Price |
$116.30
|
| Rate for Payer: Cofinity Commercial |
$101.77
|
| Rate for Payer: Cofinity Commercial |
$125.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$101.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.30
|
| Rate for Payer: Healthscope Commercial |
$130.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$101.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.57
|
| Rate for Payer: PHP Commercial |
$123.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.50
|
| Rate for Payer: Priority Health SBD |
$91.59
|
| Rate for Payer: UMR Bronson Commercial |
$63.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.04
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$139.71
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.47 |
| Max. Negotiated Rate |
$125.74 |
| Rate for Payer: Aetna American Axle |
$90.81
|
| Rate for Payer: Aetna Commercial |
$118.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.81
|
| Rate for Payer: Cash Price |
$111.77
|
| Rate for Payer: Cofinity Commercial |
$120.15
|
| Rate for Payer: Cofinity Commercial |
$97.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.77
|
| Rate for Payer: Healthscope Commercial |
$125.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.75
|
| Rate for Payer: PHP Commercial |
$118.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.81
|
| Rate for Payer: Priority Health SBD |
$88.02
|
| Rate for Payer: UMR Bronson Commercial |
$61.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.78
|
|
|
SULFADIAZINE 500 MG TABLET
|
Facility
|
OP
|
$946.83
|
|
|
Service Code
|
NDC 00185075701
|
| Hospital Charge Code |
7554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$350.33 |
| Max. Negotiated Rate |
$852.15 |
| Rate for Payer: Aetna American Axle |
$615.44
|
| Rate for Payer: Aetna Commercial |
$804.81
|
| Rate for Payer: Aetna Medicare |
$473.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$615.44
|
| Rate for Payer: BCBS Complete |
$378.73
|
| Rate for Payer: Cash Price |
$757.46
|
| Rate for Payer: Cofinity Commercial |
$662.78
|
| Rate for Payer: Cofinity Commercial |
$814.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$662.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$757.46
|
| Rate for Payer: Healthscope Commercial |
$852.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$662.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$710.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$804.81
|
| Rate for Payer: PHP Commercial |
$804.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$615.44
|
| Rate for Payer: Priority Health SBD |
$596.50
|
| Rate for Payer: UMR Bronson Commercial |
$350.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$710.12
|
|
|
SULFADIAZINE 500 MG TABLET
|
Facility
|
IP
|
$946.83
|
|
|
Service Code
|
NDC 00185075701
|
| Hospital Charge Code |
7554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$416.61 |
| Max. Negotiated Rate |
$852.15 |
| Rate for Payer: Aetna American Axle |
$615.44
|
| Rate for Payer: Aetna Commercial |
$804.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$615.44
|
| Rate for Payer: Cash Price |
$757.46
|
| Rate for Payer: Cofinity Commercial |
$662.78
|
| Rate for Payer: Cofinity Commercial |
$814.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$662.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$757.46
|
| Rate for Payer: Healthscope Commercial |
$852.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$662.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$710.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$804.81
|
| Rate for Payer: PHP Commercial |
$804.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$615.44
|
| Rate for Payer: Priority Health SBD |
$596.50
|
| Rate for Payer: UMR Bronson Commercial |
$416.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$710.12
|
|
|
SULFADIAZINE 500 MG TABLET
|
Facility
|
IP
|
$3,309.36
|
|
|
Service Code
|
NDC 42806075760
|
| Hospital Charge Code |
7554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,456.12 |
| Max. Negotiated Rate |
$2,978.42 |
| Rate for Payer: Aetna American Axle |
$2,151.08
|
| Rate for Payer: Aetna Commercial |
$2,812.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,151.08
|
| Rate for Payer: Cash Price |
$2,647.49
|
| Rate for Payer: Cofinity Commercial |
$2,316.55
|
| Rate for Payer: Cofinity Commercial |
$2,846.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,316.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,647.49
|
| Rate for Payer: Healthscope Commercial |
$2,978.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,316.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,482.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,812.96
|
| Rate for Payer: PHP Commercial |
$2,812.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,151.08
|
| Rate for Payer: Priority Health SBD |
$2,084.90
|
| Rate for Payer: UMR Bronson Commercial |
$1,456.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,482.02
|
|
|
SULFADIAZINE 500 MG TABLET
|
Facility
|
OP
|
$3,309.36
|
|
|
Service Code
|
NDC 42806075760
|
| Hospital Charge Code |
7554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,224.46 |
| Max. Negotiated Rate |
$2,978.42 |
| Rate for Payer: Aetna American Axle |
$2,151.08
|
| Rate for Payer: Aetna Commercial |
$2,812.96
|
| Rate for Payer: Aetna Medicare |
$1,654.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,151.08
|
| Rate for Payer: BCBS Complete |
$1,323.74
|
| Rate for Payer: Cash Price |
$2,647.49
|
| Rate for Payer: Cofinity Commercial |
$2,316.55
|
| Rate for Payer: Cofinity Commercial |
$2,846.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,316.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,647.49
|
| Rate for Payer: Healthscope Commercial |
$2,978.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,316.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,482.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,812.96
|
| Rate for Payer: PHP Commercial |
$2,812.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,151.08
|
| Rate for Payer: Priority Health SBD |
$2,084.90
|
| Rate for Payer: UMR Bronson Commercial |
$1,224.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,482.02
|
|
