|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$308.02
|
|
|
Service Code
|
NDC 50383082316
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.53 |
| Max. Negotiated Rate |
$277.22 |
| Rate for Payer: Cofinity Commercial |
$215.61
|
| Rate for Payer: Cofinity Commercial |
$264.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.61
|
| Rate for Payer: Aetna American Axle |
$200.21
|
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.21
|
| Rate for Payer: Cash Price |
$246.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.42
|
| Rate for Payer: Healthscope Commercial |
$277.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: PHP Commercial |
$261.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.21
|
| Rate for Payer: Priority Health SBD |
$194.05
|
| Rate for Payer: UMR Bronson Commercial |
$135.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$148.76
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna American Axle |
$96.69
|
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.69
|
| Rate for Payer: Cash Price |
$119.01
|
| Rate for Payer: Cofinity Commercial |
$104.13
|
| Rate for Payer: Cofinity Commercial |
$127.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.01
|
| Rate for Payer: Healthscope Commercial |
$133.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.45
|
| Rate for Payer: PHP Commercial |
$126.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.69
|
| Rate for Payer: Priority Health SBD |
$93.72
|
| Rate for Payer: UMR Bronson Commercial |
$65.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.57
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$308.02
|
|
|
Service Code
|
NDC 50383082416
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.53 |
| Max. Negotiated Rate |
$277.22 |
| Rate for Payer: Aetna American Axle |
$200.21
|
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.21
|
| Rate for Payer: Cash Price |
$246.42
|
| Rate for Payer: Cofinity Commercial |
$215.61
|
| Rate for Payer: Cofinity Commercial |
$264.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.42
|
| Rate for Payer: Healthscope Commercial |
$277.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: PHP Commercial |
$261.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.21
|
| Rate for Payer: Priority Health SBD |
$194.05
|
| Rate for Payer: UMR Bronson Commercial |
$135.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$122.51
|
|
|
Service Code
|
NDC 70954025810
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.33 |
| Max. Negotiated Rate |
$110.26 |
| Rate for Payer: Aetna American Axle |
$79.63
|
| Rate for Payer: Aetna Commercial |
$104.13
|
| Rate for Payer: Aetna Medicare |
$61.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.63
|
| Rate for Payer: BCBS Complete |
$49.00
|
| Rate for Payer: Cash Price |
$98.01
|
| Rate for Payer: Cofinity Commercial |
$105.36
|
| Rate for Payer: Cofinity Commercial |
$85.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$85.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.01
|
| Rate for Payer: Healthscope Commercial |
$110.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.13
|
| Rate for Payer: PHP Commercial |
$104.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.63
|
| Rate for Payer: Priority Health SBD |
$77.18
|
| Rate for Payer: UMR Bronson Commercial |
$45.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.88
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$308.02
|
|
|
Service Code
|
NDC 50383082416
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.97 |
| Max. Negotiated Rate |
$277.22 |
| Rate for Payer: Aetna American Axle |
$200.21
|
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna Medicare |
$154.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.21
|
| Rate for Payer: BCBS Complete |
$123.21
|
| Rate for Payer: Cash Price |
$246.42
|
| Rate for Payer: Cofinity Commercial |
$215.61
|
| Rate for Payer: Cofinity Commercial |
$264.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.42
|
| Rate for Payer: Healthscope Commercial |
$277.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: PHP Commercial |
$261.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.21
|
| Rate for Payer: Priority Health SBD |
$194.05
|
| Rate for Payer: UMR Bronson Commercial |
$113.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$148.76
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$133.88 |
| Rate for Payer: Aetna American Axle |
$96.69
|
| Rate for Payer: Aetna Commercial |
$126.45
|
| Rate for Payer: Aetna Medicare |
$74.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.69
|
| Rate for Payer: BCBS Complete |
$59.50
|
| Rate for Payer: Cash Price |
$119.01
|
| Rate for Payer: Cofinity Commercial |
$104.13
|
| Rate for Payer: Cofinity Commercial |
$127.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.01
|
| Rate for Payer: Healthscope Commercial |
$133.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.45
|
| Rate for Payer: PHP Commercial |
$126.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.69
|
| Rate for Payer: Priority Health SBD |
$93.72
|
| Rate for Payer: UMR Bronson Commercial |
$55.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.57
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$308.02
|
|
|
Service Code
|
NDC 50383082316
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.97 |
| Max. Negotiated Rate |
$277.22 |
| Rate for Payer: Aetna American Axle |
$200.21
|
| Rate for Payer: Aetna Commercial |
$261.82
|
| Rate for Payer: Aetna Medicare |
$154.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.21
|
| Rate for Payer: BCBS Complete |
$123.21
|
| Rate for Payer: Cash Price |
$246.42
|
| Rate for Payer: Cofinity Commercial |
$215.61
|
| Rate for Payer: Cofinity Commercial |
$264.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.42
|
| Rate for Payer: Healthscope Commercial |
$277.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: PHP Commercial |
$261.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.21
|
| Rate for Payer: Priority Health SBD |
$194.05
|
| Rate for Payer: UMR Bronson Commercial |
$113.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.02
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$122.51
|
|
|
Service Code
|
NDC 70954025810
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$110.26 |
| Rate for Payer: Aetna American Axle |
$79.63
|
| Rate for Payer: Aetna Commercial |
$104.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.63
|
| Rate for Payer: Cash Price |
$98.01
|
| Rate for Payer: Cofinity Commercial |
$105.36
|
| Rate for Payer: Cofinity Commercial |
$85.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$85.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.01
|
| Rate for Payer: Healthscope Commercial |
$110.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.13
|
| Rate for Payer: PHP Commercial |
$104.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.63
|
| Rate for Payer: Priority Health SBD |
$77.18
|
| Rate for Payer: UMR Bronson Commercial |
$53.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.88
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.44
|
|
|
Service Code
|
NDC 00703950303
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$22.90 |
| Rate for Payer: Aetna American Axle |
$16.54
|
| Rate for Payer: Aetna Commercial |
$21.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.54
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cofinity Commercial |
$17.81
|
| Rate for Payer: Cofinity Commercial |
$21.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.35
|
| Rate for Payer: Healthscope Commercial |
$22.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.62
|
| Rate for Payer: PHP Commercial |
$21.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.54
|
| Rate for Payer: Priority Health SBD |
$16.03
|
| Rate for Payer: UMR Bronson Commercial |
$11.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.08
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$25.44
|
|
|
Service Code
|
NDC 00703950303
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$22.90 |
| Rate for Payer: Aetna American Axle |
$16.54
|
| Rate for Payer: Aetna Commercial |
$21.62
|
| Rate for Payer: Aetna Medicare |
$12.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.54
|
| Rate for Payer: BCBS Complete |
$10.18
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cofinity Commercial |
$17.81
|
| Rate for Payer: Cofinity Commercial |
$21.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.35
|
| Rate for Payer: Healthscope Commercial |
$22.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.62
|
| Rate for Payer: PHP Commercial |
$21.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.54
|
| Rate for Payer: Priority Health SBD |
$16.03
|
| Rate for Payer: UMR Bronson Commercial |
$9.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.08
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$418.30
|
|
|
Service Code
|
NDC 53489014501
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.77 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.90
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna Medicare |
$209.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.90
|
| Rate for Payer: BCBS Complete |
$167.32
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.90
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$154.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.72
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$131.60
|
|
|
Service Code
|
NDC 65862041901
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.90 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna American Axle |
$85.54
|
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$92.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.54
|
| Rate for Payer: Priority Health SBD |
$82.91
|
| Rate for Payer: UMR Bronson Commercial |
$57.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$418.30
|
|
|
Service Code
|
NDC 53489014501
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.05 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.90
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.90
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.90
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$184.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.72
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 65162027110
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.56 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.26
|
| Rate for Payer: Aetna Commercial |
$91.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.26
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.88
|
| Rate for Payer: PHP Commercial |
$91.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.26
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UMR Bronson Commercial |
$47.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$108.10
|
|
|
Service Code
|
NDC 65162027110
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.26
|
| Rate for Payer: Aetna Commercial |
$91.88
|
| Rate for Payer: Aetna Medicare |
$54.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.26
|
| Rate for Payer: BCBS Complete |
$43.24
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.88
|
| Rate for Payer: PHP Commercial |
$91.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.26
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UMR Bronson Commercial |
$40.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$101.05
|
|
|
Service Code
|
NDC 53746027101
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.39 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna American Axle |
$65.68
|
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna Medicare |
$50.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: BCBS Complete |
$40.42
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.68
|
| Rate for Payer: Priority Health SBD |
$63.66
|
| Rate for Payer: UMR Bronson Commercial |
$37.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
OP
|
$131.60
|
|
|
Service Code
|
NDC 65862041901
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.69 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna American Axle |
$85.54
|
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: Aetna Medicare |
$65.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.54
|
| Rate for Payer: BCBS Complete |
$52.64
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Cofinity Commercial |
$92.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.54
|
| Rate for Payer: Priority Health SBD |
$82.91
|
| Rate for Payer: UMR Bronson Commercial |
$48.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
NDC 53746027101
|
| Hospital Charge Code |
7557
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.46 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna American Axle |
$65.68
|
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.89
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.68
|
| Rate for Payer: Priority Health SBD |
$63.66
|
| Rate for Payer: UMR Bronson Commercial |
$44.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 60687053101
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.73
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UMR Bronson Commercial |
$177.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.22 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna American Axle |
$189.41
|
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health SBD |
$183.58
|
| Rate for Payer: UMR Bronson Commercial |
$128.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.82 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna American Axle |
$189.41
|
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna Medicare |
$145.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health SBD |
$183.58
|
| Rate for Payer: UMR Bronson Commercial |
$107.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$404.20
|
|
|
Service Code
|
NDC 60687053101
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.55 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna American Axle |
$262.73
|
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna Medicare |
$202.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: BCBS Complete |
$161.68
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.73
|
| Rate for Payer: Priority Health SBD |
$254.65
|
| Rate for Payer: UMR Bronson Commercial |
$149.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.15
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$4.05
|
|
|
Service Code
|
NDC 60687053111
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna American Axle |
$2.63
|
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.63
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cofinity Commercial |
$2.84
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.24
|
| Rate for Payer: Healthscope Commercial |
$3.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.63
|
| Rate for Payer: Priority Health SBD |
$2.55
|
| Rate for Payer: UMR Bronson Commercial |
$1.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.04
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$4.05
|
|
|
Service Code
|
NDC 60687053111
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Aetna American Axle |
$2.63
|
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Aetna Medicare |
$2.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.63
|
| Rate for Payer: BCBS Complete |
$1.62
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cofinity Commercial |
$2.84
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.24
|
| Rate for Payer: Healthscope Commercial |
$3.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.63
|
| Rate for Payer: Priority Health SBD |
$2.55
|
| Rate for Payer: UMR Bronson Commercial |
$1.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.04
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$2,259.36
|
|
|
Service Code
|
NDC 00013010130
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$835.96 |
| Max. Negotiated Rate |
$2,033.42 |
| Rate for Payer: Aetna American Axle |
$1,468.58
|
| Rate for Payer: Aetna Commercial |
$1,920.46
|
| Rate for Payer: Aetna Medicare |
$1,129.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,468.58
|
| Rate for Payer: BCBS Complete |
$903.74
|
| Rate for Payer: Cash Price |
$1,807.49
|
| Rate for Payer: Cofinity Commercial |
$1,581.55
|
| Rate for Payer: Cofinity Commercial |
$1,943.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,581.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,807.49
|
| Rate for Payer: Healthscope Commercial |
$2,033.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,581.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,694.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,920.46
|
| Rate for Payer: PHP Commercial |
$1,920.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,468.58
|
| Rate for Payer: Priority Health SBD |
$1,423.40
|
| Rate for Payer: UMR Bronson Commercial |
$835.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,694.52
|
|
