|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$30.14
|
|
|
Service Code
|
NDC 904747066
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.15 |
| Max. Negotiated Rate |
$30.14 |
| Rate for Payer: Aetna Commercial |
$27.13
|
| Rate for Payer: Aetna Medicare |
$11.15
|
| Rate for Payer: ASR ASR |
$29.24
|
| Rate for Payer: BCBS Complete |
$12.06
|
| Rate for Payer: BCBS Trust/PPO |
$24.85
|
| Rate for Payer: BCN Commercial |
$24.85
|
| Rate for Payer: Cash Price |
$24.12
|
| Rate for Payer: Cofinity Commercial |
$28.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.12
|
| Rate for Payer: Healthscope Commercial |
$29.24
|
| Rate for Payer: Healthscope Whirlpool |
$30.14
|
| Rate for Payer: Mclaren Commercial |
$27.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.62
|
| Rate for Payer: Nomi Health Commercial |
$24.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.61
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$26.41
|
| Rate for Payer: Priority Health Narrow Network |
$21.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.53
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$794.47
|
|
|
Service Code
|
NDC 66689030516
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$595.85 |
| Max. Negotiated Rate |
$794.47 |
| Rate for Payer: Aetna Commercial |
$715.02
|
| Rate for Payer: ASR ASR |
$770.63
|
| Rate for Payer: BCBS Trust/PPO |
$652.42
|
| Rate for Payer: BCN Commercial |
$652.42
|
| Rate for Payer: Cash Price |
$635.57
|
| Rate for Payer: Cofinity Commercial |
$746.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$635.57
|
| Rate for Payer: Healthscope Commercial |
$770.63
|
| Rate for Payer: Healthscope Whirlpool |
$794.47
|
| Rate for Payer: Mclaren Commercial |
$715.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$675.30
|
| Rate for Payer: Nomi Health Commercial |
$651.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$595.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$699.13
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$45.13
|
|
|
Service Code
|
NDC 904747018
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.84 |
| Max. Negotiated Rate |
$45.12 |
| Rate for Payer: Aetna Commercial |
$40.61
|
| Rate for Payer: ASR ASR |
$43.77
|
| Rate for Payer: BCBS Trust/PPO |
$37.06
|
| Rate for Payer: BCN Commercial |
$37.06
|
| Rate for Payer: Cash Price |
$36.10
|
| Rate for Payer: Cofinity Commercial |
$42.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.10
|
| Rate for Payer: Healthscope Commercial |
$43.77
|
| Rate for Payer: Healthscope Whirlpool |
$45.12
|
| Rate for Payer: Mclaren Commercial |
$40.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.36
|
| Rate for Payer: Nomi Health Commercial |
$37.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.71
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$2.86
|
|
|
Service Code
|
NDC 60687069511
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna Commercial |
$2.57
|
| Rate for Payer: ASR ASR |
$2.77
|
| Rate for Payer: BCBS Trust/PPO |
$2.35
|
| Rate for Payer: BCN Commercial |
$2.35
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.29
|
| Rate for Payer: Healthscope Commercial |
$2.77
|
| Rate for Payer: Healthscope Whirlpool |
$2.86
|
| Rate for Payer: Mclaren Commercial |
$2.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.43
|
| Rate for Payer: Nomi Health Commercial |
$2.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.52
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$285.95
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.80 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Aetna Commercial |
$257.36
|
| Rate for Payer: Aetna Medicare |
$105.80
|
| Rate for Payer: ASR ASR |
$277.37
|
| Rate for Payer: BCBS Complete |
$114.38
|
| Rate for Payer: BCBS Trust/PPO |
$235.77
|
| Rate for Payer: BCN Commercial |
$235.77
|
| Rate for Payer: Cash Price |
$228.76
|
| Rate for Payer: Cofinity Commercial |
$268.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.76
|
| Rate for Payer: Healthscope Commercial |
$277.37
|
| Rate for Payer: Healthscope Whirlpool |
$285.95
|
| Rate for Payer: Mclaren Commercial |
$257.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$228.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.06
|
| Rate for Payer: Nomi Health Commercial |
$234.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$214.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$250.55
|
| Rate for Payer: Priority Health Narrow Network |
$200.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$251.64
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$310.65
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.99 |
| Max. Negotiated Rate |
$310.65 |
| Rate for Payer: Aetna Commercial |
$279.58
|
| Rate for Payer: ASR ASR |
$301.33
|
| Rate for Payer: BCBS Trust/PPO |
$255.11
|
| Rate for Payer: BCN Commercial |
$255.11
|
| Rate for Payer: Cash Price |
$248.52
|
| Rate for Payer: Cofinity Commercial |
$292.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.52
|
| Rate for Payer: Healthscope Commercial |
$301.33
|
| Rate for Payer: Healthscope Whirlpool |
$310.65
|
| Rate for Payer: Mclaren Commercial |
$279.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.05
|
| Rate for Payer: Nomi Health Commercial |
$254.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$273.37
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$237.50
|
|
|
Service Code
|
NDC 93221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.12 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Aetna Commercial |
$213.75
|
| Rate for Payer: ASR ASR |
$230.38
|
| Rate for Payer: BCBS Trust/PPO |
$195.03
|
| Rate for Payer: BCN Commercial |
$195.03
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cofinity Commercial |
$223.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.00
|
| Rate for Payer: Healthscope Commercial |
$230.38
|
| Rate for Payer: Healthscope Whirlpool |
$237.50
|
| Rate for Payer: Mclaren Commercial |
$213.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.88
|
| Rate for Payer: Nomi Health Commercial |
$194.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$209.00
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$3.11
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna Commercial |
$2.80
|
| Rate for Payer: Aetna Medicare |
$1.15
|
| Rate for Payer: ASR ASR |
$3.01
|
| Rate for Payer: BCBS Complete |
$1.24
|
| Rate for Payer: BCBS Trust/PPO |
$2.56
|
| Rate for Payer: BCN Commercial |
$2.56
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$3.01
|
| Rate for Payer: Healthscope Whirlpool |
$3.11
|
| Rate for Payer: Mclaren Commercial |
$2.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: Nomi Health Commercial |
$2.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.72
|
| Rate for Payer: Priority Health Narrow Network |
$2.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.73
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$3.11
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna Commercial |
$2.80
|
| Rate for Payer: ASR ASR |
$3.01
|
| Rate for Payer: BCBS Trust/PPO |
$2.55
|
| Rate for Payer: BCN Commercial |
$2.55
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$3.01
|
| Rate for Payer: Healthscope Whirlpool |
$3.11
|
| Rate for Payer: Mclaren Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: Nomi Health Commercial |
$2.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.73
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$310.65
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.94 |
| Max. Negotiated Rate |
$310.65 |
| Rate for Payer: Aetna Commercial |
$279.58
|
| Rate for Payer: Aetna Medicare |
$114.94
|
| Rate for Payer: ASR ASR |
$301.33
|
| Rate for Payer: BCBS Complete |
$124.26
|
| Rate for Payer: BCBS Trust/PPO |
$256.13
|
| Rate for Payer: BCN Commercial |
$256.13
|
| Rate for Payer: Cash Price |
$248.52
|
| Rate for Payer: Cofinity Commercial |
$292.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.52
|
| Rate for Payer: Healthscope Commercial |
$301.33
|
| Rate for Payer: Healthscope Whirlpool |
$310.65
|
| Rate for Payer: Mclaren Commercial |
$279.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$248.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.05
|
| Rate for Payer: Nomi Health Commercial |
$254.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.99
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$272.19
|
| Rate for Payer: Priority Health Narrow Network |
$217.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$273.37
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$2.86
|
|
|
Service Code
|
NDC 60687069511
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna Commercial |
$2.57
|
| Rate for Payer: Aetna Medicare |
$1.06
|
| Rate for Payer: ASR ASR |
$2.77
|
| Rate for Payer: BCBS Complete |
$1.14
|
| Rate for Payer: BCBS Trust/PPO |
$2.36
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.29
|
| Rate for Payer: Healthscope Commercial |
$2.77
|
| Rate for Payer: Healthscope Whirlpool |
$2.86
|
| Rate for Payer: Mclaren Commercial |
$2.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.43
|
| Rate for Payer: Nomi Health Commercial |
$2.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.51
|
| Rate for Payer: Priority Health Narrow Network |
$2.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.52
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$237.50
|
|
|
Service Code
|
NDC 93221001
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.88 |
| Max. Negotiated Rate |
$237.50 |
| Rate for Payer: Aetna Commercial |
$213.75
|
| Rate for Payer: Aetna Medicare |
$87.88
|
| Rate for Payer: ASR ASR |
$230.38
|
| Rate for Payer: BCBS Complete |
$95.00
|
| Rate for Payer: BCBS Trust/PPO |
$195.82
|
| Rate for Payer: BCN Commercial |
$195.82
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cofinity Commercial |
$223.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.00
|
| Rate for Payer: Healthscope Commercial |
$230.38
|
| Rate for Payer: Healthscope Whirlpool |
$237.50
|
| Rate for Payer: Mclaren Commercial |
$213.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.88
|
| Rate for Payer: Nomi Health Commercial |
$194.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$208.10
|
| Rate for Payer: Priority Health Narrow Network |
$166.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$209.00
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$285.95
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.46 |
| Max. Negotiated Rate |
$285.95 |
| Rate for Payer: Aetna Commercial |
$257.36
|
| Rate for Payer: ASR ASR |
$277.37
|
| Rate for Payer: BCBS Trust/PPO |
$234.82
|
| Rate for Payer: BCN Commercial |
$234.82
|
| Rate for Payer: Cash Price |
$228.76
|
| Rate for Payer: Cofinity Commercial |
$268.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.76
|
| Rate for Payer: Healthscope Commercial |
$277.37
|
| Rate for Payer: Healthscope Whirlpool |
$285.95
|
| Rate for Payer: Mclaren Commercial |
$257.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.06
|
| Rate for Payer: Nomi Health Commercial |
$234.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$214.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$251.64
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$471.90
|
|
|
Service Code
|
NDC 6542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$174.60 |
| Max. Negotiated Rate |
$471.90 |
| Rate for Payer: Aetna Commercial |
$424.71
|
| Rate for Payer: Aetna Medicare |
$174.60
|
| Rate for Payer: ASR ASR |
$457.74
|
| Rate for Payer: BCBS Complete |
$188.76
|
| Rate for Payer: BCBS Trust/PPO |
$389.08
|
| Rate for Payer: BCN Commercial |
$389.08
|
| Rate for Payer: Cash Price |
$377.52
|
| Rate for Payer: Cofinity Commercial |
$443.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.52
|
| Rate for Payer: Healthscope Commercial |
$457.74
|
| Rate for Payer: Healthscope Whirlpool |
$471.90
|
| Rate for Payer: Mclaren Commercial |
$424.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$377.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Nomi Health Commercial |
$386.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$413.48
|
| Rate for Payer: Priority Health Narrow Network |
$330.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$415.27
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$471.90
|
|
|
Service Code
|
NDC 6542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$174.60 |
| Max. Negotiated Rate |
$471.90 |
| Rate for Payer: Aetna Commercial |
$424.71
|
| Rate for Payer: Aetna Medicare |
$174.60
|
| Rate for Payer: ASR ASR |
$457.74
|
| Rate for Payer: BCBS Complete |
$188.76
|
| Rate for Payer: BCBS Trust/PPO |
$389.08
|
| Rate for Payer: BCN Commercial |
$389.08
|
| Rate for Payer: Cash Price |
$377.52
|
| Rate for Payer: Cofinity Commercial |
$443.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.52
|
| Rate for Payer: Healthscope Commercial |
$457.74
|
| Rate for Payer: Healthscope Whirlpool |
$471.90
|
| Rate for Payer: Mclaren Commercial |
$424.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$377.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Nomi Health Commercial |
$386.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$413.48
|
| Rate for Payer: Priority Health Narrow Network |
$330.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$415.27
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$471.90
|
|
|
Service Code
|
NDC 6542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$353.93 |
| Max. Negotiated Rate |
$471.90 |
| Rate for Payer: Aetna Commercial |
$424.71
|
| Rate for Payer: ASR ASR |
$457.74
|
| Rate for Payer: BCBS Trust/PPO |
$387.53
|
| Rate for Payer: BCN Commercial |
$387.53
|
| Rate for Payer: Cash Price |
$377.52
|
| Rate for Payer: Cofinity Commercial |
$443.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.52
|
| Rate for Payer: Healthscope Commercial |
$457.74
|
| Rate for Payer: Healthscope Whirlpool |
$471.90
|
| Rate for Payer: Mclaren Commercial |
$424.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Nomi Health Commercial |
$386.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$415.27
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$471.90
|
|
|
Service Code
|
NDC 6542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$353.93 |
| Max. Negotiated Rate |
$471.90 |
| Rate for Payer: Aetna Commercial |
$424.71
|
| Rate for Payer: ASR ASR |
$457.74
|
| Rate for Payer: BCBS Trust/PPO |
$387.53
|
| Rate for Payer: BCN Commercial |
$387.53
|
| Rate for Payer: Cash Price |
$377.52
|
| Rate for Payer: Cofinity Commercial |
$443.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$377.52
|
| Rate for Payer: Healthscope Commercial |
$457.74
|
| Rate for Payer: Healthscope Whirlpool |
$471.90
|
| Rate for Payer: Mclaren Commercial |
$424.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.12
|
| Rate for Payer: Nomi Health Commercial |
$386.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$353.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$415.27
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS
|
Facility
|
IP
|
$48.76
|
|
|
Service Code
|
NDC 24208031705
|
| Hospital Charge Code |
70392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.57 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$43.88
|
| Rate for Payer: ASR ASR |
$47.29
|
| Rate for Payer: BCBS Trust/PPO |
$40.04
|
| Rate for Payer: BCN Commercial |
$40.04
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cofinity Commercial |
$45.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.00
|
| Rate for Payer: Healthscope Commercial |
$47.29
|
| Rate for Payer: Healthscope Whirlpool |
$48.76
|
| Rate for Payer: Mclaren Commercial |
$43.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.44
|
| Rate for Payer: Nomi Health Commercial |
$39.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.90
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS
|
Facility
|
OP
|
$48.76
|
|
|
Service Code
|
NDC 24208031705
|
| Hospital Charge Code |
70392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.04 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$43.88
|
| Rate for Payer: Aetna Medicare |
$18.04
|
| Rate for Payer: ASR ASR |
$47.29
|
| Rate for Payer: BCBS Complete |
$19.50
|
| Rate for Payer: BCBS Trust/PPO |
$40.20
|
| Rate for Payer: BCN Commercial |
$40.20
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cofinity Commercial |
$45.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.00
|
| Rate for Payer: Healthscope Commercial |
$47.29
|
| Rate for Payer: Healthscope Whirlpool |
$48.76
|
| Rate for Payer: Mclaren Commercial |
$43.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.44
|
| Rate for Payer: Nomi Health Commercial |
$39.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.57
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$42.72
|
| Rate for Payer: Priority Health Narrow Network |
$34.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.90
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$142.43
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$142.43 |
| Rate for Payer: Aetna Commercial |
$128.19
|
| Rate for Payer: Aetna Medicare |
$52.70
|
| Rate for Payer: ASR ASR |
$138.16
|
| Rate for Payer: BCBS Complete |
$56.97
|
| Rate for Payer: BCBS Trust/PPO |
$117.44
|
| Rate for Payer: BCN Commercial |
$117.44
|
| Rate for Payer: Cash Price |
$113.95
|
| Rate for Payer: Cofinity Commercial |
$133.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.95
|
| Rate for Payer: Healthscope Commercial |
$138.16
|
| Rate for Payer: Healthscope Whirlpool |
$142.43
|
| Rate for Payer: Mclaren Commercial |
$128.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.07
|
| Rate for Payer: Nomi Health Commercial |
$116.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$124.80
|
| Rate for Payer: Priority Health Narrow Network |
$99.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$125.34
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$142.43
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.82 |
| Max. Negotiated Rate |
$142.43 |
| Rate for Payer: Aetna Commercial |
$128.19
|
| Rate for Payer: ASR ASR |
$138.16
|
| Rate for Payer: BCBS Trust/PPO |
$116.97
|
| Rate for Payer: BCN Commercial |
$116.97
|
| Rate for Payer: Cash Price |
$113.95
|
| Rate for Payer: Cofinity Commercial |
$133.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.95
|
| Rate for Payer: Healthscope Commercial |
$138.16
|
| Rate for Payer: Healthscope Whirlpool |
$142.43
|
| Rate for Payer: Mclaren Commercial |
$128.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.07
|
| Rate for Payer: Nomi Health Commercial |
$116.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$125.34
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$126.01
|
|
|
Service Code
|
NDC 70954025810
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.51 |
| Max. Negotiated Rate |
$126.01 |
| Rate for Payer: Aetna Commercial |
$113.41
|
| Rate for Payer: ASR ASR |
$122.23
|
| Rate for Payer: BCBS Trust/PPO |
$103.48
|
| Rate for Payer: BCN Commercial |
$103.48
|
| Rate for Payer: Cash Price |
$100.81
|
| Rate for Payer: Cofinity Commercial |
$118.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.81
|
| Rate for Payer: Healthscope Commercial |
$122.23
|
| Rate for Payer: Healthscope Whirlpool |
$126.01
|
| Rate for Payer: Mclaren Commercial |
$113.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.11
|
| Rate for Payer: Nomi Health Commercial |
$103.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$110.89
|
|
|
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 |
$111.57 |
| Max. Negotiated Rate |
$148.76 |
| Rate for Payer: Aetna Commercial |
$133.88
|
| Rate for Payer: ASR ASR |
$144.30
|
| Rate for Payer: BCBS Trust/PPO |
$122.16
|
| Rate for Payer: BCN Commercial |
$122.16
|
| Rate for Payer: Cash Price |
$119.01
|
| Rate for Payer: Cofinity Commercial |
$139.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.01
|
| Rate for Payer: Healthscope Commercial |
$144.30
|
| Rate for Payer: Healthscope Whirlpool |
$148.76
|
| Rate for Payer: Mclaren Commercial |
$133.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.45
|
| Rate for Payer: Nomi Health Commercial |
$121.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.91
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.02
|
|
|
Service Code
|
NDC 121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.25 |
| Max. Negotiated Rate |
$52.02 |
| Rate for Payer: Aetna Commercial |
$46.82
|
| Rate for Payer: Aetna Medicare |
$19.25
|
| Rate for Payer: ASR ASR |
$50.46
|
| Rate for Payer: BCBS Complete |
$20.81
|
| Rate for Payer: BCBS Trust/PPO |
$42.89
|
| Rate for Payer: BCN Commercial |
$42.89
|
| Rate for Payer: Cash Price |
$41.62
|
| Rate for Payer: Cofinity Commercial |
$48.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.62
|
| Rate for Payer: Healthscope Commercial |
$50.46
|
| Rate for Payer: Healthscope Whirlpool |
$52.02
|
| Rate for Payer: Mclaren Commercial |
$46.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.22
|
| Rate for Payer: Nomi Health Commercial |
$42.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.02
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$45.58
|
| Rate for Payer: Priority Health Narrow Network |
$36.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.78
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 9900001165
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Aetna Medicare |
$1.01
|
| Rate for Payer: ASR ASR |
$2.65
|
| Rate for Payer: BCBS Complete |
$1.09
|
| Rate for Payer: BCBS Trust/PPO |
$2.26
|
| Rate for Payer: BCN Commercial |
$2.26
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.65
|
| Rate for Payer: Healthscope Whirlpool |
$2.74
|
| Rate for Payer: Mclaren Commercial |
$2.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: Nomi Health Commercial |
$2.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.40
|
| Rate for Payer: Priority Health Narrow Network |
$1.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.41
|
|
