|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.02
|
|
|
Service Code
|
NDC 121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.02 |
| Max. Negotiated Rate |
$52.02 |
| Rate for Payer: Aetna Commercial |
$46.82
|
| Rate for Payer: ASR ASR |
$50.46
|
| Rate for Payer: BCBS Trust/PPO |
$42.72
|
| Rate for Payer: BCN Commercial |
$42.72
|
| 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: 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: UHC All Payor (Choice/PPO) + Core |
$45.78
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$7.72
|
|
|
Service Code
|
NDC 17856000705
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$7.71 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Aetna Medicare |
$2.85
|
| Rate for Payer: ASR ASR |
$7.48
|
| Rate for Payer: BCBS Complete |
$3.09
|
| Rate for Payer: BCBS Trust/PPO |
$6.36
|
| Rate for Payer: BCN Commercial |
$6.36
|
| Rate for Payer: Cash Price |
$6.17
|
| Rate for Payer: Cofinity Commercial |
$7.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.17
|
| Rate for Payer: Healthscope Commercial |
$7.48
|
| Rate for Payer: Healthscope Whirlpool |
$7.71
|
| Rate for Payer: Mclaren Commercial |
$6.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.56
|
| Rate for Payer: Nomi Health Commercial |
$6.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$6.76
|
| Rate for Payer: Priority Health Narrow Network |
$5.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.79
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$126.01
|
|
|
Service Code
|
NDC 70954025810
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.62 |
| Max. Negotiated Rate |
$126.01 |
| Rate for Payer: Aetna Commercial |
$113.41
|
| Rate for Payer: Aetna Medicare |
$46.62
|
| Rate for Payer: ASR ASR |
$122.23
|
| Rate for Payer: BCBS Complete |
$50.40
|
| Rate for Payer: BCBS Trust/PPO |
$103.89
|
| Rate for Payer: BCN Commercial |
$103.89
|
| 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: MI Amish Medical Board Commercial |
$100.81
|
| 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: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$110.41
|
| Rate for Payer: Priority Health Narrow Network |
$88.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$110.89
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.02
|
|
|
Service Code
|
NDC 121085320
|
| 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
|
IP
|
$2.74
|
|
|
Service Code
|
NDC 9900001165
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: ASR ASR |
$2.65
|
| Rate for Payer: BCBS Trust/PPO |
$2.25
|
| Rate for Payer: BCN Commercial |
$2.25
|
| 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: 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: UHC All Payor (Choice/PPO) + Core |
$2.41
|
|
|
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 |
$148.76 |
| Rate for Payer: Aetna Commercial |
$133.88
|
| Rate for Payer: Aetna Medicare |
$55.04
|
| Rate for Payer: ASR ASR |
$144.30
|
| Rate for Payer: BCBS Complete |
$59.50
|
| Rate for Payer: BCBS Trust/PPO |
$122.65
|
| Rate for Payer: BCN Commercial |
$122.65
|
| 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: MI Amish Medical Board Commercial |
$119.01
|
| 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: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$130.34
|
| Rate for Payer: Priority Health Narrow Network |
$104.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.91
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$7.72
|
|
|
Service Code
|
NDC 17856000705
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$7.71 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: ASR ASR |
$7.48
|
| Rate for Payer: BCBS Trust/PPO |
$6.34
|
| Rate for Payer: BCN Commercial |
$6.34
|
| Rate for Payer: Cash Price |
$6.17
|
| Rate for Payer: Cofinity Commercial |
$7.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.17
|
| Rate for Payer: Healthscope Commercial |
$7.48
|
| Rate for Payer: Healthscope Whirlpool |
$7.71
|
| Rate for Payer: Mclaren Commercial |
$6.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.56
|
| Rate for Payer: Nomi Health Commercial |
$6.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.79
|
|
|
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 |
$308.02 |
| Rate for Payer: Aetna Commercial |
$277.22
|
| Rate for Payer: Aetna Medicare |
$113.97
|
| Rate for Payer: ASR ASR |
$298.78
|
| Rate for Payer: BCBS Complete |
$123.21
|
| Rate for Payer: BCBS Trust/PPO |
$253.96
|
| Rate for Payer: BCN Commercial |
$253.96
|
| Rate for Payer: Cash Price |
$246.41
|
| Rate for Payer: Cofinity Commercial |
$289.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.41
|
| Rate for Payer: Healthscope Commercial |
$298.78
|
| Rate for Payer: Healthscope Whirlpool |
$308.02
|
| Rate for Payer: Mclaren Commercial |
$277.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$246.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: Nomi Health Commercial |
$252.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$231.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$269.89
|
| Rate for Payer: Priority Health Narrow Network |
$215.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$271.06
|
|
|
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 |
$231.01 |
| Max. Negotiated Rate |
$308.02 |
| Rate for Payer: Aetna Commercial |
$277.22
|
| Rate for Payer: ASR ASR |
$298.78
|
| Rate for Payer: BCBS Trust/PPO |
$252.94
|
| Rate for Payer: BCN Commercial |
$252.94
|
| Rate for Payer: Cash Price |
$246.41
|
| Rate for Payer: Cofinity Commercial |
$289.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.41
|
| Rate for Payer: Healthscope Commercial |
$298.78
|
| Rate for Payer: Healthscope Whirlpool |
$308.02
|
| Rate for Payer: Mclaren Commercial |
$277.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: Nomi Health Commercial |
$252.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$231.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$271.06
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.02
|
|
|
Service Code
|
NDC 121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.02 |
| Max. Negotiated Rate |
$52.02 |
| Rate for Payer: Aetna Commercial |
$46.82
|
| Rate for Payer: ASR ASR |
$50.46
|
| Rate for Payer: BCBS Trust/PPO |
$42.72
|
| Rate for Payer: BCN Commercial |
$42.72
|
| 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: 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: UHC All Payor (Choice/PPO) + Core |
$45.78
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.08
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.56 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna Commercial |
$23.47
|
| Rate for Payer: Aetna Commercial |
$46.70
|
| Rate for Payer: ASR ASR |
$50.33
|
| Rate for Payer: ASR ASR |
$25.29
|
| Rate for Payer: BCBS Trust/PPO |
$42.61
|
| Rate for Payer: BCBS Trust/PPO |
$21.41
|
| Rate for Payer: BCN Commercial |
$42.61
|
| Rate for Payer: BCN Commercial |
$21.41
|
| Rate for Payer: Cash Price |
$41.51
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Cofinity Commercial |
$24.51
|
| Rate for Payer: Cofinity Commercial |
$48.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.86
|
| Rate for Payer: Healthscope Commercial |
$25.29
|
| Rate for Payer: Healthscope Commercial |
$50.33
|
| Rate for Payer: Healthscope Whirlpool |
$51.89
|
| Rate for Payer: Healthscope Whirlpool |
$26.08
|
| Rate for Payer: Mclaren Commercial |
$46.70
|
| Rate for Payer: Mclaren Commercial |
$23.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.17
|
| Rate for Payer: Nomi Health Commercial |
$42.55
|
| Rate for Payer: Nomi Health Commercial |
$21.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.66
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$51.89
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$51.89 |
| Rate for Payer: Aetna Commercial |
$46.70
|
| Rate for Payer: Aetna Commercial |
$23.47
|
| Rate for Payer: Aetna Medicare |
$9.65
|
| Rate for Payer: Aetna Medicare |
$19.20
|
| Rate for Payer: ASR ASR |
$50.33
|
| Rate for Payer: ASR ASR |
$25.29
|
| Rate for Payer: BCBS Complete |
$10.43
|
| Rate for Payer: BCBS Complete |
$20.75
|
| Rate for Payer: BCBS Trust/PPO |
$42.78
|
| Rate for Payer: BCBS Trust/PPO |
$21.50
|
| Rate for Payer: BCN Commercial |
$21.50
|
| Rate for Payer: BCN Commercial |
$42.78
|
| Rate for Payer: Cash Price |
$41.51
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Cash Price |
$41.51
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Cofinity Commercial |
$24.51
|
| Rate for Payer: Cofinity Commercial |
$48.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.86
|
| Rate for Payer: Healthscope Commercial |
$50.33
|
| Rate for Payer: Healthscope Commercial |
$25.29
|
| Rate for Payer: Healthscope Whirlpool |
$51.89
|
| Rate for Payer: Healthscope Whirlpool |
$26.08
|
| Rate for Payer: Mclaren Commercial |
$46.70
|
| Rate for Payer: Mclaren Commercial |
$23.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.10
|
| Rate for Payer: Nomi Health Commercial |
$21.38
|
| Rate for Payer: Nomi Health Commercial |
$42.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.92
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.04
|
| Rate for Payer: Priority Health Narrow Network |
$0.03
|
| Rate for Payer: Priority Health Narrow Network |
$0.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.66
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$136.30
|
|
|
Service Code
|
NDC 53746027201
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$136.30 |
| Rate for Payer: Aetna Commercial |
$122.67
|
| Rate for Payer: Aetna Medicare |
$50.43
|
| Rate for Payer: ASR ASR |
$132.21
|
| Rate for Payer: BCBS Complete |
$54.52
|
| Rate for Payer: BCBS Trust/PPO |
$112.38
|
| Rate for Payer: BCN Commercial |
$112.38
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$128.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$132.21
|
| Rate for Payer: Healthscope Whirlpool |
$136.30
|
| Rate for Payer: Mclaren Commercial |
$122.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$109.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: Nomi Health Commercial |
$111.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$102.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$119.43
|
| Rate for Payer: Priority Health Narrow Network |
$95.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$119.94
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$364.25
|
|
|
Service Code
|
NDC 904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.77 |
| Max. Negotiated Rate |
$364.25 |
| Rate for Payer: Aetna Commercial |
$327.82
|
| Rate for Payer: Aetna Medicare |
$134.77
|
| Rate for Payer: ASR ASR |
$353.32
|
| Rate for Payer: BCBS Complete |
$145.70
|
| Rate for Payer: BCBS Trust/PPO |
$300.32
|
| Rate for Payer: BCN Commercial |
$300.32
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Commercial |
$342.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Healthscope Commercial |
$353.32
|
| Rate for Payer: Healthscope Whirlpool |
$364.25
|
| Rate for Payer: Mclaren Commercial |
$327.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$291.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$309.61
|
| Rate for Payer: Nomi Health Commercial |
$298.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.19
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$319.16
|
| Rate for Payer: Priority Health Narrow Network |
$255.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$320.54
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$136.30
|
|
|
Service Code
|
NDC 53746027201
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.22 |
| Max. Negotiated Rate |
$136.30 |
| Rate for Payer: Aetna Commercial |
$122.67
|
| Rate for Payer: ASR ASR |
$132.21
|
| Rate for Payer: BCBS Trust/PPO |
$111.93
|
| Rate for Payer: BCN Commercial |
$111.93
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$128.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$132.21
|
| Rate for Payer: Healthscope Whirlpool |
$136.30
|
| Rate for Payer: Mclaren Commercial |
$122.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: Nomi Health Commercial |
$111.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$102.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$119.94
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$364.25
|
|
|
Service Code
|
NDC 904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.19 |
| Max. Negotiated Rate |
$364.25 |
| Rate for Payer: Aetna Commercial |
$327.82
|
| Rate for Payer: ASR ASR |
$353.32
|
| Rate for Payer: BCBS Trust/PPO |
$299.12
|
| Rate for Payer: BCN Commercial |
$299.12
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Commercial |
$342.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Healthscope Commercial |
$353.32
|
| Rate for Payer: Healthscope Whirlpool |
$364.25
|
| Rate for Payer: Mclaren Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$309.61
|
| Rate for Payer: Nomi Health Commercial |
$298.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$320.54
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$641.25
|
|
|
Service Code
|
NDC 59762500006
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$480.94 |
| Max. Negotiated Rate |
$641.25 |
| Rate for Payer: Aetna Commercial |
$577.12
|
| Rate for Payer: ASR ASR |
$622.01
|
| Rate for Payer: BCBS Trust/PPO |
$526.59
|
| Rate for Payer: BCN Commercial |
$526.59
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cofinity Commercial |
$602.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$513.00
|
| Rate for Payer: Healthscope Commercial |
$622.01
|
| Rate for Payer: Healthscope Whirlpool |
$641.25
|
| Rate for Payer: Mclaren Commercial |
$577.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$545.06
|
| Rate for Payer: Nomi Health Commercial |
$525.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$480.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$564.30
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$641.25
|
|
|
Service Code
|
NDC 59762500006
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$237.26 |
| Max. Negotiated Rate |
$641.25 |
| Rate for Payer: Aetna Commercial |
$577.12
|
| Rate for Payer: Aetna Medicare |
$237.26
|
| Rate for Payer: ASR ASR |
$622.01
|
| Rate for Payer: BCBS Complete |
$256.50
|
| Rate for Payer: BCBS Trust/PPO |
$528.71
|
| Rate for Payer: BCN Commercial |
$528.71
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cofinity Commercial |
$602.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$513.00
|
| Rate for Payer: Healthscope Commercial |
$622.01
|
| Rate for Payer: Healthscope Whirlpool |
$641.25
|
| Rate for Payer: Mclaren Commercial |
$577.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$513.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$545.06
|
| Rate for Payer: Nomi Health Commercial |
$525.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$480.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$561.86
|
| Rate for Payer: Priority Health Narrow Network |
$449.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$564.30
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.31 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$192.38
|
| Rate for Payer: ASR ASR |
$207.34
|
| Rate for Payer: BCBS Trust/PPO |
$175.53
|
| Rate for Payer: BCN Commercial |
$175.53
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$200.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$207.34
|
| Rate for Payer: Healthscope Whirlpool |
$213.75
|
| Rate for Payer: Mclaren Commercial |
$192.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$188.10
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$213.75
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.09 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$192.38
|
| Rate for Payer: Aetna Medicare |
$79.09
|
| Rate for Payer: ASR ASR |
$207.34
|
| Rate for Payer: BCBS Complete |
$85.50
|
| Rate for Payer: BCBS Trust/PPO |
$176.24
|
| Rate for Payer: BCN Commercial |
$176.24
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$200.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$207.34
|
| Rate for Payer: Healthscope Whirlpool |
$213.75
|
| Rate for Payer: Mclaren Commercial |
$192.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$171.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$187.29
|
| Rate for Payer: Priority Health Narrow Network |
$149.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$188.10
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
OP
|
$26.74
|
|
|
Service Code
|
NDC 65862014836
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$26.74 |
| Rate for Payer: Aetna Commercial |
$24.07
|
| Rate for Payer: Aetna Medicare |
$9.89
|
| Rate for Payer: ASR ASR |
$25.94
|
| Rate for Payer: BCBS Complete |
$10.70
|
| Rate for Payer: BCBS Trust/PPO |
$22.05
|
| Rate for Payer: BCN Commercial |
$22.05
|
| Rate for Payer: Cash Price |
$21.39
|
| Rate for Payer: Cofinity Commercial |
$25.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.39
|
| Rate for Payer: Healthscope Commercial |
$25.94
|
| Rate for Payer: Healthscope Whirlpool |
$26.74
|
| Rate for Payer: Mclaren Commercial |
$24.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.73
|
| Rate for Payer: Nomi Health Commercial |
$21.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23.43
|
| Rate for Payer: Priority Health Narrow Network |
$18.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.53
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$26.74
|
|
|
Service Code
|
NDC 65862014836
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.06 |
| Max. Negotiated Rate |
$26.74 |
| Rate for Payer: Aetna Commercial |
$24.07
|
| Rate for Payer: ASR ASR |
$25.94
|
| Rate for Payer: BCBS Trust/PPO |
$21.96
|
| Rate for Payer: BCN Commercial |
$21.96
|
| Rate for Payer: Cash Price |
$21.39
|
| Rate for Payer: Cofinity Commercial |
$25.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.39
|
| Rate for Payer: Healthscope Commercial |
$25.94
|
| Rate for Payer: Healthscope Whirlpool |
$26.74
|
| Rate for Payer: Mclaren Commercial |
$24.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.73
|
| Rate for Payer: Nomi Health Commercial |
$21.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.53
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$27.19
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.39 |
| Max. Negotiated Rate |
$27.19 |
| Rate for Payer: Aetna Commercial |
$24.47
|
| Rate for Payer: Aetna Commercial |
$22.39
|
| Rate for Payer: Aetna Commercial |
$44.51
|
| Rate for Payer: Aetna Commercial |
$16.94
|
| Rate for Payer: ASR ASR |
$47.97
|
| Rate for Payer: ASR ASR |
$26.37
|
| Rate for Payer: ASR ASR |
$24.13
|
| Rate for Payer: ASR ASR |
$18.26
|
| Rate for Payer: BCBS Trust/PPO |
$22.33
|
| Rate for Payer: BCBS Trust/PPO |
$15.46
|
| Rate for Payer: BCBS Trust/PPO |
$20.43
|
| Rate for Payer: BCBS Trust/PPO |
$40.61
|
| Rate for Payer: BCN Commercial |
$15.46
|
| Rate for Payer: BCN Commercial |
$40.61
|
| Rate for Payer: BCN Commercial |
$20.43
|
| Rate for Payer: BCN Commercial |
$22.33
|
| Rate for Payer: Cash Price |
$39.57
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$15.06
|
| Rate for Payer: Cofinity Commercial |
$25.56
|
| Rate for Payer: Cofinity Commercial |
$17.69
|
| Rate for Payer: Cofinity Commercial |
$46.49
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.06
|
| Rate for Payer: Healthscope Commercial |
$26.37
|
| Rate for Payer: Healthscope Commercial |
$18.26
|
| Rate for Payer: Healthscope Commercial |
$24.13
|
| Rate for Payer: Healthscope Commercial |
$47.97
|
| Rate for Payer: Healthscope Whirlpool |
$27.19
|
| Rate for Payer: Healthscope Whirlpool |
$49.46
|
| Rate for Payer: Healthscope Whirlpool |
$18.82
|
| Rate for Payer: Healthscope Whirlpool |
$24.88
|
| Rate for Payer: Mclaren Commercial |
$16.94
|
| Rate for Payer: Mclaren Commercial |
$44.51
|
| Rate for Payer: Mclaren Commercial |
$22.39
|
| Rate for Payer: Mclaren Commercial |
$24.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.00
|
| Rate for Payer: Nomi Health Commercial |
$20.40
|
| Rate for Payer: Nomi Health Commercial |
$40.56
|
| Rate for Payer: Nomi Health Commercial |
$22.29
|
| Rate for Payer: Nomi Health Commercial |
$15.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$43.52
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$49.46
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$49.46 |
| Rate for Payer: Aetna Commercial |
$44.51
|
| Rate for Payer: Aetna Commercial |
$22.39
|
| Rate for Payer: Aetna Commercial |
$24.47
|
| Rate for Payer: Aetna Commercial |
$16.94
|
| Rate for Payer: Aetna Medicare |
$6.96
|
| Rate for Payer: Aetna Medicare |
$18.30
|
| Rate for Payer: Aetna Medicare |
$10.06
|
| Rate for Payer: Aetna Medicare |
$9.20
|
| Rate for Payer: ASR ASR |
$26.37
|
| Rate for Payer: ASR ASR |
$24.13
|
| Rate for Payer: ASR ASR |
$18.26
|
| Rate for Payer: ASR ASR |
$47.97
|
| Rate for Payer: BCBS Complete |
$10.88
|
| Rate for Payer: BCBS Complete |
$7.53
|
| Rate for Payer: BCBS Complete |
$19.78
|
| Rate for Payer: BCBS Complete |
$9.95
|
| Rate for Payer: BCBS Trust/PPO |
$20.51
|
| Rate for Payer: BCBS Trust/PPO |
$40.78
|
| Rate for Payer: BCBS Trust/PPO |
$22.42
|
| Rate for Payer: BCBS Trust/PPO |
$15.52
|
| Rate for Payer: BCN Commercial |
$40.78
|
| Rate for Payer: BCN Commercial |
$22.42
|
| Rate for Payer: BCN Commercial |
$15.52
|
| Rate for Payer: BCN Commercial |
$20.51
|
| Rate for Payer: Cash Price |
$15.06
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$39.57
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$15.06
|
| Rate for Payer: Cash Price |
$39.57
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$46.49
|
| Rate for Payer: Cofinity Commercial |
$17.69
|
| Rate for Payer: Cofinity Commercial |
$25.56
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Healthscope Commercial |
$47.97
|
| Rate for Payer: Healthscope Commercial |
$18.26
|
| Rate for Payer: Healthscope Commercial |
$24.13
|
| Rate for Payer: Healthscope Commercial |
$26.37
|
| Rate for Payer: Healthscope Whirlpool |
$18.82
|
| Rate for Payer: Healthscope Whirlpool |
$27.19
|
| Rate for Payer: Healthscope Whirlpool |
$49.46
|
| Rate for Payer: Healthscope Whirlpool |
$24.88
|
| Rate for Payer: Mclaren Commercial |
$24.47
|
| Rate for Payer: Mclaren Commercial |
$22.39
|
| Rate for Payer: Mclaren Commercial |
$16.94
|
| Rate for Payer: Mclaren Commercial |
$44.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.04
|
| Rate for Payer: Nomi Health Commercial |
$15.44
|
| Rate for Payer: Nomi Health Commercial |
$22.29
|
| Rate for Payer: Nomi Health Commercial |
$40.56
|
| Rate for Payer: Nomi Health Commercial |
$20.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$25.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$25.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$25.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$25.50
|
| Rate for Payer: Priority Health Narrow Network |
$20.40
|
| Rate for Payer: Priority Health Narrow Network |
$20.40
|
| Rate for Payer: Priority Health Narrow Network |
$20.40
|
| Rate for Payer: Priority Health Narrow Network |
$20.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$43.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.89
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$5,837.50
|
|
|
Service Code
|
APR-DRG 2043
|
| Min. Negotiated Rate |
$5,277.80 |
| Max. Negotiated Rate |
$5,837.50 |
| Rate for Payer: BCBS Complete |
$5,837.50
|
| Rate for Payer: Mclaren Medicaid |
$5,559.53
|
| Rate for Payer: Meridian Medicaid |
$5,837.50
|
| Rate for Payer: PHP Medicaid |
$5,277.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,559.53
|
| Rate for Payer: UHC Medicaid |
$5,559.53
|
| Rate for Payer: UHCCP Medicaid |
$5,559.53
|
|
