|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$139.70
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.80 |
| Max. Negotiated Rate |
$139.70 |
| Rate for Payer: Aetna Commercial |
$125.73
|
| Rate for Payer: ASR ASR |
$135.51
|
| Rate for Payer: ASR Commercial |
$135.51
|
| Rate for Payer: BCBS Trust/PPO |
$113.84
|
| Rate for Payer: BCN Commercial |
$108.31
|
| Rate for Payer: Cash Price |
$111.76
|
| Rate for Payer: Cofinity Commercial |
$131.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.76
|
| Rate for Payer: Healthscope Commercial |
$139.70
|
| Rate for Payer: Healthscope Whirlpool |
$135.51
|
| Rate for Payer: Mclaren Commercial |
$125.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.74
|
| Rate for Payer: Nomi Health Commercial |
$114.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$122.94
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
IP
|
$145.37
|
|
|
Service Code
|
NDC 61314070101
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.49 |
| Max. Negotiated Rate |
$145.37 |
| Rate for Payer: Aetna Commercial |
$130.83
|
| Rate for Payer: ASR ASR |
$141.01
|
| Rate for Payer: ASR Commercial |
$141.01
|
| Rate for Payer: BCBS Trust/PPO |
$118.46
|
| Rate for Payer: BCN Commercial |
$112.71
|
| Rate for Payer: Cash Price |
$116.30
|
| Rate for Payer: Cofinity Commercial |
$136.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.30
|
| Rate for Payer: Healthscope Commercial |
$145.37
|
| Rate for Payer: Healthscope Whirlpool |
$141.01
|
| Rate for Payer: Mclaren Commercial |
$130.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.56
|
| Rate for Payer: Nomi Health Commercial |
$119.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$127.93
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$145.37
|
|
|
Service Code
|
NDC 61314070101
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.15 |
| Max. Negotiated Rate |
$145.37 |
| Rate for Payer: Aetna Commercial |
$130.83
|
| Rate for Payer: Aetna Medicare |
$72.68
|
| Rate for Payer: ASR ASR |
$141.01
|
| Rate for Payer: ASR Commercial |
$141.01
|
| Rate for Payer: BCBS Complete |
$58.15
|
| Rate for Payer: BCBS Trust/PPO |
$119.04
|
| Rate for Payer: BCN Commercial |
$112.71
|
| Rate for Payer: Cash Price |
$116.30
|
| Rate for Payer: Cofinity Commercial |
$136.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.30
|
| Rate for Payer: Healthscope Commercial |
$145.37
|
| Rate for Payer: Healthscope Whirlpool |
$141.01
|
| Rate for Payer: Mclaren Commercial |
$130.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.56
|
| Rate for Payer: Nomi Health Commercial |
$119.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$127.37
|
| Rate for Payer: Priority Health Narrow Network |
$101.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$127.93
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS
|
Facility
|
OP
|
$139.70
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.88 |
| Max. Negotiated Rate |
$139.70 |
| Rate for Payer: Aetna Commercial |
$125.73
|
| Rate for Payer: Aetna Medicare |
$69.85
|
| Rate for Payer: ASR ASR |
$135.51
|
| Rate for Payer: ASR Commercial |
$135.51
|
| Rate for Payer: BCBS Complete |
$55.88
|
| Rate for Payer: BCBS Trust/PPO |
$114.40
|
| Rate for Payer: BCN Commercial |
$108.31
|
| Rate for Payer: Cash Price |
$111.76
|
| Rate for Payer: Cofinity Commercial |
$131.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.76
|
| Rate for Payer: Healthscope Commercial |
$139.70
|
| Rate for Payer: Healthscope Whirlpool |
$135.51
|
| Rate for Payer: Mclaren Commercial |
$125.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$118.74
|
| Rate for Payer: Nomi Health Commercial |
$114.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$122.41
|
| Rate for Payer: Priority Health Narrow Network |
$97.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$122.94
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
NDC 09900001165
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.47
|
| Rate for Payer: ASR ASR |
$2.66
|
| Rate for Payer: ASR Commercial |
$2.66
|
| Rate for Payer: BCBS Trust/PPO |
$2.23
|
| Rate for Payer: BCN Commercial |
$2.12
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Healthscope Whirlpool |
$2.66
|
| Rate for Payer: Mclaren Commercial |
$2.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: Nomi Health Commercial |
$2.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.41
|
|
|
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 |
$200.21 |
| Max. Negotiated Rate |
$308.02 |
| Rate for Payer: Aetna Commercial |
$277.22
|
| Rate for Payer: ASR ASR |
$298.78
|
| Rate for Payer: ASR Commercial |
$298.78
|
| Rate for Payer: BCBS Trust/PPO |
$251.01
|
| Rate for Payer: BCN Commercial |
$238.81
|
| Rate for Payer: Cash Price |
$246.41
|
| Rate for Payer: Cofinity Commercial |
$289.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.42
|
| Rate for Payer: Healthscope Commercial |
$308.02
|
| Rate for Payer: Healthscope Whirlpool |
$298.78
|
| Rate for Payer: Mclaren Commercial |
$277.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: Nomi Health Commercial |
$252.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$271.06
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.69
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.08 |
| Max. Negotiated Rate |
$52.69 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: Aetna Medicare |
$26.34
|
| Rate for Payer: ASR ASR |
$51.11
|
| Rate for Payer: ASR Commercial |
$51.11
|
| Rate for Payer: BCBS Complete |
$21.08
|
| Rate for Payer: BCBS Trust/PPO |
$43.15
|
| Rate for Payer: BCN Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$49.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$52.69
|
| Rate for Payer: Healthscope Whirlpool |
$51.11
|
| Rate for Payer: Mclaren Commercial |
$47.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$46.17
|
| Rate for Payer: Priority Health Narrow Network |
$36.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$46.37
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 09900001165
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.47
|
| Rate for Payer: Aetna Medicare |
$1.37
|
| Rate for Payer: ASR ASR |
$2.66
|
| Rate for Payer: ASR Commercial |
$2.66
|
| Rate for Payer: BCBS Complete |
$1.10
|
| Rate for Payer: BCBS Trust/PPO |
$2.24
|
| Rate for Payer: BCN Commercial |
$2.12
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Healthscope Whirlpool |
$2.66
|
| Rate for Payer: Mclaren Commercial |
$2.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: Nomi Health Commercial |
$2.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: 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
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$52.69
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.08 |
| Max. Negotiated Rate |
$52.69 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: Aetna Medicare |
$26.34
|
| Rate for Payer: ASR ASR |
$51.11
|
| Rate for Payer: ASR Commercial |
$51.11
|
| Rate for Payer: BCBS Complete |
$21.08
|
| Rate for Payer: BCBS Trust/PPO |
$43.15
|
| Rate for Payer: BCN Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$49.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$52.69
|
| Rate for Payer: Healthscope Whirlpool |
$51.11
|
| Rate for Payer: Mclaren Commercial |
$47.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$46.17
|
| Rate for Payer: Priority Health Narrow Network |
$36.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$46.37
|
|
|
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 |
$5.02 |
| Max. Negotiated Rate |
$7.72 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: ASR ASR |
$7.49
|
| Rate for Payer: ASR Commercial |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$6.29
|
| Rate for Payer: BCN Commercial |
$5.99
|
| Rate for Payer: Cash Price |
$6.17
|
| Rate for Payer: Cofinity Commercial |
$7.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.18
|
| Rate for Payer: Healthscope Commercial |
$7.72
|
| Rate for Payer: Healthscope Whirlpool |
$7.49
|
| Rate for Payer: Mclaren Commercial |
$6.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.56
|
| Rate for Payer: Nomi Health Commercial |
$6.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.79
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$52.69
|
|
|
Service Code
|
NDC 00121085340
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$52.69 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: ASR ASR |
$51.11
|
| Rate for Payer: ASR Commercial |
$51.11
|
| Rate for Payer: BCBS Trust/PPO |
$42.94
|
| Rate for Payer: BCN Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$49.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$52.69
|
| Rate for Payer: Healthscope Whirlpool |
$51.11
|
| Rate for Payer: Mclaren Commercial |
$47.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$46.37
|
|
|
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 |
$96.69 |
| Max. Negotiated Rate |
$148.76 |
| Rate for Payer: Aetna Commercial |
$133.88
|
| Rate for Payer: ASR ASR |
$144.30
|
| Rate for Payer: ASR Commercial |
$144.30
|
| Rate for Payer: BCBS Trust/PPO |
$121.22
|
| Rate for Payer: BCN Commercial |
$115.33
|
| 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 |
$148.76
|
| Rate for Payer: Healthscope Whirlpool |
$144.30
|
| 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: Priority Health Cigna Priority Health |
$96.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.91
|
|
|
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 |
$123.21 |
| Max. Negotiated Rate |
$308.02 |
| Rate for Payer: Aetna Commercial |
$277.22
|
| Rate for Payer: Aetna Medicare |
$154.01
|
| Rate for Payer: ASR ASR |
$298.78
|
| Rate for Payer: ASR Commercial |
$298.78
|
| Rate for Payer: BCBS Complete |
$123.21
|
| Rate for Payer: BCBS Trust/PPO |
$252.24
|
| Rate for Payer: BCN Commercial |
$238.81
|
| Rate for Payer: Cash Price |
$246.41
|
| Rate for Payer: Cofinity Commercial |
$289.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.42
|
| Rate for Payer: Healthscope Commercial |
$308.02
|
| Rate for Payer: Healthscope Whirlpool |
$298.78
|
| Rate for Payer: Mclaren Commercial |
$277.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.82
|
| Rate for Payer: Nomi Health Commercial |
$252.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.21
|
| Rate for Payer: 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
|
OP
|
$7.72
|
|
|
Service Code
|
NDC 17856000705
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$7.72 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Aetna Medicare |
$3.86
|
| Rate for Payer: ASR ASR |
$7.49
|
| Rate for Payer: ASR Commercial |
$7.49
|
| Rate for Payer: BCBS Complete |
$3.09
|
| Rate for Payer: BCBS Trust/PPO |
$6.32
|
| Rate for Payer: BCN Commercial |
$5.99
|
| Rate for Payer: Cash Price |
$6.17
|
| Rate for Payer: Cofinity Commercial |
$7.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.18
|
| Rate for Payer: Healthscope Commercial |
$7.72
|
| Rate for Payer: Healthscope Whirlpool |
$7.49
|
| Rate for Payer: Mclaren Commercial |
$6.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.56
|
| Rate for Payer: Nomi Health Commercial |
$6.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.02
|
| Rate for Payer: 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
|
IP
|
$52.69
|
|
|
Service Code
|
NDC 00121085320
|
| Hospital Charge Code |
22560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$52.69 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: ASR ASR |
$51.11
|
| Rate for Payer: ASR Commercial |
$51.11
|
| Rate for Payer: BCBS Trust/PPO |
$42.94
|
| Rate for Payer: BCN Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$42.15
|
| Rate for Payer: Cofinity Commercial |
$49.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.15
|
| Rate for Payer: Healthscope Commercial |
$52.69
|
| Rate for Payer: Healthscope Whirlpool |
$51.11
|
| Rate for Payer: Mclaren Commercial |
$47.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.79
|
| Rate for Payer: Nomi Health Commercial |
$43.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$46.37
|
|
|
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 |
$59.50 |
| Max. Negotiated Rate |
$148.76 |
| Rate for Payer: Aetna Commercial |
$133.88
|
| Rate for Payer: Aetna Medicare |
$74.38
|
| Rate for Payer: ASR ASR |
$144.30
|
| Rate for Payer: ASR Commercial |
$144.30
|
| Rate for Payer: BCBS Complete |
$59.50
|
| Rate for Payer: BCBS Trust/PPO |
$121.82
|
| Rate for Payer: BCN Commercial |
$115.33
|
| 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 |
$148.76
|
| Rate for Payer: Healthscope Whirlpool |
$144.30
|
| 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: Priority Health Cigna Priority Health |
$96.69
|
| Rate for Payer: 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 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.62
|
|
|
Service Code
|
NDC 00703951493
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$19.62 |
| Rate for Payer: Aetna Commercial |
$17.66
|
| Rate for Payer: Aetna Medicare |
$9.81
|
| Rate for Payer: ASR ASR |
$19.03
|
| Rate for Payer: ASR Commercial |
$19.03
|
| Rate for Payer: BCBS Complete |
$7.85
|
| Rate for Payer: BCBS Trust/PPO |
$16.07
|
| Rate for Payer: BCN Commercial |
$15.21
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$19.62
|
| Rate for Payer: Healthscope Whirlpool |
$19.03
|
| Rate for Payer: Mclaren Commercial |
$17.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.68
|
| Rate for Payer: Nomi Health Commercial |
$16.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.19
|
| Rate for Payer: Priority Health Narrow Network |
$13.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.27
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.08
|
|
|
Service Code
|
NDC 70069036201
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.95 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna Commercial |
$23.47
|
| Rate for Payer: ASR ASR |
$25.30
|
| Rate for Payer: ASR Commercial |
$25.30
|
| Rate for Payer: BCBS Trust/PPO |
$21.25
|
| Rate for Payer: BCN Commercial |
$20.22
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Cofinity Commercial |
$24.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.86
|
| Rate for Payer: Healthscope Commercial |
$26.08
|
| Rate for Payer: Healthscope Whirlpool |
$25.30
|
| Rate for Payer: Mclaren Commercial |
$23.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.17
|
| Rate for Payer: Nomi Health Commercial |
$21.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.95
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.08
|
|
|
Service Code
|
NDC 70069036210
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna Commercial |
$23.47
|
| Rate for Payer: Aetna Medicare |
$13.04
|
| Rate for Payer: ASR ASR |
$25.30
|
| Rate for Payer: ASR Commercial |
$25.30
|
| Rate for Payer: BCBS Complete |
$10.43
|
| Rate for Payer: BCBS Trust/PPO |
$21.36
|
| Rate for Payer: BCN Commercial |
$20.22
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Cofinity Commercial |
$24.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.86
|
| Rate for Payer: Healthscope Commercial |
$26.08
|
| Rate for Payer: Healthscope Whirlpool |
$25.30
|
| Rate for Payer: Mclaren Commercial |
$23.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.17
|
| Rate for Payer: Nomi Health Commercial |
$21.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.85
|
| Rate for Payer: Priority Health Narrow Network |
$18.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.95
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.08
|
|
|
Service Code
|
NDC 70069036201
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna Commercial |
$23.47
|
| Rate for Payer: Aetna Medicare |
$13.04
|
| Rate for Payer: ASR ASR |
$25.30
|
| Rate for Payer: ASR Commercial |
$25.30
|
| Rate for Payer: BCBS Complete |
$10.43
|
| Rate for Payer: BCBS Trust/PPO |
$21.36
|
| Rate for Payer: BCN Commercial |
$20.22
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Cofinity Commercial |
$24.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.86
|
| Rate for Payer: Healthscope Commercial |
$26.08
|
| Rate for Payer: Healthscope Whirlpool |
$25.30
|
| Rate for Payer: Mclaren Commercial |
$23.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.17
|
| Rate for Payer: Nomi Health Commercial |
$21.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.85
|
| Rate for Payer: Priority Health Narrow Network |
$18.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.95
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.62
|
|
|
Service Code
|
NDC 00703951493
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$19.62 |
| Rate for Payer: Aetna Commercial |
$17.66
|
| Rate for Payer: ASR ASR |
$19.03
|
| Rate for Payer: ASR Commercial |
$19.03
|
| Rate for Payer: BCBS Trust/PPO |
$15.99
|
| Rate for Payer: BCN Commercial |
$15.21
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$19.62
|
| Rate for Payer: Healthscope Whirlpool |
$19.03
|
| Rate for Payer: Mclaren Commercial |
$17.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.68
|
| Rate for Payer: Nomi Health Commercial |
$16.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.27
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.62
|
|
|
Service Code
|
NDC 00703951491
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$19.62 |
| Rate for Payer: Aetna Commercial |
$17.66
|
| Rate for Payer: ASR ASR |
$19.03
|
| Rate for Payer: ASR Commercial |
$19.03
|
| Rate for Payer: BCBS Trust/PPO |
$15.99
|
| Rate for Payer: BCN Commercial |
$15.21
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$19.62
|
| Rate for Payer: Healthscope Whirlpool |
$19.03
|
| Rate for Payer: Mclaren Commercial |
$17.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.68
|
| Rate for Payer: Nomi Health Commercial |
$16.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.27
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.08
|
|
|
Service Code
|
NDC 70069036210
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.95 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna Commercial |
$23.47
|
| Rate for Payer: ASR ASR |
$25.30
|
| Rate for Payer: ASR Commercial |
$25.30
|
| Rate for Payer: BCBS Trust/PPO |
$21.25
|
| Rate for Payer: BCN Commercial |
$20.22
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Cofinity Commercial |
$24.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.86
|
| Rate for Payer: Healthscope Commercial |
$26.08
|
| Rate for Payer: Healthscope Whirlpool |
$25.30
|
| Rate for Payer: Mclaren Commercial |
$23.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.17
|
| Rate for Payer: Nomi Health Commercial |
$21.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.95
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.62
|
|
|
Service Code
|
NDC 00703951491
|
| Hospital Charge Code |
7556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$19.62 |
| Rate for Payer: Aetna Commercial |
$17.66
|
| Rate for Payer: Aetna Medicare |
$9.81
|
| Rate for Payer: ASR ASR |
$19.03
|
| Rate for Payer: ASR Commercial |
$19.03
|
| Rate for Payer: BCBS Complete |
$7.85
|
| Rate for Payer: BCBS Trust/PPO |
$16.07
|
| Rate for Payer: BCN Commercial |
$15.21
|
| Rate for Payer: Cash Price |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.70
|
| Rate for Payer: Healthscope Commercial |
$19.62
|
| Rate for Payer: Healthscope Whirlpool |
$19.03
|
| Rate for Payer: Mclaren Commercial |
$17.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.68
|
| Rate for Payer: Nomi Health Commercial |
$16.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.19
|
| Rate for Payer: Priority Health Narrow Network |
$13.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.27
|
|
|
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 |
$88.60 |
| Max. Negotiated Rate |
$136.30 |
| Rate for Payer: Aetna Commercial |
$122.67
|
| Rate for Payer: ASR ASR |
$132.21
|
| Rate for Payer: ASR Commercial |
$132.21
|
| Rate for Payer: BCBS Trust/PPO |
$111.07
|
| Rate for Payer: BCN Commercial |
$105.67
|
| 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 |
$136.30
|
| Rate for Payer: Healthscope Whirlpool |
$132.21
|
| 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: Priority Health Cigna Priority Health |
$88.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$119.94
|
|
