|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
IP
|
$3.14
|
|
|
Service Code
|
NDC 51079075301
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.14 |
| Rate for Payer: Aetna Commercial |
$2.83
|
| Rate for Payer: ASR ASR |
$3.05
|
| Rate for Payer: ASR Commercial |
$3.05
|
| Rate for Payer: BCBS Trust/PPO |
$2.56
|
| Rate for Payer: BCN Commercial |
$2.43
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cofinity Commercial |
$2.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.51
|
| Rate for Payer: Healthscope Commercial |
$3.14
|
| Rate for Payer: Healthscope Whirlpool |
$3.05
|
| Rate for Payer: Mclaren Commercial |
$2.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.67
|
| Rate for Payer: Nomi Health Commercial |
$2.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.76
|
|
|
SUCRALFATE 1 GRAM TABLET
|
Facility
|
OP
|
$314.45
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
11442
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.78 |
| Max. Negotiated Rate |
$314.45 |
| Rate for Payer: Aetna Commercial |
$283.00
|
| Rate for Payer: Aetna Medicare |
$157.22
|
| Rate for Payer: ASR ASR |
$305.02
|
| Rate for Payer: ASR Commercial |
$305.02
|
| Rate for Payer: BCBS Complete |
$125.78
|
| Rate for Payer: BCBS Trust/PPO |
$257.50
|
| Rate for Payer: BCN Commercial |
$243.79
|
| Rate for Payer: Cash Price |
$251.56
|
| Rate for Payer: Cofinity Commercial |
$295.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$251.56
|
| Rate for Payer: Healthscope Commercial |
$314.45
|
| Rate for Payer: Healthscope Whirlpool |
$305.02
|
| Rate for Payer: Mclaren Commercial |
$283.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$267.28
|
| Rate for Payer: Nomi Health Commercial |
$257.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$275.52
|
| Rate for Payer: Priority Health Narrow Network |
$220.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$276.72
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$449.45
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$292.14 |
| Max. Negotiated Rate |
$449.45 |
| Rate for Payer: Aetna Commercial |
$404.50
|
| Rate for Payer: ASR ASR |
$435.97
|
| Rate for Payer: ASR Commercial |
$435.97
|
| Rate for Payer: BCBS Trust/PPO |
$366.26
|
| Rate for Payer: BCN Commercial |
$348.46
|
| Rate for Payer: Cash Price |
$359.56
|
| Rate for Payer: Cofinity Commercial |
$422.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.56
|
| Rate for Payer: Healthscope Commercial |
$449.45
|
| Rate for Payer: Healthscope Whirlpool |
$435.97
|
| Rate for Payer: Mclaren Commercial |
$404.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.03
|
| Rate for Payer: Nomi Health Commercial |
$368.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$395.52
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$449.45
|
|
|
Service Code
|
NDC 00006542312
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$179.78 |
| Max. Negotiated Rate |
$449.45 |
| Rate for Payer: Aetna Commercial |
$404.50
|
| Rate for Payer: Aetna Medicare |
$224.72
|
| Rate for Payer: ASR ASR |
$435.97
|
| Rate for Payer: ASR Commercial |
$435.97
|
| Rate for Payer: BCBS Complete |
$179.78
|
| Rate for Payer: BCBS Trust/PPO |
$368.05
|
| Rate for Payer: BCN Commercial |
$348.46
|
| Rate for Payer: Cash Price |
$359.56
|
| Rate for Payer: Cofinity Commercial |
$422.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.56
|
| Rate for Payer: Healthscope Commercial |
$449.45
|
| Rate for Payer: Healthscope Whirlpool |
$435.97
|
| Rate for Payer: Mclaren Commercial |
$404.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.03
|
| Rate for Payer: Nomi Health Commercial |
$368.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$393.81
|
| Rate for Payer: Priority Health Narrow Network |
$315.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$395.52
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$449.45
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$179.78 |
| Max. Negotiated Rate |
$449.45 |
| Rate for Payer: Aetna Commercial |
$404.50
|
| Rate for Payer: Aetna Medicare |
$224.72
|
| Rate for Payer: ASR ASR |
$435.97
|
| Rate for Payer: ASR Commercial |
$435.97
|
| Rate for Payer: BCBS Complete |
$179.78
|
| Rate for Payer: BCBS Trust/PPO |
$368.05
|
| Rate for Payer: BCN Commercial |
$348.46
|
| Rate for Payer: Cash Price |
$359.56
|
| Rate for Payer: Cofinity Commercial |
$422.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.56
|
| Rate for Payer: Healthscope Commercial |
$449.45
|
| Rate for Payer: Healthscope Whirlpool |
$435.97
|
| Rate for Payer: Mclaren Commercial |
$404.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.03
|
| Rate for Payer: Nomi Health Commercial |
$368.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$393.81
|
| Rate for Payer: Priority Health Narrow Network |
$315.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$395.52
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$449.45
|
|
|
Service Code
|
NDC 00006542302
|
| Hospital Charge Code |
177099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$292.14 |
| Max. Negotiated Rate |
$449.45 |
| Rate for Payer: Aetna Commercial |
$404.50
|
| Rate for Payer: ASR ASR |
$435.97
|
| Rate for Payer: ASR Commercial |
$435.97
|
| Rate for Payer: BCBS Trust/PPO |
$366.26
|
| Rate for Payer: BCN Commercial |
$348.46
|
| Rate for Payer: Cash Price |
$359.56
|
| Rate for Payer: Cofinity Commercial |
$422.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.56
|
| Rate for Payer: Healthscope Commercial |
$449.45
|
| Rate for Payer: Healthscope Whirlpool |
$435.97
|
| Rate for Payer: Mclaren Commercial |
$404.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.03
|
| Rate for Payer: Nomi Health Commercial |
$368.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$395.52
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS
|
Facility
|
IP
|
$48.79
|
|
|
Service Code
|
NDC 24208031705
|
| Hospital Charge Code |
70392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.71 |
| Max. Negotiated Rate |
$48.79 |
| Rate for Payer: Aetna Commercial |
$43.91
|
| Rate for Payer: ASR ASR |
$47.33
|
| Rate for Payer: ASR Commercial |
$47.33
|
| Rate for Payer: BCBS Trust/PPO |
$39.76
|
| Rate for Payer: BCN Commercial |
$37.83
|
| Rate for Payer: Cash Price |
$39.03
|
| Rate for Payer: Cofinity Commercial |
$45.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.03
|
| Rate for Payer: Healthscope Commercial |
$48.79
|
| Rate for Payer: Healthscope Whirlpool |
$47.33
|
| Rate for Payer: Mclaren Commercial |
$43.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.47
|
| Rate for Payer: Nomi Health Commercial |
$40.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.94
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS
|
Facility
|
OP
|
$48.79
|
|
|
Service Code
|
NDC 24208031705
|
| Hospital Charge Code |
70392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.52 |
| Max. Negotiated Rate |
$48.79 |
| Rate for Payer: Aetna Commercial |
$43.91
|
| Rate for Payer: Aetna Medicare |
$24.39
|
| Rate for Payer: ASR ASR |
$47.33
|
| Rate for Payer: ASR Commercial |
$47.33
|
| Rate for Payer: BCBS Complete |
$19.52
|
| Rate for Payer: BCBS Trust/PPO |
$39.95
|
| Rate for Payer: BCN Commercial |
$37.83
|
| Rate for Payer: Cash Price |
$39.03
|
| Rate for Payer: Cofinity Commercial |
$45.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.03
|
| Rate for Payer: Healthscope Commercial |
$48.79
|
| Rate for Payer: Healthscope Whirlpool |
$47.33
|
| Rate for Payer: Mclaren Commercial |
$43.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.47
|
| Rate for Payer: Nomi Health Commercial |
$40.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$42.75
|
| Rate for Payer: Priority Health Narrow Network |
$34.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.94
|
|
|
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 |
$72.69
|
| 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
|
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
|
IP
|
$139.70
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
7359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.81 |
| 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 |
$118.75
|
| Rate for Payer: Nomi Health Commercial |
$114.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$122.94
|
|
|
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 |
$118.75
|
| Rate for Payer: Nomi Health Commercial |
$114.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.81
|
| 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
|
$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
|
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
|
$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
|
$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
|
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 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
|
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
|
$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
|
$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 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
|
$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
|
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 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
|
|
