|
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
|
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
|
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 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
|
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
|
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
|
$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 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.56 |
| Max. Negotiated Rate |
$291.40 |
| Rate for Payer: Aetna Commercial |
$262.26
|
| Rate for Payer: Aetna Medicare |
$145.70
|
| Rate for Payer: ASR ASR |
$282.66
|
| Rate for Payer: ASR Commercial |
$282.66
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: BCBS Trust/PPO |
$238.63
|
| Rate for Payer: BCN Commercial |
$225.92
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$273.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$291.40
|
| Rate for Payer: Healthscope Whirlpool |
$282.66
|
| Rate for Payer: Mclaren Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$255.32
|
| Rate for Payer: Priority Health Narrow Network |
$204.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$256.43
|
|
|
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 |
$88.59 |
| 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 |
$88.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$119.94
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904272561
|
| Hospital Charge Code |
7555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.41 |
| Max. Negotiated Rate |
$291.40 |
| Rate for Payer: Aetna Commercial |
$262.26
|
| Rate for Payer: ASR ASR |
$282.66
|
| Rate for Payer: ASR Commercial |
$282.66
|
| Rate for Payer: BCBS Trust/PPO |
$237.46
|
| Rate for Payer: BCN Commercial |
$225.92
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$273.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$291.40
|
| Rate for Payer: Healthscope Whirlpool |
$282.66
|
| Rate for Payer: Mclaren Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$256.43
|
|
|
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 |
$54.52 |
| Max. Negotiated Rate |
$136.30 |
| Rate for Payer: Aetna Commercial |
$122.67
|
| Rate for Payer: Aetna Medicare |
$68.15
|
| Rate for Payer: ASR ASR |
$132.21
|
| Rate for Payer: ASR Commercial |
$132.21
|
| Rate for Payer: BCBS Complete |
$54.52
|
| Rate for Payer: BCBS Trust/PPO |
$111.62
|
| 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 |
$88.59
|
| Rate for Payer: 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
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$1,240.80
|
|
|
Service Code
|
NDC 59762500006
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$496.32 |
| Max. Negotiated Rate |
$1,240.80 |
| Rate for Payer: Aetna Commercial |
$1,116.72
|
| Rate for Payer: Aetna Medicare |
$620.40
|
| Rate for Payer: ASR ASR |
$1,203.58
|
| Rate for Payer: ASR Commercial |
$1,203.58
|
| Rate for Payer: BCBS Complete |
$496.32
|
| Rate for Payer: BCBS Trust/PPO |
$1,016.09
|
| Rate for Payer: BCN Commercial |
$961.99
|
| Rate for Payer: Cash Price |
$992.64
|
| Rate for Payer: Cofinity Commercial |
$1,166.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$992.64
|
| Rate for Payer: Healthscope Commercial |
$1,240.80
|
| Rate for Payer: Healthscope Whirlpool |
$1,203.58
|
| Rate for Payer: Mclaren Commercial |
$1,116.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,054.68
|
| Rate for Payer: Nomi Health Commercial |
$1,017.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$806.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,087.19
|
| Rate for Payer: Priority Health Narrow Network |
$869.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,091.90
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$274.95 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Aetna Commercial |
$380.70
|
| Rate for Payer: ASR ASR |
$410.31
|
| Rate for Payer: ASR Commercial |
$410.31
|
| Rate for Payer: BCBS Trust/PPO |
$344.70
|
| Rate for Payer: BCN Commercial |
$327.95
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$397.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$423.00
|
| Rate for Payer: Healthscope Whirlpool |
$410.31
|
| Rate for Payer: Mclaren Commercial |
$380.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.55
|
| Rate for Payer: Nomi Health Commercial |
$346.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$372.24
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
OP
|
$423.00
|
|
|
Service Code
|
NDC 59762500005
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.20 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Aetna Commercial |
$380.70
|
| Rate for Payer: Aetna Medicare |
$211.50
|
| Rate for Payer: ASR ASR |
$410.31
|
| Rate for Payer: ASR Commercial |
$410.31
|
| Rate for Payer: BCBS Complete |
$169.20
|
| Rate for Payer: BCBS Trust/PPO |
$346.39
|
| Rate for Payer: BCN Commercial |
$327.95
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$397.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$423.00
|
| Rate for Payer: Healthscope Whirlpool |
$410.31
|
| Rate for Payer: Mclaren Commercial |
$380.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.55
|
| Rate for Payer: Nomi Health Commercial |
$346.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$370.63
|
| Rate for Payer: Priority Health Narrow Network |
$296.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$372.24
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$1,240.80
|
|
|
Service Code
|
NDC 59762500006
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$806.52 |
| Max. Negotiated Rate |
$1,240.80 |
| Rate for Payer: Aetna Commercial |
$1,116.72
|
| Rate for Payer: ASR ASR |
$1,203.58
|
| Rate for Payer: ASR Commercial |
$1,203.58
|
| Rate for Payer: BCBS Trust/PPO |
$1,011.13
|
| Rate for Payer: BCN Commercial |
$961.99
|
| Rate for Payer: Cash Price |
$992.64
|
| Rate for Payer: Cofinity Commercial |
$1,166.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$992.64
|
| Rate for Payer: Healthscope Commercial |
$1,240.80
|
| Rate for Payer: Healthscope Whirlpool |
$1,203.58
|
| Rate for Payer: Mclaren Commercial |
$1,116.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,054.68
|
| Rate for Payer: Nomi Health Commercial |
$1,017.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$806.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,091.90
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$21.99
|
|
|
Service Code
|
NDC 65862014836
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$21.99 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: ASR ASR |
$21.33
|
| Rate for Payer: ASR Commercial |
$21.33
|
| Rate for Payer: BCBS Trust/PPO |
$17.92
|
| Rate for Payer: BCN Commercial |
$17.05
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.59
|
| Rate for Payer: Healthscope Commercial |
$21.99
|
| Rate for Payer: Healthscope Whirlpool |
$21.33
|
| Rate for Payer: Mclaren Commercial |
$19.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.69
|
| Rate for Payer: Nomi Health Commercial |
$18.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.35
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
OP
|
$21.99
|
|
|
Service Code
|
NDC 65862014836
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$21.99 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Medicare |
$10.99
|
| Rate for Payer: ASR ASR |
$21.33
|
| Rate for Payer: ASR Commercial |
$21.33
|
| Rate for Payer: BCBS Complete |
$8.80
|
| Rate for Payer: BCBS Trust/PPO |
$18.01
|
| Rate for Payer: BCN Commercial |
$17.05
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.59
|
| Rate for Payer: Healthscope Commercial |
$21.99
|
| Rate for Payer: Healthscope Whirlpool |
$21.33
|
| Rate for Payer: Mclaren Commercial |
$19.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.69
|
| Rate for Payer: Nomi Health Commercial |
$18.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.27
|
| Rate for Payer: Priority Health Narrow Network |
$15.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.35
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$24.88
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.17 |
| Max. Negotiated Rate |
$24.88 |
| Rate for Payer: Aetna Commercial |
$22.39
|
| Rate for Payer: Aetna Commercial |
$22.35
|
| Rate for Payer: Aetna Commercial |
$24.47
|
| Rate for Payer: Aetna Commercial |
$16.94
|
| Rate for Payer: ASR ASR |
$18.26
|
| Rate for Payer: ASR ASR |
$24.13
|
| Rate for Payer: ASR ASR |
$24.09
|
| Rate for Payer: ASR ASR |
$26.37
|
| Rate for Payer: ASR Commercial |
$24.13
|
| Rate for Payer: ASR Commercial |
$26.37
|
| Rate for Payer: ASR Commercial |
$24.09
|
| Rate for Payer: ASR Commercial |
$18.26
|
| Rate for Payer: BCBS Trust/PPO |
$22.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.34
|
| Rate for Payer: BCBS Trust/PPO |
$20.23
|
| Rate for Payer: BCBS Trust/PPO |
$20.27
|
| Rate for Payer: BCN Commercial |
$21.08
|
| Rate for Payer: BCN Commercial |
$14.59
|
| Rate for Payer: BCN Commercial |
$19.29
|
| Rate for Payer: BCN Commercial |
$19.25
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Cash Price |
$15.06
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cofinity Commercial |
$23.39
|
| Rate for Payer: Cofinity Commercial |
$23.34
|
| Rate for Payer: Cofinity Commercial |
$25.56
|
| Rate for Payer: Cofinity Commercial |
$17.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Healthscope Commercial |
$24.83
|
| Rate for Payer: Healthscope Commercial |
$18.82
|
| Rate for Payer: Healthscope Commercial |
$24.88
|
| Rate for Payer: Healthscope Commercial |
$27.19
|
| Rate for Payer: Healthscope Whirlpool |
$26.37
|
| Rate for Payer: Healthscope Whirlpool |
$24.09
|
| Rate for Payer: Healthscope Whirlpool |
$24.13
|
| Rate for Payer: Healthscope Whirlpool |
$18.26
|
| Rate for Payer: Mclaren Commercial |
$22.39
|
| Rate for Payer: Mclaren Commercial |
$24.47
|
| Rate for Payer: Mclaren Commercial |
$22.35
|
| Rate for Payer: Mclaren Commercial |
$16.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.00
|
| Rate for Payer: Nomi Health Commercial |
$15.43
|
| Rate for Payer: Nomi Health Commercial |
$22.30
|
| Rate for Payer: Nomi Health Commercial |
$20.40
|
| Rate for Payer: Nomi Health Commercial |
$20.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.85
|
| 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 |
$16.56
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$24.83
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.93 |
| Max. Negotiated Rate |
$24.83 |
| Rate for Payer: Aetna Commercial |
$22.35
|
| Rate for Payer: Aetna Commercial |
$24.47
|
| Rate for Payer: Aetna Commercial |
$16.94
|
| Rate for Payer: Aetna Commercial |
$22.39
|
| Rate for Payer: Aetna Medicare |
$13.60
|
| Rate for Payer: Aetna Medicare |
$12.41
|
| Rate for Payer: Aetna Medicare |
$12.44
|
| Rate for Payer: Aetna Medicare |
$9.41
|
| Rate for Payer: ASR ASR |
$24.13
|
| Rate for Payer: ASR ASR |
$18.26
|
| Rate for Payer: ASR ASR |
$26.37
|
| Rate for Payer: ASR ASR |
$24.09
|
| Rate for Payer: ASR Commercial |
$24.09
|
| Rate for Payer: ASR Commercial |
$24.13
|
| Rate for Payer: ASR Commercial |
$26.37
|
| Rate for Payer: ASR Commercial |
$18.26
|
| Rate for Payer: BCBS Complete |
$7.53
|
| Rate for Payer: BCBS Complete |
$10.88
|
| Rate for Payer: BCBS Complete |
$9.95
|
| Rate for Payer: BCBS Complete |
$9.93
|
| Rate for Payer: BCBS Trust/PPO |
$20.33
|
| Rate for Payer: BCBS Trust/PPO |
$22.27
|
| Rate for Payer: BCBS Trust/PPO |
$15.41
|
| Rate for Payer: BCBS Trust/PPO |
$20.37
|
| Rate for Payer: BCN Commercial |
$21.08
|
| Rate for Payer: BCN Commercial |
$19.25
|
| Rate for Payer: BCN Commercial |
$14.59
|
| Rate for Payer: BCN Commercial |
$19.29
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Cash Price |
$15.06
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$17.69
|
| Rate for Payer: Cofinity Commercial |
$23.34
|
| Rate for Payer: Cofinity Commercial |
$23.39
|
| Rate for Payer: Cofinity Commercial |
$25.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.86
|
| Rate for Payer: Healthscope Commercial |
$24.88
|
| Rate for Payer: Healthscope Commercial |
$18.82
|
| Rate for Payer: Healthscope Commercial |
$24.83
|
| Rate for Payer: Healthscope Commercial |
$27.19
|
| Rate for Payer: Healthscope Whirlpool |
$26.37
|
| Rate for Payer: Healthscope Whirlpool |
$24.13
|
| Rate for Payer: Healthscope Whirlpool |
$24.09
|
| Rate for Payer: Healthscope Whirlpool |
$18.26
|
| Rate for Payer: Mclaren Commercial |
$16.94
|
| Rate for Payer: Mclaren Commercial |
$22.35
|
| Rate for Payer: Mclaren Commercial |
$22.39
|
| Rate for Payer: Mclaren Commercial |
$24.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.15
|
| Rate for Payer: Nomi Health Commercial |
$20.40
|
| Rate for Payer: Nomi Health Commercial |
$20.36
|
| Rate for Payer: Nomi Health Commercial |
$22.30
|
| Rate for Payer: Nomi Health Commercial |
$15.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.49
|
| Rate for Payer: Priority Health Narrow Network |
$17.44
|
| Rate for Payer: Priority Health Narrow Network |
$17.41
|
| Rate for Payer: Priority Health Narrow Network |
$19.06
|
| Rate for Payer: Priority Health Narrow Network |
$13.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.85
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$243.20
|
|
|
Service Code
|
NDC 68382013201
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.08 |
| Max. Negotiated Rate |
$243.20 |
| Rate for Payer: Aetna Commercial |
$218.88
|
| Rate for Payer: ASR ASR |
$235.90
|
| Rate for Payer: ASR Commercial |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$198.18
|
| Rate for Payer: BCN Commercial |
$188.55
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Commercial |
$228.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$243.20
|
| Rate for Payer: Healthscope Whirlpool |
$235.90
|
| Rate for Payer: Mclaren Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.72
|
| Rate for Payer: Nomi Health Commercial |
$199.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$214.02
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$192.85
|
|
|
Service Code
|
NDC 00904640161
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.14 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna Commercial |
$173.56
|
| Rate for Payer: Aetna Medicare |
$96.42
|
| Rate for Payer: ASR ASR |
$187.06
|
| Rate for Payer: ASR Commercial |
$187.06
|
| Rate for Payer: BCBS Complete |
$77.14
|
| Rate for Payer: BCBS Trust/PPO |
$157.92
|
| Rate for Payer: BCN Commercial |
$149.52
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$181.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$192.85
|
| Rate for Payer: Healthscope Whirlpool |
$187.06
|
| Rate for Payer: Mclaren Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: Nomi Health Commercial |
$158.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$168.98
|
| Rate for Payer: Priority Health Narrow Network |
$135.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$169.71
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$192.85
|
|
|
Service Code
|
NDC 00904640161
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.35 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna Commercial |
$173.56
|
| Rate for Payer: ASR ASR |
$187.06
|
| Rate for Payer: ASR Commercial |
$187.06
|
| Rate for Payer: BCBS Trust/PPO |
$157.15
|
| Rate for Payer: BCN Commercial |
$149.52
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$181.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$192.85
|
| Rate for Payer: Healthscope Whirlpool |
$187.06
|
| Rate for Payer: Mclaren Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: Nomi Health Commercial |
$158.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$169.71
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$192.85
|
|
|
Service Code
|
NDC 00904738361
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.35 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna Commercial |
$173.56
|
| Rate for Payer: ASR ASR |
$187.06
|
| Rate for Payer: ASR Commercial |
$187.06
|
| Rate for Payer: BCBS Trust/PPO |
$157.15
|
| Rate for Payer: BCN Commercial |
$149.52
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$181.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$192.85
|
| Rate for Payer: Healthscope Whirlpool |
$187.06
|
| Rate for Payer: Mclaren Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: Nomi Health Commercial |
$158.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$169.71
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$192.85
|
|
|
Service Code
|
NDC 00904738361
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.14 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna Commercial |
$173.56
|
| Rate for Payer: Aetna Medicare |
$96.42
|
| Rate for Payer: ASR ASR |
$187.06
|
| Rate for Payer: ASR Commercial |
$187.06
|
| Rate for Payer: BCBS Complete |
$77.14
|
| Rate for Payer: BCBS Trust/PPO |
$157.92
|
| Rate for Payer: BCN Commercial |
$149.52
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$181.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$192.85
|
| Rate for Payer: Healthscope Whirlpool |
$187.06
|
| Rate for Payer: Mclaren Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: Nomi Health Commercial |
$158.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$168.98
|
| Rate for Payer: Priority Health Narrow Network |
$135.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$169.71
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$243.20
|
|
|
Service Code
|
NDC 68382013201
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.28 |
| Max. Negotiated Rate |
$243.20 |
| Rate for Payer: Aetna Commercial |
$218.88
|
| Rate for Payer: Aetna Medicare |
$121.60
|
| Rate for Payer: ASR ASR |
$235.90
|
| Rate for Payer: ASR Commercial |
$235.90
|
| Rate for Payer: BCBS Complete |
$97.28
|
| Rate for Payer: BCBS Trust/PPO |
$199.16
|
| Rate for Payer: BCN Commercial |
$188.55
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Commercial |
$228.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$243.20
|
| Rate for Payer: Healthscope Whirlpool |
$235.90
|
| Rate for Payer: Mclaren Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.72
|
| Rate for Payer: Nomi Health Commercial |
$199.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$213.09
|
| Rate for Payer: Priority Health Narrow Network |
$170.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$214.02
|
|
