|
SUCRALFATE 1 G PO TABS
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 5107975301
|
| Hospital Charge Code |
5107975301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.19
|
| Rate for Payer: Aetna Government |
$0.19
|
| Rate for Payer: Brighton Health Commercial |
$0.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.26
|
| Rate for Payer: EmblemHealth Commercial |
$0.19
|
| Rate for Payer: Group Health Inc Commercial |
$0.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.25
|
|
|
SUCRALFATE 1 G PO TABS
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 5107975320
|
| Hospital Charge Code |
5107975320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.19
|
|
|
SUCRALFATE 1 G PO TABS
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 5107975320
|
| Hospital Charge Code |
5107975320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.21
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.19
|
| Rate for Payer: Aetna Government |
$0.19
|
| Rate for Payer: Brighton Health Commercial |
$0.29
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.30
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.26
|
| Rate for Payer: EmblemHealth Commercial |
$0.19
|
| Rate for Payer: Group Health Inc Commercial |
$0.19
|
| Rate for Payer: Group Health Inc Medicare |
$0.13
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.19
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.19
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.25
|
|
|
SUGAMMADEX SODIUM 200 MG/2ML IV SOLN
|
Facility
|
IP
|
$77.80
|
|
|
Service Code
|
NDC 0006542312
|
| Hospital Charge Code |
0006542312
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$38.90 |
| Max. Negotiated Rate |
$38.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.90
|
|
|
SUGAMMADEX SODIUM 200 MG/2ML IV SOLN
|
Facility
|
IP
|
$77.80
|
|
|
Service Code
|
NDC 0006542302
|
| Hospital Charge Code |
0006542302
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$38.90 |
| Max. Negotiated Rate |
$38.90 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.90
|
|
|
SUGAMMADEX SODIUM 200 MG/2ML IV SOLN
|
Facility
|
OP
|
$77.80
|
|
|
Service Code
|
NDC 0006542312
|
| Hospital Charge Code |
0006542312
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$27.23 |
| Max. Negotiated Rate |
$62.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$42.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.90
|
| Rate for Payer: Aetna Government |
$38.90
|
| Rate for Payer: Brighton Health Commercial |
$58.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$62.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$52.90
|
| Rate for Payer: EmblemHealth Commercial |
$38.90
|
| Rate for Payer: Group Health Inc Commercial |
$38.90
|
| Rate for Payer: Group Health Inc Medicare |
$27.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$50.57
|
|
|
SUGAMMADEX SODIUM 200 MG/2ML IV SOLN
|
Facility
|
OP
|
$77.80
|
|
|
Service Code
|
NDC 0006542302
|
| Hospital Charge Code |
0006542302
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$27.23 |
| Max. Negotiated Rate |
$62.24 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$42.79
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$38.90
|
| Rate for Payer: Aetna Government |
$38.90
|
| Rate for Payer: Brighton Health Commercial |
$58.35
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$62.24
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$52.90
|
| Rate for Payer: EmblemHealth Commercial |
$38.90
|
| Rate for Payer: Group Health Inc Commercial |
$38.90
|
| Rate for Payer: Group Health Inc Medicare |
$27.23
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$38.90
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$38.90
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$50.57
|
|
|
SUGAMMADEX SODIUM 500 MG/5ML IV SOLN
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
NDC 0006542515
|
| Hospital Charge Code |
0006542515
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.50
|
|
|
SUGAMMADEX SODIUM 500 MG/5ML IV SOLN
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
NDC 0006542515
|
| Hospital Charge Code |
0006542515
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$28.50
|
| Rate for Payer: Aetna Government |
$28.50
|
| Rate for Payer: Brighton Health Commercial |
$42.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$38.76
|
| Rate for Payer: EmblemHealth Commercial |
$28.50
|
| Rate for Payer: Group Health Inc Commercial |
$28.50
|
| Rate for Payer: Group Health Inc Medicare |
$19.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$37.05
|
|
|
SUGAMMADEX SODIUM 500 MG/5ML IV SOLN
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
NDC 0006542505
|
| Hospital Charge Code |
0006542505
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.50
|
|
|
SUGAMMADEX SODIUM 500 MG/5ML IV SOLN
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
NDC 0006542505
|
| Hospital Charge Code |
0006542505
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$45.60 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$31.35
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$28.50
|
| Rate for Payer: Aetna Government |
$28.50
|
| Rate for Payer: Brighton Health Commercial |
$42.75
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$45.60
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$38.76
|
| Rate for Payer: EmblemHealth Commercial |
$28.50
|
| Rate for Payer: Group Health Inc Commercial |
$28.50
|
| Rate for Payer: Group Health Inc Medicare |
$19.95
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$28.50
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$28.50
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$37.05
|
|
|
SULFACETAMIDE SODIUM 10 % OP SOLN
|
Facility
|
OP
|
$4.07
|
|
|
Service Code
|
NDC 2420867004
|
| Hospital Charge Code |
2420867004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$2.24
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$2.03
|
| Rate for Payer: Aetna Government |
$2.03
|
| Rate for Payer: Brighton Health Commercial |
$3.05
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$3.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$2.77
|
| Rate for Payer: EmblemHealth Commercial |
$2.03
|
| Rate for Payer: Group Health Inc Commercial |
$2.03
|
| Rate for Payer: Group Health Inc Medicare |
$1.42
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.03
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$2.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$2.64
|
|
|
SULFACETAMIDE SODIUM 10 % OP SOLN
|
Facility
|
IP
|
$4.07
|
|
|
Service Code
|
NDC 2420867004
|
| Hospital Charge Code |
2420867004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$2.03
|
|
|
SULFADIAZINE 500 MG PO TABS
|
Facility
|
IP
|
$20.04
|
|
|
Service Code
|
NDC 4280675760
|
| Hospital Charge Code |
4280675760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.02 |
| Max. Negotiated Rate |
$10.02 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.02
|
|
|
SULFADIAZINE 500 MG PO TABS
|
Facility
|
OP
|
$20.04
|
|
|
Service Code
|
NDC 4280675760
|
| Hospital Charge Code |
4280675760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$16.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$11.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$10.02
|
| Rate for Payer: Aetna Government |
$10.02
|
| Rate for Payer: Brighton Health Commercial |
$15.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$16.03
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$13.63
|
| Rate for Payer: EmblemHealth Commercial |
$10.02
|
| Rate for Payer: Group Health Inc Commercial |
$10.02
|
| Rate for Payer: Group Health Inc Medicare |
$7.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$10.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$10.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$13.02
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 0121085416
|
| Hospital Charge Code |
0121085416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.12
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 0121085340
|
| Hospital Charge Code |
0121085340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.45
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 0121085340
|
| Hospital Charge Code |
0121085340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.49
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.45
|
| Rate for Payer: Aetna Government |
$0.45
|
| Rate for Payer: Brighton Health Commercial |
$0.67
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.72
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.61
|
| Rate for Payer: EmblemHealth Commercial |
$0.45
|
| Rate for Payer: Group Health Inc Commercial |
$0.45
|
| Rate for Payer: Group Health Inc Medicare |
$0.31
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.45
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.58
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 5038382416
|
| Hospital Charge Code |
5038382416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.25
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.23
|
| Rate for Payer: Aetna Government |
$0.23
|
| Rate for Payer: Brighton Health Commercial |
$0.34
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.36
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.31
|
| Rate for Payer: EmblemHealth Commercial |
$0.23
|
| Rate for Payer: Group Health Inc Commercial |
$0.23
|
| Rate for Payer: Group Health Inc Medicare |
$0.16
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.23
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.23
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.30
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 5038382416
|
| Hospital Charge Code |
5038382416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.23
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 0121085416
|
| Hospital Charge Code |
0121085416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.13
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna Government |
$0.12
|
| Rate for Payer: Brighton Health Commercial |
$0.18
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.19
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.16
|
| Rate for Payer: EmblemHealth Commercial |
$0.12
|
| Rate for Payer: Group Health Inc Commercial |
$0.12
|
| Rate for Payer: Group Health Inc Medicare |
$0.08
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.12
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.12
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.16
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 0703951403
|
| Hospital Charge Code |
0703951403
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.75
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 7006936201
|
| Hospital Charge Code |
7006936201
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.76
|
| Rate for Payer: Aetna Government |
$0.76
|
| Rate for Payer: Brighton Health Commercial |
$1.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.03
|
| Rate for Payer: EmblemHealth Commercial |
$0.76
|
| Rate for Payer: Group Health Inc Commercial |
$0.76
|
| Rate for Payer: Group Health Inc Medicare |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.99
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 7006936210
|
| Hospital Charge Code |
7006936210
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.84
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.76
|
| Rate for Payer: Aetna Government |
$0.76
|
| Rate for Payer: Brighton Health Commercial |
$1.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.22
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.03
|
| Rate for Payer: EmblemHealth Commercial |
$0.76
|
| Rate for Payer: Group Health Inc Commercial |
$0.76
|
| Rate for Payer: Group Health Inc Medicare |
$0.53
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.99
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN
|
Facility
|
IP
|
$1.25
|
|
|
Service Code
|
NDC 0703951401
|
| Hospital Charge Code |
0703951401
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.63
|
|
