|
ACETAMINOPHEN 325 MG TABLET
|
Facility
OP
|
$184.00
|
|
|
Service Code
|
NDC 0904-6773-61
|
| Hospital Charge Code |
101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.60 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Aetna Commercial |
$156.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.60
|
| Rate for Payer: BCBS Complete |
$73.60
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cofinity Commercial |
$128.80
|
| Rate for Payer: Cofinity Commercial |
$158.24
|
| Rate for Payer: Healthscope Commercial |
$165.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$156.40
|
| Rate for Payer: PHP Commercial |
$156.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.80
|
| Rate for Payer: Priority Health SBD |
$115.92
|
|
|
ACETAMINOPHEN 500 MG TABLET
|
Facility
IP
|
$124.00
|
|
|
Service Code
|
NDC 0904-6730-61
|
| Hospital Charge Code |
102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.12 |
| Max. Negotiated Rate |
$111.60 |
| Rate for Payer: Aetna Commercial |
$105.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.60
|
| Rate for Payer: Cash Price |
$99.20
|
| Rate for Payer: Cofinity Commercial |
$86.80
|
| Rate for Payer: Cofinity Commercial |
$106.64
|
| Rate for Payer: Healthscope Commercial |
$111.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$105.40
|
| Rate for Payer: PHP Commercial |
$105.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.80
|
| Rate for Payer: Priority Health SBD |
$78.12
|
|
|
ACETAMINOPHEN 500 MG TABLET
|
Facility
IP
|
$378.00
|
|
|
Service Code
|
NDC 0904-6720-40
|
| Hospital Charge Code |
102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$238.14 |
| Max. Negotiated Rate |
$340.20 |
| Rate for Payer: Aetna Commercial |
$321.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$245.70
|
| Rate for Payer: Cash Price |
$302.40
|
| Rate for Payer: Cofinity Commercial |
$264.60
|
| Rate for Payer: Cofinity Commercial |
$325.08
|
| Rate for Payer: Healthscope Commercial |
$340.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$321.30
|
| Rate for Payer: PHP Commercial |
$321.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.60
|
| Rate for Payer: Priority Health SBD |
$238.14
|
|
|
ACETAMINOPHEN 500 MG TABLET
|
Facility
IP
|
$819.00
|
|
|
Service Code
|
NDC 0904-6720-80
|
| Hospital Charge Code |
102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$737.10 |
| Rate for Payer: Aetna Commercial |
$696.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$532.35
|
| Rate for Payer: Cash Price |
$655.20
|
| Rate for Payer: Cofinity Commercial |
$573.30
|
| Rate for Payer: Cofinity Commercial |
$704.34
|
| Rate for Payer: Healthscope Commercial |
$737.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$696.15
|
| Rate for Payer: PHP Commercial |
$696.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$573.30
|
| Rate for Payer: Priority Health SBD |
$515.97
|
|
|
ACETAMINOPHEN 500 MG TABLET
|
Facility
IP
|
$144.90
|
|
|
Service Code
|
NDC 50580-457-11
|
| Hospital Charge Code |
102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.29 |
| Max. Negotiated Rate |
$130.41 |
| Rate for Payer: Aetna Commercial |
$123.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.18
|
| Rate for Payer: Cash Price |
$115.92
|
| Rate for Payer: Cofinity Commercial |
$101.43
|
| Rate for Payer: Cofinity Commercial |
$124.61
|
| Rate for Payer: Healthscope Commercial |
$130.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$123.16
|
| Rate for Payer: PHP Commercial |
$123.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.43
|
| Rate for Payer: Priority Health SBD |
$91.29
|
|
|
ACETAMINOPHEN 500 MG TABLET
|
Facility
OP
|
$1,449.00
|
|
|
Service Code
|
NDC 00450-45045
|
| Hospital Charge Code |
102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$579.60 |
| Max. Negotiated Rate |
$1,304.10 |
| Rate for Payer: Aetna Commercial |
$1,231.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$941.85
|
| Rate for Payer: BCBS Complete |
$579.60
|
| Rate for Payer: Cash Price |
$1,159.20
|
| Rate for Payer: Cofinity Commercial |
$1,014.30
|
| Rate for Payer: Cofinity Commercial |
$1,246.14
|
| Rate for Payer: Healthscope Commercial |
$1,304.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,231.65
|
| Rate for Payer: PHP Commercial |
$1,231.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,014.30
|
| Rate for Payer: Priority Health SBD |
$912.87
|
|
|
ACETAMINOPHEN 500 MG TABLET
|
Facility
IP
|
$819.00
|
|
|
Service Code
|
NDC 0904-6730-80
|
| Hospital Charge Code |
102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$737.10 |
| Rate for Payer: Aetna Commercial |
$696.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$532.35
|
| Rate for Payer: Cash Price |
$655.20
|
| Rate for Payer: Cofinity Commercial |
$573.30
|
| Rate for Payer: Cofinity Commercial |
$704.34
|
| Rate for Payer: Healthscope Commercial |
$737.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$696.15
|
| Rate for Payer: PHP Commercial |
$696.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$573.30
|
| Rate for Payer: Priority Health SBD |
$515.97
|
|
|
ACETAMINOPHEN 500 MG TABLET
|
Facility
IP
|
$1,449.00
|
|
|
Service Code
|
NDC 00450-45045
|
| Hospital Charge Code |
102
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$912.87 |
| Max. Negotiated Rate |
$1,304.10 |
| Rate for Payer: Aetna Commercial |
$1,231.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$941.85
|
| Rate for Payer: Cash Price |
$1,159.20
|
| Rate for Payer: Cofinity Commercial |
$1,014.30
|
| Rate for Payer: Cofinity Commercial |
$1,246.14
|
| Rate for Payer: Healthscope Commercial |
$1,304.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,231.65
|
| Rate for Payer: PHP Commercial |
$1,231.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,014.30
|
| Rate for Payer: Priority Health SBD |
$912.87
|
|
|
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION
|
Facility
IP
|
$5.06
|
|
|
Service Code
|
NDC 0121-1971-21
|
| Hospital Charge Code |
119323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$4.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.29
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Cofinity Commercial |
$4.35
|
| Rate for Payer: Healthscope Commercial |
$4.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.30
|
| Rate for Payer: PHP Commercial |
$4.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.54
|
| Rate for Payer: Priority Health SBD |
$3.19
|
|
|
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION
|
Facility
OP
|
$5.01
|
|
|
Service Code
|
NDC 66689-056-99
|
| Hospital Charge Code |
119323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$4.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.26
|
| Rate for Payer: BCBS Complete |
$2.00
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cofinity Commercial |
$3.51
|
| Rate for Payer: Cofinity Commercial |
$4.31
|
| Rate for Payer: Healthscope Commercial |
$4.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.26
|
| Rate for Payer: PHP Commercial |
$4.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.51
|
| Rate for Payer: Priority Health SBD |
$3.16
|
|
|
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION
|
Facility
IP
|
$5.06
|
|
|
Service Code
|
NDC 0121-1971-00
|
| Hospital Charge Code |
119323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$4.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.29
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Cofinity Commercial |
$4.35
|
| Rate for Payer: Healthscope Commercial |
$4.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.30
|
| Rate for Payer: PHP Commercial |
$4.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.54
|
| Rate for Payer: Priority Health SBD |
$3.19
|
|
|
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION
|
Facility
IP
|
$5.01
|
|
|
Service Code
|
NDC 66689-056-01
|
| Hospital Charge Code |
119323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$4.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.26
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cofinity Commercial |
$3.51
|
| Rate for Payer: Cofinity Commercial |
$4.31
|
| Rate for Payer: Healthscope Commercial |
$4.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.26
|
| Rate for Payer: PHP Commercial |
$4.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.51
|
| Rate for Payer: Priority Health SBD |
$3.16
|
|
|
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION
|
Facility
IP
|
$5.01
|
|
|
Service Code
|
NDC 66689-056-99
|
| Hospital Charge Code |
119323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$4.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.26
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cofinity Commercial |
$3.51
|
| Rate for Payer: Cofinity Commercial |
$4.31
|
| Rate for Payer: Healthscope Commercial |
$4.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.26
|
| Rate for Payer: PHP Commercial |
$4.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.51
|
| Rate for Payer: Priority Health SBD |
$3.16
|
|
|
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION
|
Facility
OP
|
$5.01
|
|
|
Service Code
|
NDC 66689-056-01
|
| Hospital Charge Code |
119323
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$4.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.26
|
| Rate for Payer: BCBS Complete |
$2.00
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cofinity Commercial |
$3.51
|
| Rate for Payer: Cofinity Commercial |
$4.31
|
| Rate for Payer: Healthscope Commercial |
$4.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.26
|
| Rate for Payer: PHP Commercial |
$4.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.51
|
| Rate for Payer: Priority Health SBD |
$3.16
|
|
|
ACETAMINOPHEN 650 MG/20.3 ML ORAL SUSPENSION
|
Facility
IP
|
$8.09
|
|
|
Service Code
|
NDC 0121-2823-94
|
| Hospital Charge Code |
88505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Aetna Commercial |
$6.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.26
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Cofinity Commercial |
$5.66
|
| Rate for Payer: Cofinity Commercial |
$6.96
|
| Rate for Payer: Healthscope Commercial |
$7.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.88
|
| Rate for Payer: PHP Commercial |
$6.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.66
|
| Rate for Payer: Priority Health SBD |
$5.10
|
|
|
ACETAMINOPHEN 650 MG/20.3 ML ORAL SUSPENSION
|
Facility
IP
|
$8.09
|
|
|
Service Code
|
NDC 0121-2823-21
|
| Hospital Charge Code |
88505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Aetna Commercial |
$6.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.26
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Cofinity Commercial |
$5.66
|
| Rate for Payer: Cofinity Commercial |
$6.96
|
| Rate for Payer: Healthscope Commercial |
$7.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.88
|
| Rate for Payer: PHP Commercial |
$6.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.66
|
| Rate for Payer: Priority Health SBD |
$5.10
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY
|
Facility
IP
|
$90.65
|
|
|
Service Code
|
NDC 45802-730-32
|
| Hospital Charge Code |
105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.11 |
| Max. Negotiated Rate |
$81.58 |
| Rate for Payer: Aetna Commercial |
$77.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.92
|
| Rate for Payer: Cash Price |
$72.52
|
| Rate for Payer: Cofinity Commercial |
$63.46
|
| Rate for Payer: Cofinity Commercial |
$77.96
|
| Rate for Payer: Healthscope Commercial |
$81.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.05
|
| Rate for Payer: PHP Commercial |
$77.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.46
|
| Rate for Payer: Priority Health SBD |
$57.11
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY
|
Facility
IP
|
$17.90
|
|
|
Service Code
|
NDC 45802-730-30
|
| Hospital Charge Code |
105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$16.11 |
| Rate for Payer: Aetna Commercial |
$15.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.64
|
| Rate for Payer: Cash Price |
$14.32
|
| Rate for Payer: Cofinity Commercial |
$12.53
|
| Rate for Payer: Cofinity Commercial |
$15.39
|
| Rate for Payer: Healthscope Commercial |
$16.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.22
|
| Rate for Payer: PHP Commercial |
$15.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.53
|
| Rate for Payer: Priority Health SBD |
$11.28
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
IP
|
$9.12
|
|
|
Service Code
|
NDC 50268-054-11
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$8.21 |
| Rate for Payer: Aetna Commercial |
$7.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.93
|
| Rate for Payer: Cash Price |
$7.30
|
| Rate for Payer: Cofinity Commercial |
$6.38
|
| Rate for Payer: Cofinity Commercial |
$7.84
|
| Rate for Payer: Healthscope Commercial |
$8.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.75
|
| Rate for Payer: PHP Commercial |
$7.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.38
|
| Rate for Payer: Priority Health SBD |
$5.75
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
IP
|
$456.00
|
|
|
Service Code
|
NDC 50268-054-15
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.28 |
| Max. Negotiated Rate |
$410.40 |
| Rate for Payer: Aetna Commercial |
$387.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.40
|
| Rate for Payer: Cash Price |
$364.80
|
| Rate for Payer: Cofinity Commercial |
$319.20
|
| Rate for Payer: Cofinity Commercial |
$392.16
|
| Rate for Payer: Healthscope Commercial |
$410.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$387.60
|
| Rate for Payer: PHP Commercial |
$387.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$319.20
|
| Rate for Payer: Priority Health SBD |
$287.28
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
IP
|
$254.60
|
|
|
Service Code
|
NDC 23155-288-01
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.40 |
| Max. Negotiated Rate |
$229.14 |
| Rate for Payer: Aetna Commercial |
$216.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.49
|
| Rate for Payer: Cash Price |
$203.68
|
| Rate for Payer: Cofinity Commercial |
$178.22
|
| Rate for Payer: Cofinity Commercial |
$218.96
|
| Rate for Payer: Healthscope Commercial |
$229.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.41
|
| Rate for Payer: PHP Commercial |
$216.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.22
|
| Rate for Payer: Priority Health SBD |
$160.40
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
IP
|
$810.67
|
|
|
Service Code
|
NDC 51672-4023-1
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$510.72 |
| Max. Negotiated Rate |
$729.60 |
| Rate for Payer: Aetna Commercial |
$689.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$526.94
|
| Rate for Payer: Cash Price |
$648.54
|
| Rate for Payer: Cofinity Commercial |
$567.47
|
| Rate for Payer: Cofinity Commercial |
$697.18
|
| Rate for Payer: Healthscope Commercial |
$729.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$689.07
|
| Rate for Payer: PHP Commercial |
$689.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$567.47
|
| Rate for Payer: Priority Health SBD |
$510.72
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION
|
Facility
IP
|
$95.19
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.97 |
| Max. Negotiated Rate |
$85.67 |
| Rate for Payer: Aetna Commercial |
$80.91
|
| Rate for Payer: Aetna Commercial |
$111.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.31
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$104.99
|
| Rate for Payer: Cofinity Commercial |
$81.86
|
| Rate for Payer: Cofinity Commercial |
$112.87
|
| Rate for Payer: Cofinity Commercial |
$91.87
|
| Rate for Payer: Cofinity Commercial |
$66.63
|
| Rate for Payer: Healthscope Commercial |
$118.12
|
| Rate for Payer: Healthscope Commercial |
$85.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$80.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$111.55
|
| Rate for Payer: PHP Commercial |
$111.55
|
| Rate for Payer: PHP Commercial |
$80.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.63
|
| Rate for Payer: Priority Health SBD |
$82.68
|
| Rate for Payer: Priority Health SBD |
$59.97
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
IP
|
$340.75
|
|
|
Service Code
|
NDC 16729-331-01
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.67 |
| Max. Negotiated Rate |
$306.68 |
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.49
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cofinity Commercial |
$238.52
|
| Rate for Payer: Cofinity Commercial |
$293.04
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$289.64
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.52
|
| Rate for Payer: Priority Health SBD |
$214.67
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
IP
|
$15.23
|
|
|
Service Code
|
NDC 60687-578-11
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$13.71 |
| Rate for Payer: Aetna Commercial |
$12.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.90
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$10.66
|
| Rate for Payer: Healthscope Commercial |
$13.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.95
|
| Rate for Payer: PHP Commercial |
$12.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.66
|
| Rate for Payer: Priority Health SBD |
$9.59
|
|
