|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$467.04
|
|
|
Service Code
|
NDC 50268005415
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.24 |
| Max. Negotiated Rate |
$420.34 |
| Rate for Payer: Aetna Commercial |
$396.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$303.58
|
| Rate for Payer: Cash Price |
$373.63
|
| Rate for Payer: Cofinity Commercial |
$326.93
|
| Rate for Payer: Cofinity Commercial |
$401.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$326.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$373.63
|
| Rate for Payer: Healthscope Commercial |
$420.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$396.98
|
| Rate for Payer: PHP Commercial |
$396.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$303.58
|
| Rate for Payer: Priority Health SBD |
$294.24
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$309.70
|
|
|
Service Code
|
NDC 23155028801
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.88 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna Commercial |
$263.24
|
| Rate for Payer: Aetna Medicare |
$154.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.30
|
| Rate for Payer: BCBS Complete |
$123.88
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.24
|
| Rate for Payer: PHP Commercial |
$263.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.30
|
| Rate for Payer: Priority Health SBD |
$195.11
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$309.70
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.11 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna Commercial |
$263.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.30
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.24
|
| Rate for Payer: PHP Commercial |
$263.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.30
|
| Rate for Payer: Priority Health SBD |
$195.11
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$309.70
|
|
|
Service Code
|
NDC 23155028801
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.11 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna Commercial |
$263.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.30
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.24
|
| Rate for Payer: PHP Commercial |
$263.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.30
|
| Rate for Payer: Priority Health SBD |
$195.11
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$309.70
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.88 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna Commercial |
$263.24
|
| Rate for Payer: Aetna Medicare |
$154.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.30
|
| Rate for Payer: BCBS Complete |
$123.88
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.24
|
| Rate for Payer: PHP Commercial |
$263.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.30
|
| Rate for Payer: Priority Health SBD |
$195.11
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$9.35
|
|
|
Service Code
|
NDC 50268005411
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.08
|
| Rate for Payer: Cash Price |
$7.48
|
| Rate for Payer: Cofinity Commercial |
$6.54
|
| Rate for Payer: Cofinity Commercial |
$8.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.48
|
| Rate for Payer: Healthscope Commercial |
$8.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.95
|
| Rate for Payer: PHP Commercial |
$7.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.08
|
| Rate for Payer: Priority Health SBD |
$5.89
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$9.35
|
|
|
Service Code
|
NDC 50268005411
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Aetna Medicare |
$4.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.08
|
| Rate for Payer: BCBS Complete |
$3.74
|
| Rate for Payer: Cash Price |
$7.48
|
| Rate for Payer: Cofinity Commercial |
$6.54
|
| Rate for Payer: Cofinity Commercial |
$8.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.48
|
| Rate for Payer: Healthscope Commercial |
$8.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.95
|
| Rate for Payer: PHP Commercial |
$7.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.08
|
| Rate for Payer: Priority Health SBD |
$5.89
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$121.04
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.42 |
| Max. Negotiated Rate |
$108.94 |
| Rate for Payer: Aetna Commercial |
$102.88
|
| Rate for Payer: Aetna Medicare |
$60.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.68
|
| Rate for Payer: BCBS Complete |
$48.42
|
| Rate for Payer: BCBS Trust/PPO |
$66.79
|
| Rate for Payer: BCN Commercial |
$66.79
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cofinity Commercial |
$104.09
|
| Rate for Payer: Cofinity Commercial |
$84.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$84.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.83
|
| Rate for Payer: Healthscope Commercial |
$108.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.88
|
| Rate for Payer: PHP Commercial |
$102.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.68
|
| Rate for Payer: Priority Health SBD |
$76.26
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$121.04
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.26 |
| Max. Negotiated Rate |
$108.94 |
| Rate for Payer: Aetna Commercial |
$102.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.68
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cofinity Commercial |
$104.09
|
| Rate for Payer: Cofinity Commercial |
$84.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$84.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.83
|
| Rate for Payer: Healthscope Commercial |
$108.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.88
|
| Rate for Payer: PHP Commercial |
$102.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.68
|
| Rate for Payer: Priority Health SBD |
$76.26
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$15.50
|
|
|
Service Code
|
NDC 60687057811
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.20 |
| Max. Negotiated Rate |
$13.95 |
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna Medicare |
$7.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: BCBS Complete |
$6.20
|
| Rate for Payer: Cash Price |
$12.40
|
| Rate for Payer: Cofinity Commercial |
$10.85
|
| Rate for Payer: Cofinity Commercial |
$13.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.40
|
| Rate for Payer: Healthscope Commercial |
$13.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.18
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.08
|
| Rate for Payer: Priority Health SBD |
$9.76
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$444.60
|
|
|
Service Code
|
NDC 50742023301
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$280.10 |
| Max. Negotiated Rate |
$400.14 |
| Rate for Payer: Aetna Commercial |
$377.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.99
|
| Rate for Payer: Cash Price |
$355.68
|
| Rate for Payer: Cofinity Commercial |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$311.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.68
|
| Rate for Payer: Healthscope Commercial |
$400.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.91
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.99
|
| Rate for Payer: Priority Health SBD |
$280.10
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$555.84
|
|
|
Service Code
|
NDC 23155012001
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$350.18 |
| Max. Negotiated Rate |
$500.26 |
| Rate for Payer: Aetna Commercial |
$472.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$361.30
|
| Rate for Payer: Cash Price |
$444.67
|
| Rate for Payer: Cofinity Commercial |
$389.09
|
| Rate for Payer: Cofinity Commercial |
$478.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$389.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$444.67
|
| Rate for Payer: Healthscope Commercial |
$500.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$472.46
|
| Rate for Payer: PHP Commercial |
$472.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$361.30
|
| Rate for Payer: Priority Health SBD |
$350.18
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$244.15
|
|
|
Service Code
|
NDC 42571024301
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.66 |
| Max. Negotiated Rate |
$219.74 |
| Rate for Payer: Aetna Commercial |
$207.53
|
| Rate for Payer: Aetna Medicare |
$122.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.70
|
| Rate for Payer: BCBS Complete |
$97.66
|
| Rate for Payer: Cash Price |
$195.32
|
| Rate for Payer: Cofinity Commercial |
$170.90
|
| Rate for Payer: Cofinity Commercial |
$209.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$170.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.32
|
| Rate for Payer: Healthscope Commercial |
$219.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.53
|
| Rate for Payer: PHP Commercial |
$207.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.70
|
| Rate for Payer: Priority Health SBD |
$153.81
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$555.84
|
|
|
Service Code
|
NDC 23155012001
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$222.34 |
| Max. Negotiated Rate |
$500.26 |
| Rate for Payer: Aetna Commercial |
$472.46
|
| Rate for Payer: Aetna Medicare |
$277.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$361.30
|
| Rate for Payer: BCBS Complete |
$222.34
|
| Rate for Payer: Cash Price |
$444.67
|
| Rate for Payer: Cofinity Commercial |
$389.09
|
| Rate for Payer: Cofinity Commercial |
$478.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$389.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$444.67
|
| Rate for Payer: Healthscope Commercial |
$500.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$472.46
|
| Rate for Payer: PHP Commercial |
$472.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$361.30
|
| Rate for Payer: Priority Health SBD |
$350.18
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$244.15
|
|
|
Service Code
|
NDC 42571024301
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.81 |
| Max. Negotiated Rate |
$219.74 |
| Rate for Payer: Aetna Commercial |
$207.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.70
|
| Rate for Payer: Cash Price |
$195.32
|
| Rate for Payer: Cofinity Commercial |
$170.90
|
| Rate for Payer: Cofinity Commercial |
$209.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$170.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.32
|
| Rate for Payer: Healthscope Commercial |
$219.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.53
|
| Rate for Payer: PHP Commercial |
$207.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.70
|
| Rate for Payer: Priority Health SBD |
$153.81
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$464.98
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.99 |
| Max. Negotiated Rate |
$418.48 |
| Rate for Payer: Aetna Commercial |
$395.23
|
| Rate for Payer: Aetna Medicare |
$232.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.24
|
| Rate for Payer: BCBS Complete |
$185.99
|
| Rate for Payer: Cash Price |
$371.98
|
| Rate for Payer: Cofinity Commercial |
$325.49
|
| Rate for Payer: Cofinity Commercial |
$399.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$325.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$371.98
|
| Rate for Payer: Healthscope Commercial |
$418.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.23
|
| Rate for Payer: PHP Commercial |
$395.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$302.24
|
| Rate for Payer: Priority Health SBD |
$292.94
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$15.50
|
|
|
Service Code
|
NDC 60687057811
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.76 |
| Max. Negotiated Rate |
$13.95 |
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: Cash Price |
$12.40
|
| Rate for Payer: Cofinity Commercial |
$10.85
|
| Rate for Payer: Cofinity Commercial |
$13.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.40
|
| Rate for Payer: Healthscope Commercial |
$13.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.18
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.08
|
| Rate for Payer: Priority Health SBD |
$9.76
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$444.60
|
|
|
Service Code
|
NDC 50742023301
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.84 |
| Max. Negotiated Rate |
$400.14 |
| Rate for Payer: Aetna Commercial |
$377.91
|
| Rate for Payer: Aetna Medicare |
$222.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.99
|
| Rate for Payer: BCBS Complete |
$177.84
|
| Rate for Payer: Cash Price |
$355.68
|
| Rate for Payer: Cofinity Commercial |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$311.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.68
|
| Rate for Payer: Healthscope Commercial |
$400.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.91
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.99
|
| Rate for Payer: Priority Health SBD |
$280.10
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 16729033101
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.80 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.51
|
| Rate for Payer: Priority Health SBD |
$242.80
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$385.40
|
|
|
Service Code
|
NDC 16729033101
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.16 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna Medicare |
$192.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: BCBS Complete |
$154.16
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.51
|
| Rate for Payer: Priority Health SBD |
$242.80
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$464.98
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$292.94 |
| Max. Negotiated Rate |
$418.48 |
| Rate for Payer: Aetna Commercial |
$395.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.24
|
| Rate for Payer: Cash Price |
$371.98
|
| Rate for Payer: Cofinity Commercial |
$325.49
|
| Rate for Payer: Cofinity Commercial |
$399.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$325.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$371.98
|
| Rate for Payer: Healthscope Commercial |
$418.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.23
|
| Rate for Payer: PHP Commercial |
$395.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$302.24
|
| Rate for Payer: Priority Health SBD |
$292.94
|
|
|
ACETIC ACID (BULK) 3 % LIQUID
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
NDC 51552005106
|
| Hospital Charge Code |
15091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.96 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna Commercial |
$163.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$124.80
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Cofinity Commercial |
$134.40
|
| Rate for Payer: Cofinity Commercial |
$165.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.60
|
| Rate for Payer: Healthscope Commercial |
$172.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.20
|
| Rate for Payer: PHP Commercial |
$163.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.80
|
| Rate for Payer: Priority Health SBD |
$120.96
|
|
|
ACETIC ACID (BULK) 3 % LIQUID
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
NDC 51552005106
|
| Hospital Charge Code |
15091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.80 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna Commercial |
$163.20
|
| Rate for Payer: Aetna Medicare |
$96.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$124.80
|
| Rate for Payer: BCBS Complete |
$76.80
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Cofinity Commercial |
$134.40
|
| Rate for Payer: Cofinity Commercial |
$165.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.60
|
| Rate for Payer: Healthscope Commercial |
$172.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.20
|
| Rate for Payer: PHP Commercial |
$163.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.80
|
| Rate for Payer: Priority Health SBD |
$120.96
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$130.43
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$117.39 |
| Rate for Payer: Aetna Commercial |
$110.87
|
| Rate for Payer: Aetna Commercial |
$133.11
|
| Rate for Payer: Aetna Commercial |
$146.05
|
| Rate for Payer: Aetna Commercial |
$575.48
|
| Rate for Payer: Aetna Commercial |
$80.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$111.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$440.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.79
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$125.28
|
| Rate for Payer: Cash Price |
$541.62
|
| Rate for Payer: Cash Price |
$137.46
|
| Rate for Payer: Cash Price |
$104.34
|
| Rate for Payer: Cofinity Commercial |
$109.62
|
| Rate for Payer: Cofinity Commercial |
$112.17
|
| Rate for Payer: Cofinity Commercial |
$91.30
|
| Rate for Payer: Cofinity Commercial |
$81.86
|
| Rate for Payer: Cofinity Commercial |
$66.63
|
| Rate for Payer: Cofinity Commercial |
$134.68
|
| Rate for Payer: Cofinity Commercial |
$582.25
|
| Rate for Payer: Cofinity Commercial |
$473.92
|
| Rate for Payer: Cofinity Commercial |
$120.27
|
| Rate for Payer: Cofinity Commercial |
$147.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$120.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$473.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$137.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$541.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.15
|
| Rate for Payer: Healthscope Commercial |
$154.64
|
| Rate for Payer: Healthscope Commercial |
$140.94
|
| Rate for Payer: Healthscope Commercial |
$117.39
|
| Rate for Payer: Healthscope Commercial |
$609.33
|
| Rate for Payer: Healthscope Commercial |
$85.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$575.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$133.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.87
|
| Rate for Payer: PHP Commercial |
$575.48
|
| Rate for Payer: PHP Commercial |
$80.91
|
| Rate for Payer: PHP Commercial |
$146.05
|
| Rate for Payer: PHP Commercial |
$133.11
|
| Rate for Payer: PHP Commercial |
$110.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$440.07
|
| Rate for Payer: Priority Health SBD |
$426.53
|
| Rate for Payer: Priority Health SBD |
$98.66
|
| Rate for Payer: Priority Health SBD |
$108.25
|
| Rate for Payer: Priority Health SBD |
$82.17
|
| Rate for Payer: Priority Health SBD |
$59.97
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$171.82
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$154.64 |
| Rate for Payer: Aetna Commercial |
$146.05
|
| Rate for Payer: Aetna Commercial |
$80.91
|
| Rate for Payer: Aetna Commercial |
$110.87
|
| Rate for Payer: Aetna Commercial |
$575.48
|
| Rate for Payer: Aetna Commercial |
$133.11
|
| Rate for Payer: Aetna Medicare |
$338.52
|
| Rate for Payer: Aetna Medicare |
$85.91
|
| Rate for Payer: Aetna Medicare |
$65.22
|
| Rate for Payer: Aetna Medicare |
$78.30
|
| Rate for Payer: Aetna Medicare |
$47.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$440.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$111.68
|
| Rate for Payer: BCBS Complete |
$52.17
|
| Rate for Payer: BCBS Complete |
$38.08
|
| Rate for Payer: BCBS Complete |
$68.73
|
| Rate for Payer: BCBS Complete |
$270.81
|
| Rate for Payer: BCBS Complete |
$62.64
|
| Rate for Payer: BCBS Trust/PPO |
$1.58
|
| Rate for Payer: BCBS Trust/PPO |
$1.58
|
| Rate for Payer: BCBS Trust/PPO |
$1.58
|
| Rate for Payer: BCBS Trust/PPO |
$1.58
|
| Rate for Payer: BCBS Trust/PPO |
$1.58
|
| Rate for Payer: BCN Commercial |
$1.58
|
| Rate for Payer: BCN Commercial |
$1.58
|
| Rate for Payer: BCN Commercial |
$1.58
|
| Rate for Payer: BCN Commercial |
$1.58
|
| Rate for Payer: BCN Commercial |
$1.58
|
| Rate for Payer: Cash Price |
$541.62
|
| Rate for Payer: Cash Price |
$104.34
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$137.46
|
| Rate for Payer: Cash Price |
$125.28
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$125.28
|
| Rate for Payer: Cash Price |
$137.46
|
| Rate for Payer: Cash Price |
$104.34
|
| Rate for Payer: Cash Price |
$541.62
|
| Rate for Payer: Cofinity Commercial |
$81.86
|
| Rate for Payer: Cofinity Commercial |
$66.63
|
| Rate for Payer: Cofinity Commercial |
$112.17
|
| Rate for Payer: Cofinity Commercial |
$91.30
|
| Rate for Payer: Cofinity Commercial |
$109.62
|
| Rate for Payer: Cofinity Commercial |
$134.68
|
| Rate for Payer: Cofinity Commercial |
$120.27
|
| Rate for Payer: Cofinity Commercial |
$147.77
|
| Rate for Payer: Cofinity Commercial |
$473.92
|
| Rate for Payer: Cofinity Commercial |
$582.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$120.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$473.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$109.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$137.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$541.62
|
| Rate for Payer: Healthscope Commercial |
$154.64
|
| Rate for Payer: Healthscope Commercial |
$85.67
|
| Rate for Payer: Healthscope Commercial |
$140.94
|
| Rate for Payer: Healthscope Commercial |
$609.33
|
| Rate for Payer: Healthscope Commercial |
$117.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$133.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$575.48
|
| Rate for Payer: PHP Commercial |
$80.91
|
| Rate for Payer: PHP Commercial |
$110.87
|
| Rate for Payer: PHP Commercial |
$146.05
|
| Rate for Payer: PHP Commercial |
$133.11
|
| Rate for Payer: PHP Commercial |
$575.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$440.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.78
|
| Rate for Payer: Priority Health SBD |
$98.66
|
| Rate for Payer: Priority Health SBD |
$108.25
|
| Rate for Payer: Priority Health SBD |
$82.17
|
| Rate for Payer: Priority Health SBD |
$59.97
|
| Rate for Payer: Priority Health SBD |
$426.53
|
|
