|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$7.80
|
|
|
Service Code
|
NDC 50268005411
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$7.02 |
| Rate for Payer: Aetna Commercial |
$6.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.07
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cofinity Advantage |
$5.46
|
| Rate for Payer: Cofinity Commercial |
$6.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Healthscope Commercial |
$7.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.85
|
| Rate for Payer: PHP Commercial |
$6.63
|
| Rate for Payer: Priority Health SBD |
$4.91
|
|
|
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 |
$263.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.31
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Advantage |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| 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 |
$263.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.28
|
| Rate for Payer: PHP Commercial |
$263.25
|
| Rate for Payer: Priority Health SBD |
$195.11
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$389.98
|
|
|
Service Code
|
NDC 50268005415
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.26 |
| Max. Negotiated Rate |
$350.98 |
| Rate for Payer: Aetna Commercial |
$331.48
|
| Rate for Payer: Aetna Medicare |
$194.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.49
|
| Rate for Payer: BCBS Complete |
$155.99
|
| Rate for Payer: Cash Price |
$311.98
|
| Rate for Payer: Cofinity Advantage |
$272.99
|
| Rate for Payer: Cofinity Commercial |
$335.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.98
|
| Rate for Payer: Healthscope Commercial |
$350.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$311.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.49
|
| Rate for Payer: PHP Commercial |
$331.48
|
| Rate for Payer: Priority Health SBD |
$245.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$253.49
|
| Rate for Payer: UHC Core |
$203.18
|
| Rate for Payer: UHC Exchange |
$153.26
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$389.98
|
|
|
Service Code
|
NDC 50268005415
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.69 |
| Max. Negotiated Rate |
$350.98 |
| Rate for Payer: Aetna Commercial |
$331.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.49
|
| Rate for Payer: Cash Price |
$311.98
|
| Rate for Payer: Cofinity Advantage |
$272.99
|
| Rate for Payer: Cofinity Commercial |
$335.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.98
|
| Rate for Payer: Healthscope Commercial |
$350.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.49
|
| Rate for Payer: PHP Commercial |
$331.48
|
| Rate for Payer: Priority Health SBD |
$245.69
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$309.70
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.71 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna Commercial |
$263.25
|
| Rate for Payer: Aetna Medicare |
$154.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.31
|
| Rate for Payer: BCBS Complete |
$123.88
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Advantage |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$247.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.28
|
| Rate for Payer: PHP Commercial |
$263.25
|
| Rate for Payer: Priority Health SBD |
$195.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$201.31
|
| Rate for Payer: UHC Core |
$161.35
|
| Rate for Payer: UHC Exchange |
$121.71
|
|
|
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 |
$263.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.31
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Advantage |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| 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 |
$263.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.28
|
| Rate for Payer: PHP Commercial |
$263.25
|
| Rate for Payer: Priority Health SBD |
$195.11
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$309.70
|
|
|
Service Code
|
NDC 23155028801
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.71 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna Commercial |
$263.25
|
| Rate for Payer: Aetna Medicare |
$154.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.31
|
| Rate for Payer: BCBS Complete |
$123.88
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Advantage |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$247.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.28
|
| Rate for Payer: PHP Commercial |
$263.25
|
| Rate for Payer: Priority Health SBD |
$195.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$201.31
|
| Rate for Payer: UHC Core |
$161.35
|
| Rate for Payer: UHC Exchange |
$121.71
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$7.80
|
|
|
Service Code
|
NDC 50268005411
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$7.02 |
| Rate for Payer: Aetna Commercial |
$6.63
|
| Rate for Payer: Aetna Medicare |
$3.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.07
|
| Rate for Payer: BCBS Complete |
$3.12
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cofinity Advantage |
$5.46
|
| Rate for Payer: Cofinity Commercial |
$6.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Healthscope Commercial |
$7.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.85
|
| Rate for Payer: PHP Commercial |
$6.63
|
| Rate for Payer: Priority Health SBD |
$4.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.07
|
| Rate for Payer: UHC Core |
$4.06
|
| Rate for Payer: UHC Exchange |
$3.07
|
|
|
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 Commercial |
$101.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.75
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cofinity Advantage |
$84.73
|
| Rate for Payer: Cofinity Advantage |
$83.73
|
| Rate for Payer: Cofinity Commercial |
$102.87
|
| Rate for Payer: Cofinity Commercial |
$104.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.70
|
| Rate for Payer: Healthscope Commercial |
$108.94
|
| Rate for Payer: Healthscope Commercial |
$107.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$90.78
|
| Rate for Payer: PHP Commercial |
$101.68
|
| Rate for Payer: PHP Commercial |
$102.88
|
| Rate for Payer: Priority Health SBD |
$76.26
|
| Rate for Payer: Priority Health SBD |
$75.36
|
|
|
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 |
$42.22 |
| Max. Negotiated Rate |
$108.94 |
| Rate for Payer: Aetna Commercial |
$102.88
|
| Rate for Payer: Aetna Commercial |
$101.68
|
| Rate for Payer: Aetna Medicare |
$59.81
|
| Rate for Payer: Aetna Medicare |
$60.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.75
|
| Rate for Payer: BCBS Complete |
$47.85
|
| Rate for Payer: BCBS Complete |
$48.42
|
| Rate for Payer: BCBS Trust/PPO |
$64.19
|
| Rate for Payer: BCBS Trust/PPO |
$64.19
|
| Rate for Payer: BCN Commercial |
$64.19
|
| Rate for Payer: BCN Commercial |
$64.19
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cofinity Advantage |
$84.73
|
| Rate for Payer: Cofinity Advantage |
$83.73
|
| Rate for Payer: Cofinity Commercial |
$104.09
|
| Rate for Payer: Cofinity Commercial |
$102.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.83
|
| Rate for Payer: Healthscope Commercial |
$107.66
|
| Rate for Payer: Healthscope Commercial |
$108.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$96.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$90.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.72
|
| Rate for Payer: PHP Commercial |
$102.88
|
| Rate for Payer: PHP Commercial |
$101.68
|
| Rate for Payer: Priority Health SBD |
$76.26
|
| Rate for Payer: Priority Health SBD |
$75.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.22
|
| Rate for Payer: UHC Core |
$42.22
|
| Rate for Payer: UHC Core |
$42.22
|
| Rate for Payer: UHC Exchange |
$42.22
|
| Rate for Payer: UHC Exchange |
$42.22
|
|
|
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 Advantage |
$389.09
|
| Rate for Payer: Cofinity Commercial |
$478.02
|
| 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: Opus (Opus Packaging Group) HMA |
$416.88
|
| Rate for Payer: PHP Commercial |
$472.46
|
| Rate for Payer: Priority Health SBD |
$350.18
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$283.10
|
|
|
Service Code
|
NDC 42571024301
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.26 |
| Max. Negotiated Rate |
$254.79 |
| Rate for Payer: Aetna Commercial |
$240.63
|
| Rate for Payer: Aetna Medicare |
$141.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.01
|
| Rate for Payer: BCBS Complete |
$113.24
|
| Rate for Payer: Cash Price |
$226.48
|
| Rate for Payer: Cofinity Advantage |
$198.17
|
| Rate for Payer: Cofinity Commercial |
$243.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$226.48
|
| Rate for Payer: Healthscope Commercial |
$254.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$226.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$240.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$212.32
|
| Rate for Payer: PHP Commercial |
$240.63
|
| Rate for Payer: Priority Health SBD |
$178.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$184.01
|
| Rate for Payer: UHC Core |
$147.50
|
| Rate for Payer: UHC Exchange |
$111.26
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$505.94
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$318.74 |
| Max. Negotiated Rate |
$455.35 |
| Rate for Payer: Aetna Commercial |
$430.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$328.86
|
| Rate for Payer: Cash Price |
$404.75
|
| Rate for Payer: Cofinity Advantage |
$354.16
|
| Rate for Payer: Cofinity Commercial |
$435.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$404.75
|
| Rate for Payer: Healthscope Commercial |
$455.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$430.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$379.45
|
| Rate for Payer: PHP Commercial |
$430.05
|
| Rate for Payer: Priority Health SBD |
$318.74
|
|
|
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 Advantage |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| 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: Opus (Opus Packaging Group) HMA |
$333.45
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health SBD |
$280.10
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$441.75
|
|
|
Service Code
|
NDC 16729033101
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.61 |
| Max. Negotiated Rate |
$397.57 |
| Rate for Payer: Aetna Commercial |
$375.49
|
| Rate for Payer: Aetna Medicare |
$220.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.14
|
| Rate for Payer: BCBS Complete |
$176.70
|
| Rate for Payer: Cash Price |
$353.40
|
| Rate for Payer: Cofinity Advantage |
$309.23
|
| Rate for Payer: Cofinity Commercial |
$379.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.40
|
| Rate for Payer: Healthscope Commercial |
$397.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$353.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$331.31
|
| Rate for Payer: PHP Commercial |
$375.49
|
| Rate for Payer: Priority Health SBD |
$278.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$287.14
|
| Rate for Payer: UHC Core |
$230.15
|
| Rate for Payer: UHC Exchange |
$173.61
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$505.94
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.83 |
| Max. Negotiated Rate |
$455.35 |
| Rate for Payer: Aetna Commercial |
$430.05
|
| Rate for Payer: Aetna Medicare |
$252.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$328.86
|
| Rate for Payer: BCBS Complete |
$202.38
|
| Rate for Payer: Cash Price |
$404.75
|
| Rate for Payer: Cofinity Advantage |
$354.16
|
| Rate for Payer: Cofinity Commercial |
$435.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$404.75
|
| Rate for Payer: Healthscope Commercial |
$455.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$404.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$430.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$379.45
|
| Rate for Payer: PHP Commercial |
$430.05
|
| Rate for Payer: Priority Health SBD |
$318.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$328.86
|
| Rate for Payer: UHC Core |
$263.59
|
| Rate for Payer: UHC Exchange |
$198.83
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$283.10
|
|
|
Service Code
|
NDC 42571024301
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.35 |
| Max. Negotiated Rate |
$254.79 |
| Rate for Payer: Aetna Commercial |
$240.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.01
|
| Rate for Payer: Cash Price |
$226.48
|
| Rate for Payer: Cofinity Advantage |
$198.17
|
| Rate for Payer: Cofinity Commercial |
$243.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$226.48
|
| Rate for Payer: Healthscope Commercial |
$254.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$240.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$212.32
|
| Rate for Payer: PHP Commercial |
$240.63
|
| Rate for Payer: Priority Health SBD |
$178.35
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$441.75
|
|
|
Service Code
|
NDC 16729033101
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.30 |
| Max. Negotiated Rate |
$397.57 |
| Rate for Payer: Aetna Commercial |
$375.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.14
|
| Rate for Payer: Cash Price |
$353.40
|
| Rate for Payer: Cofinity Advantage |
$309.23
|
| Rate for Payer: Cofinity Commercial |
$379.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.40
|
| Rate for Payer: Healthscope Commercial |
$397.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$331.31
|
| Rate for Payer: PHP Commercial |
$375.49
|
| Rate for Payer: Priority Health SBD |
$278.30
|
|
|
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 |
$218.45 |
| 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 Advantage |
$389.09
|
| Rate for Payer: Cofinity Commercial |
$478.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$444.67
|
| Rate for Payer: Healthscope Commercial |
$500.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$444.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$472.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$416.88
|
| Rate for Payer: PHP Commercial |
$472.46
|
| Rate for Payer: Priority Health SBD |
$350.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$361.30
|
| Rate for Payer: UHC Core |
$289.59
|
| Rate for Payer: UHC Exchange |
$218.45
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$16.87
|
|
|
Service Code
|
NDC 60687057811
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna Commercial |
$14.34
|
| Rate for Payer: Aetna Medicare |
$8.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.97
|
| Rate for Payer: BCBS Complete |
$6.75
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cofinity Advantage |
$11.81
|
| Rate for Payer: Cofinity Commercial |
$14.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.50
|
| Rate for Payer: Healthscope Commercial |
$15.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.65
|
| Rate for Payer: PHP Commercial |
$14.34
|
| Rate for Payer: Priority Health SBD |
$10.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.97
|
| Rate for Payer: UHC Core |
$8.79
|
| Rate for Payer: UHC Exchange |
$6.63
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$16.87
|
|
|
Service Code
|
NDC 60687057811
|
| Hospital Charge Code |
8962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna Commercial |
$14.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.97
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cofinity Advantage |
$11.81
|
| Rate for Payer: Cofinity Commercial |
$14.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.50
|
| Rate for Payer: Healthscope Commercial |
$15.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.65
|
| Rate for Payer: PHP Commercial |
$14.34
|
| Rate for Payer: Priority Health SBD |
$10.63
|
|
|
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 |
$174.73 |
| 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 Advantage |
$311.22
|
| Rate for Payer: Cofinity Commercial |
$382.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.68
|
| Rate for Payer: Healthscope Commercial |
$400.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$355.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$333.45
|
| Rate for Payer: PHP Commercial |
$377.91
|
| Rate for Payer: Priority Health SBD |
$280.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$288.99
|
| Rate for Payer: UHC Core |
$231.64
|
| Rate for Payer: UHC Exchange |
$174.73
|
|
|
ACETIC ACID (BULK) 3 % LIQUID
|
Facility
|
OP
|
$258.00
|
|
|
Service Code
|
NDC 51552005106
|
| Hospital Charge Code |
15091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.39 |
| Max. Negotiated Rate |
$232.20 |
| Rate for Payer: Aetna Commercial |
$219.30
|
| Rate for Payer: Aetna Medicare |
$129.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.70
|
| Rate for Payer: BCBS Complete |
$103.20
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cofinity Advantage |
$180.60
|
| Rate for Payer: Cofinity Commercial |
$221.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.40
|
| Rate for Payer: Healthscope Commercial |
$232.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$206.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$193.50
|
| Rate for Payer: PHP Commercial |
$219.30
|
| Rate for Payer: Priority Health SBD |
$162.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$167.70
|
| Rate for Payer: UHC Core |
$134.42
|
| Rate for Payer: UHC Exchange |
$101.39
|
|
|
ACETIC ACID (BULK) 3 % LIQUID
|
Facility
|
IP
|
$258.00
|
|
|
Service Code
|
NDC 51552005106
|
| Hospital Charge Code |
15091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.54 |
| Max. Negotiated Rate |
$232.20 |
| Rate for Payer: Aetna Commercial |
$219.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.70
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cofinity Advantage |
$180.60
|
| Rate for Payer: Cofinity Commercial |
$221.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.40
|
| Rate for Payer: Healthscope Commercial |
$232.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$193.50
|
| Rate for Payer: PHP Commercial |
$219.30
|
| Rate for Payer: Priority Health SBD |
$162.54
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$95.19
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$85.67 |
| Rate for Payer: Aetna Commercial |
$80.91
|
| Rate for Payer: Aetna Commercial |
$66.95
|
| Rate for Payer: Aetna Commercial |
$131.18
|
| Rate for Payer: Aetna Commercial |
$72.97
|
| Rate for Payer: Aetna Commercial |
$87.49
|
| Rate for Payer: Aetna Medicare |
$51.47
|
| Rate for Payer: Aetna Medicare |
$77.17
|
| Rate for Payer: Aetna Medicare |
$39.38
|
| Rate for Payer: Aetna Medicare |
$47.59
|
| Rate for Payer: Aetna Medicare |
$42.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$55.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.90
|
| Rate for Payer: BCBS Complete |
$38.08
|
| Rate for Payer: BCBS Complete |
$61.73
|
| Rate for Payer: BCBS Complete |
$31.51
|
| Rate for Payer: BCBS Complete |
$41.17
|
| Rate for Payer: BCBS Complete |
$34.34
|
| Rate for Payer: BCBS Trust/PPO |
$0.91
|
| Rate for Payer: BCBS Trust/PPO |
$0.91
|
| Rate for Payer: BCBS Trust/PPO |
$0.91
|
| Rate for Payer: BCBS Trust/PPO |
$0.91
|
| Rate for Payer: BCBS Trust/PPO |
$0.91
|
| Rate for Payer: BCN Commercial |
$0.91
|
| Rate for Payer: BCN Commercial |
$0.91
|
| Rate for Payer: BCN Commercial |
$0.91
|
| Rate for Payer: BCN Commercial |
$0.91
|
| Rate for Payer: BCN Commercial |
$0.91
|
| Rate for Payer: Cash Price |
$68.68
|
| Rate for Payer: Cash Price |
$123.46
|
| Rate for Payer: Cash Price |
$82.34
|
| Rate for Payer: Cash Price |
$82.34
|
| Rate for Payer: Cash Price |
$63.02
|
| Rate for Payer: Cash Price |
$123.46
|
| Rate for Payer: Cash Price |
$63.02
|
| Rate for Payer: Cash Price |
$68.68
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cofinity Advantage |
$66.63
|
| Rate for Payer: Cofinity Advantage |
$60.09
|
| Rate for Payer: Cofinity Advantage |
$108.03
|
| Rate for Payer: Cofinity Advantage |
$72.05
|
| Rate for Payer: Cofinity Advantage |
$55.14
|
| Rate for Payer: Cofinity Commercial |
$67.74
|
| Rate for Payer: Cofinity Commercial |
$132.72
|
| Rate for Payer: Cofinity Commercial |
$73.83
|
| Rate for Payer: Cofinity Commercial |
$81.86
|
| Rate for Payer: Cofinity Commercial |
$88.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.46
|
| Rate for Payer: Healthscope Commercial |
$138.90
|
| Rate for Payer: Healthscope Commercial |
$85.67
|
| Rate for Payer: Healthscope Commercial |
$77.27
|
| Rate for Payer: Healthscope Commercial |
$70.89
|
| Rate for Payer: Healthscope Commercial |
$92.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$123.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$115.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.39
|
| Rate for Payer: PHP Commercial |
$66.95
|
| Rate for Payer: PHP Commercial |
$131.18
|
| Rate for Payer: PHP Commercial |
$87.49
|
| Rate for Payer: PHP Commercial |
$80.91
|
| Rate for Payer: PHP Commercial |
$72.97
|
| Rate for Payer: Priority Health SBD |
$49.63
|
| Rate for Payer: Priority Health SBD |
$54.09
|
| Rate for Payer: Priority Health SBD |
$59.97
|
| Rate for Payer: Priority Health SBD |
$97.23
|
| Rate for Payer: Priority Health SBD |
$64.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.61
|
| Rate for Payer: UHC Core |
$0.61
|
| Rate for Payer: UHC Core |
$0.61
|
| Rate for Payer: UHC Core |
$0.61
|
| Rate for Payer: UHC Core |
$0.61
|
| Rate for Payer: UHC Core |
$0.61
|
| Rate for Payer: UHC Exchange |
$0.61
|
| Rate for Payer: UHC Exchange |
$0.61
|
| Rate for Payer: UHC Exchange |
$0.61
|
| Rate for Payer: UHC Exchange |
$0.61
|
| Rate for Payer: UHC Exchange |
$0.61
|
|
