|
ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0904-5791-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 51672-2114-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.78
|
| Rate for Payer: Cigna of CA PPO |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Senior |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.95
|
| Rate for Payer: Global Benefits Group Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.95
|
|
|
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 51672-2114-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.78
|
| Rate for Payer: Cigna of CA PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Senior |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.95
|
| Rate for Payer: Global Benefits Group Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO |
$0.56
|
| Rate for Payer: United Healthcare HMO Rider |
$0.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Vantage Medical Group Senior |
$0.95
|
|
|
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 51672-2114-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.78
|
| Rate for Payer: Cigna of CA PPO |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Senior |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.95
|
| Rate for Payer: Global Benefits Group Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.95
|
|
|
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 51672-2114-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.78
|
| Rate for Payer: Cigna of CA PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Senior |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.95
|
| Rate for Payer: Global Benefits Group Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.67
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO |
$0.56
|
| Rate for Payer: United Healthcare HMO Rider |
$0.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Vantage Medical Group Senior |
$0.95
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 70756-721-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 50268-054-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.25
|
| Rate for Payer: Cigna of CA PPO |
$2.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.74
|
| Rate for Payer: Global Benefits Group Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.58
|
| Rate for Payer: Networks By Design Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Other HMO |
$1.61
|
| Rate for Payer: United Healthcare HMO Rider |
$1.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.74
|
| Rate for Payer: Vantage Medical Group Senior |
$2.74
|
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.98
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 50268-054-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.38
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.25
|
| Rate for Payer: Cigna of CA PPO |
$2.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.74
|
| Rate for Payer: Global Benefits Group Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.58
|
| Rate for Payer: Networks By Design Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.74
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 50268-054-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.38
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.25
|
| Rate for Payer: Cigna of CA PPO |
$2.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.74
|
| Rate for Payer: Global Benefits Group Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.58
|
| Rate for Payer: Networks By Design Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.74
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 50268-054-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.98
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.25
|
| Rate for Payer: Cigna of CA PPO |
$2.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.74
|
| Rate for Payer: Global Benefits Group Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.58
|
| Rate for Payer: Networks By Design Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Other HMO |
$1.61
|
| Rate for Payer: United Healthcare HMO Rider |
$1.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.74
|
| Rate for Payer: Vantage Medical Group Senior |
$2.74
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 70756-721-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$97.77 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$9.53
|
| Rate for Payer: Adventist Health Commercial |
$10.55
|
| Rate for Payer: Adventist Health Commercial |
$7.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$31.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$24.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$34.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$31.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$32.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$39.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$97.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$97.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$97.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$97.77
|
| Rate for Payer: Blue Shield of California Commercial |
$43.19
|
| Rate for Payer: Blue Shield of California Commercial |
$43.19
|
| Rate for Payer: Blue Shield of California Commercial |
$43.19
|
| Rate for Payer: Blue Shield of California Commercial |
$43.19
|
| Rate for Payer: Blue Shield of California EPN |
$43.19
|
| Rate for Payer: Blue Shield of California EPN |
$43.19
|
| Rate for Payer: Blue Shield of California EPN |
$43.19
|
| Rate for Payer: Blue Shield of California EPN |
$43.19
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Cash Price |
$26.20
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Cash Price |
$26.20
|
| Rate for Payer: Cash Price |
$29.01
|
| Rate for Payer: Cash Price |
$29.01
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna of CA HMO |
$26.46
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$33.35
|
| Rate for Payer: Cigna of CA HMO |
$36.92
|
| Rate for Payer: Cigna of CA PPO |
$36.92
|
| Rate for Payer: Cigna of CA PPO |
$26.46
|
| Rate for Payer: Cigna of CA PPO |
$33.35
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$44.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$44.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$44.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.10
|
| Rate for Payer: EPIC Health Plan Senior |
$15.12
|
| Rate for Payer: EPIC Health Plan Senior |
$21.10
|
| Rate for Payer: EPIC Health Plan Senior |
$19.20
|
| Rate for Payer: EPIC Health Plan Senior |
$19.06
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$40.49
|
| Rate for Payer: Galaxy Health WC |
$32.13
|
| Rate for Payer: Galaxy Health WC |
$44.84
|
| Rate for Payer: Global Benefits Group Commercial |
$28.58
|
| Rate for Payer: Global Benefits Group Commercial |
$31.65
|
| Rate for Payer: Global Benefits Group Commercial |
$22.68
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$35.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$36.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$26.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$36.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.35
|
| Rate for Payer: Multiplan Commercial |
$38.11
|
| Rate for Payer: Multiplan Commercial |
$30.24
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Multiplan Commercial |
$42.20
|
| Rate for Payer: Networks By Design Commercial |
$26.38
|
| Rate for Payer: Networks By Design Commercial |
$23.82
|
| Rate for Payer: Networks By Design Commercial |
$18.90
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Prime Health Services Commercial |
$40.49
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$32.13
|
| Rate for Payer: Prime Health Services Commercial |
$44.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.01
|
| Rate for Payer: United Healthcare All Other HMO |
$17.53
|
| Rate for Payer: United Healthcare All Other HMO |
$19.27
|
| Rate for Payer: United Healthcare All Other HMO |
$13.81
|
| Rate for Payer: United Healthcare All Other HMO |
$17.40
|
| Rate for Payer: United Healthcare HMO Rider |
$17.03
|
| Rate for Payer: United Healthcare HMO Rider |
$17.16
|
| Rate for Payer: United Healthcare HMO Rider |
$13.51
|
| Rate for Payer: United Healthcare HMO Rider |
$18.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$44.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$44.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.49
|
| Rate for Payer: Vantage Medical Group Senior |
$44.84
|
| Rate for Payer: Vantage Medical Group Senior |
$40.49
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$32.13
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]
|
Facility
|
IP
|
$47.64
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$40.49 |
| Rate for Payer: Galaxy Health WC |
$40.49
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$44.84
|
| Rate for Payer: Global Benefits Group Commercial |
$31.65
|
| Rate for Payer: Global Benefits Group Commercial |
$22.68
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$35.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.66
|
| Rate for Payer: Multiplan Commercial |
$30.24
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Multiplan Commercial |
$38.11
|
| Rate for Payer: Multiplan Commercial |
$42.20
|
| Rate for Payer: Networks By Design Commercial |
$23.82
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$26.38
|
| Rate for Payer: Networks By Design Commercial |
$18.90
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$32.13
|
| Rate for Payer: Prime Health Services Commercial |
$44.84
|
| Rate for Payer: Prime Health Services Commercial |
$40.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$17.40
|
| Rate for Payer: United Healthcare All Other HMO |
$19.27
|
| Rate for Payer: United Healthcare All Other HMO |
$17.53
|
| Rate for Payer: United Healthcare All Other HMO |
$13.81
|
| Rate for Payer: United Healthcare HMO Rider |
$17.03
|
| Rate for Payer: United Healthcare HMO Rider |
$13.51
|
| Rate for Payer: United Healthcare HMO Rider |
$18.85
|
| Rate for Payer: United Healthcare HMO Rider |
$17.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.72
|
| Rate for Payer: Adventist Health Commercial |
$9.53
|
| Rate for Payer: Adventist Health Commercial |
$10.55
|
| Rate for Payer: Adventist Health Commercial |
$7.56
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Blue Shield of California Commercial |
$27.90
|
| Rate for Payer: Blue Shield of California Commercial |
$38.93
|
| Rate for Payer: Blue Shield of California Commercial |
$35.42
|
| Rate for Payer: Blue Shield of California Commercial |
$35.16
|
| Rate for Payer: Blue Shield of California EPN |
$18.37
|
| Rate for Payer: Blue Shield of California EPN |
$23.15
|
| Rate for Payer: Blue Shield of California EPN |
$23.33
|
| Rate for Payer: Blue Shield of California EPN |
$25.64
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Cash Price |
$29.01
|
| Rate for Payer: Cash Price |
$26.20
|
| Rate for Payer: Cigna of CA HMO |
$26.46
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$33.35
|
| Rate for Payer: Cigna of CA HMO |
$36.92
|
| Rate for Payer: Cigna of CA PPO |
$36.92
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$26.46
|
| Rate for Payer: Cigna of CA PPO |
$33.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.10
|
| Rate for Payer: EPIC Health Plan Senior |
$15.12
|
| Rate for Payer: EPIC Health Plan Senior |
$19.20
|
| Rate for Payer: EPIC Health Plan Senior |
$19.06
|
| Rate for Payer: EPIC Health Plan Senior |
$21.10
|
| Rate for Payer: Galaxy Health WC |
$32.13
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
IP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO |
$3.72
|
| Rate for Payer: Cigna of CA PPO |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$4.25
|
| Rate for Payer: Networks By Design Commercial |
$3.45
|
| Rate for Payer: Prime Health Services Commercial |
$4.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
OP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.26
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO |
$3.72
|
| Rate for Payer: Cigna of CA PPO |
$3.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$4.25
|
| Rate for Payer: Networks By Design Commercial |
$3.45
|
| Rate for Payer: Prime Health Services Commercial |
$4.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.65
|
| Rate for Payer: United Healthcare All Other HMO |
$2.65
|
| Rate for Payer: United Healthcare HMO Rider |
$2.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 50742-233-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 42571-243-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.63
|
| Rate for Payer: Cigna of CA PPO |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 50742-233-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
IP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO |
$3.72
|
| Rate for Payer: Cigna of CA PPO |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Multiplan Commercial |
$4.25
|
| Rate for Payer: Networks By Design Commercial |
$3.45
|
| Rate for Payer: Prime Health Services Commercial |
$4.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 42571-243-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.63
|
| Rate for Payer: Cigna of CA PPO |
$0.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
OP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.26
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO |
$3.72
|
| Rate for Payer: Cigna of CA PPO |
$3.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$4.25
|
| Rate for Payer: Networks By Design Commercial |
$3.45
|
| Rate for Payer: Prime Health Services Commercial |
$4.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.65
|
| Rate for Payer: United Healthcare All Other HMO |
$2.65
|
| Rate for Payer: United Healthcare HMO Rider |
$2.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]
|
Facility
|
IP
|
$2.77
|
|
|
Service Code
|
NDC 9994-0802-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$2.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cigna of CA HMO |
$1.94
|
| Rate for Payer: Cigna of CA PPO |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: EPIC Health Plan Senior |
$1.11
|
| Rate for Payer: Galaxy Health WC |
$2.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: Networks By Design Commercial |
$1.80
|
| Rate for Payer: Prime Health Services Commercial |
$2.35
|
|
|
ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]
|
Facility
|
OP
|
$2.77
|
|
|
Service Code
|
NDC 9994-0802-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.70
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cigna of CA HMO |
$1.94
|
| Rate for Payer: Cigna of CA PPO |
$1.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: EPIC Health Plan Senior |
$1.11
|
| Rate for Payer: Galaxy Health WC |
$2.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: Networks By Design Commercial |
$1.80
|
| Rate for Payer: Prime Health Services Commercial |
$2.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO |
$1.39
|
| Rate for Payer: United Healthcare HMO Rider |
$1.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Vantage Medical Group Senior |
$2.35
|
|
|
ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-2304-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-2304-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
