|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 45802-730-00
|
| Hospital Charge Code |
1748012
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 45802-730-32
|
| Hospital Charge Code |
1748012
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 45802-730-32
|
| Hospital Charge Code |
1748012
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0904-5791-46
|
| Hospital Charge Code |
1711191
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| 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: EPIC Health Plan Commercial |
$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: LLUH Dept of Risk Management WC |
$0.02
|
| 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
|
|
|
ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0904-5791-46
|
| Hospital Charge Code |
1711191
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| 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 |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Distinction Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$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 Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.06
|
| 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: LLUH Dept of Risk Management WC |
$0.02
|
| 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
|
$0.84
|
|
|
Service Code
|
NDC 51672-2114-2
|
| Hospital Charge Code |
1711987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 51672-2114-2
|
| Hospital Charge Code |
1711987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Distinction Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Media |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 51672-2114-0
|
| Hospital Charge Code |
1711987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Blue Distinction Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Media |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 51672-2114-0
|
| Hospital Charge Code |
1711987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.59
|
| Rate for Payer: Cigna of CA PPO |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.67
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$4.19
|
|
|
Service Code
|
NDC 68084-541-01
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.50
|
| Rate for Payer: Blue Distinction Transplant |
$2.51
|
| Rate for Payer: Blue Shield of California Commercial |
$3.09
|
| Rate for Payer: Blue Shield of California EPN |
$2.45
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.93
|
| Rate for Payer: Cigna of CA PPO |
$2.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.56
|
| Rate for Payer: Dignity Health Media |
$3.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.56
|
| Rate for Payer: Global Benefits Group Commercial |
$2.51
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.35
|
| Rate for Payer: Networks By Design Commercial |
$2.72
|
| Rate for Payer: Prime Health Services Commercial |
$3.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.56
|
| Rate for Payer: Vantage Medical Group Senior |
$3.56
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$4.19
|
|
|
Service Code
|
NDC 68084-541-11
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.50
|
| Rate for Payer: Blue Distinction Transplant |
$2.51
|
| Rate for Payer: Blue Shield of California Commercial |
$3.09
|
| Rate for Payer: Blue Shield of California EPN |
$2.45
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.93
|
| Rate for Payer: Cigna of CA PPO |
$2.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.56
|
| Rate for Payer: Dignity Health Media |
$3.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.56
|
| Rate for Payer: Global Benefits Group Commercial |
$2.51
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.35
|
| Rate for Payer: Networks By Design Commercial |
$2.72
|
| Rate for Payer: Prime Health Services Commercial |
$3.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.56
|
| Rate for Payer: Vantage Medical Group Senior |
$3.56
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 0527-1050-01
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 70756-721-11
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| 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: 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: 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
|
IP
|
$4.19
|
|
|
Service Code
|
NDC 68084-541-11
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.93
|
| Rate for Payer: Cigna of CA PPO |
$2.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.56
|
| Rate for Payer: Global Benefits Group Commercial |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.35
|
| Rate for Payer: Networks By Design Commercial |
$2.72
|
| Rate for Payer: Prime Health Services Commercial |
$3.56
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$27.68
|
|
|
Service Code
|
NDC 51672-4023-1
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.64 |
| Max. Negotiated Rate |
$23.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.49
|
| Rate for Payer: Blue Distinction Transplant |
$16.61
|
| Rate for Payer: Blue Shield of California Commercial |
$20.40
|
| Rate for Payer: Blue Shield of California EPN |
$16.17
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cigna of CA HMO |
$19.38
|
| Rate for Payer: Cigna of CA PPO |
$19.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.53
|
| Rate for Payer: Dignity Health Media |
$23.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.07
|
| Rate for Payer: Galaxy Health WC |
$23.53
|
| Rate for Payer: Global Benefits Group Commercial |
$16.61
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$20.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.64
|
| Rate for Payer: Multiplan Commercial |
$22.14
|
| Rate for Payer: Networks By Design Commercial |
$17.99
|
| Rate for Payer: Prime Health Services Commercial |
$23.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.84
|
| Rate for Payer: United Healthcare All Other HMO |
$13.84
|
| Rate for Payer: United Healthcare HMO Rider |
$13.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.53
|
| Rate for Payer: Vantage Medical Group Senior |
$23.53
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$4.19
|
|
|
Service Code
|
NDC 68084-541-01
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Blue Shield of California Commercial |
$2.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.93
|
| Rate for Payer: Cigna of CA PPO |
$2.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.56
|
| Rate for Payer: Global Benefits Group Commercial |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.35
|
| Rate for Payer: Networks By Design Commercial |
$2.72
|
| Rate for Payer: Prime Health Services Commercial |
$3.56
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 70756-721-11
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| 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 |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Distinction Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| 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 Media |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| 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: 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
|
| 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 250 MG TABLET [113]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 23155-288-01
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| 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 |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Distinction Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| 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 Media |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| 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: 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
|
| 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 250 MG TABLET [113]
|
Facility
|
IP
|
$27.68
|
|
|
Service Code
|
NDC 51672-4023-1
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.64 |
| Max. Negotiated Rate |
$23.53 |
| Rate for Payer: Blue Shield of California Commercial |
$19.71
|
| Rate for Payer: Blue Shield of California EPN |
$14.17
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cigna of CA HMO |
$19.38
|
| Rate for Payer: Cigna of CA PPO |
$19.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: Galaxy Health WC |
$23.53
|
| Rate for Payer: Global Benefits Group Commercial |
$16.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.64
|
| Rate for Payer: Multiplan Commercial |
$22.14
|
| Rate for Payer: Networks By Design Commercial |
$17.99
|
| Rate for Payer: Prime Health Services Commercial |
$23.53
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 23155-288-01
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| 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: 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: 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
|
$1.20
|
|
|
Service Code
|
NDC 0527-1050-01
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Blue Distinction Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Media |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]
|
Facility
|
IP
|
$37.80
|
|
|
Service Code
|
CPT J1120
|
| Hospital Charge Code |
1720067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.07 |
| Max. Negotiated Rate |
$32.13 |
| Rate for Payer: Blue Shield of California Commercial |
$26.91
|
| Rate for Payer: Blue Shield of California Commercial |
$33.92
|
| Rate for Payer: Blue Shield of California Commercial |
$34.18
|
| Rate for Payer: Blue Shield of California EPN |
$24.39
|
| Rate for Payer: Blue Shield of California EPN |
$24.58
|
| Rate for Payer: Blue Shield of California EPN |
$19.35
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$21.60
|
| 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 |
$26.46
|
| 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: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.06
|
| Rate for Payer: Galaxy Health WC |
$40.49
|
| Rate for Payer: Galaxy Health WC |
$32.13
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$22.68
|
| Rate for Payer: Global Benefits Group Commercial |
$28.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.78
|
| 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 Medi-Cal |
$14.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.29
|
| 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: Multiplan Commercial |
$30.24
|
| Rate for Payer: Multiplan Commercial |
$38.11
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| 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 |
$32.13
|
| Rate for Payer: Prime Health Services Commercial |
$40.49
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.27
|
| Rate for Payer: United Healthcare All Other HMO |
$17.57
|
| Rate for Payer: United Healthcare All Other HMO |
$13.94
|
| Rate for Payer: United Healthcare All Other HMO |
$17.70
|
| Rate for Payer: United Healthcare HMO Rider |
$17.32
|
| Rate for Payer: United Healthcare HMO Rider |
$13.64
|
| Rate for Payer: United Healthcare HMO Rider |
$17.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.84
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]
|
Facility
|
OP
|
$37.80
|
|
|
Service Code
|
CPT J1120
|
| Hospital Charge Code |
1720067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.07 |
| Max. Negotiated Rate |
$176.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$176.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$176.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$176.85
|
| 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 Commercial/Exchange |
$32.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.79
|
| Rate for Payer: Blue Distinction Transplant |
$28.80
|
| Rate for Payer: Blue Distinction Transplant |
$28.58
|
| Rate for Payer: Blue Distinction Transplant |
$22.68
|
| Rate for Payer: Blue Shield of California Commercial |
$35.11
|
| Rate for Payer: Blue Shield of California Commercial |
$27.86
|
| Rate for Payer: Blue Shield of California Commercial |
$35.38
|
| Rate for Payer: Blue Shield of California EPN |
$46.91
|
| Rate for Payer: Blue Shield of California EPN |
$46.91
|
| Rate for Payer: Blue Shield of California EPN |
$46.91
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$26.46
|
| Rate for Payer: Cigna of CA HMO |
$33.35
|
| 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: Dignity Health Commercial/Exchange |
$40.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Media |
$40.49
|
| Rate for Payer: Dignity Health Media |
$32.13
|
| Rate for Payer: Dignity Health Media |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.06
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$32.13
|
| Rate for Payer: Galaxy Health WC |
$40.49
|
| Rate for Payer: Global Benefits Group Commercial |
$28.58
|
| Rate for Payer: Global Benefits Group Commercial |
$22.68
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$28.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$35.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$36.00
|
| 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 |
$25.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.90
|
| 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 |
$11.43
|
| Rate for Payer: Multiplan Commercial |
$38.11
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Multiplan Commercial |
$30.24
|
| 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 |
$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 |
$40.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Other HMO |
$24.00
|
| Rate for Payer: United Healthcare All Other HMO |
$18.90
|
| Rate for Payer: United Healthcare All Other HMO |
$23.82
|
| Rate for Payer: United Healthcare HMO Rider |
$18.90
|
| Rate for Payer: United Healthcare HMO Rider |
$23.82
|
| Rate for Payer: United Healthcare HMO Rider |
$24.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.13
|
| 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 Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.49
|
| Rate for Payer: Vantage Medical Group Senior |
$32.13
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
OP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-12
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.51 |
| 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 |
$2.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.16
|
| Rate for Payer: Blue Distinction Transplant |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$3.91
|
| Rate for Payer: Blue Shield of California EPN |
$3.10
|
| Rate for Payer: Cash Price |
$2.39
|
| 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 Media |
$4.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.98
|
| 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: 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
|
| 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 |
$2.66
|
| Rate for Payer: United Healthcare All Other HMO |
$2.66
|
| Rate for Payer: United Healthcare HMO Rider |
$2.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.66
|
| 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
|
$0.90
|
|
|
Service Code
|
NDC 42571-243-01
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.77 |
| 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 |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Distinction Transplant |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| 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 Media |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.68
|
| 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: 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
|
| 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
|
|
