|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 57896-204-01
|
| Hospital Charge Code |
1711186
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$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 Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904-6730-80
|
| Hospital Charge Code |
1711186
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 57896-201-10
|
| Hospital Charge Code |
1711186
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$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 Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 57896-204-01
|
| Hospital Charge Code |
1711186
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ACETAMINOPHEN 500 MG TABLET [102]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 57896-201-10
|
| Hospital Charge Code |
1711186
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 45802-730-00
|
| Hospital Charge Code |
1748012
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: BCBS Transplant Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| 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: 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 Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.26
|
| Rate for Payer: IEHP medi-cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: Riverside University Health MISP |
$0.14
|
| 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 Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
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 |
$0.07 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| 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: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| 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 |
$0.07 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| 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: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| 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 |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: BCBS Transplant Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| 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: 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 Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.26
|
| Rate for Payer: IEHP medi-cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: Riverside University Health MISP |
$0.14
|
| 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| 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: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| 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: 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 Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.06
|
| Rate for Payer: IEHP medi-cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Riverside University Health MISP |
$0.03
|
| 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 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 |
$0.17 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| 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: Health Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| 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 51672-2114-0
|
| Hospital Charge Code |
1711987
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: BCBS Transplant Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| 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: 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 Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.63
|
| Rate for Payer: IEHP medi-cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: Riverside University Health MISP |
$0.34
|
| 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 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 |
$0.17 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| 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: Health Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| 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 |
$0.17 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: BCBS Transplant Transplant |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Central Health Plan Commercial |
$0.67
|
| 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: 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 Management Network EPO/PPO |
$0.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.63
|
| Rate for Payer: IEHP medi-cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: Riverside University Health MISP |
$0.34
|
| 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 Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: BCBS Transplant Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| 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: 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 Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: Riverside University Health MISP |
$0.17
|
| 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 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 |
$5.54 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$20.76
|
| Rate for Payer: Blue Shield of California EPN |
$14.78
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Central Health Plan Commercial |
$22.14
|
| 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: Health Management Network EPO/PPO |
$24.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.54
|
| Rate for Payer: Multiplan Commercial |
$20.76
|
| Rate for Payer: Networks By Design Commercial |
$17.99
|
| Rate for Payer: Prime Health Services Commercial |
$23.53
|
|
|
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 |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: BCBS Transplant Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| 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: 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 Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.90
|
| Rate for Payer: IEHP medi-cal |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: Riverside University Health MISP |
$0.48
|
| 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 Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
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 |
$5.54 |
| Max. Negotiated Rate |
$24.91 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$15.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$13.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.35
|
| Rate for Payer: BCBS Transplant Transplant |
$16.61
|
| Rate for Payer: Blue Shield of California Commercial |
$17.41
|
| Rate for Payer: Blue Shield of California EPN |
$13.54
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Central Health Plan Commercial |
$22.14
|
| 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: 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 Management Network EPO/PPO |
$24.91
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$20.76
|
| Rate for Payer: IEHP medi-cal |
$9.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.54
|
| Rate for Payer: Multiplan Commercial |
$20.76
|
| Rate for Payer: Networks By Design Commercial |
$17.99
|
| Rate for Payer: Prime Health Services Commercial |
$23.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$16.61
|
| Rate for Payer: Riverside University Health MISP |
$11.07
|
| 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 Medi-Cal |
$23.53
|
| Rate for Payer: Vantage Medical Group Senior |
$23.53
|
|
|
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 |
$0.24 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| 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: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| 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 |
$0.08 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| 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: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| 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 |
$0.84 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.35
|
| 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: Health Management Network EPO/PPO |
$3.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.14
|
| 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
|
$4.19
|
|
|
Service Code
|
NDC 68084-541-11
|
| Hospital Charge Code |
1710302
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: IEHP medi-cal |
$1.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.48
|
| Rate for Payer: BCBS Transplant Transplant |
$2.51
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.35
|
| 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: 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 Management Network EPO/PPO |
$3.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.14
|
| Rate for Payer: Networks By Design Commercial |
$2.72
|
| Rate for Payer: Prime Health Services Commercial |
$3.56
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.51
|
| Rate for Payer: Riverside University Health MISP |
$1.68
|
| 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 Medi-Cal |
$3.56
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: BCBS Transplant Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| 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: 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 Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: Riverside University Health MISP |
$0.17
|
| 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 Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| 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: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
