|
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
|
$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 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 |
$7.56 |
| Max. Negotiated Rate |
$174.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$174.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$174.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$174.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$60.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$60.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$60.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$65.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$65.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$65.87
|
| Rate for Payer: BCBS Transplant Transplant |
$22.68
|
| Rate for Payer: BCBS Transplant Transplant |
$28.80
|
| Rate for Payer: BCBS Transplant Transplant |
$28.58
|
| Rate for Payer: Blue Shield of California Commercial |
$51.60
|
| Rate for Payer: Blue Shield of California Commercial |
$51.60
|
| Rate for Payer: Blue Shield of California Commercial |
$51.60
|
| 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 |
$21.44
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Central Health Plan Commercial |
$38.40
|
| Rate for Payer: Central Health Plan Commercial |
$38.11
|
| Rate for Payer: Central Health Plan Commercial |
$30.24
|
| 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 |
$33.35
|
| Rate for Payer: Cigna of CA PPO |
$26.46
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.06
|
| Rate for Payer: Galaxy Health WC |
$32.13
|
| Rate for Payer: Galaxy Health WC |
$40.49
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Global Benefits Group Commercial |
$22.68
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$42.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$43.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$34.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$36.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$35.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$28.35
|
| Rate for Payer: IEHP medi-cal |
$24.04
|
| Rate for Payer: IEHP medi-cal |
$24.04
|
| Rate for Payer: IEHP medi-cal |
$24.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.53
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$35.73
|
| Rate for Payer: Multiplan Commercial |
$28.35
|
| Rate for Payer: Networks By Design Commercial |
$18.90
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$23.82
|
| Rate for Payer: Prime Health Services Commercial |
$32.13
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$40.49
|
| Rate for Payer: Riverside University Health MISP |
$19.20
|
| Rate for Payer: Riverside University Health MISP |
$15.12
|
| Rate for Payer: Riverside University Health MISP |
$19.06
|
| 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 |
$24.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.90
|
| 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 |
$23.82
|
| Rate for Payer: United Healthcare HMO Rider |
$18.90
|
| 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 |
$23.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.00
|
| 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 |
$32.13
|
| Rate for Payer: Vantage Medical Group Senior |
$40.49
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]
|
Facility
IP
|
$47.64
|
|
|
Service Code
|
CPT J1120
|
| Hospital Charge Code |
1720067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$35.73
|
| Rate for Payer: Blue Shield of California Commercial |
$36.00
|
| Rate for Payer: Blue Shield of California Commercial |
$28.35
|
| Rate for Payer: Blue Shield of California EPN |
$20.19
|
| Rate for Payer: Blue Shield of California EPN |
$25.44
|
| Rate for Payer: Blue Shield of California EPN |
$25.63
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Central Health Plan Commercial |
$38.11
|
| Rate for Payer: Central Health Plan Commercial |
$30.24
|
| Rate for Payer: Central Health Plan Commercial |
$38.40
|
| 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: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.06
|
| Rate for Payer: Galaxy Health WC |
$40.49
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$32.13
|
| Rate for Payer: Global Benefits Group Commercial |
$22.68
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$42.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$43.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$34.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$35.73
|
| Rate for Payer: Multiplan Commercial |
$28.35
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Networks By Design Commercial |
$18.90
|
| Rate for Payer: Networks By Design Commercial |
$23.82
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Prime Health Services Commercial |
$40.49
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$32.13
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
IP
|
$0.90
|
|
|
Service Code
|
NDC 42571-243-01
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| 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 |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$0.63
|
| Rate for Payer: Cigna of CA PPO |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
OP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-12
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.14
|
| Rate for Payer: BCBS Transplant Transplant |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$3.34
|
| Rate for Payer: Blue Shield of California EPN |
$2.60
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Central Health Plan Commercial |
$4.25
|
| 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: 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 Management Network EPO/PPO |
$4.78
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.98
|
| Rate for Payer: IEHP medi-cal |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: Networks By Design Commercial |
$3.45
|
| Rate for Payer: Prime Health Services Commercial |
$4.51
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.19
|
| Rate for Payer: Riverside University Health MISP |
$2.12
|
| 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 Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 50742-233-01
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| 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 |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
OP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-11
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.14
|
| Rate for Payer: BCBS Transplant Transplant |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$3.34
|
| Rate for Payer: Blue Shield of California EPN |
$2.60
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Central Health Plan Commercial |
$4.25
|
| 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: 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 Management Network EPO/PPO |
$4.78
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.98
|
| Rate for Payer: IEHP medi-cal |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: Networks By Design Commercial |
$3.45
|
| Rate for Payer: Prime Health Services Commercial |
$4.51
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.19
|
| Rate for Payer: Riverside University Health MISP |
$2.12
|
| 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 Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 50742-233-01
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: BCBS Transplant Transplant |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.45
|
| Rate for Payer: IEHP medi-cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: Riverside University Health MISP |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
IP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-12
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| 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 |
$3.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.84
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Central Health Plan Commercial |
$4.25
|
| Rate for Payer: Cigna of CA HMO |
$3.72
|
| Rate for Payer: Cigna of CA PPO |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: Networks By Design Commercial |
$3.45
|
| Rate for Payer: Prime Health Services Commercial |
$4.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
OP
|
$0.90
|
|
|
Service Code
|
NDC 42571-243-01
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.53
|
| Rate for Payer: BCBS Transplant Transplant |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.72
|
| 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: 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 Management Network EPO/PPO |
$0.81
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.68
|
| Rate for Payer: IEHP medi-cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.54
|
| Rate for Payer: Riverside University Health MISP |
$0.36
|
| 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 Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
IP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-11
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| 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 |
$3.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.84
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Central Health Plan Commercial |
$4.25
|
| Rate for Payer: Cigna of CA HMO |
$3.72
|
| Rate for Payer: Cigna of CA PPO |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: Networks By Design Commercial |
$3.45
|
| Rate for Payer: Prime Health Services Commercial |
$4.51
|
|
|
ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]
|
Facility
IP
|
$2.77
|
|
|
Service Code
|
NDC 9994-0802-33
|
| Hospital Charge Code |
ERX4080233
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| 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 |
$2.08
|
| Rate for Payer: Blue Shield of California EPN |
$1.48
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Central Health Plan Commercial |
$2.22
|
| Rate for Payer: Cigna of CA HMO |
$1.94
|
| Rate for Payer: Cigna of CA PPO |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Galaxy Health WC |
$2.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.80
|
| Rate for Payer: Prime Health Services Commercial |
$2.35
|
|
|
ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]
|
Facility
OP
|
$2.77
|
|
|
Service Code
|
NDC 9994-0802-33
|
| Hospital Charge Code |
ERX4080233
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.64
|
| Rate for Payer: BCBS Transplant Transplant |
$1.66
|
| Rate for Payer: Blue Shield of California Commercial |
$1.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Central Health Plan Commercial |
$2.22
|
| Rate for Payer: Cigna of CA HMO |
$1.94
|
| Rate for Payer: Cigna of CA PPO |
$1.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.11
|
| Rate for Payer: Galaxy Health WC |
$2.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.49
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.08
|
| Rate for Payer: IEHP medi-cal |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.80
|
| Rate for Payer: Prime Health Services Commercial |
$2.35
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.66
|
| Rate for Payer: Riverside University Health MISP |
$1.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.38
|
| Rate for Payer: United Healthcare All Other HMO |
$1.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Vantage Medical Group Senior |
$2.35
|
|
|
ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-2304-00
|
| Hospital Charge Code |
1770001
|
|
Hospital Revenue Code
|
250
|
| 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 |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$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 |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-2304-00
|
| Hospital Charge Code |
1770001
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| 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 |
$0.00
|
| 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 |
$0.00
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.01
|
| Rate for Payer: IEHP medi-cal |
$0.00
|
| 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 |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$0.00
|
| 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 |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ACETIC ACID 2 % EAR SOLUTION [17801]
|
Facility
IP
|
$2.24
|
|
|
Service Code
|
NDC 52817-816-15
|
| Hospital Charge Code |
1740195
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Cigna of CA PPO |
$1.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Central Health Plan Commercial |
$1.79
|
| Rate for Payer: Cigna of CA HMO |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Galaxy Health WC |
$1.90
|
| Rate for Payer: Global Benefits Group Commercial |
$1.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: Networks By Design Commercial |
$1.46
|
| Rate for Payer: Prime Health Services Commercial |
$1.90
|
|
|
ACETIC ACID 2 % EAR SOLUTION [17801]
|
Facility
OP
|
$2.24
|
|
|
Service Code
|
NDC 52817-816-15
|
| Hospital Charge Code |
1740195
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.32
|
| Rate for Payer: BCBS Transplant Transplant |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.10
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Central Health Plan Commercial |
$1.79
|
| Rate for Payer: Cigna of CA HMO |
$1.57
|
| Rate for Payer: Cigna of CA PPO |
$1.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.90
|
| Rate for Payer: Galaxy Health WC |
$1.90
|
| Rate for Payer: Global Benefits Group Commercial |
$1.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.68
|
| Rate for Payer: IEHP medi-cal |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: Networks By Design Commercial |
$1.46
|
| Rate for Payer: Prime Health Services Commercial |
$1.90
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.34
|
| Rate for Payer: Riverside University Health MISP |
$0.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.12
|
| Rate for Payer: United Healthcare All Other HMO |
$1.12
|
| Rate for Payer: United Healthcare HMO Rider |
$1.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
ACETIC ACID (BULK) 3 % LIQUID [15091]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 5155200516
|
| Hospital Charge Code |
NDG15091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
ACETIC ACID (BULK) 3 % LIQUID [15091]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 5155200516
|
| Hospital Charge Code |
NDG15091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.03
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
|
|
ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]
|
Facility
OP
|
$145.63
|
|
|
Service Code
|
NDC 24208-539-20
|
| Hospital Charge Code |
1740086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.13 |
| Max. Negotiated Rate |
$131.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$88.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$123.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$80.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$80.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$70.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.04
|
| Rate for Payer: BCBS Transplant Transplant |
$87.38
|
| Rate for Payer: Blue Shield of California Commercial |
$91.60
|
| Rate for Payer: Blue Shield of California EPN |
$71.21
|
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: Central Health Plan Commercial |
$116.50
|
| Rate for Payer: Cigna of CA HMO |
$101.94
|
| Rate for Payer: Cigna of CA PPO |
$101.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$58.25
|
| Rate for Payer: Galaxy Health WC |
$123.79
|
| Rate for Payer: Global Benefits Group Commercial |
$87.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$131.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$109.22
|
| Rate for Payer: IEHP medi-cal |
$50.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.13
|
| Rate for Payer: Multiplan Commercial |
$109.22
|
| Rate for Payer: Networks By Design Commercial |
$94.66
|
| Rate for Payer: Prime Health Services Commercial |
$123.79
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$87.38
|
| Rate for Payer: Riverside University Health MISP |
$58.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$87.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$87.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$72.82
|
| Rate for Payer: United Healthcare All Other HMO |
$72.82
|
| Rate for Payer: United Healthcare HMO Rider |
$72.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.79
|
| Rate for Payer: Vantage Medical Group Senior |
$123.79
|
|
|
ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]
|
Facility
IP
|
$145.63
|
|
|
Service Code
|
NDC 24208-539-20
|
| Hospital Charge Code |
1740086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.13 |
| 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 |
$109.22
|
| Rate for Payer: Blue Shield of California EPN |
$77.77
|
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: Central Health Plan Commercial |
$116.50
|
| Rate for Payer: Cigna of CA HMO |
$101.94
|
| Rate for Payer: Cigna of CA PPO |
$101.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.25
|
| Rate for Payer: Galaxy Health WC |
$123.79
|
| Rate for Payer: Global Benefits Group Commercial |
$87.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$131.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.13
|
| Rate for Payer: Multiplan Commercial |
$109.22
|
| Rate for Payer: Networks By Design Commercial |
$94.66
|
| Rate for Payer: Prime Health Services Commercial |
$123.79
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
IP
|
$0.51
|
|
|
Service Code
|
NDC 0409-3307-03
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| 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 |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
OP
|
$0.51
|
|
|
Service Code
|
NDC 0409-3307-03
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: BCBS Transplant Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.46
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.38
|
| Rate for Payer: IEHP medi-cal |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: Riverside University Health MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
IP
|
$0.73
|
|
|
Service Code
|
NDC 63323-691-30
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| 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 |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.51
|
| Rate for Payer: Cigna of CA PPO |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.62
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.62
|
|
