|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 5026805411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Central Health Plan Commercial |
$2.58
|
| Rate for Payer: Cigna of CA HMO |
$2.25
|
| Rate for Payer: Cigna of CA PPO |
$2.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.74
|
| Rate for Payer: Global Benefits Group Commercial |
$1.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Networks By Design Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.74
|
|
|
ACETAZOLAMIDE 250 MG TABLET [113]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 7075672111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| 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 500 MG SOLUTION FOR INJECTION [114]
|
Facility
|
OP
|
$52.75
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.55 |
| Max. Negotiated Rate |
$118.11 |
| Rate for Payer: Adventist Health Commercial |
$10.55
|
| Rate for Payer: Adventist Health Commercial |
$9.53
|
| Rate for Payer: Adventist Health Commercial |
$7.56
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$118.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$118.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$118.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$118.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$32.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$39.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: 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 Exchange |
$60.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.08
|
| Rate for Payer: Blue Shield of California Commercial |
$47.51
|
| Rate for Payer: Blue Shield of California Commercial |
$47.51
|
| Rate for Payer: Blue Shield of California Commercial |
$47.51
|
| Rate for Payer: Blue Shield of California Commercial |
$47.51
|
| Rate for Payer: Blue Shield of California EPN |
$43.19
|
| Rate for Payer: Blue Shield of California EPN |
$43.19
|
| Rate for Payer: Blue Shield of California EPN |
$43.19
|
| Rate for Payer: Blue Shield of California EPN |
$43.19
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$23.74
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cash Price |
$23.74
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Central Health Plan Commercial |
$30.24
|
| Rate for Payer: Central Health Plan Commercial |
$42.20
|
| Rate for Payer: Central Health Plan Commercial |
$38.40
|
| Rate for Payer: Central Health Plan Commercial |
$38.11
|
| Rate for Payer: Cigna of CA HMO |
$33.35
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$36.92
|
| Rate for Payer: Cigna of CA HMO |
$26.46
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$36.92
|
| Rate for Payer: Cigna of CA PPO |
$26.46
|
| Rate for Payer: Cigna of CA PPO |
$33.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$44.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$44.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$44.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$33.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$33.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$26.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: EPIC Health Plan Senior |
$19.20
|
| Rate for Payer: EPIC Health Plan Senior |
$15.12
|
| Rate for Payer: EPIC Health Plan Senior |
$19.06
|
| Rate for Payer: EPIC Health Plan Senior |
$21.10
|
| Rate for Payer: Galaxy Health WC |
$44.84
|
| 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 |
$31.65
|
| Rate for Payer: Global Benefits Group Commercial |
$28.58
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$22.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$42.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$47.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$34.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$43.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$28.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$28.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$28.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$28.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$24.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$30.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$30.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.55
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$26.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$36.92
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$35.73
|
| Rate for Payer: Multiplan Commercial |
$39.56
|
| Rate for Payer: Multiplan Commercial |
$28.35
|
| Rate for Payer: Networks By Design Commercial |
$26.38
|
| Rate for Payer: Networks By Design Commercial |
$23.82
|
| Rate for Payer: Networks By Design Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$18.90
|
| Rate for Payer: Prime Health Services Commercial |
$44.84
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$32.13
|
| Rate for Payer: Prime Health Services Commercial |
$40.49
|
| Rate for Payer: Riverside University Health System MISP |
$15.12
|
| Rate for Payer: Riverside University Health System MISP |
$19.06
|
| Rate for Payer: Riverside University Health System MISP |
$19.20
|
| Rate for Payer: Riverside University Health System MISP |
$21.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.80
|
| 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 |
$31.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.27
|
| Rate for Payer: United Healthcare All Other HMO |
$17.53
|
| Rate for Payer: United Healthcare All Other HMO |
$13.81
|
| Rate for Payer: United Healthcare All Other HMO |
$17.40
|
| Rate for Payer: United Healthcare HMO Rider |
$17.16
|
| Rate for Payer: United Healthcare HMO Rider |
$13.51
|
| Rate for Payer: United Healthcare HMO Rider |
$17.03
|
| Rate for Payer: United Healthcare HMO Rider |
$18.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$44.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$44.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.49
|
| Rate for Payer: Vantage Medical Group Senior |
$44.84
|
| Rate for Payer: Vantage Medical Group Senior |
$40.49
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$32.13
|
|
|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]
|
Facility
|
IP
|
$47.64
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$42.88 |
| Rate for Payer: Adventist Health Commercial |
$9.53
|
| Rate for Payer: Adventist Health Commercial |
$10.55
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Adventist Health Commercial |
$7.56
|
| Rate for Payer: Blue Shield of California Commercial |
$38.21
|
| Rate for Payer: Blue Shield of California Commercial |
$30.32
|
| Rate for Payer: Blue Shield of California Commercial |
$42.31
|
| Rate for Payer: Blue Shield of California Commercial |
$38.50
|
| Rate for Payer: Blue Shield of California EPN |
$24.01
|
| Rate for Payer: Blue Shield of California EPN |
$19.05
|
| Rate for Payer: Blue Shield of California EPN |
$24.19
|
| Rate for Payer: Blue Shield of California EPN |
$26.59
|
| Rate for Payer: Cash Price |
$23.74
|
| 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 |
$42.20
|
| 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 |
$33.35
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA HMO |
$36.92
|
| Rate for Payer: Cigna of CA HMO |
$26.46
|
| Rate for Payer: Cigna of CA PPO |
$26.46
|
| Rate for Payer: Cigna of CA PPO |
$33.35
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$36.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$26.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$33.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$33.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: EPIC Health Plan Senior |
$19.06
|
| Rate for Payer: EPIC Health Plan Senior |
$19.20
|
| Rate for Payer: EPIC Health Plan Senior |
$21.10
|
| Rate for Payer: EPIC Health Plan Senior |
$15.12
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Galaxy Health WC |
$32.13
|
| Rate for Payer: Galaxy Health WC |
$40.49
|
| Rate for Payer: Galaxy Health WC |
$44.84
|
| Rate for Payer: Global Benefits Group Commercial |
$31.65
|
| Rate for Payer: Global Benefits Group Commercial |
$28.58
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Global Benefits Group Commercial |
$22.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$47.48
|
| 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 Foundation Hospitals Commercial/Self Funded |
$33.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$30.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$30.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$24.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$39.56
|
| 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 |
$26.38
|
| 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 |
$40.80
|
| Rate for Payer: Prime Health Services Commercial |
$40.49
|
| Rate for Payer: Prime Health Services Commercial |
$32.13
|
| Rate for Payer: Prime Health Services Commercial |
$44.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.88
|
| Rate for Payer: United Healthcare All Other HMO |
$17.40
|
| Rate for Payer: United Healthcare All Other HMO |
$13.81
|
| Rate for Payer: United Healthcare All Other HMO |
$19.27
|
| Rate for Payer: United Healthcare All Other HMO |
$17.53
|
| Rate for Payer: United Healthcare HMO Rider |
$13.51
|
| Rate for Payer: United Healthcare HMO Rider |
$17.16
|
| Rate for Payer: United Healthcare HMO Rider |
$18.85
|
| Rate for Payer: United Healthcare HMO Rider |
$17.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.72
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 5074223301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| 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: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| 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: Riverside University Health System 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 Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
OP
|
$5.31
|
|
|
Service Code
|
NDC 5026804211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.09
|
| Rate for Payer: Blue Shield of California Commercial |
$3.37
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| 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: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.72
|
| 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: Riverside University Health System 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 |
$2.65
|
| Rate for Payer: United Healthcare All Other HMO |
$2.65
|
| Rate for Payer: United Healthcare HMO Rider |
$2.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 4257124301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.40
|
| 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: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.63
|
| 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: Riverside University Health System 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 Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 5074223301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.35
|
| 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
|
IP
|
$5.31
|
|
|
Service Code
|
NDC 5026804212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California Commercial |
$4.26
|
| Rate for Payer: Blue Shield of California EPN |
$2.68
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.13
|
| 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
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 4257124301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.40
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.53
|
| 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
|
IP
|
$5.31
|
|
|
Service Code
|
NDC 5026804211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California Commercial |
$4.26
|
| Rate for Payer: Blue Shield of California EPN |
$2.68
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.13
|
| 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
|
$5.31
|
|
|
Service Code
|
NDC 5026804212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.09
|
| Rate for Payer: Blue Shield of California Commercial |
$3.37
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| 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: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.12
|
| Rate for Payer: EPIC Health Plan Senior |
$2.12
|
| Rate for Payer: Galaxy Health WC |
$4.51
|
| Rate for Payer: Global Benefits Group Commercial |
$3.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.72
|
| 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: Riverside University Health System 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 |
$2.65
|
| Rate for Payer: United Healthcare All Other HMO |
$2.65
|
| Rate for Payer: United Healthcare HMO Rider |
$2.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]
|
Facility
|
OP
|
$2.77
|
|
|
Service Code
|
NDC 9994080233
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.61
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California EPN |
$1.11
|
| 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: Dignity Health Medi-Cal |
$2.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: EPIC Health Plan Senior |
$1.11
|
| Rate for Payer: Galaxy Health WC |
$2.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.94
|
| 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: Riverside University Health System 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 |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO |
$1.39
|
| Rate for Payer: United Healthcare HMO Rider |
$1.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Vantage Medical Group Senior |
$2.35
|
|
|
ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]
|
Facility
|
IP
|
$2.77
|
|
|
Service Code
|
NDC 9994080233
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.49 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: EPIC Health Plan Senior |
$1.11
|
| Rate for Payer: Galaxy Health WC |
$2.35
|
| Rate for Payer: Global Benefits Group Commercial |
$1.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.63
|
| 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
|
|
|
ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264230400
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264230400
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| 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 System 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 Commercial/Exchange |
$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
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 5281781615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| 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: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: EPIC Health Plan Senior |
$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 Foundation Hospitals Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.57
|
| 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: Riverside University Health System 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 Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
ACETIC ACID 2 % EAR SOLUTION [17801]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 5281781615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$1.80
|
| Rate for Payer: Blue Shield of California EPN |
$1.13
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: EPIC Health Plan Senior |
$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 Foundation Hospitals Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.32
|
| 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 (BULK) 3 % LIQUID [15091]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 5155200516
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ACETIC ACID (BULK) 3 % LIQUID [15091]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 5155200516
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
ACETYLCHOLINE CHLORIDE (10 MG/ML) BASE FOR IC MIXTURE [4088832559]
|
Facility
|
IP
|
$156.68
|
|
|
Service Code
|
NDC 2420853920
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.34 |
| Max. Negotiated Rate |
$141.01 |
| Rate for Payer: Adventist Health Commercial |
$31.34
|
| Rate for Payer: Blue Shield of California Commercial |
$125.66
|
| Rate for Payer: Blue Shield of California EPN |
$78.97
|
| Rate for Payer: Cash Price |
$70.51
|
| Rate for Payer: Central Health Plan Commercial |
$125.34
|
| Rate for Payer: Cigna of CA HMO |
$109.68
|
| Rate for Payer: Cigna of CA PPO |
$109.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$109.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.67
|
| Rate for Payer: EPIC Health Plan Senior |
$62.67
|
| Rate for Payer: Galaxy Health WC |
$133.18
|
| Rate for Payer: Global Benefits Group Commercial |
$94.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$141.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$99.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$92.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.34
|
| Rate for Payer: Multiplan Commercial |
$117.51
|
| Rate for Payer: Networks By Design Commercial |
$101.84
|
| Rate for Payer: Prime Health Services Commercial |
$133.18
|
|
|
ACETYLCHOLINE CHLORIDE (10 MG/ML) BASE FOR IC MIXTURE [4088832559]
|
Facility
|
OP
|
$156.68
|
|
|
Service Code
|
NDC 2420853920
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.34 |
| Max. Negotiated Rate |
$141.01 |
| Rate for Payer: Adventist Health Commercial |
$31.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$95.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$133.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$86.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$117.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$75.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.14
|
| Rate for Payer: Blue Shield of California Commercial |
$99.34
|
| Rate for Payer: Blue Shield of California EPN |
$62.52
|
| Rate for Payer: Cash Price |
$70.51
|
| Rate for Payer: Central Health Plan Commercial |
$125.34
|
| Rate for Payer: Cigna of CA HMO |
$109.68
|
| Rate for Payer: Cigna of CA PPO |
$109.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$133.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$133.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$133.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$109.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.67
|
| Rate for Payer: EPIC Health Plan Senior |
$62.67
|
| Rate for Payer: Galaxy Health WC |
$133.18
|
| Rate for Payer: Global Benefits Group Commercial |
$94.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$141.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$99.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$92.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$109.68
|
| Rate for Payer: Multiplan Commercial |
$117.51
|
| Rate for Payer: Networks By Design Commercial |
$101.84
|
| Rate for Payer: Prime Health Services Commercial |
$133.18
|
| Rate for Payer: Riverside University Health System MISP |
$62.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$94.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$94.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.34
|
| Rate for Payer: United Healthcare All Other HMO |
$78.34
|
| Rate for Payer: United Healthcare HMO Rider |
$78.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$78.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$133.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$133.18
|
| Rate for Payer: Vantage Medical Group Senior |
$133.18
|
|
|
ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]
|
Facility
|
IP
|
$156.68
|
|
|
Service Code
|
NDC 2420853920
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.34 |
| Max. Negotiated Rate |
$141.01 |
| Rate for Payer: Adventist Health Commercial |
$31.34
|
| Rate for Payer: Blue Shield of California Commercial |
$125.66
|
| Rate for Payer: Blue Shield of California EPN |
$78.97
|
| Rate for Payer: Cash Price |
$70.51
|
| Rate for Payer: Central Health Plan Commercial |
$125.34
|
| Rate for Payer: Cigna of CA HMO |
$109.68
|
| Rate for Payer: Cigna of CA PPO |
$109.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$109.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.67
|
| Rate for Payer: EPIC Health Plan Senior |
$62.67
|
| Rate for Payer: Galaxy Health WC |
$133.18
|
| Rate for Payer: Global Benefits Group Commercial |
$94.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$141.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$99.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$92.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.34
|
| Rate for Payer: Multiplan Commercial |
$117.51
|
| Rate for Payer: Networks By Design Commercial |
$101.84
|
| Rate for Payer: Prime Health Services Commercial |
$133.18
|
|
|
ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]
|
Facility
|
OP
|
$156.68
|
|
|
Service Code
|
NDC 2420853920
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.34 |
| Max. Negotiated Rate |
$141.01 |
| Rate for Payer: Adventist Health Commercial |
$31.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$95.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$133.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$86.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$117.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$75.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.14
|
| Rate for Payer: Blue Shield of California Commercial |
$99.34
|
| Rate for Payer: Blue Shield of California EPN |
$62.52
|
| Rate for Payer: Cash Price |
$70.51
|
| Rate for Payer: Central Health Plan Commercial |
$125.34
|
| Rate for Payer: Cigna of CA HMO |
$109.68
|
| Rate for Payer: Cigna of CA PPO |
$109.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$133.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$133.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$133.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$109.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.67
|
| Rate for Payer: EPIC Health Plan Senior |
$62.67
|
| Rate for Payer: Galaxy Health WC |
$133.18
|
| Rate for Payer: Global Benefits Group Commercial |
$94.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$141.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$99.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$92.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$109.68
|
| Rate for Payer: Multiplan Commercial |
$117.51
|
| Rate for Payer: Networks By Design Commercial |
$101.84
|
| Rate for Payer: Prime Health Services Commercial |
$133.18
|
| Rate for Payer: Riverside University Health System MISP |
$62.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$94.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$94.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.34
|
| Rate for Payer: United Healthcare All Other HMO |
$78.34
|
| Rate for Payer: United Healthcare HMO Rider |
$78.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$78.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$133.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$133.18
|
| Rate for Payer: Vantage Medical Group Senior |
$133.18
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 0517750425
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.71
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Central Health Plan Commercial |
$2.72
|
| Rate for Payer: Cigna of CA HMO |
$2.38
|
| Rate for Payer: Cigna of CA PPO |
$2.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: EPIC Health Plan Senior |
$1.36
|
| Rate for Payer: Galaxy Health WC |
$2.89
|
| Rate for Payer: Global Benefits Group Commercial |
$2.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
| Rate for Payer: Networks By Design Commercial |
$2.21
|
| Rate for Payer: Prime Health Services Commercial |
$2.89
|
|
