|
ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]
|
Facility
IP
|
$37.80
|
|
|
Service Code
|
CPT J1120
|
| Hospital Charge Code |
1720067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$28.35 |
| Rate for Payer: Adventist Health Commercial |
$7.56
|
| Rate for Payer: Adventist Health Commercial |
$9.53
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.73
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cash Price |
$17.01
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.50
|
| Rate for Payer: Heritage Provider Network Senior |
$32.25
|
| Rate for Payer: Heritage Provider Network Senior |
$25.59
|
| Rate for Payer: Heritage Provider Network Senior |
$32.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.45
|
| Rate for Payer: Multiplan Commercial |
$35.73
|
| Rate for Payer: Multiplan Commercial |
$28.35
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.04
|
|
|
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 |
$6.84 |
| Max. Negotiated Rate |
$69.08 |
| Rate for Payer: Adventist Health Commercial |
$7.56
|
| Rate for Payer: Adventist Health Commercial |
$9.53
|
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$69.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$69.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$69.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.20
|
| 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 Medicare Advantage/Dual Product |
$35.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$28.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.96
|
| Rate for Payer: Blue Shield of California Commercial |
$40.03
|
| Rate for Payer: Blue Shield of California Commercial |
$40.03
|
| Rate for Payer: Blue Shield of California Commercial |
$40.03
|
| Rate for Payer: Blue Shield of California EPN |
$40.03
|
| Rate for Payer: Blue Shield of California EPN |
$40.03
|
| Rate for Payer: Blue Shield of California EPN |
$40.03
|
| 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 |
$21.60
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Senior |
$32.13
|
| Rate for Payer: Dignity Health Senior |
$40.80
|
| Rate for Payer: Dignity Health Senior |
$40.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.06
|
| Rate for Payer: Heritage Provider Network Senior |
$22.22
|
| Rate for Payer: Heritage Provider Network Senior |
$22.06
|
| Rate for Payer: Heritage Provider Network Senior |
$17.50
|
| Rate for Payer: IEHP Medi-Cal |
$50.82
|
| Rate for Payer: IEHP Medi-Cal |
$50.82
|
| Rate for Payer: IEHP Medi-Cal |
$50.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.45
|
| Rate for Payer: Multiplan Commercial |
$28.35
|
| Rate for Payer: Multiplan Commercial |
$35.73
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.49
|
| 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 Senior |
$40.49
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$32.13
|
|
|
ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]
|
Facility
OP
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-12
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.65
|
| 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 |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.30
|
| Rate for Payer: Blue Shield of California EPN |
$3.12
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Senior |
$4.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.29
|
| Rate for Payer: Heritage Provider Network Senior |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| 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
|
$5.31
|
|
|
Service Code
|
NDC 50268-042-11
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.98 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.65
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
|
|
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 |
$0.96 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.65
|
| 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 |
$3.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.30
|
| Rate for Payer: Blue Shield of California EPN |
$3.12
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Senior |
$4.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.29
|
| Rate for Payer: Heritage Provider Network Senior |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| 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
|
$0.90
|
|
|
Service Code
|
NDC 42571-243-01
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
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 |
$0.96 |
| Max. Negotiated Rate |
$3.98 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.65
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
|
|
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 |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| 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 |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Senior |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| 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
|
$0.90
|
|
|
Service Code
|
NDC 42571-243-01
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| 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 |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| 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 50742-233-01
|
| Hospital Charge Code |
1710308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
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 |
$0.50 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.90
|
| 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 |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.35
|
| Rate for Payer: Dignity Health Senior |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Senior |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| 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 9994-0802-33
|
| Hospital Charge Code |
ERX4080233
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.90
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
|
|
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: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
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 |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
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 |
$0.41 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| 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 |
$1.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| 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 52817-816-15
|
| Hospital Charge Code |
1740195
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.54
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
|
|
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 |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan 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 |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$26.36 |
| Max. Negotiated Rate |
$123.79 |
| Rate for Payer: Adventist Health Commercial |
$29.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$77.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.05
|
| 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 |
$109.22
|
| Rate for Payer: Blue Shield of California Commercial |
$90.44
|
| Rate for Payer: Blue Shield of California EPN |
$85.48
|
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.79
|
| Rate for Payer: Dignity Health Senior |
$123.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$90.14
|
| Rate for Payer: Heritage Provider Network Senior |
$90.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$70.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.41
|
| Rate for Payer: Multiplan Commercial |
$109.22
|
| 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 |
$26.36 |
| Max. Negotiated Rate |
$109.22 |
| Rate for Payer: Adventist Health Commercial |
$29.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.05
|
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.59
|
| Rate for Payer: Heritage Provider Network Senior |
$98.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.41
|
| Rate for Payer: Multiplan Commercial |
$109.22
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| 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 |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| 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
|
$2.77
|
|
|
Service Code
|
NDC 0517-7504-25
|
| Hospital Charge Code |
1781091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.90
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
|
|
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 |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
OP
|
$2.77
|
|
|
Service Code
|
NDC 0517-7504-25
|
| Hospital Charge Code |
1781091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.90
|
| 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 |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.35
|
| Rate for Payer: Dignity Health Senior |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Senior |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Vantage Medical Group Senior |
$2.35
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
OP
|
$3.36
|
|
|
Service Code
|
NDC 63323-695-04
|
| Hospital Charge Code |
1781091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Senior |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
