|
ALPRAZOLAM 0.5 MG TABLET [325]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0228-2029-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
|
|
ALPRAZOLAM 1 MG TABLET [326]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 59762-3721-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
ALPRAZOLAM 1 MG TABLET [326]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 59762-3721-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
ALPRAZOLAM 1 MG TABLET [326]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 65862-678-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
ALPRAZOLAM 1 MG TABLET [326]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 65862-678-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
ALTEPLASE 2 MG INTRA-ARTERIAL SOLUTION FOR NEURO IR [40823708]
|
Facility
|
IP
|
$222.20
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.44 |
| Max. Negotiated Rate |
$188.87 |
| Rate for Payer: Adventist Health Commercial |
$44.44
|
| Rate for Payer: Adventist Health Commercial |
$36.73
|
| Rate for Payer: Blue Shield of California Commercial |
$163.98
|
| Rate for Payer: Blue Shield of California Commercial |
$135.55
|
| Rate for Payer: Blue Shield of California EPN |
$89.26
|
| Rate for Payer: Blue Shield of California EPN |
$107.99
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cigna of CA HMO |
$155.54
|
| Rate for Payer: Cigna of CA HMO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$155.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.88
|
| Rate for Payer: EPIC Health Plan Senior |
$73.47
|
| Rate for Payer: EPIC Health Plan Senior |
$88.88
|
| Rate for Payer: Galaxy Health WC |
$156.12
|
| Rate for Payer: Galaxy Health WC |
$188.87
|
| Rate for Payer: Global Benefits Group Commercial |
$110.20
|
| Rate for Payer: Global Benefits Group Commercial |
$133.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$148.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$137.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.33
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: Multiplan Commercial |
$177.76
|
| Rate for Payer: Networks By Design Commercial |
$111.10
|
| Rate for Payer: Networks By Design Commercial |
$91.83
|
| Rate for Payer: Prime Health Services Commercial |
$188.87
|
| Rate for Payer: Prime Health Services Commercial |
$156.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.39
|
| Rate for Payer: United Healthcare All Other HMO |
$81.17
|
| Rate for Payer: United Healthcare All Other HMO |
$67.09
|
| Rate for Payer: United Healthcare HMO Rider |
$65.64
|
| Rate for Payer: United Healthcare HMO Rider |
$79.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.77
|
|
|
ALTEPLASE 2 MG INTRA-ARTERIAL SOLUTION FOR NEURO IR [40823708]
|
Facility
|
OP
|
$183.67
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.73 |
| Max. Negotiated Rate |
$245.27 |
| Rate for Payer: Adventist Health Commercial |
$36.73
|
| Rate for Payer: Adventist Health Commercial |
$44.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$120.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$145.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.27
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Blue Shield of California EPN |
$105.71
|
| Rate for Payer: Blue Shield of California EPN |
$105.71
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cigna of CA HMO |
$155.54
|
| Rate for Payer: Cigna of CA HMO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$155.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$103.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$103.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$103.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$103.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.10
|
| Rate for Payer: EPIC Health Plan Senior |
$94.15
|
| Rate for Payer: EPIC Health Plan Senior |
$94.15
|
| Rate for Payer: Galaxy Health WC |
$156.12
|
| Rate for Payer: Galaxy Health WC |
$188.87
|
| Rate for Payer: Global Benefits Group Commercial |
$133.32
|
| Rate for Payer: Global Benefits Group Commercial |
$110.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$94.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$94.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$148.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$118.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$118.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.16
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: Multiplan Commercial |
$177.76
|
| Rate for Payer: Networks By Design Commercial |
$111.10
|
| Rate for Payer: Networks By Design Commercial |
$91.83
|
| Rate for Payer: Prime Health Services Commercial |
$156.12
|
| Rate for Payer: Prime Health Services Commercial |
$188.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$133.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$133.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.93
|
| Rate for Payer: United Healthcare All Other HMO |
$67.09
|
| Rate for Payer: United Healthcare All Other HMO |
$81.17
|
| Rate for Payer: United Healthcare HMO Rider |
$65.64
|
| Rate for Payer: United Healthcare HMO Rider |
$79.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$94.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$94.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Vantage Medical Group Senior |
$103.56
|
| Rate for Payer: Vantage Medical Group Senior |
$103.56
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]
|
Facility
|
IP
|
$222.20
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.44 |
| Max. Negotiated Rate |
$188.87 |
| Rate for Payer: Adventist Health Commercial |
$44.44
|
| Rate for Payer: Adventist Health Commercial |
$36.73
|
| Rate for Payer: Blue Shield of California Commercial |
$163.98
|
| Rate for Payer: Blue Shield of California Commercial |
$135.55
|
| Rate for Payer: Blue Shield of California EPN |
$89.26
|
| Rate for Payer: Blue Shield of California EPN |
$107.99
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cigna of CA HMO |
$155.54
|
| Rate for Payer: Cigna of CA HMO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$155.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.88
|
| Rate for Payer: EPIC Health Plan Senior |
$73.47
|
| Rate for Payer: EPIC Health Plan Senior |
$88.88
|
| Rate for Payer: Galaxy Health WC |
$156.12
|
| Rate for Payer: Galaxy Health WC |
$188.87
|
| Rate for Payer: Global Benefits Group Commercial |
$110.20
|
| Rate for Payer: Global Benefits Group Commercial |
$133.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$148.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$137.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.33
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: Multiplan Commercial |
$177.76
|
| Rate for Payer: Networks By Design Commercial |
$111.10
|
| Rate for Payer: Networks By Design Commercial |
$91.83
|
| Rate for Payer: Prime Health Services Commercial |
$188.87
|
| Rate for Payer: Prime Health Services Commercial |
$156.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.39
|
| Rate for Payer: United Healthcare All Other HMO |
$81.17
|
| Rate for Payer: United Healthcare All Other HMO |
$67.09
|
| Rate for Payer: United Healthcare HMO Rider |
$65.64
|
| Rate for Payer: United Healthcare HMO Rider |
$79.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.77
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]
|
Facility
|
OP
|
$183.67
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.73 |
| Max. Negotiated Rate |
$245.27 |
| Rate for Payer: Blue Shield of California EPN |
$105.71
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cigna of CA HMO |
$155.54
|
| Rate for Payer: Cigna of CA HMO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$155.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$103.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$103.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$103.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$103.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.10
|
| Rate for Payer: EPIC Health Plan Senior |
$94.15
|
| Rate for Payer: EPIC Health Plan Senior |
$94.15
|
| Rate for Payer: Galaxy Health WC |
$156.12
|
| Rate for Payer: Galaxy Health WC |
$188.87
|
| Rate for Payer: Global Benefits Group Commercial |
$133.32
|
| Rate for Payer: Global Benefits Group Commercial |
$110.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$94.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$94.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$148.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$118.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$118.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.16
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: Multiplan Commercial |
$177.76
|
| Rate for Payer: Networks By Design Commercial |
$111.10
|
| Rate for Payer: Networks By Design Commercial |
$91.83
|
| Rate for Payer: Prime Health Services Commercial |
$156.12
|
| Rate for Payer: Prime Health Services Commercial |
$188.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$133.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$133.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.93
|
| Rate for Payer: United Healthcare All Other HMO |
$67.09
|
| Rate for Payer: United Healthcare All Other HMO |
$81.17
|
| Rate for Payer: United Healthcare HMO Rider |
$65.64
|
| Rate for Payer: United Healthcare HMO Rider |
$79.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$94.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$94.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Vantage Medical Group Senior |
$103.56
|
| Rate for Payer: Vantage Medical Group Senior |
$103.56
|
| Rate for Payer: Adventist Health Commercial |
$36.73
|
| Rate for Payer: Adventist Health Commercial |
$44.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$120.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$145.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.27
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Blue Shield of California EPN |
$105.71
|
|
|
ALTEPLASE (CATHFLO) SYRINGE 2 MG/2 ML FOR NEBULIZATION [4081953]
|
Facility
|
IP
|
$222.20
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.44 |
| Max. Negotiated Rate |
$188.87 |
| Rate for Payer: Adventist Health Commercial |
$44.44
|
| Rate for Payer: Adventist Health Commercial |
$36.73
|
| Rate for Payer: Blue Shield of California Commercial |
$163.98
|
| Rate for Payer: Blue Shield of California Commercial |
$135.55
|
| Rate for Payer: Blue Shield of California EPN |
$89.26
|
| Rate for Payer: Blue Shield of California EPN |
$107.99
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cigna of CA HMO |
$155.54
|
| Rate for Payer: Cigna of CA HMO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$155.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.88
|
| Rate for Payer: EPIC Health Plan Senior |
$73.47
|
| Rate for Payer: EPIC Health Plan Senior |
$88.88
|
| Rate for Payer: Galaxy Health WC |
$156.12
|
| Rate for Payer: Galaxy Health WC |
$188.87
|
| Rate for Payer: Global Benefits Group Commercial |
$110.20
|
| Rate for Payer: Global Benefits Group Commercial |
$133.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$148.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$137.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.33
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: Multiplan Commercial |
$177.76
|
| Rate for Payer: Networks By Design Commercial |
$111.10
|
| Rate for Payer: Networks By Design Commercial |
$91.83
|
| Rate for Payer: Prime Health Services Commercial |
$188.87
|
| Rate for Payer: Prime Health Services Commercial |
$156.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.39
|
| Rate for Payer: United Healthcare All Other HMO |
$81.17
|
| Rate for Payer: United Healthcare All Other HMO |
$67.09
|
| Rate for Payer: United Healthcare HMO Rider |
$65.64
|
| Rate for Payer: United Healthcare HMO Rider |
$79.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.77
|
|
|
ALTEPLASE (CATHFLO) SYRINGE 2 MG/2 ML FOR NEBULIZATION [4081953]
|
Facility
|
OP
|
$183.67
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.73 |
| Max. Negotiated Rate |
$245.27 |
| Rate for Payer: Adventist Health Commercial |
$36.73
|
| Rate for Payer: Adventist Health Commercial |
$44.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$120.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$145.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.27
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Blue Shield of California EPN |
$105.71
|
| Rate for Payer: Blue Shield of California EPN |
$105.71
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cigna of CA HMO |
$155.54
|
| Rate for Payer: Cigna of CA HMO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$155.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$103.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$103.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$103.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$103.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.10
|
| Rate for Payer: EPIC Health Plan Senior |
$94.15
|
| Rate for Payer: EPIC Health Plan Senior |
$94.15
|
| Rate for Payer: Galaxy Health WC |
$156.12
|
| Rate for Payer: Galaxy Health WC |
$188.87
|
| Rate for Payer: Global Benefits Group Commercial |
$133.32
|
| Rate for Payer: Global Benefits Group Commercial |
$110.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$94.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$94.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$148.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$118.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$118.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.16
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: Multiplan Commercial |
$177.76
|
| Rate for Payer: Networks By Design Commercial |
$111.10
|
| Rate for Payer: Networks By Design Commercial |
$91.83
|
| Rate for Payer: Prime Health Services Commercial |
$156.12
|
| Rate for Payer: Prime Health Services Commercial |
$188.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$133.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$133.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.93
|
| Rate for Payer: United Healthcare All Other HMO |
$67.09
|
| Rate for Payer: United Healthcare All Other HMO |
$81.17
|
| Rate for Payer: United Healthcare HMO Rider |
$65.64
|
| Rate for Payer: United Healthcare HMO Rider |
$79.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$94.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$94.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Vantage Medical Group Senior |
$103.56
|
| Rate for Payer: Vantage Medical Group Senior |
$103.56
|
|
|
ALTEPLASE INTRAVENTRICULAR 2 MG/2 ML SYRINGE [40820125]
|
Facility
|
OP
|
$183.67
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.73 |
| Max. Negotiated Rate |
$245.27 |
| Rate for Payer: Adventist Health Commercial |
$36.73
|
| Rate for Payer: Adventist Health Commercial |
$44.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$120.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$145.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.27
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Blue Shield of California EPN |
$105.71
|
| Rate for Payer: Blue Shield of California EPN |
$105.71
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cigna of CA HMO |
$155.54
|
| Rate for Payer: Cigna of CA HMO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$155.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$103.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$103.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$103.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$103.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.10
|
| Rate for Payer: EPIC Health Plan Senior |
$94.15
|
| Rate for Payer: EPIC Health Plan Senior |
$94.15
|
| Rate for Payer: Galaxy Health WC |
$156.12
|
| Rate for Payer: Galaxy Health WC |
$188.87
|
| Rate for Payer: Global Benefits Group Commercial |
$133.32
|
| Rate for Payer: Global Benefits Group Commercial |
$110.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$94.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$94.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$148.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$118.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$118.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.16
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: Multiplan Commercial |
$177.76
|
| Rate for Payer: Networks By Design Commercial |
$111.10
|
| Rate for Payer: Networks By Design Commercial |
$91.83
|
| Rate for Payer: Prime Health Services Commercial |
$156.12
|
| Rate for Payer: Prime Health Services Commercial |
$188.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$133.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$133.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.93
|
| Rate for Payer: United Healthcare All Other HMO |
$67.09
|
| Rate for Payer: United Healthcare All Other HMO |
$81.17
|
| Rate for Payer: United Healthcare HMO Rider |
$65.64
|
| Rate for Payer: United Healthcare HMO Rider |
$79.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$94.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$94.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$103.56
|
| Rate for Payer: Vantage Medical Group Senior |
$103.56
|
| Rate for Payer: Vantage Medical Group Senior |
$103.56
|
|
|
ALTEPLASE INTRAVENTRICULAR 2 MG/2 ML SYRINGE [40820125]
|
Facility
|
IP
|
$222.20
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.44 |
| Max. Negotiated Rate |
$188.87 |
| Rate for Payer: Adventist Health Commercial |
$44.44
|
| Rate for Payer: Adventist Health Commercial |
$36.73
|
| Rate for Payer: Blue Shield of California Commercial |
$163.98
|
| Rate for Payer: Blue Shield of California Commercial |
$135.55
|
| Rate for Payer: Blue Shield of California EPN |
$89.26
|
| Rate for Payer: Blue Shield of California EPN |
$107.99
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Cash Price |
$101.02
|
| Rate for Payer: Cigna of CA HMO |
$155.54
|
| Rate for Payer: Cigna of CA HMO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$128.57
|
| Rate for Payer: Cigna of CA PPO |
$155.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.88
|
| Rate for Payer: EPIC Health Plan Senior |
$73.47
|
| Rate for Payer: EPIC Health Plan Senior |
$88.88
|
| Rate for Payer: Galaxy Health WC |
$156.12
|
| Rate for Payer: Galaxy Health WC |
$188.87
|
| Rate for Payer: Global Benefits Group Commercial |
$110.20
|
| Rate for Payer: Global Benefits Group Commercial |
$133.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$148.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$137.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.33
|
| Rate for Payer: Multiplan Commercial |
$146.94
|
| Rate for Payer: Multiplan Commercial |
$177.76
|
| Rate for Payer: Networks By Design Commercial |
$111.10
|
| Rate for Payer: Networks By Design Commercial |
$91.83
|
| Rate for Payer: Prime Health Services Commercial |
$188.87
|
| Rate for Payer: Prime Health Services Commercial |
$156.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.39
|
| Rate for Payer: United Healthcare All Other HMO |
$81.17
|
| Rate for Payer: United Healthcare All Other HMO |
$67.09
|
| Rate for Payer: United Healthcare HMO Rider |
$65.64
|
| Rate for Payer: United Healthcare HMO Rider |
$79.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.77
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION [353]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-0091-85
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| 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: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION [353]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536-0091-85
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$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 |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: 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 |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION [24314]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904-7727-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| 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: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION [24314]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0904-7727-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$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: 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: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA 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: 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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 57896-629-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$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: 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: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA 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: 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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0536-1293-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| 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: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0536-1293-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$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: 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: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA 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: 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
|
| 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 HMO/PPO |
$0.01
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0121-1761-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| 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 |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| 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 |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9994-0838-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| 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: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 57896-629-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| 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: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 9994-0838-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| 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 HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$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: 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: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA 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: 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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0121-1761-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
