|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Blue Shield of California Commercial |
$34.01
|
| Rate for Payer: Blue Shield of California EPN |
$22.39
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Senior |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.06
|
| Rate for Payer: Multiplan Commercial |
$36.86
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0802-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$467.37 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Blue Shield of California Commercial |
$405.79
|
| Rate for Payer: Blue Shield of California EPN |
$267.23
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO |
$384.89
|
| Rate for Payer: Cigna of CA PPO |
$384.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.37
|
| Rate for Payer: Global Benefits Group Commercial |
$329.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.96
|
| Rate for Payer: Multiplan Commercial |
$439.88
|
| Rate for Payer: Networks By Design Commercial |
$357.40
|
| Rate for Payer: Prime Health Services Commercial |
$467.37
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$467.38 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Blue Shield of California Commercial |
$405.80
|
| Rate for Payer: Blue Shield of California EPN |
$267.23
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO |
$384.90
|
| Rate for Payer: Cigna of CA PPO |
$384.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.38
|
| Rate for Payer: Global Benefits Group Commercial |
$329.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.97
|
| Rate for Payer: Multiplan Commercial |
$439.89
|
| Rate for Payer: Networks By Design Commercial |
$357.41
|
| Rate for Payer: Prime Health Services Commercial |
$467.38
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Senior |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$36.86
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.04
|
| Rate for Payer: United Healthcare All Other HMO |
$23.04
|
| Rate for Payer: United Healthcare HMO Rider |
$23.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.30
|
| Rate for Payer: Cash Price |
$25.35
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$467.38 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$360.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$337.67
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO |
$384.90
|
| Rate for Payer: Cigna of CA PPO |
$384.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$467.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.38
|
| Rate for Payer: Global Benefits Group Commercial |
$329.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.90
|
| Rate for Payer: Multiplan Commercial |
$439.89
|
| Rate for Payer: Networks By Design Commercial |
$357.41
|
| Rate for Payer: Prime Health Services Commercial |
$467.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$329.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$329.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$274.93
|
| Rate for Payer: United Healthcare All Other HMO |
$274.93
|
| Rate for Payer: United Healthcare HMO Rider |
$274.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.38
|
| Rate for Payer: Vantage Medical Group Senior |
$467.38
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$467.38 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$360.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$337.67
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO |
$384.90
|
| Rate for Payer: Cigna of CA PPO |
$384.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$467.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.38
|
| Rate for Payer: Global Benefits Group Commercial |
$329.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.90
|
| Rate for Payer: Multiplan Commercial |
$439.89
|
| Rate for Payer: Networks By Design Commercial |
$357.41
|
| Rate for Payer: Prime Health Services Commercial |
$467.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$329.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$329.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$274.93
|
| Rate for Payer: United Healthcare All Other HMO |
$274.93
|
| Rate for Payer: United Healthcare HMO Rider |
$274.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.38
|
| Rate for Payer: Vantage Medical Group Senior |
$467.38
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$467.37 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Blue Shield of California Commercial |
$405.79
|
| Rate for Payer: Blue Shield of California EPN |
$267.23
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO |
$384.89
|
| Rate for Payer: Cigna of CA PPO |
$384.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.37
|
| Rate for Payer: Global Benefits Group Commercial |
$329.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.96
|
| Rate for Payer: Multiplan Commercial |
$439.88
|
| Rate for Payer: Networks By Design Commercial |
$357.40
|
| Rate for Payer: Prime Health Services Commercial |
$467.37
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Senior |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$36.86
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.04
|
| Rate for Payer: United Healthcare All Other HMO |
$23.04
|
| Rate for Payer: United Healthcare HMO Rider |
$23.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.30
|
| Rate for Payer: Cash Price |
$25.35
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$549.86
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$467.38 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Blue Shield of California Commercial |
$405.80
|
| Rate for Payer: Blue Shield of California EPN |
$267.23
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO |
$384.90
|
| Rate for Payer: Cigna of CA PPO |
$384.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.38
|
| Rate for Payer: Global Benefits Group Commercial |
$329.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.97
|
| Rate for Payer: Multiplan Commercial |
$439.89
|
| Rate for Payer: Networks By Design Commercial |
$357.41
|
| Rate for Payer: Prime Health Services Commercial |
$467.38
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$549.85
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.97 |
| Max. Negotiated Rate |
$467.37 |
| Rate for Payer: Adventist Health Commercial |
$109.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$360.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$302.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$412.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$337.66
|
| Rate for Payer: Cash Price |
$302.42
|
| Rate for Payer: Cigna of CA HMO |
$384.89
|
| Rate for Payer: Cigna of CA PPO |
$384.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$467.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$467.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$467.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.94
|
| Rate for Payer: EPIC Health Plan Senior |
$219.94
|
| Rate for Payer: Galaxy Health WC |
$467.37
|
| Rate for Payer: Global Benefits Group Commercial |
$329.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$366.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$209.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$340.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$131.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.89
|
| Rate for Payer: Multiplan Commercial |
$439.88
|
| Rate for Payer: Networks By Design Commercial |
$357.40
|
| Rate for Payer: Prime Health Services Commercial |
$467.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$329.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$329.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$274.93
|
| Rate for Payer: United Healthcare All Other HMO |
$274.93
|
| Rate for Payer: United Healthcare HMO Rider |
$274.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$274.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$467.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$467.37
|
| Rate for Payer: Vantage Medical Group Senior |
$467.37
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Blue Shield of California Commercial |
$34.01
|
| Rate for Payer: Blue Shield of California EPN |
$22.39
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Cigna of CA HMO |
$32.26
|
| Rate for Payer: Cigna of CA PPO |
$32.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.43
|
| Rate for Payer: EPIC Health Plan Senior |
$18.43
|
| Rate for Payer: Galaxy Health WC |
$39.17
|
| Rate for Payer: Global Benefits Group Commercial |
$27.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.06
|
| Rate for Payer: Multiplan Commercial |
$36.86
|
| Rate for Payer: Networks By Design Commercial |
$29.95
|
| Rate for Payer: Prime Health Services Commercial |
$39.17
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
OP
|
$6.99
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna of CA HMO |
$4.89
|
| Rate for Payer: Cigna of CA HMO |
$3.00
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.00
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$4.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Galaxy Health WC |
$5.94
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$5.59
|
| Rate for Payer: Multiplan Commercial |
$3.43
|
| Rate for Payer: Networks By Design Commercial |
$3.50
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| Rate for Payer: Prime Health Services Commercial |
$5.94
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Other HMO |
$2.55
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$1.57
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Vantage Medical Group Senior |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.94
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$3.54
|
| Rate for Payer: Blue Shield of California Commercial |
$5.16
|
| Rate for Payer: Blue Shield of California Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$2.33
|
| Rate for Payer: Blue Shield of California EPN |
$2.08
|
| Rate for Payer: Blue Shield of California EPN |
$3.40
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$3.00
|
| Rate for Payer: Cigna of CA HMO |
$4.89
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.00
|
| Rate for Payer: Cigna of CA PPO |
$4.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1.72
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Galaxy Health WC |
$3.65
|
| Rate for Payer: Galaxy Health WC |
$5.94
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Global Benefits Group Commercial |
$2.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$3.43
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$5.59
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$3.50
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| Rate for Payer: Prime Health Services Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Prime Health Services Commercial |
$5.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.62
|
| Rate for Payer: United Healthcare All Other HMO |
$2.55
|
| Rate for Payer: United Healthcare All Other HMO |
$1.57
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$3.43
|
| Rate for Payer: Blue Shield of California Commercial |
$3.54
|
| Rate for Payer: Blue Shield of California Commercial |
$3.32
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Blue Shield of California EPN |
$2.19
|
| Rate for Payer: Blue Shield of California EPN |
$2.33
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cigna of CA HMO |
$3.25
|
| Rate for Payer: Cigna of CA HMO |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA PPO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.15
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1.86
|
| Rate for Payer: Galaxy Health WC |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$3.83
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.70
|
| Rate for Payer: Global Benefits Group Commercial |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.25
|
| Rate for Payer: Prime Health Services Commercial |
$3.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.95
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$1.64
|
| Rate for Payer: United Healthcare All Other HMO |
$1.70
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare HMO Rider |
$1.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.86
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cigna of CA HMO |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.15
|
| Rate for Payer: Cigna of CA PPO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$1.92
|
| Rate for Payer: EPIC Health Plan Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Senior |
$1.86
|
| Rate for Payer: Galaxy Health WC |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$4.08
|
| Rate for Payer: Galaxy Health WC |
$3.83
|
| Rate for Payer: Global Benefits Group Commercial |
$2.79
|
| Rate for Payer: Global Benefits Group Commercial |
$2.70
|
| Rate for Payer: Global Benefits Group Commercial |
$2.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Networks By Design Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Networks By Design Commercial |
$2.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.08
|
| Rate for Payer: Prime Health Services Commercial |
$3.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.69
|
| Rate for Payer: United Healthcare All Other HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1.64
|
| Rate for Payer: United Healthcare HMO Rider |
$1.61
|
| Rate for Payer: United Healthcare HMO Rider |
$1.72
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$3.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$3.95
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 0574-0292-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Senior |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 0574-0292-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Senior |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
|
IP
|
$1.15
|
|
|
Service Code
|
NDC 31722-035-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.98
|
| Rate for Payer: Global Benefits Group Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.98
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
|
OP
|
$1.15
|
|
|
Service Code
|
NDC 31722-035-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.98
|
| Rate for Payer: Global Benefits Group Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Vantage Medical Group Senior |
$0.98
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$4.30 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.30
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 60687-739-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$24.39 |
| Rate for Payer: Adventist Health Commercial |
$5.74
|
| Rate for Payer: Blue Shield of California Commercial |
$21.18
|
| Rate for Payer: Blue Shield of California EPN |
$13.95
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Cigna of CA HMO |
$20.09
|
| Rate for Payer: Cigna of CA PPO |
$20.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.48
|
| Rate for Payer: EPIC Health Plan Senior |
$11.48
|
| Rate for Payer: Galaxy Health WC |
$24.39
|
| Rate for Payer: Global Benefits Group Commercial |
$17.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.89
|
| Rate for Payer: Multiplan Commercial |
$22.96
|
| Rate for Payer: Networks By Design Commercial |
$18.66
|
| Rate for Payer: Prime Health Services Commercial |
$24.39
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 70377-102-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Adventist Health Commercial |
$2.80
|
| Rate for Payer: Blue Shield of California Commercial |
$10.33
|
| Rate for Payer: Blue Shield of California EPN |
$6.80
|
| Rate for Payer: Cash Price |
$7.70
|
| Rate for Payer: Cigna of CA HMO |
$9.80
|
| Rate for Payer: Cigna of CA PPO |
$9.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.60
|
| Rate for Payer: EPIC Health Plan Senior |
$5.60
|
| Rate for Payer: Galaxy Health WC |
$11.90
|
| Rate for Payer: Global Benefits Group Commercial |
$8.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$11.20
|
| Rate for Payer: Networks By Design Commercial |
$9.10
|
| Rate for Payer: Prime Health Services Commercial |
$11.90
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 60687-739-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$24.39 |
| Rate for Payer: Cigna of CA HMO |
$20.09
|
| Rate for Payer: Cigna of CA PPO |
$20.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.48
|
| Rate for Payer: EPIC Health Plan Senior |
$11.48
|
| Rate for Payer: Galaxy Health WC |
$24.39
|
| Rate for Payer: Global Benefits Group Commercial |
$17.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.09
|
| Rate for Payer: Multiplan Commercial |
$22.96
|
| Rate for Payer: Networks By Design Commercial |
$18.66
|
| Rate for Payer: Prime Health Services Commercial |
$24.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.35
|
| Rate for Payer: United Healthcare All Other HMO |
$14.35
|
| Rate for Payer: United Healthcare HMO Rider |
$14.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.39
|
| Rate for Payer: Vantage Medical Group Senior |
$24.39
|
| Rate for Payer: Adventist Health Commercial |
$5.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.62
|
| Rate for Payer: Cash Price |
$15.79
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 72205-049-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Blue Shield of California Commercial |
$9.59
|
| Rate for Payer: Blue Shield of California EPN |
$6.32
|
| Rate for Payer: Cash Price |
$7.15
|
| Rate for Payer: Cigna of CA HMO |
$9.10
|
| Rate for Payer: Cigna of CA PPO |
$9.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.20
|
| Rate for Payer: EPIC Health Plan Senior |
$5.20
|
| Rate for Payer: Galaxy Health WC |
$11.05
|
| Rate for Payer: Global Benefits Group Commercial |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: Networks By Design Commercial |
$8.45
|
| Rate for Payer: Prime Health Services Commercial |
$11.05
|
|
