|
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
|
|
|
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
|
$28.70
|
|
|
Service Code
|
NDC 60687-739-25
|
| 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
|
$7.16
|
|
|
Service Code
|
NDC 69680-115-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.40
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO |
$5.01
|
| Rate for Payer: Cigna of CA PPO |
$5.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: EPIC Health Plan Senior |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.09
|
| Rate for Payer: Global Benefits Group Commercial |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.01
|
| Rate for Payer: Multiplan Commercial |
$5.73
|
| Rate for Payer: Networks By Design Commercial |
$4.65
|
| Rate for Payer: Prime Health Services Commercial |
$6.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3.58
|
| Rate for Payer: United Healthcare HMO Rider |
$3.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.09
|
| Rate for Payer: Vantage Medical Group Senior |
$6.09
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$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: Cigna of CA HMO |
$9.10
|
| Rate for Payer: Cigna of CA PPO |
$9.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.05
|
| 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: Molina Healthcare of CA Medi-Cal |
$9.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.10
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.50
|
| Rate for Payer: United Healthcare All Other HMO |
$6.50
|
| Rate for Payer: United Healthcare HMO Rider |
$6.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.05
|
| Rate for Payer: Vantage Medical Group Senior |
$11.05
|
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.98
|
| Rate for Payer: Cash Price |
$7.15
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$35.90 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.90
|
| Rate for Payer: Blue Shield of California Commercial |
$13.10
|
| Rate for Payer: Blue Shield of California EPN |
$13.10
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION CDL ONLY [4084072]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$35.90 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.90
|
| Rate for Payer: Blue Shield of California Commercial |
$13.10
|
| Rate for Payer: Blue Shield of California EPN |
$13.10
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION CDL ONLY [4084072]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION (RAD) [4084071]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$35.90 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.90
|
| Rate for Payer: Blue Shield of California Commercial |
$13.10
|
| Rate for Payer: Blue Shield of California EPN |
$13.10
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION (RAD) [4084071]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
|
|
AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION CDL ONLY [408407]
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Senior |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
|
|
AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION CDL ONLY [408407]
|
Facility
|
OP
|
$0.77
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$35.90 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.90
|
| Rate for Payer: Blue Shield of California Commercial |
$13.10
|
| Rate for Payer: Blue Shield of California EPN |
$13.10
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Senior |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Vantage Medical Group Senior |
$0.65
|
|
|
AMINOPHYLLINE ORAL SOLUTION (IV FORM) 25 MG/ML [4080417]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0804-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
AMINOPHYLLINE ORAL SOLUTION (IV FORM) 25 MG/ML [4080417]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0804-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
AMIODARONE 150 MG/3 ML VIAL - CODE [4080561]
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.50
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.41
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$1.50
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
|
|
AMIODARONE 150 MG/3 ML VIAL - CODE [4080561]
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$1.23
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$1.50
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$1.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.64
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$1.50
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 60687-437-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| 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 Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0245-0147-89
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| 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 Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 60687-437-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| 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 Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services 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: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 60687-437-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| 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 Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services 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: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 68382-227-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0245-0147-89
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| 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 Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services 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: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
|
|
AMIODARONE 200 MG TABLET [9066]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 72888-039-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
