|
WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 7214063386
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 7214063608
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 7214063608
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
WHITE PETROLATUM 41 % TOPICAL OINTMENT [115556]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 7214063386
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [119525]
|
Facility
|
IP
|
$3.35
|
|
|
Service Code
|
NDC 0023031204
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.85
|
| Rate for Payer: Global Benefits Group Commercial |
$2.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.68
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.85
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT [119525]
|
Facility
|
OP
|
$3.35
|
|
|
Service Code
|
NDC 0023031204
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.15
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.85
|
| Rate for Payer: Global Benefits Group Commercial |
$2.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$2.68
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.85
|
| Rate for Payer: Vantage Medical Group Senior |
$2.85
|
|
|
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 9999902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.80
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$1.64
|
| Rate for Payer: Cigna of CA PPO |
$1.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: EPIC Health Plan Senior |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$1.99
|
|
|
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 1011902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.62
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.76
|
| Rate for Payer: Cigna of CA PPO |
$1.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: EPIC Health Plan Senior |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$2.14
|
| Rate for Payer: Global Benefits Group Commercial |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.64
|
| Rate for Payer: Prime Health Services Commercial |
$2.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO |
$1.26
|
| Rate for Payer: United Healthcare HMO Rider |
$1.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.14
|
| Rate for Payer: Vantage Medical Group Senior |
$2.14
|
|
|
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
NDC 9999902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$1.64
|
| Rate for Payer: Cigna of CA PPO |
$1.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.94
|
| Rate for Payer: EPIC Health Plan Senior |
$0.94
|
| Rate for Payer: Galaxy Health WC |
$1.99
|
| Rate for Payer: Global Benefits Group Commercial |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$1.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.17
|
| Rate for Payer: United Healthcare All Other HMO |
$1.17
|
| Rate for Payer: United Healthcare HMO Rider |
$1.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1.99
|
|
|
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT [119541]
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 1011902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.76
|
| Rate for Payer: Cigna of CA PPO |
$1.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: EPIC Health Plan Senior |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$2.14
|
| Rate for Payer: Global Benefits Group Commercial |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.64
|
| Rate for Payer: Prime Health Services Commercial |
$2.14
|
|
|
WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [119339]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 0904648838
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$1.29
|
| Rate for Payer: Cigna of CA PPO |
$1.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.93
|
| Rate for Payer: United Healthcare All Other HMO |
$0.93
|
| Rate for Payer: United Healthcare HMO Rider |
$0.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT [119339]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 0904648838
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$1.29
|
| Rate for Payer: Cigna of CA PPO |
$1.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
|
|
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT [119919]
|
Facility
|
IP
|
$2.45
|
|
|
Service Code
|
NDC 0065051801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.08
|
| Rate for Payer: Global Benefits Group Commercial |
$1.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.96
|
| Rate for Payer: Networks By Design Commercial |
$1.59
|
| Rate for Payer: Prime Health Services Commercial |
$2.08
|
|
|
WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT [119919]
|
Facility
|
OP
|
$2.45
|
|
|
Service Code
|
NDC 0065051801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.57
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.08
|
| Rate for Payer: Global Benefits Group Commercial |
$1.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.96
|
| Rate for Payer: Networks By Design Commercial |
$1.59
|
| Rate for Payer: Prime Health Services Commercial |
$2.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Vantage Medical Group Senior |
$2.08
|
|
|
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT [115913]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 4628750704
|
| 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 |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
|
|
WHITE PETROLATUM-MINERAL OIL TOPICAL OINTMENT [115913]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 4628750704
|
| 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 |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
|
|
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC
|
Facility
|
IP
|
$134,519.42
|
|
|
Service Code
|
MSDRG 464
|
| Min. Negotiated Rate |
$34,033.00 |
| Max. Negotiated Rate |
$134,519.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$94,425.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$134,519.42
|
| Rate for Payer: EPIC Health Plan Senior |
$89,679.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$81,526.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$114,137.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$109,246.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$112,353.00
|
| Rate for Payer: United Healthcare All Other HMO |
$112,353.00
|
| Rate for Payer: United Healthcare HMO Rider |
$37,147.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34,033.00
|
|
|
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC
|
Facility
|
IP
|
$180,386.25
|
|
|
Service Code
|
MSDRG 463
|
| Min. Negotiated Rate |
$46,778.00 |
| Max. Negotiated Rate |
$180,386.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$172,786.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$180,386.25
|
| Rate for Payer: EPIC Health Plan Senior |
$120,257.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$109,325.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$153,055.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$146,495.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$112,353.00
|
| Rate for Payer: United Healthcare All Other HMO |
$112,353.00
|
| Rate for Payer: United Healthcare HMO Rider |
$51,058.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$46,778.00
|
|
|
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$112,353.00
|
|
|
Service Code
|
MSDRG 465
|
| Min. Negotiated Rate |
$27,650.00 |
| Max. Negotiated Rate |
$112,353.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$55,287.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$111,610.87
|
| Rate for Payer: EPIC Health Plan Senior |
$74,407.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67,642.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94,700.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$90,641.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$112,353.00
|
| Rate for Payer: United Healthcare All Other HMO |
$112,353.00
|
| Rate for Payer: United Healthcare HMO Rider |
$30,180.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27,650.00
|
|
|
WOUND DEBRIDEMENTS FOR INJURIES WITH CC
|
Facility
|
IP
|
$113,222.08
|
|
|
Service Code
|
MSDRG 902
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$113,222.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$58,039.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$113,222.08
|
| Rate for Payer: EPIC Health Plan Senior |
$75,481.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$68,619.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$96,067.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$91,950.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC
|
Facility
|
IP
|
$153,717.55
|
|
|
Service Code
|
MSDRG 901
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$153,717.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$127,224.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$153,717.55
|
| Rate for Payer: EPIC Health Plan Senior |
$102,478.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$93,162.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$130,427.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$124,837.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC
|
Facility
|
IP
|
$100,003.98
|
|
|
Service Code
|
MSDRG 903
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$100,003.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$35,457.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$100,003.98
|
| Rate for Payer: EPIC Health Plan Senior |
$66,669.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$60,608.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84,851.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$81,215.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
X2C0361
|
Facility
|
IP
|
$13,133.00
|
|
|
Service Code
|
ICD X2C0361
|
| Hospital Charge Code |
2777
|
| Min. Negotiated Rate |
$13,133.00 |
| Max. Negotiated Rate |
$13,133.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,133.00
|
|
|
X2RF032
|
Facility
|
IP
|
$13,133.00
|
|
|
Service Code
|
ICD X2RF032
|
| Hospital Charge Code |
2778
|
| Min. Negotiated Rate |
$13,133.00 |
| Max. Negotiated Rate |
$13,133.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,133.00
|
|
|
X2RF332
|
Facility
|
IP
|
$13,133.00
|
|
|
Service Code
|
ICD X2RF332
|
| Hospital Charge Code |
2779
|
| Min. Negotiated Rate |
$13,133.00 |
| Max. Negotiated Rate |
$13,133.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,133.00
|
|
