|
ALTEPLASE 100 MG INTRAVENOUS SOLUTION (ACUTE THROMBOEMBOLIC STROKE) [4081495]
|
Facility
|
OP
|
$10,560.43
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.98 |
| Max. Negotiated Rate |
$8,976.37 |
| Rate for Payer: Adventist Health Commercial |
$2,112.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$575.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.98
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Cash Price |
$4,752.19
|
| Rate for Payer: Cash Price |
$4,752.19
|
| Rate for Payer: Cigna of CA HMO |
$7,392.30
|
| Rate for Payer: Cigna of CA PPO |
$7,392.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7,392.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.67
|
| Rate for Payer: EPIC Health Plan Senior |
$108.45
|
| Rate for Payer: Galaxy Health WC |
$8,976.37
|
| Rate for Payer: Global Benefits Group Commercial |
$6,336.26
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$161.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$98.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$98.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6,705.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$178.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$138.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,534.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$124.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$132.11
|
| Rate for Payer: Multiplan Commercial |
$8,448.34
|
| Rate for Payer: Networks By Design Commercial |
$5,280.22
|
| Rate for Payer: Prime Health Services Commercial |
$8,976.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6,336.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6,336.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,963.33
|
| Rate for Payer: United Healthcare All Other HMO |
$3,857.73
|
| Rate for Payer: United Healthcare HMO Rider |
$3,774.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,458.54
|
| Rate for Payer: Upland Medical Group Pediatric |
$98.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Vantage Medical Group Senior |
$108.45
|
|
|
ALTEPLASE 1 MG/2 ML SYRINGE [408189]
|
Facility
|
IP
|
$52.80
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$44.88 |
| Rate for Payer: Adventist Health Commercial |
$10.56
|
| Rate for Payer: Blue Shield of California Commercial |
$26.77
|
| Rate for Payer: Blue Shield of California Commercial |
$40.60
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cigna of CA HMO |
$36.96
|
| Rate for Payer: Cigna of CA PPO |
$36.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.12
|
| Rate for Payer: EPIC Health Plan Senior |
$21.12
|
| Rate for Payer: Galaxy Health WC |
$44.88
|
| Rate for Payer: Global Benefits Group Commercial |
$31.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.67
|
| Rate for Payer: Multiplan Commercial |
$42.24
|
| Rate for Payer: Networks By Design Commercial |
$26.40
|
| Rate for Payer: Prime Health Services Commercial |
$44.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.82
|
| Rate for Payer: United Healthcare All Other HMO |
$19.29
|
| Rate for Payer: United Healthcare HMO Rider |
$18.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.29
|
|
|
ALTEPLASE 1 MG/2 ML SYRINGE [408189]
|
Facility
|
OP
|
$52.80
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$575.27 |
| Rate for Payer: Adventist Health Commercial |
$10.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$575.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.98
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cigna of CA HMO |
$36.96
|
| Rate for Payer: Cigna of CA PPO |
$36.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.67
|
| Rate for Payer: EPIC Health Plan Senior |
$108.45
|
| Rate for Payer: Galaxy Health WC |
$44.88
|
| Rate for Payer: Global Benefits Group Commercial |
$31.68
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$161.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$98.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$98.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$178.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$138.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$124.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$132.11
|
| Rate for Payer: Multiplan Commercial |
$42.24
|
| Rate for Payer: Networks By Design Commercial |
$26.40
|
| Rate for Payer: Prime Health Services Commercial |
$44.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.82
|
| Rate for Payer: United Healthcare All Other HMO |
$19.29
|
| Rate for Payer: United Healthcare HMO Rider |
$18.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.29
|
| Rate for Payer: Upland Medical Group Pediatric |
$98.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Vantage Medical Group Senior |
$108.45
|
|
|
ALTEPLASE 2 MG INTRA-ARTERIAL SOLUTION FOR IR [40823708]
|
Facility
|
IP
|
$52.80
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$44.88 |
| Rate for Payer: Adventist Health Commercial |
$10.56
|
| Rate for Payer: Blue Shield of California Commercial |
$26.77
|
| Rate for Payer: Blue Shield of California Commercial |
$40.60
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cigna of CA HMO |
$36.96
|
| Rate for Payer: Cigna of CA PPO |
$36.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.12
|
| Rate for Payer: EPIC Health Plan Senior |
$21.12
|
| Rate for Payer: Galaxy Health WC |
$44.88
|
| Rate for Payer: Global Benefits Group Commercial |
$31.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.67
|
| Rate for Payer: Multiplan Commercial |
$42.24
|
| Rate for Payer: Networks By Design Commercial |
$26.40
|
| Rate for Payer: Prime Health Services Commercial |
$44.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.82
|
| Rate for Payer: United Healthcare All Other HMO |
$19.29
|
| Rate for Payer: United Healthcare HMO Rider |
$18.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.29
|
|
|
ALTEPLASE 2 MG INTRA-ARTERIAL SOLUTION FOR IR [40823708]
|
Facility
|
OP
|
$52.80
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$575.27 |
| Rate for Payer: Adventist Health Commercial |
$10.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$575.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.98
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cigna of CA HMO |
$36.96
|
| Rate for Payer: Cigna of CA PPO |
$36.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.67
|
| Rate for Payer: EPIC Health Plan Senior |
$108.45
|
| Rate for Payer: Galaxy Health WC |
$44.88
|
| Rate for Payer: Global Benefits Group Commercial |
$31.68
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$161.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$98.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$98.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$178.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$138.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$124.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$132.11
|
| Rate for Payer: Multiplan Commercial |
$42.24
|
| Rate for Payer: Networks By Design Commercial |
$26.40
|
| Rate for Payer: Prime Health Services Commercial |
$44.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.82
|
| Rate for Payer: United Healthcare All Other HMO |
$19.29
|
| Rate for Payer: United Healthcare HMO Rider |
$18.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.29
|
| Rate for Payer: Upland Medical Group Pediatric |
$98.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Vantage Medical Group Senior |
$108.45
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]
|
Facility
|
OP
|
$5,280.22
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.98 |
| Max. Negotiated Rate |
$4,488.19 |
| Rate for Payer: Adventist Health Commercial |
$1,056.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$575.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.98
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Cash Price |
$2,376.10
|
| Rate for Payer: Cash Price |
$2,376.10
|
| Rate for Payer: Cigna of CA HMO |
$3,696.15
|
| Rate for Payer: Cigna of CA PPO |
$3,696.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,696.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.67
|
| Rate for Payer: EPIC Health Plan Senior |
$108.45
|
| Rate for Payer: Galaxy Health WC |
$4,488.19
|
| Rate for Payer: Global Benefits Group Commercial |
$3,168.13
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$161.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$98.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$98.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,352.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$178.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$138.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,267.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$124.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$132.11
|
| Rate for Payer: Multiplan Commercial |
$4,224.18
|
| Rate for Payer: Networks By Design Commercial |
$2,640.11
|
| Rate for Payer: Prime Health Services Commercial |
$4,488.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,168.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,168.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,981.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,928.86
|
| Rate for Payer: United Healthcare HMO Rider |
$1,887.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,729.27
|
| Rate for Payer: Upland Medical Group Pediatric |
$98.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Vantage Medical Group Senior |
$108.45
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]
|
Facility
|
IP
|
$5,280.22
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,056.04 |
| Max. Negotiated Rate |
$4,488.19 |
| Rate for Payer: Adventist Health Commercial |
$1,056.04
|
| Rate for Payer: Blue Shield of California Commercial |
$2,677.07
|
| Rate for Payer: Blue Shield of California Commercial |
$4,060.49
|
| Rate for Payer: Cash Price |
$2,376.10
|
| Rate for Payer: Cigna of CA HMO |
$3,696.15
|
| Rate for Payer: Cigna of CA PPO |
$3,696.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,696.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,112.09
|
| Rate for Payer: EPIC Health Plan Senior |
$2,112.09
|
| Rate for Payer: Galaxy Health WC |
$4,488.19
|
| Rate for Payer: Global Benefits Group Commercial |
$3,168.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,352.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,115.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,267.25
|
| Rate for Payer: Multiplan Commercial |
$4,224.18
|
| Rate for Payer: Networks By Design Commercial |
$2,640.11
|
| Rate for Payer: Prime Health Services Commercial |
$4,488.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,981.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,928.86
|
| Rate for Payer: United Healthcare HMO Rider |
$1,887.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,729.27
|
|
|
ALTEPLASE INTRAVENTRICULAR 1 MG/2 ML SYRINGE [40820125]
|
Facility
|
OP
|
$52.80
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$575.27 |
| Rate for Payer: Galaxy Health WC |
$44.88
|
| Rate for Payer: Adventist Health Commercial |
$10.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$575.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.98
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cigna of CA HMO |
$36.96
|
| Rate for Payer: Cigna of CA PPO |
$36.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.67
|
| Rate for Payer: EPIC Health Plan Senior |
$108.45
|
| Rate for Payer: Global Benefits Group Commercial |
$31.68
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$161.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$98.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$98.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$178.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$138.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$124.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$132.11
|
| Rate for Payer: Multiplan Commercial |
$42.24
|
| Rate for Payer: Networks By Design Commercial |
$26.40
|
| Rate for Payer: Prime Health Services Commercial |
$44.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.82
|
| Rate for Payer: United Healthcare All Other HMO |
$19.29
|
| Rate for Payer: United Healthcare HMO Rider |
$18.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.29
|
| Rate for Payer: Upland Medical Group Pediatric |
$98.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Vantage Medical Group Senior |
$108.45
|
|
|
ALTEPLASE INTRAVENTRICULAR 1 MG/2 ML SYRINGE [40820125]
|
Facility
|
IP
|
$52.80
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$44.88 |
| Rate for Payer: Adventist Health Commercial |
$10.56
|
| Rate for Payer: Blue Shield of California Commercial |
$26.77
|
| Rate for Payer: Blue Shield of California Commercial |
$40.60
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cigna of CA HMO |
$36.96
|
| Rate for Payer: Cigna of CA PPO |
$36.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.12
|
| Rate for Payer: EPIC Health Plan Senior |
$21.12
|
| Rate for Payer: Galaxy Health WC |
$44.88
|
| Rate for Payer: Global Benefits Group Commercial |
$31.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.67
|
| Rate for Payer: Multiplan Commercial |
$42.24
|
| Rate for Payer: Networks By Design Commercial |
$26.40
|
| Rate for Payer: Prime Health Services Commercial |
$44.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.82
|
| Rate for Payer: United Healthcare All Other HMO |
$19.29
|
| Rate for Payer: United Healthcare HMO Rider |
$18.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.29
|
|
|
ALTEPLASE SYRINGE 1 MG/2 ML FOR NEBULIZATION [4081953]
|
Facility
|
OP
|
$52.80
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$575.27 |
| Rate for Payer: Adventist Health Commercial |
$10.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$575.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.98
|
| Rate for Payer: Blue Shield of California Commercial |
$105.71
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cigna of CA HMO |
$36.96
|
| Rate for Payer: Cigna of CA PPO |
$36.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.67
|
| Rate for Payer: EPIC Health Plan Senior |
$108.45
|
| Rate for Payer: Galaxy Health WC |
$44.88
|
| Rate for Payer: Global Benefits Group Commercial |
$31.68
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$161.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$98.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$98.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$178.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$138.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$124.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$132.11
|
| Rate for Payer: Multiplan Commercial |
$42.24
|
| Rate for Payer: Networks By Design Commercial |
$26.40
|
| Rate for Payer: Prime Health Services Commercial |
$44.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$31.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$31.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.82
|
| Rate for Payer: United Healthcare All Other HMO |
$19.29
|
| Rate for Payer: United Healthcare HMO Rider |
$18.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.29
|
| Rate for Payer: Upland Medical Group Pediatric |
$98.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.45
|
| Rate for Payer: Vantage Medical Group Senior |
$108.45
|
|
|
ALTEPLASE SYRINGE 1 MG/2 ML FOR NEBULIZATION [4081953]
|
Facility
|
IP
|
$52.80
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$44.88 |
| Rate for Payer: Adventist Health Commercial |
$10.56
|
| Rate for Payer: Blue Shield of California Commercial |
$26.77
|
| Rate for Payer: Blue Shield of California Commercial |
$40.60
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Cigna of CA HMO |
$36.96
|
| Rate for Payer: Cigna of CA PPO |
$36.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.12
|
| Rate for Payer: EPIC Health Plan Senior |
$21.12
|
| Rate for Payer: Galaxy Health WC |
$44.88
|
| Rate for Payer: Global Benefits Group Commercial |
$31.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$33.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.67
|
| Rate for Payer: Multiplan Commercial |
$42.24
|
| Rate for Payer: Networks By Design Commercial |
$26.40
|
| Rate for Payer: Prime Health Services Commercial |
$44.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.82
|
| Rate for Payer: United Healthcare All Other HMO |
$19.29
|
| Rate for Payer: United Healthcare HMO Rider |
$18.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.29
|
|
|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$23,343.95
|
|
|
Service Code
|
APR-DRG 0523
|
| Min. Negotiated Rate |
$18,644.45 |
| Max. Negotiated Rate |
$23,343.95 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,644.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23,343.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20,886.69
|
|
|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$12,548.91
|
|
|
Service Code
|
APR-DRG 0521
|
| Min. Negotiated Rate |
$10,022.62 |
| Max. Negotiated Rate |
$12,548.91 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,022.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,548.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,227.97
|
|
|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$50,747.00
|
|
|
Service Code
|
APR-DRG 0524
|
| Min. Negotiated Rate |
$40,530.83 |
| Max. Negotiated Rate |
$50,747.00 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$40,530.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50,747.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$45,405.21
|
|
|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$16,635.79
|
|
|
Service Code
|
APR-DRG 0522
|
| Min. Negotiated Rate |
$13,286.74 |
| Max. Negotiated Rate |
$16,635.79 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,286.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16,635.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14,884.66
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION [353]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536009185
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION [353]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536009185
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION [24314]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904772714
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION [24314]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904772714
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0121176130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 5789662912
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0536129383
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0536129383
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0121176130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [38285]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 5789662912
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
