|
COLISTIN (COLISTIMETHATE) 150 MG MED NEB SOLUTION [4080399]
|
Facility
IP
|
$33.59
|
|
|
Service Code
|
CPT J0770
|
| Hospital Charge Code |
ERX4080399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$28.55 |
| Rate for Payer: Blue Shield of California Commercial |
$23.92
|
| Rate for Payer: Blue Shield of California Commercial |
$23.92
|
| Rate for Payer: Blue Shield of California EPN |
$17.20
|
| Rate for Payer: Blue Shield of California EPN |
$17.20
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO |
$23.52
|
| Rate for Payer: Cigna of CA HMO |
$23.51
|
| Rate for Payer: Cigna of CA PPO |
$23.51
|
| Rate for Payer: Cigna of CA PPO |
$23.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.44
|
| Rate for Payer: Galaxy Health WC |
$28.55
|
| Rate for Payer: Galaxy Health WC |
$28.56
|
| Rate for Payer: Global Benefits Group Commercial |
$20.15
|
| Rate for Payer: Global Benefits Group Commercial |
$20.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$26.87
|
| Rate for Payer: Multiplan Commercial |
$26.88
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Prime Health Services Commercial |
$28.55
|
| Rate for Payer: Prime Health Services Commercial |
$28.56
|
|
|
COLISTIN (COLISTIMETHATE) 150 MG MED NEB SOLUTION [4080399]
|
Facility
OP
|
$33.60
|
|
|
Service Code
|
CPT J0770
|
| Hospital Charge Code |
ERX4080399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$101.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$87.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$87.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.27
|
| Rate for Payer: BCBS Transplant Transplant |
$20.16
|
| Rate for Payer: BCBS Transplant Transplant |
$20.15
|
| Rate for Payer: Blue Shield of California Commercial |
$24.76
|
| Rate for Payer: Blue Shield of California Commercial |
$24.76
|
| Rate for Payer: Blue Shield of California EPN |
$33.35
|
| Rate for Payer: Blue Shield of California EPN |
$33.35
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO |
$23.52
|
| Rate for Payer: Cigna of CA HMO |
$23.51
|
| Rate for Payer: Cigna of CA PPO |
$23.51
|
| Rate for Payer: Cigna of CA PPO |
$23.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.55
|
| Rate for Payer: Dignity Health Media |
$28.56
|
| Rate for Payer: Dignity Health Media |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.44
|
| Rate for Payer: Galaxy Health WC |
$28.55
|
| Rate for Payer: Galaxy Health WC |
$28.56
|
| Rate for Payer: Global Benefits Group Commercial |
$20.16
|
| Rate for Payer: Global Benefits Group Commercial |
$20.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$25.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$25.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$26.87
|
| Rate for Payer: Multiplan Commercial |
$26.88
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Prime Health Services Commercial |
$28.56
|
| Rate for Payer: Prime Health Services Commercial |
$28.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO |
$16.80
|
| Rate for Payer: United Healthcare HMO Rider |
$16.80
|
| Rate for Payer: United Healthcare HMO Rider |
$16.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.55
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$28.55
|
|
|
COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]
|
Facility
IP
|
$33.59
|
|
|
Service Code
|
CPT J0770
|
| Hospital Charge Code |
ERX4082134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$28.55 |
| Rate for Payer: Blue Shield of California Commercial |
$23.92
|
| Rate for Payer: Blue Shield of California Commercial |
$23.92
|
| Rate for Payer: Blue Shield of California EPN |
$17.20
|
| Rate for Payer: Blue Shield of California EPN |
$17.20
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO |
$23.51
|
| Rate for Payer: Cigna of CA HMO |
$23.52
|
| Rate for Payer: Cigna of CA PPO |
$23.51
|
| Rate for Payer: Cigna of CA PPO |
$23.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.44
|
| Rate for Payer: Galaxy Health WC |
$28.56
|
| Rate for Payer: Galaxy Health WC |
$28.55
|
| Rate for Payer: Global Benefits Group Commercial |
$20.16
|
| Rate for Payer: Global Benefits Group Commercial |
$20.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$26.87
|
| Rate for Payer: Multiplan Commercial |
$26.88
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Prime Health Services Commercial |
$28.55
|
| Rate for Payer: Prime Health Services Commercial |
$28.56
|
|
|
COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]
|
Facility
OP
|
$33.59
|
|
|
Service Code
|
CPT J0770
|
| Hospital Charge Code |
ERX4082134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$101.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$87.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$87.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.27
|
| Rate for Payer: BCBS Transplant Transplant |
$20.16
|
| Rate for Payer: BCBS Transplant Transplant |
$20.15
|
| Rate for Payer: Blue Shield of California Commercial |
$24.76
|
| Rate for Payer: Blue Shield of California Commercial |
$24.76
|
| Rate for Payer: Blue Shield of California EPN |
$33.35
|
| Rate for Payer: Blue Shield of California EPN |
$33.35
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO |
$23.52
|
| Rate for Payer: Cigna of CA HMO |
$23.51
|
| Rate for Payer: Cigna of CA PPO |
$23.52
|
| Rate for Payer: Cigna of CA PPO |
$23.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Media |
$28.56
|
| Rate for Payer: Dignity Health Media |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.44
|
| Rate for Payer: Galaxy Health WC |
$28.56
|
| Rate for Payer: Galaxy Health WC |
$28.55
|
| Rate for Payer: Global Benefits Group Commercial |
$20.16
|
| Rate for Payer: Global Benefits Group Commercial |
$20.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$25.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$25.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.06
|
| Rate for Payer: Multiplan Commercial |
$26.88
|
| Rate for Payer: Multiplan Commercial |
$26.87
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Prime Health Services Commercial |
$28.56
|
| Rate for Payer: Prime Health Services Commercial |
$28.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO |
$16.80
|
| Rate for Payer: United Healthcare HMO Rider |
$16.80
|
| Rate for Payer: United Healthcare HMO Rider |
$16.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$28.55
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
OP
|
$10.95
|
|
|
Service Code
|
NDC 50484-010-90
|
| Hospital Charge Code |
NDG9682B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$9.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.52
|
| Rate for Payer: BCBS Transplant Transplant |
$6.57
|
| Rate for Payer: Blue Shield of California Commercial |
$8.07
|
| Rate for Payer: Blue Shield of California EPN |
$6.39
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna of CA HMO |
$7.66
|
| Rate for Payer: Cigna of CA PPO |
$7.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.31
|
| Rate for Payer: Dignity Health Media |
$9.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.38
|
| Rate for Payer: Galaxy Health WC |
$9.31
|
| Rate for Payer: Global Benefits Group Commercial |
$6.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.63
|
| Rate for Payer: Multiplan Commercial |
$8.76
|
| Rate for Payer: Networks By Design Commercial |
$7.12
|
| Rate for Payer: Prime Health Services Commercial |
$9.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.48
|
| Rate for Payer: United Healthcare All Other HMO |
$5.48
|
| Rate for Payer: United Healthcare HMO Rider |
$5.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.31
|
| Rate for Payer: Vantage Medical Group Senior |
$9.31
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
IP
|
$11.52
|
|
|
Service Code
|
NDC 50484-010-30
|
| Hospital Charge Code |
1743273
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Blue Shield of California Commercial |
$8.20
|
| Rate for Payer: Blue Shield of California EPN |
$5.90
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cigna of CA HMO |
$8.06
|
| Rate for Payer: Cigna of CA PPO |
$8.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: Galaxy Health WC |
$9.79
|
| Rate for Payer: Global Benefits Group Commercial |
$6.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
| Rate for Payer: Networks By Design Commercial |
$7.49
|
| Rate for Payer: Prime Health Services Commercial |
$9.79
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
IP
|
$10.95
|
|
|
Service Code
|
NDC 50484-010-90
|
| Hospital Charge Code |
NDG9682B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$9.31 |
| Rate for Payer: Blue Shield of California Commercial |
$7.80
|
| Rate for Payer: Blue Shield of California EPN |
$5.61
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna of CA HMO |
$7.66
|
| Rate for Payer: Cigna of CA PPO |
$7.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.38
|
| Rate for Payer: Galaxy Health WC |
$9.31
|
| Rate for Payer: Global Benefits Group Commercial |
$6.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.63
|
| Rate for Payer: Multiplan Commercial |
$8.76
|
| Rate for Payer: Networks By Design Commercial |
$7.12
|
| Rate for Payer: Prime Health Services Commercial |
$9.31
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
OP
|
$11.52
|
|
|
Service Code
|
NDC 50484-010-30
|
| Hospital Charge Code |
1743273
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.86
|
| Rate for Payer: BCBS Transplant Transplant |
$6.91
|
| Rate for Payer: Blue Shield of California Commercial |
$8.49
|
| Rate for Payer: Blue Shield of California EPN |
$6.73
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cigna of CA HMO |
$8.06
|
| Rate for Payer: Cigna of CA PPO |
$8.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.79
|
| Rate for Payer: Dignity Health Media |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.61
|
| Rate for Payer: Galaxy Health WC |
$9.79
|
| Rate for Payer: Global Benefits Group Commercial |
$6.91
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$9.22
|
| Rate for Payer: Networks By Design Commercial |
$7.49
|
| Rate for Payer: Prime Health Services Commercial |
$9.79
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.76
|
| Rate for Payer: United Healthcare All Other HMO |
$5.76
|
| Rate for Payer: United Healthcare HMO Rider |
$5.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Vantage Medical Group Senior |
$9.79
|
|
|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 574030416
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 574030416
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: BCBS Transplant Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 574030316
|
| Hospital Charge Code |
NDG211818
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 574030316
|
| Hospital Charge Code |
NDG211818
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: BCBS Transplant Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 574030216
|
| Hospital Charge Code |
NDG120588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: BCBS Transplant Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 574030216
|
| Hospital Charge Code |
NDG120588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 395009416
|
| Hospital Charge Code |
NDG120588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: 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
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 395009416
|
| Hospital Charge Code |
NDG120588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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 Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 3172295901
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 3172295901
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: BCBS Transplant Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 574030416
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 395009016
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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 Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 395009016
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 3877907448
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$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 Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 3877907448
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.05
|
| 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: 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: 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 574030416
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: BCBS Transplant Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA
|
Facility
IP
|
$8,384.93
|
|
|
Service Code
|
APR-DRG 0571
|
| Min. Negotiated Rate |
$6,432.12 |
| Max. Negotiated Rate |
$8,384.93 |
| Rate for Payer: IEHP Medi-Cal |
$6,432.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,384.93
|
|
