|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| 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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030316
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$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: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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: 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: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030316
|
| 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 |
$0.02
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030216
|
| 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 |
$0.02
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0395009416
|
| 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 EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0395009416
|
| 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 |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| 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: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| 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 |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| 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
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030216
|
| 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 |
$0.03
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0395009016
|
| 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 |
$0.03
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| 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 |
$0.03
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3172295901
|
| 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 |
$0.03
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$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 |
$0.02
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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: 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0395009016
|
| 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 |
$0.02
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 3877907448
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 3877907448
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3172295901
|
| 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 |
$0.02
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA 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
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET [9973]
|
Facility
|
IP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1100-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.27
|
| Rate for Payer: Blue Shield of California EPN |
$4.13
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Senior |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$6.79
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET [9973]
|
Facility
|
OP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1100-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.21
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Senior |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$6.79
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Other HMO |
$4.25
|
| Rate for Payer: United Healthcare HMO Rider |
$4.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.22
|
| Rate for Payer: Vantage Medical Group Senior |
$7.22
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]
|
Facility
|
IP
|
$18.43
|
|
|
Service Code
|
NDC 0046-0872-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Blue Shield of California Commercial |
$13.60
|
| Rate for Payer: Blue Shield of California EPN |
$8.96
|
| Rate for Payer: Cash Price |
$10.14
|
| Rate for Payer: Cigna of CA HMO |
$12.90
|
| Rate for Payer: Cigna of CA PPO |
$12.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.37
|
| Rate for Payer: EPIC Health Plan Senior |
$7.37
|
| Rate for Payer: Galaxy Health WC |
$15.67
|
| Rate for Payer: Global Benefits Group Commercial |
$11.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$14.74
|
| Rate for Payer: Networks By Design Commercial |
$11.98
|
| Rate for Payer: Prime Health Services Commercial |
$15.67
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]
|
Facility
|
OP
|
$18.43
|
|
|
Service Code
|
NDC 0046-0872-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.32
|
| Rate for Payer: Cash Price |
$10.14
|
| Rate for Payer: Cigna of CA HMO |
$12.90
|
| Rate for Payer: Cigna of CA PPO |
$12.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.37
|
| Rate for Payer: EPIC Health Plan Senior |
$7.37
|
| Rate for Payer: Galaxy Health WC |
$15.67
|
| Rate for Payer: Global Benefits Group Commercial |
$11.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.90
|
| Rate for Payer: Multiplan Commercial |
$14.74
|
| Rate for Payer: Networks By Design Commercial |
$11.98
|
| Rate for Payer: Prime Health Services Commercial |
$15.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.21
|
| Rate for Payer: United Healthcare All Other HMO |
$9.21
|
| Rate for Payer: United Healthcare HMO Rider |
$9.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.67
|
| Rate for Payer: Vantage Medical Group Senior |
$15.67
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET [9974]
|
Facility
|
OP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1102-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.21
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Senior |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$6.79
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Other HMO |
$4.25
|
| Rate for Payer: United Healthcare HMO Rider |
$4.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.22
|
| Rate for Payer: Vantage Medical Group Senior |
$7.22
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET [9974]
|
Facility
|
IP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1102-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.27
|
| Rate for Payer: Blue Shield of California EPN |
$4.13
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Senior |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$6.79
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
|
IP
|
$452.26
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.45 |
| Max. Negotiated Rate |
$384.42 |
| Rate for Payer: Adventist Health Commercial |
$90.45
|
| Rate for Payer: Blue Shield of California Commercial |
$333.77
|
| Rate for Payer: Blue Shield of California EPN |
$219.80
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Cigna of CA HMO |
$316.58
|
| Rate for Payer: Cigna of CA PPO |
$316.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.90
|
| Rate for Payer: EPIC Health Plan Senior |
$180.90
|
| Rate for Payer: Galaxy Health WC |
$384.42
|
| Rate for Payer: Global Benefits Group Commercial |
$271.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$301.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$172.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$279.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.54
|
| Rate for Payer: Multiplan Commercial |
$361.81
|
| Rate for Payer: Networks By Design Commercial |
$226.13
|
| Rate for Payer: Prime Health Services Commercial |
$384.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$169.73
|
| Rate for Payer: United Healthcare All Other HMO |
$165.21
|
| Rate for Payer: United Healthcare HMO Rider |
$161.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$148.12
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
|
OP
|
$452.26
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.45 |
| Max. Negotiated Rate |
$1,023.78 |
| Rate for Payer: Adventist Health Commercial |
$90.45
|
| Rate for Payer: Aetna of CA HMO/PPO |
$296.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$488.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$429.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$429.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,023.78
|
| Rate for Payer: Blue Shield of California Commercial |
$441.66
|
| Rate for Payer: Blue Shield of California EPN |
$441.66
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Cigna of CA HMO |
$316.58
|
| Rate for Payer: Cigna of CA PPO |
$316.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$488.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$429.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$429.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$527.50
|
| Rate for Payer: EPIC Health Plan Senior |
$390.74
|
| Rate for Payer: Galaxy Health WC |
$384.42
|
| Rate for Payer: Global Benefits Group Commercial |
$271.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$640.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$382.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$390.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$301.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$736.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$390.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$492.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$523.59
|
| Rate for Payer: Multiplan Commercial |
$361.81
|
| Rate for Payer: Networks By Design Commercial |
$226.13
|
| Rate for Payer: Prime Health Services Commercial |
$384.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$271.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$271.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$169.73
|
| Rate for Payer: United Healthcare All Other HMO |
$165.21
|
| Rate for Payer: United Healthcare HMO Rider |
$161.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$148.12
|
| Rate for Payer: Upland Medical Group Pediatric |
$390.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$488.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$429.81
|
| Rate for Payer: Vantage Medical Group Senior |
$429.81
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.26
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Senior |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.60
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Senior |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.82
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
