|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
IP
|
$104.88
|
|
|
Service Code
|
NDC 0002-4732-30
|
| Hospital Charge Code |
ERX225594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.17 |
| Max. Negotiated Rate |
$89.15 |
| Rate for Payer: Blue Shield of California Commercial |
$74.67
|
| Rate for Payer: Blue Shield of California EPN |
$53.70
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO |
$73.42
|
| Rate for Payer: Cigna of CA PPO |
$73.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.95
|
| Rate for Payer: Galaxy Health WC |
$89.15
|
| Rate for Payer: Global Benefits Group Commercial |
$62.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.17
|
| Rate for Payer: Multiplan Commercial |
$83.90
|
| Rate for Payer: Networks By Design Commercial |
$68.17
|
| Rate for Payer: Prime Health Services Commercial |
$89.15
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
OP
|
$104.88
|
|
|
Service Code
|
NDC 0002-4732-30
|
| Hospital Charge Code |
ERX225594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.17 |
| Max. Negotiated Rate |
$89.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$68.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.49
|
| Rate for Payer: Blue Distinction Transplant |
$62.93
|
| Rate for Payer: Blue Shield of California Commercial |
$77.30
|
| Rate for Payer: Blue Shield of California EPN |
$61.25
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO |
$73.42
|
| Rate for Payer: Cigna of CA PPO |
$73.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.15
|
| Rate for Payer: Dignity Health Media |
$89.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.95
|
| Rate for Payer: Galaxy Health WC |
$89.15
|
| Rate for Payer: Global Benefits Group Commercial |
$62.93
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$78.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.17
|
| Rate for Payer: Multiplan Commercial |
$83.90
|
| Rate for Payer: Networks By Design Commercial |
$68.17
|
| Rate for Payer: Prime Health Services Commercial |
$89.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$62.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$62.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.44
|
| Rate for Payer: United Healthcare All Other HMO |
$52.44
|
| Rate for Payer: United Healthcare HMO Rider |
$52.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.15
|
| Rate for Payer: Vantage Medical Group Senior |
$89.15
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
|
OP
|
$104.88
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
ERX221907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.17 |
| Max. Negotiated Rate |
$89.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$68.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.68
|
| Rate for Payer: Blue Distinction Transplant |
$62.93
|
| Rate for Payer: Blue Shield of California Commercial |
$77.30
|
| Rate for Payer: Blue Shield of California EPN |
$61.25
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO |
$73.42
|
| Rate for Payer: Cigna of CA PPO |
$73.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.15
|
| Rate for Payer: Dignity Health Media |
$89.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.95
|
| Rate for Payer: Galaxy Health WC |
$89.15
|
| Rate for Payer: Global Benefits Group Commercial |
$62.93
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$78.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.17
|
| Rate for Payer: Multiplan Commercial |
$83.90
|
| Rate for Payer: Networks By Design Commercial |
$52.44
|
| Rate for Payer: Prime Health Services Commercial |
$89.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$62.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$62.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.44
|
| Rate for Payer: United Healthcare All Other HMO |
$52.44
|
| Rate for Payer: United Healthcare HMO Rider |
$52.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.15
|
| Rate for Payer: Vantage Medical Group Senior |
$89.15
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
|
IP
|
$104.88
|
|
|
Service Code
|
CPT J8499
|
| Hospital Charge Code |
ERX221907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.17 |
| Max. Negotiated Rate |
$89.15 |
| Rate for Payer: Blue Shield of California Commercial |
$74.67
|
| Rate for Payer: Blue Shield of California EPN |
$53.70
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO |
$73.42
|
| Rate for Payer: Cigna of CA PPO |
$73.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.95
|
| Rate for Payer: Galaxy Health WC |
$89.15
|
| Rate for Payer: Global Benefits Group Commercial |
$62.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.17
|
| Rate for Payer: Multiplan Commercial |
$83.90
|
| Rate for Payer: Networks By Design Commercial |
$52.44
|
| Rate for Payer: Prime Health Services Commercial |
$89.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.60
|
| Rate for Payer: United Healthcare All Other HMO |
$38.68
|
| Rate for Payer: United Healthcare HMO Rider |
$37.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.61
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 32909-167-55
|
| Hospital Charge Code |
NDG972961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| 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) Other |
$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: 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
|
| 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
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 32909-167-55
|
| Hospital Charge Code |
NDG972961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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: 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: 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
|
|
|
BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [223877]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 32909-121-07
|
| Hospital Charge Code |
NDG120621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [223877]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 32909-121-07
|
| Hospital Charge Code |
NDG120621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Distinction Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Media |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 32909-750-01
|
| Hospital Charge Code |
NDG13031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 32909-750-01
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 32909-750-01
|
| Hospital Charge Code |
NDG13031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 32909-750-03
|
| Hospital Charge Code |
NDG13031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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: 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: 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
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 32909-750-01
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 32909-750-03
|
| Hospital Charge Code |
NDG13031
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| 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) Other |
$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: 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
|
| 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
|
|
|
BASILIXIMAB 20 MG INTRAVENOUS SOLUTION [23082]
|
Facility
|
IP
|
$5,155.45
|
|
|
Service Code
|
CPT J0480
|
| Hospital Charge Code |
1757346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,237.31 |
| Max. Negotiated Rate |
$4,382.13 |
| Rate for Payer: Blue Shield of California Commercial |
$3,670.68
|
| Rate for Payer: Blue Shield of California EPN |
$2,639.59
|
| Rate for Payer: Cash Price |
$2,319.95
|
| Rate for Payer: Cigna of CA HMO |
$3,608.82
|
| Rate for Payer: Cigna of CA PPO |
$3,608.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,062.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,062.18
|
| Rate for Payer: Galaxy Health WC |
$4,382.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3,093.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,438.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,964.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,237.31
|
| Rate for Payer: Multiplan Commercial |
$4,124.36
|
| Rate for Payer: Networks By Design Commercial |
$2,577.72
|
| Rate for Payer: Prime Health Services Commercial |
$4,382.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,946.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1,901.33
|
| Rate for Payer: United Healthcare HMO Rider |
$1,860.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,701.30
|
|
|
BASILIXIMAB 20 MG INTRAVENOUS SOLUTION [23082]
|
Facility
|
OP
|
$5,155.45
|
|
|
Service Code
|
CPT J0480
|
| Hospital Charge Code |
1757346
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,237.31 |
| Max. Negotiated Rate |
$28,153.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$28,153.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,595.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,923.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,923.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,996.38
|
| Rate for Payer: Blue Distinction Transplant |
$3,093.27
|
| Rate for Payer: Blue Shield of California Commercial |
$3,799.57
|
| Rate for Payer: Blue Shield of California EPN |
$4,719.29
|
| Rate for Payer: Cash Price |
$2,319.95
|
| Rate for Payer: Cash Price |
$2,319.95
|
| Rate for Payer: Cigna of CA HMO |
$3,608.82
|
| Rate for Payer: Cigna of CA PPO |
$3,608.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,714.40
|
| Rate for Payer: Dignity Health Media |
$4,476.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,923.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,042.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,476.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,476.26
|
| Rate for Payer: Galaxy Health WC |
$4,382.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3,093.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3,866.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,341.07
|
| Rate for Payer: Heritage Provider Network Transplant |
$7,341.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,251.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$7,251.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,476.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,438.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,513.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,476.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,237.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,640.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,998.20
|
| Rate for Payer: Multiplan Commercial |
$4,124.36
|
| Rate for Payer: Networks By Design Commercial |
$2,577.72
|
| Rate for Payer: Prime Health Services Commercial |
$4,382.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,093.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,093.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,577.72
|
| Rate for Payer: United Healthcare All Other HMO |
$2,577.72
|
| Rate for Payer: United Healthcare HMO Rider |
$2,577.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,577.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,714.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,923.89
|
| Rate for Payer: Vantage Medical Group Senior |
$4,476.26
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION [117851]
|
Facility
|
OP
|
$188.48
|
|
|
Service Code
|
CPT J9030
|
| Hospital Charge Code |
1759920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$160.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$160.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$103.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$103.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.69
|
| Rate for Payer: Blue Distinction Transplant |
$113.09
|
| Rate for Payer: Blue Shield of California Commercial |
$138.91
|
| Rate for Payer: Blue Shield of California EPN |
$3.77
|
| Rate for Payer: Cash Price |
$84.82
|
| Rate for Payer: Cash Price |
$84.82
|
| Rate for Payer: Cigna of CA HMO |
$131.94
|
| Rate for Payer: Cigna of CA PPO |
$131.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$160.21
|
| Rate for Payer: Dignity Health Media |
$160.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$160.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$75.39
|
| Rate for Payer: Galaxy Health WC |
$160.21
|
| Rate for Payer: Global Benefits Group Commercial |
$113.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$141.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$125.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.24
|
| Rate for Payer: Multiplan Commercial |
$150.78
|
| Rate for Payer: Networks By Design Commercial |
$94.24
|
| Rate for Payer: Prime Health Services Commercial |
$160.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$113.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$113.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$94.24
|
| Rate for Payer: United Healthcare All Other HMO |
$94.24
|
| Rate for Payer: United Healthcare HMO Rider |
$94.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$94.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$160.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$160.21
|
| Rate for Payer: Vantage Medical Group Senior |
$160.21
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION [117851]
|
Facility
|
IP
|
$188.48
|
|
|
Service Code
|
CPT J9030
|
| Hospital Charge Code |
1759920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.24 |
| Max. Negotiated Rate |
$160.21 |
| Rate for Payer: Blue Shield of California Commercial |
$134.20
|
| Rate for Payer: Blue Shield of California EPN |
$96.50
|
| Rate for Payer: Cash Price |
$84.82
|
| Rate for Payer: Cigna of CA HMO |
$131.94
|
| Rate for Payer: Cigna of CA PPO |
$131.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$75.39
|
| Rate for Payer: Galaxy Health WC |
$160.21
|
| Rate for Payer: Global Benefits Group Commercial |
$113.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$125.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.24
|
| Rate for Payer: Multiplan Commercial |
$150.78
|
| Rate for Payer: Networks By Design Commercial |
$94.24
|
| Rate for Payer: Prime Health Services Commercial |
$160.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$71.17
|
| Rate for Payer: United Healthcare All Other HMO |
$69.51
|
| Rate for Payer: United Healthcare HMO Rider |
$68.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.20
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 3160401338
|
| Hospital Charge Code |
ERX408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Distinction Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 3160401338
|
| Hospital Charge Code |
ERX408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
ERX408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| 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) Other |
$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: 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
|
| 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
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 9999-9998-07
|
| Hospital Charge Code |
NDC408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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: 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: 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
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 9999-9998-07
|
| Hospital Charge Code |
NDC408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| 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) Other |
$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: 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
|
| 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
|
|
|
B-COMPLEX WITH VITAMIN C 1/2 TABLET [408807]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
ERX408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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: 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: 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
|
|
|
B-COMPLEX WITH VITAMIN C TABLET [807]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 9999-9998-07
|
| Hospital Charge Code |
NDC408807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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: 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: 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
|
|
