|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1721126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Blue Shield of California Commercial |
$3.13
|
| Rate for Payer: Blue Shield of California Commercial |
$5.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$5.34
|
| Rate for Payer: Blue Shield of California EPN |
$3.85
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Blue Shield of California EPN |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO |
$3.08
|
| Rate for Payer: Cigna of CA HMO |
$5.25
|
| Rate for Payer: Cigna of CA HMO |
$5.26
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$5.26
|
| Rate for Payer: Cigna of CA PPO |
$5.25
|
| Rate for Payer: Cigna of CA PPO |
$3.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.00
|
| Rate for Payer: Galaxy Health WC |
$3.74
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Galaxy Health WC |
$6.38
|
| Rate for Payer: Galaxy Health WC |
$6.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Global Benefits Group Commercial |
$2.64
|
| Rate for Payer: Global Benefits Group Commercial |
$4.50
|
| Rate for Payer: Global Benefits Group Commercial |
$4.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$3.52
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.02
|
| Rate for Payer: Networks By Design Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$3.76
|
| Rate for Payer: Networks By Design Commercial |
$2.20
|
| Rate for Payer: Networks By Design Commercial |
$3.75
|
| Rate for Payer: Prime Health Services Commercial |
$6.38
|
| Rate for Payer: Prime Health Services Commercial |
$3.74
|
| Rate for Payer: Prime Health Services Commercial |
$6.39
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.77
|
| Rate for Payer: United Healthcare All Other HMO |
$2.77
|
| Rate for Payer: United Healthcare All Other HMO |
$1.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.55
|
| Rate for Payer: United Healthcare HMO Rider |
$2.71
|
| Rate for Payer: United Healthcare HMO Rider |
$1.59
|
| Rate for Payer: United Healthcare HMO Rider |
$2.71
|
| Rate for Payer: United Healthcare HMO Rider |
$0.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.45
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1744013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$23.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.90
|
| Rate for Payer: Blue Distinction Transplant |
$0.55
|
| Rate for Payer: Blue Distinction Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Media |
$0.22
|
| Rate for Payer: Dignity Health Media |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| 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 Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| 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 Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1781092
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2.99
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.84
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1744013
|
|
Hospital Revenue Code
|
259
|
| 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 Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| 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 Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1781092
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$23.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.90
|
| Rate for Payer: Blue Distinction Transplant |
$2.52
|
| Rate for Payer: Blue Distinction Transplant |
$2.16
|
| Rate for Payer: Blue Distinction Transplant |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California Commercial |
$3.10
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$2.45
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Media |
$1.53
|
| Rate for Payer: Dignity Health Media |
$3.06
|
| Rate for Payer: Dignity Health Media |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE [118614]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 7985404097
|
| Hospital Charge Code |
1710863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| 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: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| 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 |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE [118614]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 7985404097
|
| Hospital Charge Code |
1710863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| 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 |
$0.07
|
| 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 |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| 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 |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| 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 |
$0.05
|
| 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 |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 9994-0804-15
|
| Hospital Charge Code |
1715996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Distinction Transplant |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Media |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 9994-0804-15
|
| Hospital Charge Code |
1715996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]
|
Facility
|
OP
|
$3.84
|
|
|
Service Code
|
NDC 9994-0802-35
|
| Hospital Charge Code |
1715121
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.29
|
| Rate for Payer: Blue Distinction Transplant |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.83
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.69
|
| Rate for Payer: Cigna of CA PPO |
$2.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.26
|
| Rate for Payer: Dignity Health Media |
$3.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.26
|
| Rate for Payer: Global Benefits Group Commercial |
$2.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.07
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.26
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]
|
Facility
|
IP
|
$3.84
|
|
|
Service Code
|
NDC 9994-0802-35
|
| Hospital Charge Code |
1715121
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.69
|
| Rate for Payer: Cigna of CA PPO |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.26
|
| Rate for Payer: Global Benefits Group Commercial |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.07
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.26
|
|
|
ACETYLCYSTEINE ORAL SOLUTION COMPOUND 50 MG/ML (5%) [4080234]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 9994-0802-34
|
| Hospital Charge Code |
1715221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Distinction Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Media |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
ACETYLCYSTEINE ORAL SOLUTION COMPOUND 50 MG/ML (5%) [4080234]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 9994-0802-34
|
| Hospital Charge Code |
1715221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
ACITRETIN 25 MG CAPSULE [13979]
|
Facility
|
IP
|
$18.46
|
|
|
Service Code
|
NDC 0115-1753-08
|
| Hospital Charge Code |
ERX13979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$15.69 |
| Rate for Payer: Blue Shield of California Commercial |
$13.14
|
| Rate for Payer: Blue Shield of California EPN |
$9.45
|
| Rate for Payer: Cash Price |
$8.31
|
| Rate for Payer: Cigna of CA HMO |
$12.92
|
| Rate for Payer: Cigna of CA PPO |
$12.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.38
|
| Rate for Payer: Galaxy Health WC |
$15.69
|
| Rate for Payer: Global Benefits Group Commercial |
$11.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.43
|
| Rate for Payer: Multiplan Commercial |
$14.77
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Prime Health Services Commercial |
$15.69
|
|
|
ACITRETIN 25 MG CAPSULE [13979]
|
Facility
|
OP
|
$18.46
|
|
|
Service Code
|
NDC 0115-1753-08
|
| Hospital Charge Code |
ERX13979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$15.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.00
|
| Rate for Payer: Blue Distinction Transplant |
$11.08
|
| Rate for Payer: Blue Shield of California Commercial |
$13.61
|
| Rate for Payer: Blue Shield of California EPN |
$10.78
|
| Rate for Payer: Cash Price |
$8.31
|
| Rate for Payer: Cigna of CA HMO |
$12.92
|
| Rate for Payer: Cigna of CA PPO |
$12.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.69
|
| Rate for Payer: Dignity Health Media |
$15.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.38
|
| Rate for Payer: Galaxy Health WC |
$15.69
|
| Rate for Payer: Global Benefits Group Commercial |
$11.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$13.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.43
|
| Rate for Payer: Multiplan Commercial |
$14.77
|
| Rate for Payer: Networks By Design Commercial |
$12.00
|
| Rate for Payer: Prime Health Services Commercial |
$15.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.23
|
| Rate for Payer: United Healthcare All Other HMO |
$9.23
|
| Rate for Payer: United Healthcare HMO Rider |
$9.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.69
|
| Rate for Payer: Vantage Medical Group Senior |
$15.69
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [117013]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0574-0521-74
|
| Hospital Charge Code |
1719162
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Media |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [117013]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0574-0521-74
|
| Hospital Charge Code |
1719162
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 66689-201-08
|
| Hospital Charge Code |
1719161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Distinction Transplant |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Media |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| 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 |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0574-0521-76
|
| Hospital Charge Code |
1719161
|
|
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
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 66689-201-08
|
| Hospital Charge Code |
1719161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| 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 |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0574-0521-76
|
| Hospital Charge Code |
1719161
|
|
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: 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 |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction 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) 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: 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
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$23,196.85
|
|
|
Service Code
|
APR-DRG 1933
|
| Min. Negotiated Rate |
$17,794.43 |
| Max. Negotiated Rate |
$23,196.85 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17,794.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,196.85
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$36,049.12
|
|
|
Service Code
|
APR-DRG 1934
|
| Min. Negotiated Rate |
$27,653.47 |
| Max. Negotiated Rate |
$36,049.12 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,653.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36,049.12
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$11,889.27
|
|
|
Service Code
|
APR-DRG 1931
|
| Min. Negotiated Rate |
$9,120.32 |
| Max. Negotiated Rate |
$11,889.27 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,120.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,889.27
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$17,512.93
|
|
|
Service Code
|
APR-DRG 1932
|
| Min. Negotiated Rate |
$13,434.26 |
| Max. Negotiated Rate |
$17,512.93 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,434.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,512.93
|
|
