|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$39.60
|
|
|
Service Code
|
NDC 53436-168-30
|
| Hospital Charge Code |
ERX211786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$25.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: Blue Distinction Transplant |
$23.76
|
| Rate for Payer: Blue Shield of California Commercial |
$29.19
|
| Rate for Payer: Blue Shield of California EPN |
$23.13
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.66
|
| Rate for Payer: Dignity Health Media |
$33.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$29.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$31.68
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.80
|
| Rate for Payer: United Healthcare HMO Rider |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.66
|
| Rate for Payer: Vantage Medical Group Senior |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
IP
|
$39.60
|
|
|
Service Code
|
NDC 53436-168-01
|
| Hospital Charge Code |
ERX211786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Blue Shield of California Commercial |
$28.20
|
| Rate for Payer: Blue Shield of California EPN |
$20.28
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$31.68
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
IP
|
$39.60
|
|
|
Service Code
|
NDC 53436-168-30
|
| Hospital Charge Code |
ERX211786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Blue Shield of California Commercial |
$28.20
|
| Rate for Payer: Blue Shield of California EPN |
$20.28
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$31.68
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$39.60
|
|
|
Service Code
|
NDC 53436-168-01
|
| Hospital Charge Code |
ERX211786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$25.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: Blue Distinction Transplant |
$23.76
|
| Rate for Payer: Blue Shield of California Commercial |
$29.19
|
| Rate for Payer: Blue Shield of California EPN |
$23.13
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.66
|
| Rate for Payer: Dignity Health Media |
$33.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$29.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$31.68
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.80
|
| Rate for Payer: United Healthcare HMO Rider |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.66
|
| Rate for Payer: Vantage Medical Group Senior |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
OP
|
$39.60
|
|
|
Service Code
|
NDC 53436-084-30
|
| Hospital Charge Code |
ERX211785
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$25.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: Blue Distinction Transplant |
$23.76
|
| Rate for Payer: Blue Shield of California Commercial |
$29.19
|
| Rate for Payer: Blue Shield of California EPN |
$23.13
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.66
|
| Rate for Payer: Dignity Health Media |
$33.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$29.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$31.68
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.80
|
| Rate for Payer: United Healthcare HMO Rider |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.66
|
| Rate for Payer: Vantage Medical Group Senior |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
IP
|
$39.60
|
|
|
Service Code
|
NDC 53436-084-30
|
| Hospital Charge Code |
ERX211785
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Blue Shield of California Commercial |
$28.20
|
| Rate for Payer: Blue Shield of California EPN |
$20.28
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$31.68
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
OP
|
$39.60
|
|
|
Service Code
|
NDC 53436-084-01
|
| Hospital Charge Code |
ERX211785
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$25.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: Blue Distinction Transplant |
$23.76
|
| Rate for Payer: Blue Shield of California Commercial |
$29.19
|
| Rate for Payer: Blue Shield of California EPN |
$23.13
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.66
|
| Rate for Payer: Dignity Health Media |
$33.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$29.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$31.68
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.80
|
| Rate for Payer: United Healthcare HMO Rider |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.66
|
| Rate for Payer: Vantage Medical Group Senior |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
IP
|
$39.60
|
|
|
Service Code
|
NDC 53436-084-01
|
| Hospital Charge Code |
ERX211785
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Blue Shield of California Commercial |
$28.20
|
| Rate for Payer: Blue Shield of California EPN |
$20.28
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.50
|
| Rate for Payer: Multiplan Commercial |
$31.68
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
|
|
Pediatric Heart Transplant
|
Facility
|
IP
|
$282,540.00
|
|
|
Service Code
|
MSDRG 001
|
| Min. Negotiated Rate |
$282,540.00 |
| Max. Negotiated Rate |
$282,540.00 |
| Rate for Payer: Blue Distinction Transplant |
$282,540.00
|
|
|
Pediatric Heart Transplant
|
Facility
|
IP
|
$282,540.00
|
|
|
Service Code
|
MSDRG 002
|
| Min. Negotiated Rate |
$282,540.00 |
| Max. Negotiated Rate |
$282,540.00 |
| Rate for Payer: Blue Distinction Transplant |
$282,540.00
|
|
|
Pediatric Kidney Transplant
|
Facility
|
IP
|
$113,455.00
|
|
|
Service Code
|
MSDRG 652
|
| Min. Negotiated Rate |
$113,455.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: Blue Distinction Transplant |
$113,455.00
|
|
|
Pediatric Kidney Transplant
|
Facility
|
IP
|
$113,455.00
|
|
|
Service Code
|
MSDRG 651
|
| Min. Negotiated Rate |
$113,455.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: Blue Distinction Transplant |
$113,455.00
|
|
|
Pediatric Kidney Transplant
|
Facility
|
IP
|
$113,455.00
|
|
|
Service Code
|
MSDRG 650
|
| Min. Negotiated Rate |
$113,455.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: Blue Distinction Transplant |
$113,455.00
|
|
|
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [228315]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 87040203
|
| Hospital Charge Code |
1715260
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Distinction Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Media |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [228315]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 87040203
|
| Hospital Charge Code |
1715260
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
PEDIATRIC MULTIVITAMIN NO.40-PHYTONADIONE 400 MCG/ML ORAL DROPS [118399]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 5891421460
|
| Hospital Charge Code |
NDG118399
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Distinction Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Media |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
PEDIATRIC MULTIVITAMIN NO.40-PHYTONADIONE 400 MCG/ML ORAL DROPS [118399]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 5891421460
|
| Hospital Charge Code |
NDG118399
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
PEDIATRIC MULTIVITAMIN NO.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 5820400406
|
| Hospital Charge Code |
ERX206186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.56
|
|
|
PEDIATRIC MULTIVITAMIN NO.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 5820400406
|
| Hospital Charge Code |
ERX206186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: Blue Distinction Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Media |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
PEDI NUTRITION WITH IRON LACTOSE-FREE 0.03 GRAM-1 KCAL/ML ORAL LIQUID [120893]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 4390033511
|
| Hospital Charge Code |
NDG120893
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PEDI NUTRITION WITH IRON LACTOSE-FREE 0.03 GRAM-1 KCAL/ML ORAL LIQUID [120893]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 4390033511
|
| Hospital Charge Code |
NDG120893
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 52268-100-01
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 64380-766-21
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 64380-766-21
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 52268-100-01
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
