|
PAROXETINE 30 MG TABLET [10856]
|
Facility
OP
|
$1.14
|
|
|
Service Code
|
NDC 68084-046-11
|
| Hospital Charge Code |
1713111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.68
|
| Rate for Payer: BCBS Transplant Transplant |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.80
|
| Rate for Payer: Cigna of CA PPO |
$0.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.97
|
| Rate for Payer: Dignity Health Media |
$0.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.97
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| Rate for Payer: Networks By Design Commercial |
$0.74
|
| Rate for Payer: Prime Health Services Commercial |
$0.97
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO |
$0.57
|
| Rate for Payer: United Healthcare HMO Rider |
$0.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.97
|
| Rate for Payer: Vantage Medical Group Senior |
$0.97
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
IP
|
$0.55
|
|
|
Service Code
|
NDC 50268-642-11
|
| Hospital Charge Code |
1713111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
IP
|
$0.32
|
|
|
Service Code
|
NDC 43547-349-03
|
| Hospital Charge Code |
1713111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
IP
|
$1.14
|
|
|
Service Code
|
NDC 68084-046-11
|
| Hospital Charge Code |
1713111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.80
|
| Rate for Payer: Cigna of CA PPO |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.97
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| Rate for Payer: Networks By Design Commercial |
$0.74
|
| Rate for Payer: Prime Health Services Commercial |
$0.97
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
OP
|
$0.55
|
|
|
Service Code
|
NDC 50268-642-15
|
| Hospital Charge Code |
1713111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.33
|
| Rate for Payer: BCBS Transplant Transplant |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Media |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
OP
|
$0.23
|
|
|
Service Code
|
NDC 68382-099-06
|
| Hospital Charge Code |
1713111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: BCBS Transplant Transplant |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Media |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
IP
|
$5,705.22
|
|
|
Service Code
|
APR-DRG 8441
|
| Min. Negotiated Rate |
$4,376.51 |
| Max. Negotiated Rate |
$5,705.22 |
| Rate for Payer: IEHP Medi-Cal |
$4,376.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,705.22
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
IP
|
$9,243.27
|
|
|
Service Code
|
APR-DRG 8442
|
| Min. Negotiated Rate |
$7,090.56 |
| Max. Negotiated Rate |
$9,243.27 |
| Rate for Payer: IEHP Medi-Cal |
$7,090.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,243.27
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
IP
|
$15,886.66
|
|
|
Service Code
|
APR-DRG 8443
|
| Min. Negotiated Rate |
$12,186.74 |
| Max. Negotiated Rate |
$15,886.66 |
| Rate for Payer: IEHP Medi-Cal |
$12,186.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,886.66
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
IP
|
$36,689.34
|
|
|
Service Code
|
APR-DRG 8444
|
| Min. Negotiated Rate |
$28,144.59 |
| Max. Negotiated Rate |
$36,689.34 |
| Rate for Payer: IEHP Medi-Cal |
$28,144.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36,689.34
|
|
|
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 53436-168-30
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$23.76
|
| 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
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: AlphaCare Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$23.76
|
| 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
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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$23.76
|
| 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 53436-084-01
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.59
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$23.76
|
| 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
|
|
|
Pediatric Heart Transplant
|
Facility
IP
|
$282,540.00
|
|
|
Service Code
|
MS-DRG 001
|
| Min. Negotiated Rate |
$282,540.00 |
| Max. Negotiated Rate |
$282,540.00 |
| Rate for Payer: BCBS Transplant Transplant |
$282,540.00
|
|
|
Pediatric Heart Transplant
|
Facility
IP
|
$282,540.00
|
|
|
Service Code
|
MS-DRG 002
|
| Min. Negotiated Rate |
$282,540.00 |
| Max. Negotiated Rate |
$282,540.00 |
| Rate for Payer: BCBS Transplant Transplant |
$282,540.00
|
|
|
Pediatric Kidney Transplant
|
Facility
IP
|
$113,455.00
|
|
|
Service Code
|
MS-DRG 651
|
| Min. Negotiated Rate |
$113,455.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: BCBS Transplant Transplant |
$113,455.00
|
|
|
Pediatric Kidney Transplant
|
Facility
IP
|
$113,455.00
|
|
|
Service Code
|
MS-DRG 650
|
| Min. Negotiated Rate |
$113,455.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: BCBS Transplant Transplant |
$113,455.00
|
|
|
Pediatric Kidney Transplant
|
Facility
IP
|
$113,455.00
|
|
|
Service Code
|
MS-DRG 652
|
| Min. Negotiated Rate |
$113,455.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: BCBS Transplant 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: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.12
|
| 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
|
|
