|
COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]
|
Facility
|
IP
|
$33.60
|
|
|
Service Code
|
HCPCS J0770
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$30.24 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Blue Shield of California Commercial |
$25.97
|
| Rate for Payer: Blue Shield of California Commercial |
$25.97
|
| Rate for Payer: Blue Shield of California EPN |
$16.93
|
| Rate for Payer: Blue Shield of California EPN |
$16.93
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Central Health Plan Commercial |
$26.88
|
| Rate for Payer: Central Health Plan Commercial |
$26.87
|
| Rate for Payer: Cigna of CA HMO |
$23.51
|
| Rate for Payer: Cigna of CA HMO |
$23.52
|
| Rate for Payer: Cigna of CA PPO |
$23.51
|
| Rate for Payer: Cigna of CA PPO |
$23.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Senior |
$13.44
|
| Rate for Payer: EPIC Health Plan Senior |
$13.44
|
| Rate for Payer: Galaxy Health WC |
$28.55
|
| Rate for Payer: Galaxy Health WC |
$28.56
|
| Rate for Payer: Global Benefits Group Commercial |
$20.16
|
| Rate for Payer: Global Benefits Group Commercial |
$20.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$30.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$30.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.72
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Prime Health Services Commercial |
$28.56
|
| Rate for Payer: Prime Health Services Commercial |
$28.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.61
|
| Rate for Payer: United Healthcare All Other HMO |
$12.27
|
| Rate for Payer: United Healthcare All Other HMO |
$12.27
|
| Rate for Payer: United Healthcare HMO Rider |
$12.01
|
| Rate for Payer: United Healthcare HMO Rider |
$12.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.00
|
|
|
COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]
|
Facility
|
OP
|
$33.60
|
|
|
Service Code
|
HCPCS J0770
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$59.68 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$20.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$59.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$59.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.32
|
| Rate for Payer: Blue Shield of California Commercial |
$36.42
|
| Rate for Payer: Blue Shield of California Commercial |
$36.42
|
| Rate for Payer: Blue Shield of California EPN |
$33.11
|
| Rate for Payer: Blue Shield of California EPN |
$33.11
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Central Health Plan Commercial |
$26.88
|
| Rate for Payer: Central Health Plan Commercial |
$26.87
|
| Rate for Payer: Cigna of CA HMO |
$23.51
|
| Rate for Payer: Cigna of CA HMO |
$23.52
|
| Rate for Payer: Cigna of CA PPO |
$23.52
|
| Rate for Payer: Cigna of CA PPO |
$23.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$28.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$28.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Senior |
$13.44
|
| Rate for Payer: EPIC Health Plan Senior |
$13.44
|
| Rate for Payer: Galaxy Health WC |
$28.56
|
| Rate for Payer: Galaxy Health WC |
$28.55
|
| Rate for Payer: Global Benefits Group Commercial |
$20.16
|
| Rate for Payer: Global Benefits Group Commercial |
$20.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$30.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$30.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11.94
|
| Rate for Payer: InnovAge PACE Commercial |
$16.80
|
| Rate for Payer: InnovAge PACE Commercial |
$16.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.52
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Networks By Design Commercial |
$16.80
|
| Rate for Payer: Prime Health Services Commercial |
$28.56
|
| Rate for Payer: Prime Health Services Commercial |
$28.55
|
| Rate for Payer: Riverside University Health System MISP |
$13.44
|
| Rate for Payer: Riverside University Health System MISP |
$13.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.61
|
| Rate for Payer: United Healthcare All Other HMO |
$12.27
|
| Rate for Payer: United Healthcare All Other HMO |
$12.27
|
| Rate for Payer: United Healthcare HMO Rider |
$12.01
|
| Rate for Payer: United Healthcare HMO Rider |
$12.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$28.55
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
IP
|
$10.45
|
|
|
Service Code
|
NDC 9999-9996-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$9.40 |
| Rate for Payer: Adventist Health Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California Commercial |
$8.08
|
| Rate for Payer: Blue Shield of California EPN |
$5.27
|
| Rate for Payer: Cash Price |
$5.75
|
| Rate for Payer: Central Health Plan Commercial |
$8.36
|
| Rate for Payer: Cigna of CA HMO |
$7.32
|
| Rate for Payer: Cigna of CA PPO |
$7.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.18
|
| Rate for Payer: EPIC Health Plan Senior |
$4.18
|
| Rate for Payer: Galaxy Health WC |
$8.88
|
| Rate for Payer: Global Benefits Group Commercial |
$6.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.09
|
| Rate for Payer: Multiplan Commercial |
$7.84
|
| Rate for Payer: Networks By Design Commercial |
$6.79
|
| Rate for Payer: Prime Health Services Commercial |
$8.88
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
OP
|
$12.70
|
|
|
Service Code
|
NDC 50484-010-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$11.43 |
| Rate for Payer: Adventist Health Commercial |
$2.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.46
|
| Rate for Payer: Blue Shield of California Commercial |
$7.76
|
| Rate for Payer: Blue Shield of California EPN |
$5.07
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Central Health Plan Commercial |
$10.16
|
| Rate for Payer: Cigna of CA HMO |
$8.89
|
| Rate for Payer: Cigna of CA PPO |
$8.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.08
|
| Rate for Payer: EPIC Health Plan Senior |
$5.08
|
| Rate for Payer: Galaxy Health WC |
$10.79
|
| Rate for Payer: Global Benefits Group Commercial |
$7.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.43
|
| Rate for Payer: InnovAge PACE Commercial |
$6.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.89
|
| Rate for Payer: Multiplan Commercial |
$9.53
|
| Rate for Payer: Networks By Design Commercial |
$8.26
|
| Rate for Payer: Prime Health Services Commercial |
$10.79
|
| Rate for Payer: Riverside University Health System MISP |
$5.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.35
|
| Rate for Payer: United Healthcare All Other HMO |
$6.35
|
| Rate for Payer: United Healthcare HMO Rider |
$6.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.79
|
| Rate for Payer: Vantage Medical Group Senior |
$10.79
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
OP
|
$12.07
|
|
|
Service Code
|
NDC 50484-010-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$10.86 |
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.09
|
| Rate for Payer: Blue Shield of California Commercial |
$7.37
|
| Rate for Payer: Blue Shield of California EPN |
$4.82
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Central Health Plan Commercial |
$9.66
|
| Rate for Payer: Cigna of CA HMO |
$8.45
|
| Rate for Payer: Cigna of CA PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.83
|
| Rate for Payer: EPIC Health Plan Senior |
$4.83
|
| Rate for Payer: Galaxy Health WC |
$10.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.86
|
| Rate for Payer: InnovAge PACE Commercial |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.45
|
| Rate for Payer: Multiplan Commercial |
$9.05
|
| Rate for Payer: Networks By Design Commercial |
$7.85
|
| Rate for Payer: Prime Health Services Commercial |
$10.26
|
| Rate for Payer: Riverside University Health System MISP |
$4.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.04
|
| Rate for Payer: United Healthcare All Other HMO |
$6.04
|
| Rate for Payer: United Healthcare HMO Rider |
$6.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.26
|
| Rate for Payer: Vantage Medical Group Senior |
$10.26
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
OP
|
$10.45
|
|
|
Service Code
|
NDC 9999-9996-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$9.40 |
| Rate for Payer: Adventist Health Commercial |
$2.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.14
|
| Rate for Payer: Blue Shield of California Commercial |
$6.38
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$5.75
|
| Rate for Payer: Central Health Plan Commercial |
$8.36
|
| Rate for Payer: Cigna of CA HMO |
$7.32
|
| Rate for Payer: Cigna of CA PPO |
$7.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.18
|
| Rate for Payer: EPIC Health Plan Senior |
$4.18
|
| Rate for Payer: Galaxy Health WC |
$8.88
|
| Rate for Payer: Global Benefits Group Commercial |
$6.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.40
|
| Rate for Payer: InnovAge PACE Commercial |
$5.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.32
|
| Rate for Payer: Multiplan Commercial |
$7.84
|
| Rate for Payer: Networks By Design Commercial |
$6.79
|
| Rate for Payer: Prime Health Services Commercial |
$8.88
|
| Rate for Payer: Riverside University Health System MISP |
$4.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO |
$5.22
|
| Rate for Payer: United Healthcare HMO Rider |
$5.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.88
|
| Rate for Payer: Vantage Medical Group Senior |
$8.88
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
IP
|
$12.07
|
|
|
Service Code
|
NDC 50484-010-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$10.86 |
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California Commercial |
$9.33
|
| Rate for Payer: Blue Shield of California EPN |
$6.08
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Central Health Plan Commercial |
$9.66
|
| Rate for Payer: Cigna of CA HMO |
$8.45
|
| Rate for Payer: Cigna of CA PPO |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.83
|
| Rate for Payer: EPIC Health Plan Senior |
$4.83
|
| Rate for Payer: Galaxy Health WC |
$10.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.41
|
| Rate for Payer: Multiplan Commercial |
$9.05
|
| Rate for Payer: Networks By Design Commercial |
$7.85
|
| Rate for Payer: Prime Health Services Commercial |
$10.26
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
IP
|
$12.70
|
|
|
Service Code
|
NDC 50484-010-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$11.43 |
| Rate for Payer: Adventist Health Commercial |
$2.54
|
| Rate for Payer: Blue Shield of California Commercial |
$9.82
|
| Rate for Payer: Blue Shield of California EPN |
$6.40
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Central Health Plan Commercial |
$10.16
|
| Rate for Payer: Cigna of CA HMO |
$8.89
|
| Rate for Payer: Cigna of CA PPO |
$8.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.08
|
| Rate for Payer: EPIC Health Plan Senior |
$5.08
|
| Rate for Payer: Galaxy Health WC |
$10.79
|
| Rate for Payer: Global Benefits Group Commercial |
$7.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.54
|
| Rate for Payer: Multiplan Commercial |
$9.53
|
| Rate for Payer: Networks By Design Commercial |
$8.26
|
| Rate for Payer: Prime Health Services Commercial |
$10.79
|
|
|
COLLOIDAL OATMEAL TOPICAL PACKET [81870]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 8137003640
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: InnovAge PACE Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
COLLOIDAL OATMEAL TOPICAL PACKET [81870]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 8137003640
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030316
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030316
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030216
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030216
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0395009416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0395009416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0395009016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0395009016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 3877907448
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: InnovAge PACE Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3172295901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3172295901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
