|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC
|
Facility
|
IP
|
$92,627.09
|
|
|
Service Code
|
MSDRG 094
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$92,627.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$92,627.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$59,833.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$83,768.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$81,578.19
|
| Rate for Payer: EPIC Health Plan Senior |
$54,385.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49,441.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69,217.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$66,251.38
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$49,441.33
|
| Rate for Payer: Prime Health Services Medicare |
$52,407.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$67,881.96
|
|
|
Service Code
|
MSDRG 096
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$67,881.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$67,881.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$43,848.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61,390.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$60,182.22
|
| Rate for Payer: EPIC Health Plan Senior |
$40,121.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$36,474.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$51,063.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$48,875.25
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$36,474.07
|
| Rate for Payer: Prime Health Services Medicare |
$38,662.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0065080050
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0065080050
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$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: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.84
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.42
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.89
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.89
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Riverside University Health System MISP |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.38
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.38
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.89
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.84
|
| Rate for Payer: Cigna of CA HMO |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.74
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.74
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.42
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.89
|
| Rate for Payer: Global Benefits Group Commercial |
$0.63
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.89
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.38
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.6 EYE [118648]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 5939017513
|
| 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: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| 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: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.6 EYE [118648]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 5939017513
|
| 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 |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| 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: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 5026810213
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.56
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Senior |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
| Rate for Payer: Riverside University Health System MISP |
$0.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.98
|
| Rate for Payer: United Healthcare All Other HMO |
$0.98
|
| Rate for Payer: United Healthcare HMO Rider |
$0.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1.66
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 5026810213
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.56
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Senior |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 0054007928
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Central Health Plan Commercial |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$0.63
|
| Rate for Payer: Cigna of CA PPO |
$0.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Riverside University Health System MISP |
$0.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 5026810211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.56
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Senior |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
| Rate for Payer: Riverside University Health System MISP |
$0.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.98
|
| Rate for Payer: United Healthcare All Other HMO |
$0.98
|
| Rate for Payer: United Healthcare HMO Rider |
$0.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1.66
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 5026810211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Central Health Plan Commercial |
$1.56
|
| Rate for Payer: Cigna of CA HMO |
$1.36
|
| Rate for Payer: Cigna of CA PPO |
$1.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: EPIC Health Plan Senior |
$0.78
|
| Rate for Payer: Galaxy Health WC |
$1.66
|
| Rate for Payer: Global Benefits Group Commercial |
$1.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: Networks By Design Commercial |
$1.27
|
| Rate for Payer: Prime Health Services Commercial |
$1.66
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 0378675082
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 0054007928
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Central Health Plan Commercial |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$0.63
|
| Rate for Payer: Cigna of CA PPO |
$0.63
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 0378675082
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
| Rate for Payer: Riverside University Health System MISP |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 5898078050
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
| Rate for Payer: Riverside University Health System MISP |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 5898078050
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
|
BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 9468808470
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Riverside University Health System MISP |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 9468808470
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
OP
|
$114.02
|
|
|
Service Code
|
NDC 0002473230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$102.62 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$69.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$55.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.33
|
| Rate for Payer: Blue Shield of California Commercial |
$72.29
|
| Rate for Payer: Blue Shield of California EPN |
$45.49
|
| Rate for Payer: Cash Price |
$51.31
|
| Rate for Payer: Central Health Plan Commercial |
$91.22
|
| Rate for Payer: Cigna of CA HMO |
$79.81
|
| Rate for Payer: Cigna of CA PPO |
$79.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$79.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.61
|
| Rate for Payer: EPIC Health Plan Senior |
$45.61
|
| Rate for Payer: Galaxy Health WC |
$96.92
|
| Rate for Payer: Global Benefits Group Commercial |
$68.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$102.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$72.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$67.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.81
|
| Rate for Payer: Multiplan Commercial |
$85.52
|
| Rate for Payer: Networks By Design Commercial |
$74.11
|
| Rate for Payer: Prime Health Services Commercial |
$96.92
|
| Rate for Payer: Riverside University Health System MISP |
$45.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$68.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$68.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$57.01
|
| Rate for Payer: United Healthcare All Other HMO |
$57.01
|
| Rate for Payer: United Healthcare HMO Rider |
$57.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$57.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.92
|
| Rate for Payer: Vantage Medical Group Senior |
$96.92
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
IP
|
$114.02
|
|
|
Service Code
|
NDC 0002473230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$102.62 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Blue Shield of California Commercial |
$91.44
|
| Rate for Payer: Blue Shield of California EPN |
$57.47
|
| Rate for Payer: Cash Price |
$51.31
|
| Rate for Payer: Central Health Plan Commercial |
$91.22
|
| Rate for Payer: Cigna of CA HMO |
$79.81
|
| Rate for Payer: Cigna of CA PPO |
$79.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$79.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.61
|
| Rate for Payer: EPIC Health Plan Senior |
$45.61
|
| Rate for Payer: Galaxy Health WC |
$96.92
|
| Rate for Payer: Global Benefits Group Commercial |
$68.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$102.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$72.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$67.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.80
|
| Rate for Payer: Multiplan Commercial |
$85.52
|
| Rate for Payer: Networks By Design Commercial |
$74.11
|
| Rate for Payer: Prime Health Services Commercial |
$96.92
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
|
IP
|
$114.02
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$102.62 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Blue Shield of California Commercial |
$91.44
|
| Rate for Payer: Blue Shield of California EPN |
$57.47
|
| Rate for Payer: Cash Price |
$51.31
|
| Rate for Payer: Central Health Plan Commercial |
$91.22
|
| Rate for Payer: Cigna of CA HMO |
$79.81
|
| Rate for Payer: Cigna of CA PPO |
$79.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$79.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.61
|
| Rate for Payer: EPIC Health Plan Senior |
$45.61
|
| Rate for Payer: Galaxy Health WC |
$96.92
|
| Rate for Payer: Global Benefits Group Commercial |
$68.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$102.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$72.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$67.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.80
|
| Rate for Payer: Multiplan Commercial |
$85.52
|
| Rate for Payer: Networks By Design Commercial |
$74.11
|
| Rate for Payer: Prime Health Services Commercial |
$96.92
|
|
|
BARICITINIB 2 MG TABLET [221907]
|
Facility
|
OP
|
$114.02
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.80 |
| Max. Negotiated Rate |
$102.62 |
| Rate for Payer: Adventist Health Commercial |
$22.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$69.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.52
|
| Rate for Payer: Blue Shield of California Commercial |
$72.29
|
| Rate for Payer: Blue Shield of California EPN |
$45.49
|
| Rate for Payer: Cash Price |
$51.31
|
| Rate for Payer: Central Health Plan Commercial |
$91.22
|
| Rate for Payer: Cigna of CA HMO |
$79.81
|
| Rate for Payer: Cigna of CA PPO |
$79.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$79.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.61
|
| Rate for Payer: EPIC Health Plan Senior |
$45.61
|
| Rate for Payer: Galaxy Health WC |
$96.92
|
| Rate for Payer: Global Benefits Group Commercial |
$68.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$102.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$72.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$67.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.81
|
| Rate for Payer: Multiplan Commercial |
$85.52
|
| Rate for Payer: Networks By Design Commercial |
$74.11
|
| Rate for Payer: Prime Health Services Commercial |
$96.92
|
| Rate for Payer: Riverside University Health System MISP |
$45.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$68.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$68.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$57.01
|
| Rate for Payer: United Healthcare All Other HMO |
$57.01
|
| Rate for Payer: United Healthcare HMO Rider |
$57.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$57.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.92
|
| Rate for Payer: Vantage Medical Group Senior |
$96.92
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 3290916755
|
| 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 |
$0.01
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
