|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
IP
|
$7.40
|
|
|
Service Code
|
NDC 60687-309-11
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.08
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.01
|
| Rate for Payer: Heritage Provider Network Senior |
$5.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$5.55
|
|
|
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [114051]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
CPT J2020
|
| Hospital Charge Code |
1753528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
|
|
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK [114051]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
CPT J2020
|
| Hospital Charge Code |
1753528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$75.49 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.49
|
| Rate for Payer: Blue Shield of California Commercial |
$13.60
|
| Rate for Payer: Blue Shield of California Commercial |
$13.60
|
| Rate for Payer: Blue Shield of California EPN |
$13.60
|
| Rate for Payer: Blue Shield of California EPN |
$13.60
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION [10442]
|
Facility
|
IP
|
$493.54
|
|
|
Service Code
|
NDC 42023-120-01
|
| Hospital Charge Code |
NDG10442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.33 |
| Max. Negotiated Rate |
$370.16 |
| Rate for Payer: Adventist Health Commercial |
$98.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$339.06
|
| Rate for Payer: Cash Price |
$222.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$334.13
|
| Rate for Payer: Heritage Provider Network Senior |
$334.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.38
|
| Rate for Payer: Multiplan Commercial |
$370.16
|
|
|
LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION [10442]
|
Facility
|
OP
|
$493.54
|
|
|
Service Code
|
NDC 42023-120-01
|
| Hospital Charge Code |
NDG10442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.33 |
| Max. Negotiated Rate |
$419.51 |
| Rate for Payer: Adventist Health Commercial |
$98.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$263.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$339.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$419.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$271.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$370.16
|
| Rate for Payer: Blue Shield of California Commercial |
$306.49
|
| Rate for Payer: Blue Shield of California EPN |
$289.71
|
| Rate for Payer: Cash Price |
$222.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$320.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$419.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$419.51
|
| Rate for Payer: Dignity Health Senior |
$419.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$315.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$305.50
|
| Rate for Payer: Heritage Provider Network Senior |
$305.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$237.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.38
|
| Rate for Payer: Multiplan Commercial |
$370.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$197.42
|
| Rate for Payer: TriValley Medical Group Senior |
$197.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$419.51
|
| Rate for Payer: Vantage Medical Group Senior |
$419.51
|
|
|
LIOTHYRONINE 25 MCG TABLET [4504]
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
NDC 42794-019-12
|
| Hospital Charge Code |
1710808
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.90
|
| Rate for Payer: Dignity Health Senior |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Senior |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Vantage Medical Group Senior |
$0.90
|
|
|
LIOTHYRONINE 25 MCG TABLET [4504]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 62756-590-88
|
| Hospital Charge Code |
1710808
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
LIOTHYRONINE 25 MCG TABLET [4504]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 62756-590-88
|
| Hospital Charge Code |
1710808
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Senior |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Senior |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.74
|
|
|
LIOTHYRONINE 25 MCG TABLET [4504]
|
Facility
|
IP
|
$1.06
|
|
|
Service Code
|
NDC 42794-019-12
|
| Hospital Charge Code |
1710808
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.73
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
LIOTHYRONINE 5 MCG TABLET [10443]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 42794-018-12
|
| Hospital Charge Code |
1710809
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Senior |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Senior |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
LIOTHYRONINE 5 MCG TABLET [10443]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 42794-018-12
|
| Hospital Charge Code |
1710809
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [98035]
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 0032-1212-01
|
| Hospital Charge Code |
1712413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.26
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
|
|
LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [98035]
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 0032-1212-07
|
| Hospital Charge Code |
1712413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.04
|
| Rate for Payer: Dignity Health Senior |
$4.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.90
|
| Rate for Payer: TriValley Medical Group Senior |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.04
|
| Rate for Payer: Vantage Medical Group Senior |
$4.04
|
|
|
LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [98035]
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 0032-1212-01
|
| Hospital Charge Code |
1712413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.04
|
| Rate for Payer: Dignity Health Senior |
$4.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.90
|
| Rate for Payer: TriValley Medical Group Senior |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.04
|
| Rate for Payer: Vantage Medical Group Senior |
$4.04
|
|
|
LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL [98035]
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 0032-1212-07
|
| Hospital Charge Code |
1712413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.26
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.56
|
|
|
LIPASE-PROTEASE-AMYLASE 20,880-78,300-78,300 UNIT TABLET [196333]
|
Facility
|
OP
|
$9.14
|
|
|
Service Code
|
NDC 73562-208-10
|
| Hospital Charge Code |
1712582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$7.77 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.86
|
| Rate for Payer: Blue Shield of California Commercial |
$5.68
|
| Rate for Payer: Blue Shield of California EPN |
$5.37
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.77
|
| Rate for Payer: Dignity Health Senior |
$7.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.66
|
| Rate for Payer: Heritage Provider Network Senior |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.66
|
| Rate for Payer: TriValley Medical Group Senior |
$3.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.77
|
| Rate for Payer: Vantage Medical Group Senior |
$7.77
|
|
|
LIPASE-PROTEASE-AMYLASE 20,880-78,300-78,300 UNIT TABLET [196333]
|
Facility
|
IP
|
$9.14
|
|
|
Service Code
|
NDC 73562-208-10
|
| Hospital Charge Code |
1712582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$6.86 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.28
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.19
|
| Rate for Payer: Heritage Provider Network Senior |
$6.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$6.86
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL [98036]
|
Facility
|
OP
|
$9.26
|
|
|
Service Code
|
NDC 0032-1224-07
|
| Hospital Charge Code |
1712414
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$7.87 |
| Rate for Payer: Adventist Health Commercial |
$1.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.94
|
| Rate for Payer: Blue Shield of California Commercial |
$5.75
|
| Rate for Payer: Blue Shield of California EPN |
$5.44
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.87
|
| Rate for Payer: Dignity Health Senior |
$7.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.73
|
| Rate for Payer: Heritage Provider Network Senior |
$5.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$6.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.70
|
| Rate for Payer: TriValley Medical Group Senior |
$3.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.87
|
| Rate for Payer: Vantage Medical Group Senior |
$7.87
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL [98036]
|
Facility
|
OP
|
$9.41
|
|
|
Service Code
|
NDC 0032-1224-01
|
| Hospital Charge Code |
1712414
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.06
|
| Rate for Payer: Blue Shield of California Commercial |
$5.84
|
| Rate for Payer: Blue Shield of California EPN |
$5.52
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.00
|
| Rate for Payer: Dignity Health Senior |
$8.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.82
|
| Rate for Payer: Heritage Provider Network Senior |
$5.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$7.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.76
|
| Rate for Payer: TriValley Medical Group Senior |
$3.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.00
|
| Rate for Payer: Vantage Medical Group Senior |
$8.00
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL [98036]
|
Facility
|
IP
|
$9.26
|
|
|
Service Code
|
NDC 0032-1224-07
|
| Hospital Charge Code |
1712414
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$6.94 |
| Rate for Payer: Adventist Health Commercial |
$1.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.36
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.27
|
| Rate for Payer: Heritage Provider Network Senior |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$6.94
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL [98036]
|
Facility
|
IP
|
$9.41
|
|
|
Service Code
|
NDC 0032-1224-01
|
| Hospital Charge Code |
1712414
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.46
|
| Rate for Payer: Cash Price |
$4.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.37
|
| Rate for Payer: Heritage Provider Network Senior |
$6.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$7.06
|
|
|
LIPASE-PROTEASE-AMYLASE 3,000-9,500-15,000 UNIT CAPSULE, DELAYED REL [187996]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 0032-1203-70
|
| Hospital Charge Code |
1712583
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.18
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.71
|
| Rate for Payer: Dignity Health Senior |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.71
|
|
|
LIPASE-PROTEASE-AMYLASE 3,000-9,500-15,000 UNIT CAPSULE, DELAYED REL [187996]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 0032-1203-70
|
| Hospital Charge Code |
1712583
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Senior |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL [201958]
|
Facility
|
IP
|
$14.28
|
|
|
Service Code
|
NDC 0032-3016-28
|
| Hospital Charge Code |
ERX201958
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Adventist Health Commercial |
$2.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.81
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.67
|
| Rate for Payer: Heritage Provider Network Senior |
$9.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.57
|
| Rate for Payer: Multiplan Commercial |
$10.71
|
|
|
LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL [201958]
|
Facility
|
OP
|
$14.28
|
|
|
Service Code
|
NDC 0032-3016-28
|
| Hospital Charge Code |
ERX201958
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$12.14 |
| Rate for Payer: Adventist Health Commercial |
$2.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.71
|
| Rate for Payer: Blue Shield of California Commercial |
$8.87
|
| Rate for Payer: Blue Shield of California EPN |
$8.38
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.14
|
| Rate for Payer: Dignity Health Senior |
$12.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.84
|
| Rate for Payer: Heritage Provider Network Senior |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.57
|
| Rate for Payer: Multiplan Commercial |
$10.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.71
|
| Rate for Payer: TriValley Medical Group Senior |
$5.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.14
|
| Rate for Payer: Vantage Medical Group Senior |
$12.14
|
|
