|
OLUTASIDENIB 150 MG CAPSULE [236323]
|
Facility
|
IP
|
$683.20
|
|
|
Service Code
|
NDC 71332-005-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$123.66 |
| Max. Negotiated Rate |
$512.40 |
| Rate for Payer: Adventist Health Commercial |
$136.64
|
| Rate for Payer: Cash Price |
$375.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$368.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$462.53
|
| Rate for Payer: Heritage Provider Network Senior |
$462.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$123.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$170.80
|
| Rate for Payer: Multiplan Commercial |
$512.40
|
|
|
OMEGA-3 300 MG-DHA 120 MG-EPA 180 MG-FISH OIL 1,000 MG CAPSULE [231730]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0904723860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
OMEGA-3 300 MG-DHA 120 MG-EPA 180 MG-FISH OIL 1,000 MG CAPSULE [231730]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0904723860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 60505-3170-7
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Senior |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Senior |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 60505-3170-7
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| 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 Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.73
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 31722-936-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.23
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.10
|
| Rate for Payer: Dignity Health Senior |
$3.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.26
|
| Rate for Payer: Heritage Provider Network Senior |
$2.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.56
|
| Rate for Payer: Multiplan Commercial |
$2.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.46
|
| Rate for Payer: TriValley Medical Group Senior |
$1.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.10
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 64380-761-11
|
| 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 Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 64380-761-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 70756-423-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.23
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.10
|
| Rate for Payer: Dignity Health Senior |
$3.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.26
|
| Rate for Payer: Heritage Provider Network Senior |
$2.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.56
|
| Rate for Payer: Multiplan Commercial |
$2.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.46
|
| Rate for Payer: TriValley Medical Group Senior |
$1.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.10
|
| Rate for Payer: Vantage Medical Group Senior |
$3.10
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 70756-423-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 31722-936-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Senior |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.47
|
| Rate for Payer: Heritage Provider Network Senior |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$2.74
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE [41822]
|
Facility
|
IP
|
$3.65
|
|
|
Service Code
|
NDC 60687-127-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.47
|
| Rate for Payer: Heritage Provider Network Senior |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$2.74
|
|
|
OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 1191710202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE [10774]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 1191710202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 37000-459-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
OMEPRAZOLE MAGNESIUM 20 MG TABLET,DELAYED RELEASE [36205]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 37000-459-02
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| 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
|
|
|
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]
|
Facility
|
OP
|
$781.20
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$585.90 |
| Rate for Payer: Adventist Health Commercial |
$156.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$417.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$536.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$16.73
|
| Rate for Payer: Blue Shield of California Commercial |
$6.59
|
| Rate for Payer: Blue Shield of California EPN |
$6.59
|
| Rate for Payer: Cash Price |
$429.66
|
| Rate for Payer: Cash Price |
$429.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$359.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.15
|
| Rate for Payer: Dignity Health Senior |
$7.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$499.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$361.70
|
| Rate for Payer: Heritage Provider Network Senior |
$361.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$372.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$585.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$312.48
|
| Rate for Payer: TriValley Medical Group Senior |
$312.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$282.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$258.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.15
|
| Rate for Payer: Vantage Medical Group Senior |
$7.15
|
|
|
ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION [32700]
|
Facility
|
IP
|
$781.20
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.40 |
| Max. Negotiated Rate |
$585.90 |
| Rate for Payer: Adventist Health Commercial |
$156.24
|
| Rate for Payer: Cash Price |
$429.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$359.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$421.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$361.70
|
| Rate for Payer: Heritage Provider Network Senior |
$361.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$195.30
|
| Rate for Payer: Multiplan Commercial |
$585.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$282.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$258.66
|
|
|
ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]
|
Facility
|
IP
|
$434.40
|
|
|
Service Code
|
NDC 0023-3919-50
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.63 |
| Max. Negotiated Rate |
$325.80 |
| Rate for Payer: Adventist Health Commercial |
$86.88
|
| Rate for Payer: Cash Price |
$238.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$199.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$234.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$201.13
|
| Rate for Payer: Heritage Provider Network Senior |
$201.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.60
|
| Rate for Payer: Multiplan Commercial |
$325.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.83
|
|
|
ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION [95794]
|
Facility
|
OP
|
$434.40
|
|
|
Service Code
|
NDC 0023-3919-50
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.63 |
| Max. Negotiated Rate |
$369.24 |
| Rate for Payer: Adventist Health Commercial |
$86.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$232.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$298.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$238.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$325.80
|
| Rate for Payer: Blue Shield of California Commercial |
$264.98
|
| Rate for Payer: Blue Shield of California EPN |
$211.99
|
| Rate for Payer: Cash Price |
$238.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$199.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.24
|
| Rate for Payer: Dignity Health Senior |
$369.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$278.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$201.13
|
| Rate for Payer: Heritage Provider Network Senior |
$201.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$207.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$304.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$304.08
|
| Rate for Payer: Multiplan Commercial |
$325.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$173.76
|
| Rate for Payer: TriValley Medical Group Senior |
$173.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.24
|
| Rate for Payer: Vantage Medical Group Senior |
$369.24
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 62756-240-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
| Rate for Payer: Dignity Health Senior |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Vantage Medical Group Senior |
$0.62
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET [27697]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 57237-077-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
