|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 50268-642-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 53436-168-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$31.95 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.84
|
| Rate for Payer: Heritage Provider Network Senior |
$28.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 53436-168-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.95
|
| Rate for Payer: Blue Shield of California Commercial |
$25.99
|
| Rate for Payer: Blue Shield of California EPN |
$20.79
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.21
|
| Rate for Payer: Dignity Health Senior |
$36.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.37
|
| Rate for Payer: Heritage Provider Network Senior |
$26.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.82
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.04
|
| Rate for Payer: TriValley Medical Group Senior |
$17.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.21
|
| Rate for Payer: Vantage Medical Group Senior |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 53436-168-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$31.95 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.84
|
| Rate for Payer: Heritage Provider Network Senior |
$28.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 53436-168-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.95
|
| Rate for Payer: Blue Shield of California Commercial |
$25.99
|
| Rate for Payer: Blue Shield of California EPN |
$20.79
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.21
|
| Rate for Payer: Dignity Health Senior |
$36.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.37
|
| Rate for Payer: Heritage Provider Network Senior |
$26.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.82
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.04
|
| Rate for Payer: TriValley Medical Group Senior |
$17.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.21
|
| Rate for Payer: Vantage Medical Group Senior |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 53436-084-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.95
|
| Rate for Payer: Blue Shield of California Commercial |
$25.99
|
| Rate for Payer: Blue Shield of California EPN |
$20.79
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.21
|
| Rate for Payer: Dignity Health Senior |
$36.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.37
|
| Rate for Payer: Heritage Provider Network Senior |
$26.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.82
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.04
|
| Rate for Payer: TriValley Medical Group Senior |
$17.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.21
|
| Rate for Payer: Vantage Medical Group Senior |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 53436-084-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.95
|
| Rate for Payer: Blue Shield of California Commercial |
$25.99
|
| Rate for Payer: Blue Shield of California EPN |
$20.79
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.21
|
| Rate for Payer: Dignity Health Senior |
$36.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.37
|
| Rate for Payer: Heritage Provider Network Senior |
$26.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.82
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.04
|
| Rate for Payer: TriValley Medical Group Senior |
$17.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.21
|
| Rate for Payer: Vantage Medical Group Senior |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 53436-084-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$31.95 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.84
|
| Rate for Payer: Heritage Provider Network Senior |
$28.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 53436-084-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$31.95 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Cash Price |
$23.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.84
|
| Rate for Payer: Heritage Provider Network Senior |
$28.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Multiplan Commercial |
$31.95
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 1650007818
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| 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 |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| 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 |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068104900
|
| 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 Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 1650008619
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 1650007814
|
| 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 |
$0.04
|
| 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 |
$0.05
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068104900
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 1650007814
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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 |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| 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 |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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 |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 1650007818
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 1650008619
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [228315]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0087040203
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [228315]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 0087040203
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
PEDIATRIC MULTIVITAMIN NO.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 5820400406
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
PEDIATRIC MULTIVITAMIN NO.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 5820400406
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| 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 Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
PEDI NUTRITION WITH IRON LACTOSE-FREE 0.03 GRAM-1 KCAL/ML ORAL LIQUID [120893]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 4390033511
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PEDI NUTRITION WITH IRON LACTOSE-FREE 0.03 GRAM-1 KCAL/ML ORAL LIQUID [120893]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 4390033511
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 64380-766-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 52268-100-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
