|
PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 28122
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,208.34 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,208.34
|
| Rate for Payer: Heritage Provider Network Senior |
$5,176.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,995.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,839.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,629.17
|
| Rate for Payer: TriValley Medical Group Senior |
$4,629.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC
|
Facility
|
IP
|
$16,487.01
|
|
|
Service Code
|
MSDRG 543
|
| Min. Negotiated Rate |
$12,303.74 |
| Max. Negotiated Rate |
$16,487.01 |
| Rate for Payer: EPIC Health Plan Medicare |
$12,303.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,303.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14,149.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,487.01
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$27,827.02
|
|
|
Service Code
|
MSDRG 542
|
| Min. Negotiated Rate |
$20,766.43 |
| Max. Negotiated Rate |
$27,827.02 |
| Rate for Payer: EPIC Health Plan Medicare |
$20,766.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20,766.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23,881.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27,827.02
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$12,288.83
|
|
|
Service Code
|
MSDRG 544
|
| Min. Negotiated Rate |
$9,170.77 |
| Max. Negotiated Rate |
$12,288.83 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,170.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,170.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,546.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,288.83
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 5343616830
|
| 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 Non-Gatekeeper |
$26.33
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$21.31
|
| 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 |
$19.17
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$20.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5343616801
|
| 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: Aetna of CA Non-Gatekeeper |
$27.43
|
| Rate for Payer: Cash Price |
$19.17
|
| 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 Foundation Hospitals 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
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 5343616830
|
| 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: Aetna of CA Non-Gatekeeper |
$27.43
|
| Rate for Payer: Cash Price |
$19.17
|
| 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 Foundation Hospitals 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 5343616801
|
| 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 Non-Gatekeeper |
$26.33
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$21.31
|
| 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 |
$19.17
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$20.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5343608401
|
| 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 Non-Gatekeeper |
$26.33
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$21.31
|
| 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 |
$19.17
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$20.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5343608430
|
| 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: Aetna of CA Non-Gatekeeper |
$27.43
|
| Rate for Payer: Cash Price |
$19.17
|
| 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 Foundation Hospitals 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
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 5343608430
|
| 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 Non-Gatekeeper |
$26.33
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$21.31
|
| 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 |
$19.17
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$20.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5343608401
|
| 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: Aetna of CA Non-Gatekeeper |
$27.43
|
| Rate for Payer: Cash Price |
$19.17
|
| 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 Foundation Hospitals 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
|
$0.14
|
|
|
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: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| 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 |
$0.06
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$0.12
|
|
|
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: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| 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 Foundation Hospitals 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
|
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 Non-Gatekeeper |
$0.04
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| 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 |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.14
|
|
|
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: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| 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 Foundation Hospitals 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
|
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 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: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: 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
|
$0.13
|
|
|
Service Code
|
NDC 1650059916
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 1650059916
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| 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 |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
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 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: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| 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 |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
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: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Foundation Hospitals 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
|
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: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| 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 Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
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: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| 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 Foundation Hospitals 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.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 Non-Gatekeeper |
$0.12
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| 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 |
$0.09
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 5820400406
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| 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 |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
