|
TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]
|
Facility
|
IP
|
$163.24
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.55 |
| Max. Negotiated Rate |
$122.43 |
| Rate for Payer: Adventist Health Commercial |
$32.65
|
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$89.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$75.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.58
|
| Rate for Payer: Heritage Provider Network Senior |
$75.58
|
| Rate for Payer: Heritage Provider Network Senior |
$130.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.81
|
| Rate for Payer: Multiplan Commercial |
$211.50
|
| Rate for Payer: Multiplan Commercial |
$122.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$58.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$101.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.05
|
|
|
TORSEMIDE 100 MG TABLET [18294]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 50268-757-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| 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 Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
TORSEMIDE 100 MG TABLET [18294]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 50268-757-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
TORSEMIDE 100 MG TABLET [18294]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 50268-757-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
TORSEMIDE 100 MG TABLET [18294]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 50268-757-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| 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 Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 50268-755-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 50268-755-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 31722-531-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| 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 |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| 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 |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 31722-531-01
|
| 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 |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 68084-539-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| 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 |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 68084-539-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| 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 |
$0.32
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 65862-127-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| 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 |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| 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 |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 65862-127-01
|
| 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 |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
NDC 9994-0816-36
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$374.25 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Cash Price |
$274.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$269.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$337.82
|
| Rate for Payer: Heritage Provider Network Senior |
$337.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
NDC 9994-0816-36
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$266.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$342.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.25
|
| Rate for Payer: Blue Shield of California Commercial |
$304.39
|
| Rate for Payer: Blue Shield of California EPN |
$243.51
|
| Rate for Payer: Cash Price |
$274.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$324.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: Dignity Health Senior |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$319.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.88
|
| Rate for Payer: Heritage Provider Network Senior |
$308.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$238.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$349.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$349.30
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$199.60
|
| Rate for Payer: TriValley Medical Group Senior |
$199.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$249.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$249.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
NDC 9999-1961-40
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$266.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$342.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.25
|
| Rate for Payer: Blue Shield of California Commercial |
$304.39
|
| Rate for Payer: Blue Shield of California EPN |
$243.51
|
| Rate for Payer: Cash Price |
$274.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$324.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: Dignity Health Senior |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$319.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.88
|
| Rate for Payer: Heritage Provider Network Senior |
$308.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$238.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$349.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$349.30
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$199.60
|
| Rate for Payer: TriValley Medical Group Senior |
$199.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$249.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$249.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
NDC 9999-1961-40
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$374.25 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Cash Price |
$274.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$269.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$337.82
|
| Rate for Payer: Heritage Provider Network Senior |
$337.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 0517-9203-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.37
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.13
|
| Rate for Payer: Dignity Health Senior |
$4.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.01
|
| Rate for Payer: Heritage Provider Network Senior |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$3.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.94
|
| Rate for Payer: TriValley Medical Group Senior |
$1.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.13
|
| Rate for Payer: Vantage Medical Group Senior |
$4.13
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 0517-9203-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.29
|
| Rate for Payer: Heritage Provider Network Senior |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$3.65
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-51
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.27
|
| Rate for Payer: Heritage Provider Network Senior |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 9940-8830-17
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-51
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.72
|
| Rate for Payer: Blue Shield of California Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Senior |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.90
|
| Rate for Payer: Heritage Provider Network Senior |
$3.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 9940-8830-17
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TRACE ELEMENTS CR-CU-MN-SE-ZN 10 MCG-1 MG-0.5 MG-60 MCG-5MG/ML IV SOLN [18259]
|
Facility
|
IP
|
$7.58
|
|
|
Service Code
|
NDC 99940-8830-16
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$5.68 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.13
|
| Rate for Payer: Heritage Provider Network Senior |
$5.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$5.68
|
|
|
TRACE ELEMENTS CR-CU-MN-SE-ZN 10 MCG-1 MG-0.5 MG-60 MCG-5MG/ML IV SOLN [18259]
|
Facility
|
OP
|
$7.58
|
|
|
Service Code
|
NDC 99940-8830-16
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.68
|
| Rate for Payer: Blue Shield of California Commercial |
$4.62
|
| Rate for Payer: Blue Shield of California EPN |
$3.70
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.44
|
| Rate for Payer: Dignity Health Senior |
$6.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.69
|
| Rate for Payer: Heritage Provider Network Senior |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.31
|
| Rate for Payer: Multiplan Commercial |
$5.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.03
|
| Rate for Payer: TriValley Medical Group Senior |
$3.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: Vantage Medical Group Senior |
$6.44
|
|
