|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]
|
Facility
|
OP
|
$198.96
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$149.22 |
| Rate for Payer: Adventist Health Commercial |
$39.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$106.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$136.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Blue Shield of California Commercial |
$121.37
|
| Rate for Payer: Blue Shield of California EPN |
$97.09
|
| Rate for Payer: Cash Price |
$109.43
|
| Rate for Payer: Cash Price |
$109.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.64
|
| Rate for Payer: Dignity Health Senior |
$8.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.33
|
| Rate for Payer: EPIC Health Plan Medicare |
$7.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.12
|
| Rate for Payer: Heritage Provider Network Senior |
$92.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$94.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.90
|
| Rate for Payer: Multiplan Commercial |
$149.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$79.58
|
| Rate for Payer: TriValley Medical Group Senior |
$79.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$65.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: Vantage Medical Group Senior |
$8.64
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
OP
|
$108.24
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
901700020
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.44 |
| Max. Negotiated Rate |
$81.18 |
| Rate for Payer: Adventist Health Commercial |
$21.65
|
| Rate for Payer: Adventist Health Commercial |
$27.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$57.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$74.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$95.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.97
|
| Rate for Payer: Blue Shield of California Commercial |
$55.39
|
| Rate for Payer: Blue Shield of California Commercial |
$55.39
|
| Rate for Payer: Blue Shield of California EPN |
$44.54
|
| Rate for Payer: Blue Shield of California EPN |
$44.54
|
| Rate for Payer: Cash Price |
$76.39
|
| Rate for Payer: Cash Price |
$59.53
|
| Rate for Payer: Cash Price |
$59.53
|
| Rate for Payer: Cash Price |
$76.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$90.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.23
|
| Rate for Payer: Dignity Health Senior |
$31.12
|
| Rate for Payer: Dignity Health Senior |
$31.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.28
|
| Rate for Payer: EPIC Health Plan Medicare |
$31.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$31.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.97
|
| Rate for Payer: Heritage Provider Network Senior |
$85.97
|
| Rate for Payer: Heritage Provider Network Senior |
$67.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$31.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$31.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$66.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.21
|
| Rate for Payer: Multiplan Commercial |
$104.17
|
| Rate for Payer: Multiplan Commercial |
$81.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$31.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$31.12
|
| Rate for Payer: TriValley Medical Group Senior |
$31.12
|
| Rate for Payer: TriValley Medical Group Senior |
$31.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.23
|
| Rate for Payer: Vantage Medical Group Senior |
$31.12
|
| Rate for Payer: Vantage Medical Group Senior |
$31.12
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
IP
|
$108.24
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
901700020
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.59 |
| Max. Negotiated Rate |
$81.18 |
| Rate for Payer: Adventist Health Commercial |
$21.65
|
| Rate for Payer: Adventist Health Commercial |
$27.78
|
| Rate for Payer: Cash Price |
$59.53
|
| Rate for Payer: Cash Price |
$76.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$94.03
|
| Rate for Payer: Heritage Provider Network Senior |
$73.28
|
| Rate for Payer: Heritage Provider Network Senior |
$94.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.06
|
| Rate for Payer: Multiplan Commercial |
$81.18
|
| Rate for Payer: Multiplan Commercial |
$104.17
|
|
|
TUCATINIB 150 MG TABLET [227737]
|
Facility
|
OP
|
$263.98
|
|
|
Service Code
|
NDC 51144-002-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.78 |
| Max. Negotiated Rate |
$224.38 |
| Rate for Payer: Adventist Health Commercial |
$52.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$141.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$181.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$224.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$145.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$197.99
|
| Rate for Payer: Blue Shield of California Commercial |
$161.03
|
| Rate for Payer: Blue Shield of California EPN |
$128.82
|
| Rate for Payer: Cash Price |
$145.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$171.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$224.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$224.38
|
| Rate for Payer: Dignity Health Senior |
$224.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$168.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$163.40
|
| Rate for Payer: Heritage Provider Network Senior |
$163.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$125.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$184.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$184.79
|
| Rate for Payer: Multiplan Commercial |
$197.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$105.59
|
| Rate for Payer: TriValley Medical Group Senior |
$105.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$131.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$131.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$224.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$224.38
|
| Rate for Payer: Vantage Medical Group Senior |
$224.38
|
|
|
TUCATINIB 150 MG TABLET [227737]
|
Facility
|
IP
|
$263.98
|
|
|
Service Code
|
NDC 51144-002-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.78 |
| Max. Negotiated Rate |
$197.99 |
| Rate for Payer: Adventist Health Commercial |
$52.80
|
| Rate for Payer: Cash Price |
$145.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$142.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$178.71
|
| Rate for Payer: Heritage Provider Network Senior |
$178.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: Multiplan Commercial |
$197.99
|
|
|
TUCATINIB 50 MG TABLET [227736]
|
Facility
|
OP
|
$131.28
|
|
|
Service Code
|
NDC 51144-001-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$111.59 |
| Rate for Payer: Adventist Health Commercial |
$26.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$70.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$90.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$111.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$72.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$98.46
|
| Rate for Payer: Blue Shield of California Commercial |
$80.08
|
| Rate for Payer: Blue Shield of California EPN |
$64.06
|
| Rate for Payer: Cash Price |
$72.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$85.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$111.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$111.59
|
| Rate for Payer: Dignity Health Senior |
$111.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.26
|
| Rate for Payer: Heritage Provider Network Senior |
$81.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$62.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$91.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$91.90
|
| Rate for Payer: Multiplan Commercial |
$98.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$52.51
|
| Rate for Payer: TriValley Medical Group Senior |
$52.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$65.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$111.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$111.59
|
| Rate for Payer: Vantage Medical Group Senior |
$111.59
|
|
|
TUCATINIB 50 MG TABLET [227736]
|
Facility
|
IP
|
$131.28
|
|
|
Service Code
|
NDC 51144-001-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$98.46 |
| Rate for Payer: Adventist Health Commercial |
$26.26
|
| Rate for Payer: Cash Price |
$72.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.88
|
| Rate for Payer: Heritage Provider Network Senior |
$88.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.82
|
| Rate for Payer: Multiplan Commercial |
$98.46
|
|
|
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [14678]
|
Facility
|
IP
|
$369.36
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.85 |
| Max. Negotiated Rate |
$277.02 |
| Rate for Payer: Adventist Health Commercial |
$73.87
|
| Rate for Payer: Cash Price |
$203.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$169.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$171.01
|
| Rate for Payer: Heritage Provider Network Senior |
$171.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.34
|
| Rate for Payer: Multiplan Commercial |
$277.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$133.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$122.30
|
|
|
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [14678]
|
Facility
|
OP
|
$369.36
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.85 |
| Max. Negotiated Rate |
$313.96 |
| Rate for Payer: Adventist Health Commercial |
$73.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$197.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$253.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$313.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$203.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$277.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$304.86
|
| Rate for Payer: Blue Shield of California Commercial |
$115.24
|
| Rate for Payer: Blue Shield of California EPN |
$115.24
|
| Rate for Payer: Cash Price |
$203.15
|
| Rate for Payer: Cash Price |
$203.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$169.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$313.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$313.96
|
| Rate for Payer: Dignity Health Senior |
$313.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$236.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$171.01
|
| Rate for Payer: Heritage Provider Network Senior |
$171.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$224.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$176.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$258.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$258.55
|
| Rate for Payer: Multiplan Commercial |
$277.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$147.74
|
| Rate for Payer: TriValley Medical Group Senior |
$147.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$133.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$122.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$313.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$313.96
|
| Rate for Payer: Vantage Medical Group Senior |
$313.96
|
|
|
UREA 10 % LOTION [19779]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 5898060880
|
| 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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| 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
|
|
|
UREA 10 % LOTION [19779]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 5898060880
|
| 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: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| 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 |
$0.03
|
|
|
UREA 15 GRAM ORAL POWDER PACKET [218764]
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 6253000011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$3.26
|
|
|
UREA 15 GRAM ORAL POWDER PACKET [218764]
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 6253000011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.26
|
| Rate for Payer: Blue Shield of California Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.70
|
| Rate for Payer: Dignity Health Senior |
$3.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Senior |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.04
|
| Rate for Payer: Multiplan Commercial |
$3.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.74
|
| Rate for Payer: TriValley Medical Group Senior |
$1.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.70
|
| Rate for Payer: Vantage Medical Group Senior |
$3.70
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0884044904
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| 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 |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0536110945
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| 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 |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| 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 |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0536110945
|
| 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: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0884044904
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
UREA(C14) 37 KBQ (1 MICROCI) CAPSULE [233734]
|
Facility
|
OP
|
$42.08
|
|
|
Service Code
|
HCPCS A4641
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$35.77 |
| Rate for Payer: Adventist Health Commercial |
$8.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.56
|
| Rate for Payer: Blue Shield of California Commercial |
$25.67
|
| Rate for Payer: Blue Shield of California EPN |
$20.54
|
| Rate for Payer: Cash Price |
$23.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.77
|
| Rate for Payer: Dignity Health Senior |
$35.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.05
|
| Rate for Payer: Heritage Provider Network Senior |
$26.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$20.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.46
|
| Rate for Payer: Multiplan Commercial |
$31.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.77
|
| Rate for Payer: Vantage Medical Group Senior |
$35.77
|
|
|
UREA(C14) 37 KBQ (1 MICROCI) CAPSULE [233734]
|
Facility
|
IP
|
$42.08
|
|
|
Service Code
|
HCPCS A4641
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$31.56 |
| Rate for Payer: Adventist Health Commercial |
$8.42
|
| Rate for Payer: Cash Price |
$23.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.49
|
| Rate for Payer: Heritage Provider Network Senior |
$28.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$31.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.93
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$3.95
|
|
|
Service Code
|
NDC 0904-6890-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.36
|
| Rate for Payer: Dignity Health Senior |
$3.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.45
|
| Rate for Payer: Heritage Provider Network Senior |
$2.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.36
|
| Rate for Payer: Vantage Medical Group Senior |
$3.36
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$3.95
|
|
|
Service Code
|
NDC 0904-6890-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
|
