|
PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-14
|
| Hospital Charge Code |
ERX40840046
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 00000-1053-51
|
| Hospital Charge Code |
ERX40840046
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-14
|
| Hospital Charge Code |
ERX40840046
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE 2/0 DIALYSIS SOLUTION [40840046]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 00000-1053-51
|
| Hospital Charge Code |
ERX40840046
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-16
|
| Hospital Charge Code |
ERX40840045
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1069-57
|
| Hospital Charge Code |
ERX40840045
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1069-57
|
| Hospital Charge Code |
ERX40840045
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE 4/2.5 DIALYSIS SOLUTION [40840045]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-16
|
| Hospital Charge Code |
ERX40840045
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-17
|
| Hospital Charge Code |
ERX4080470
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-17
|
| Hospital Charge Code |
ERX4080470
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1075-01
|
| Hospital Charge Code |
ERX4080470
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PRISMASATE B22GK 4/0 DIALYSIS SOLUTION [4080470]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1075-01
|
| Hospital Charge Code |
ERX4080470
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE BGK 4/0/1.2 DIALYSIS SOLUTION [4080471]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-19
|
| Hospital Charge Code |
ERX4080471
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE BGK 4/0/1.2 DIALYSIS SOLUTION [4080471]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-19
|
| Hospital Charge Code |
ERX4080471
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1053-53
|
| Hospital Charge Code |
ERX4080472
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-15
|
| Hospital Charge Code |
ERX4080472
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1053-53
|
| Hospital Charge Code |
ERX4080472
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PRISMASATE BK 0/3.5 DIALYSIS SOLUTION [4080472]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0000-1139-15
|
| Hospital Charge Code |
ERX4080472
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PROBENECID 500 MG TABLET [6561]
|
Facility
IP
|
$0.71
|
|
|
Service Code
|
NDC 0591-5347-01
|
| Hospital Charge Code |
1711315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
PROBENECID 500 MG TABLET [6561]
|
Facility
OP
|
$0.71
|
|
|
Service Code
|
NDC 0591-5347-01
|
| Hospital Charge Code |
1711315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia
|
Facility
OP
|
$5,547.37
|
|
|
Service Code
|
CPT 68811
|
| Min. Negotiated Rate |
$174.81 |
| Max. Negotiated Rate |
$5,547.37 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: Dignity Health Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,919.67
|
| Rate for Payer: Humana Medicare |
$2,919.67
|
| Rate for Payer: IEHP Medi-Cal |
$174.81
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,547.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,445.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,678.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,211.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent
|
Facility
OP
|
$5,547.37
|
|
|
Service Code
|
CPT 68815
|
| Min. Negotiated Rate |
$69.11 |
| Max. Negotiated Rate |
$5,547.37 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: Dignity Health Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,919.67
|
| Rate for Payer: Humana Medicare |
$2,919.67
|
| Rate for Payer: IEHP Medi-Cal |
$69.11
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,547.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,445.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,678.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,211.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION [6562]
|
Facility
OP
|
$10.52
|
|
|
Service Code
|
CPT J2690
|
| Hospital Charge Code |
1720209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$359.45 |
| Rate for Payer: Adventist Health Commercial |
$2.10
|
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$359.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$359.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$182.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$182.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$160.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$160.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$160.95
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$160.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$65.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$65.66
|
| Rate for Payer: Blue Shield of California Commercial |
$350.72
|
| Rate for Payer: Blue Shield of California Commercial |
$350.72
|
| Rate for Payer: Blue Shield of California EPN |
$350.72
|
| Rate for Payer: Blue Shield of California EPN |
$350.72
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$219.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$219.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$160.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$160.95
|
| Rate for Payer: Dignity Health Senior |
$160.95
|
| Rate for Payer: Dignity Health Senior |
$160.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.73
|
| Rate for Payer: EPIC Health Plan Medicare |
$146.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$146.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.34
|
| Rate for Payer: Heritage Provider Network Senior |
$4.87
|
| Rate for Payer: Heritage Provider Network Senior |
$33.34
|
| Rate for Payer: Humana Medicare |
$146.32
|
| Rate for Payer: Humana Medicare |
$146.32
|
| Rate for Payer: IEHP Medi-Cal |
$235.22
|
| Rate for Payer: IEHP Medi-Cal |
$235.22
|
| Rate for Payer: IEHP Medicare Advantage |
$146.32
|
| Rate for Payer: IEHP Medicare Advantage |
$146.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$278.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$278.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$172.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$172.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$184.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$184.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$184.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$184.36
|
| Rate for Payer: Multiplan Commercial |
$7.89
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$160.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$160.95
|
| Rate for Payer: TriValley Medical Group Senior |
$146.32
|
| Rate for Payer: TriValley Medical Group Senior |
$146.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$219.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$219.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$160.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$160.95
|
| Rate for Payer: Vantage Medical Group Senior |
$146.32
|
| Rate for Payer: Vantage Medical Group Senior |
$146.32
|
|
|
PROCAINAMIDE 100 MG/ML INJECTION SOLUTION [6562]
|
Facility
IP
|
$10.52
|
|
|
Service Code
|
CPT J2690
|
| Hospital Charge Code |
1720209
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$7.89 |
| Rate for Payer: Adventist Health Commercial |
$2.10
|
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.12
|
| Rate for Payer: Heritage Provider Network Senior |
$48.74
|
| Rate for Payer: Heritage Provider Network Senior |
$7.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.63
|
| Rate for Payer: Multiplan Commercial |
$7.89
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.51
|
|
|
PROCAINAMIDE 500 MG/ML INJECTION SOLUTION [6563]
|
Facility
IP
|
$43.66
|
|
|
Service Code
|
CPT J2690
|
| Hospital Charge Code |
1720217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$32.74 |
| Rate for Payer: Adventist Health Commercial |
$8.73
|
| Rate for Payer: Adventist Health Commercial |
$72.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$247.32
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$19.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$165.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$194.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$243.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.56
|
| Rate for Payer: Heritage Provider Network Senior |
$29.56
|
| Rate for Payer: Heritage Provider Network Senior |
$243.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$65.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.92
|
| Rate for Payer: Multiplan Commercial |
$32.74
|
| Rate for Payer: Multiplan Commercial |
$270.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$131.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$120.28
|
|
