|
PSEUDOEPHEDRINE 15 MG/5 ML ORAL LIQUID [111029]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 50580-536-04
|
| Hospital Charge Code |
NDG111029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| 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 |
$0.04
|
|
|
PSEUDOEPHEDRINE 60 MG TABLET [6715]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 0904-6907-06
|
| Hospital Charge Code |
1710632
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
PSEUDOEPHEDRINE 60 MG TABLET [6715]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 0904-6907-06
|
| Hospital Charge Code |
1710632
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET [11218]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 37000-024-04
|
| Hospital Charge Code |
1716011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| 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 Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET [11218]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 37000-024-04
|
| Hospital Charge Code |
1716011
|
|
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 |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| 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: Multiplan Commercial |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]
|
Facility
IP
|
$0.50
|
|
|
Service Code
|
NDC 37000-023-04
|
| Hospital Charge Code |
ERX205431
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]
|
Facility
OP
|
$0.50
|
|
|
Service Code
|
NDC 37000-023-10
|
| Hospital Charge Code |
ERX205431
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]
|
Facility
OP
|
$0.50
|
|
|
Service Code
|
NDC 37000-023-04
|
| Hospital Charge Code |
ERX205431
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL POWDER PACKET [205431]
|
Facility
IP
|
$0.50
|
|
|
Service Code
|
NDC 37000-023-10
|
| Hospital Charge Code |
ERX205431
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 02733ZZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 02703ZZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 02723ZZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$9,066.00
|
|
|
Service Code
|
ICD 02C34Z6
|
| Min. Negotiated Rate |
$9,066.00 |
| Max. Negotiated Rate |
$9,066.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 027J44Z
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 027G3ZZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 027H44Z
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 02734ZZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 027F34Z
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$9,066.00
|
|
|
Service Code
|
ICD 02C14Z6
|
| Min. Negotiated Rate |
$9,066.00 |
| Max. Negotiated Rate |
$9,066.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 027H4DZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 02724Z6
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 027G4DZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 027F3DZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 02C34ZZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
PTCA/Angioplasty - #2076
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 02714Z6
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,066.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
