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Type

Price

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09HD3SZ
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09HD45Z
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09HD06Z
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09HE46Z
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09PD8SZ
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09PE0SZ
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09PE7SZ
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09HE45Z
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09HD05Z
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

Cochlear Implants (IP) - #2077

Facility IP

$27,390.00

Service Code	ICD 09PE8SZ
Min. Negotiated Rate	$27,390.00
Max. Negotiated Rate	$27,390.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$27,390.00

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility OP

$0.06

Service Code	NDC 9999-3252-16
Hospital Charge Code	1716075
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 Gatekeeper	$0.03
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.04
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.05
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.03
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	$0.04
Rate for Payer: Dignity Health Commercial/Exchange	$0.05
Rate for Payer: Dignity Health Medi-Cal	$0.05
Rate for Payer: Dignity Health Senior	$0.05
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	$0.05
Rate for Payer: Vantage Medical Group Senior	$0.05

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility IP

$0.06

Service Code	NDC 9999-3252-16
Hospital Charge Code	1716075
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	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: EPIC Health Plan Commercial	$0.03
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 Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.05

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility OP

$0.14

Service Code	NDC 0121-1775-00
Hospital Charge Code	NDG78003
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.12
Rate for Payer: Adventist Health Commercial	$0.03
Rate for Payer: Aetna of CA Gatekeeper	$0.07
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.10
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.12
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.08
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.11
Rate for Payer: Blue Shield of California Commercial	$0.09
Rate for Payer: Blue Shield of California EPN	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Dignity Health Commercial/Exchange	$0.12
Rate for Payer: Dignity Health Medi-Cal	$0.12
Rate for Payer: Dignity Health Senior	$0.12
Rate for Payer: EPIC Health Plan Commercial	$0.09
Rate for Payer: Heritage Provider Network Commercial	$0.09
Rate for Payer: Heritage Provider Network Senior	$0.09
Rate for Payer: Kaiser Permanente of CA Commercial	$0.07
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	$0.11
Rate for Payer: Vantage Medical Group Medi-Cal	$0.12
Rate for Payer: Vantage Medical Group Senior	$0.12

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility IP

$0.14

Service Code	NDC 0121-1775-05
Hospital Charge Code	NDG78003
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.11
Rate for Payer: Adventist Health Commercial	$0.03
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: EPIC Health Plan Commercial	$0.08
Rate for Payer: Heritage Provider Network Commercial	$0.09
Rate for Payer: Heritage Provider Network Senior	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.11

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility OP

$0.14

Service Code	NDC 0121-1775-05
Hospital Charge Code	NDG78003
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.12
Rate for Payer: Adventist Health Commercial	$0.03
Rate for Payer: Aetna of CA Gatekeeper	$0.07
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.10
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.12
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.08
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.11
Rate for Payer: Blue Shield of California Commercial	$0.09
Rate for Payer: Blue Shield of California EPN	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Dignity Health Commercial/Exchange	$0.12
Rate for Payer: Dignity Health Medi-Cal	$0.12
Rate for Payer: Dignity Health Senior	$0.12
Rate for Payer: EPIC Health Plan Commercial	$0.09
Rate for Payer: Heritage Provider Network Commercial	$0.09
Rate for Payer: Heritage Provider Network Senior	$0.09
Rate for Payer: Kaiser Permanente of CA Commercial	$0.07
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	$0.11
Rate for Payer: Vantage Medical Group Medi-Cal	$0.12
Rate for Payer: Vantage Medical Group Senior	$0.12

CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]

Facility IP

$0.14

Service Code	NDC 0121-1775-00
Hospital Charge Code	NDG78003
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.11
Rate for Payer: Adventist Health Commercial	$0.03
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: EPIC Health Plan Commercial	$0.08
Rate for Payer: Heritage Provider Network Commercial	$0.09
Rate for Payer: Heritage Provider Network Senior	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.11

CODEINE SULFATE 15 MG TABLET [1801]

Facility IP

$0.86

Service Code	NDC 0054-0243-24
Hospital Charge Code	1730001
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.65
Rate for Payer: Adventist Health Commercial	$0.17
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.59
Rate for Payer: Cash Price	$0.39
Rate for Payer: EPIC Health Plan Commercial	$0.46
Rate for Payer: Heritage Provider Network Commercial	$0.58
Rate for Payer: Heritage Provider Network Senior	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.65

CODEINE SULFATE 15 MG TABLET [1801]

Facility OP

$0.86

Service Code	NDC 0054-0243-24
Hospital Charge Code	1730001
Hospital Revenue Code	259
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.73
Rate for Payer: Adventist Health Commercial	$0.17
Rate for Payer: Aetna of CA Gatekeeper	$0.46
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.59
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.73
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.47
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.65
Rate for Payer: Blue Shield of California Commercial	$0.53
Rate for Payer: Blue Shield of California EPN	$0.50
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.56
Rate for Payer: Dignity Health Commercial/Exchange	$0.73
Rate for Payer: Dignity Health Medi-Cal	$0.73
Rate for Payer: Dignity Health Senior	$0.73
Rate for Payer: EPIC Health Plan Commercial	$0.55
Rate for Payer: Heritage Provider Network Commercial	$0.53
Rate for Payer: Heritage Provider Network Senior	$0.53
Rate for Payer: Kaiser Permanente of CA Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.65
Rate for Payer: Vantage Medical Group Medi-Cal	$0.73
Rate for Payer: Vantage Medical Group Senior	$0.73

CODEINE SULFATE 30 MG TABLET [1802]

Facility IP

$1.03

Service Code	NDC 0054-0244-24
Hospital Charge Code	1730025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.77
Rate for Payer: Adventist Health Commercial	$0.21
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.71
Rate for Payer: Cash Price	$0.46
Rate for Payer: EPIC Health Plan Commercial	$0.56
Rate for Payer: Heritage Provider Network Commercial	$0.70
Rate for Payer: Heritage Provider Network Senior	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.77

CODEINE SULFATE 30 MG TABLET [1802]

Facility OP

$1.43

Service Code	NDC 0527-1698-01
Hospital Charge Code	1730025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$1.22
Rate for Payer: Adventist Health Commercial	$0.29
Rate for Payer: Aetna of CA Gatekeeper	$0.76
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.98
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1.22
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.79
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1.07
Rate for Payer: Blue Shield of California Commercial	$0.89
Rate for Payer: Blue Shield of California EPN	$0.84
Rate for Payer: Cash Price	$0.64
Rate for Payer: Cigna of CA HMO/PPO	$0.93
Rate for Payer: Dignity Health Commercial/Exchange	$1.22
Rate for Payer: Dignity Health Medi-Cal	$1.22
Rate for Payer: Dignity Health Senior	$1.22
Rate for Payer: EPIC Health Plan Commercial	$0.92
Rate for Payer: Heritage Provider Network Commercial	$0.89
Rate for Payer: Heritage Provider Network Senior	$0.89
Rate for Payer: Kaiser Permanente of CA Commercial	$0.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$1.07
Rate for Payer: Vantage Medical Group Medi-Cal	$1.22
Rate for Payer: Vantage Medical Group Senior	$1.22

CODEINE SULFATE 30 MG TABLET [1802]

Facility IP

$1.43

Service Code	NDC 0527-1698-01
Hospital Charge Code	1730025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$1.07
Rate for Payer: Adventist Health Commercial	$0.29
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.98
Rate for Payer: Cash Price	$0.64
Rate for Payer: EPIC Health Plan Commercial	$0.77
Rate for Payer: Heritage Provider Network Commercial	$0.97
Rate for Payer: Heritage Provider Network Senior	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$1.07

CODEINE SULFATE 30 MG TABLET [1802]

Facility OP

$1.03

Service Code	NDC 0054-0244-24
Hospital Charge Code	1730025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.88
Rate for Payer: Adventist Health Commercial	$0.21
Rate for Payer: Aetna of CA Gatekeeper	$0.55
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.71
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.88
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.57
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.77
Rate for Payer: Blue Shield of California Commercial	$0.64
Rate for Payer: Blue Shield of California EPN	$0.60
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.67
Rate for Payer: Dignity Health Commercial/Exchange	$0.88
Rate for Payer: Dignity Health Medi-Cal	$0.88
Rate for Payer: Dignity Health Senior	$0.88
Rate for Payer: EPIC Health Plan Commercial	$0.66
Rate for Payer: Heritage Provider Network Commercial	$0.64
Rate for Payer: Heritage Provider Network Senior	$0.64
Rate for Payer: Kaiser Permanente of CA Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.77
Rate for Payer: Vantage Medical Group Medi-Cal	$0.88
Rate for Payer: Vantage Medical Group Senior	$0.88

COENZYME Q10 100 MG CAPSULE [24678]

Facility OP

$0.35

Service Code	NDC 7985407974
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.30
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Aetna of CA Gatekeeper	$0.19
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.24
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.30
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.19
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.26
Rate for Payer: Blue Shield of California Commercial	$0.22
Rate for Payer: Blue Shield of California EPN	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.23
Rate for Payer: Dignity Health Commercial/Exchange	$0.30
Rate for Payer: Dignity Health Medi-Cal	$0.30
Rate for Payer: Dignity Health Senior	$0.30
Rate for Payer: EPIC Health Plan Commercial	$0.22
Rate for Payer: Heritage Provider Network Commercial	$0.22
Rate for Payer: Heritage Provider Network Senior	$0.22
Rate for Payer: Kaiser Permanente of CA Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Vantage Medical Group Medi-Cal	$0.30
Rate for Payer: Vantage Medical Group Senior	$0.30

COENZYME Q10 100 MG CAPSULE [24678]

Facility IP

$0.35

Service Code	NDC 7985407974
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.26
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: EPIC Health Plan Commercial	$0.19
Rate for Payer: Heritage Provider Network Commercial	$0.24
Rate for Payer: Heritage Provider Network Senior	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.26

COENZYME Q10 100 MG CAPSULE [24678]

Facility IP

$0.16

Service Code	NDC 4098527413
Hospital Charge Code	1711900
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.12
Rate for Payer: Adventist Health Commercial	$0.03
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.11
Rate for Payer: Cash Price	$0.07
Rate for Payer: EPIC Health Plan Commercial	$0.09
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 Medi-Cal	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.12

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