|
COLESTIPOL 1 GRAM TABLET [13884]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
NDC 59762-0450-1
|
| Hospital Charge Code |
1711918
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
COLESTIPOL 1 GRAM TABLET [13884]
|
Facility
OP
|
$1.24
|
|
|
Service Code
|
NDC 0115-5211-16
|
| Hospital Charge Code |
1711918
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
COLESTIPOL 1 GRAM TABLET [13884]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
NDC 59762-0450-1
|
| Hospital Charge Code |
1711918
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
COLESTIPOL 5 GRAM ORAL PACKET [12218]
|
Facility
IP
|
$3.77
|
|
|
Service Code
|
NDC 0115-5212-18
|
| Hospital Charge Code |
ERX12218
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.59
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.55
|
| Rate for Payer: Heritage Provider Network Senior |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$2.83
|
|
|
COLESTIPOL 5 GRAM ORAL PACKET [12218]
|
Facility
OP
|
$3.77
|
|
|
Service Code
|
NDC 0115-5212-18
|
| Hospital Charge Code |
ERX12218
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California EPN |
$2.21
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.20
|
| Rate for Payer: Dignity Health Senior |
$3.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.33
|
| Rate for Payer: Heritage Provider Network Senior |
$2.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$2.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.20
|
| Rate for Payer: Vantage Medical Group Senior |
$3.20
|
|
|
COLISTIN (COLISTIMETHATE) 150 MG MED NEB SOLUTION [4080399]
|
Facility
OP
|
$33.59
|
|
|
Service Code
|
CPT J0770
|
| Hospital Charge Code |
ERX4080399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$101.53 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$34.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$34.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.53
|
| Rate for Payer: Blue Shield of California Commercial |
$28.22
|
| Rate for Payer: Blue Shield of California Commercial |
$28.22
|
| Rate for Payer: Blue Shield of California EPN |
$28.22
|
| Rate for Payer: Blue Shield of California EPN |
$28.22
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: Dignity Health Senior |
$28.55
|
| Rate for Payer: Dignity Health Senior |
$28.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.56
|
| Rate for Payer: Heritage Provider Network Senior |
$15.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$28.55
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
|
|
COLISTIN (COLISTIMETHATE) 150 MG MED NEB SOLUTION [4080399]
|
Facility
IP
|
$33.59
|
|
|
Service Code
|
CPT J0770
|
| Hospital Charge Code |
ERX4080399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$25.19 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.74
|
| Rate for Payer: Heritage Provider Network Senior |
$22.74
|
| Rate for Payer: Heritage Provider Network Senior |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.23
|
|
|
COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]
|
Facility
OP
|
$33.59
|
|
|
Service Code
|
CPT J0770
|
| Hospital Charge Code |
ERX4082134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$101.53 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$34.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$34.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.53
|
| Rate for Payer: Blue Shield of California Commercial |
$28.22
|
| Rate for Payer: Blue Shield of California Commercial |
$28.22
|
| Rate for Payer: Blue Shield of California EPN |
$28.22
|
| Rate for Payer: Blue Shield of California EPN |
$28.22
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: Dignity Health Senior |
$28.56
|
| Rate for Payer: Dignity Health Senior |
$28.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.56
|
| Rate for Payer: Heritage Provider Network Senior |
$15.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.55
|
| Rate for Payer: Vantage Medical Group Senior |
$28.55
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
|
|
COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]
|
Facility
IP
|
$33.59
|
|
|
Service Code
|
CPT J0770
|
| Hospital Charge Code |
ERX4082134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$25.19 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.75
|
| Rate for Payer: Heritage Provider Network Senior |
$22.74
|
| Rate for Payer: Heritage Provider Network Senior |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.23
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
IP
|
$11.52
|
|
|
Service Code
|
NDC 50484-010-30
|
| Hospital Charge Code |
1743273
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.91
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.80
|
| Rate for Payer: Heritage Provider Network Senior |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
OP
|
$11.52
|
|
|
Service Code
|
NDC 50484-010-30
|
| Hospital Charge Code |
1743273
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Blue Shield of California Commercial |
$7.15
|
| Rate for Payer: Blue Shield of California EPN |
$6.76
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.79
|
| Rate for Payer: Dignity Health Senior |
$9.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Senior |
$7.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$8.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.79
|
| Rate for Payer: Vantage Medical Group Senior |
$9.79
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
IP
|
$10.95
|
|
|
Service Code
|
NDC 50484-010-90
|
| Hospital Charge Code |
NDG9682B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$8.21 |
| Rate for Payer: Adventist Health Commercial |
$2.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.52
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.41
|
| Rate for Payer: Heritage Provider Network Senior |
$7.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.74
|
| Rate for Payer: Multiplan Commercial |
$8.21
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
OP
|
$10.95
|
|
|
Service Code
|
NDC 50484-010-90
|
| Hospital Charge Code |
NDG9682B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$9.31 |
| Rate for Payer: Adventist Health Commercial |
$2.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.21
|
| Rate for Payer: Blue Shield of California Commercial |
$6.80
|
| Rate for Payer: Blue Shield of California EPN |
$6.43
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.31
|
| Rate for Payer: Dignity Health Senior |
$9.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.78
|
| Rate for Payer: Heritage Provider Network Senior |
$6.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.74
|
| Rate for Payer: Multiplan Commercial |
$8.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.31
|
| Rate for Payer: Vantage Medical Group Senior |
$9.31
|
|
|
Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 45378
|
| Min. Negotiated Rate |
$460.56 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,712.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,256.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,141.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,712.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,256.12
|
| Rate for Payer: Dignity Health Senior |
$1,141.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,141.93
|
| Rate for Payer: Humana Medicare |
$1,141.93
|
| Rate for Payer: IEHP Medi-Cal |
$460.56
|
| Rate for Payer: IEHP Medicare Advantage |
$1,141.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,169.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,347.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,438.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,438.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,256.12
|
| Rate for Payer: TriValley Medical Group Senior |
$1,141.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,712.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,256.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1,141.93
|
|
|
Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 44388
|
| Min. Negotiated Rate |
$249.74 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,712.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,256.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,141.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,712.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,256.12
|
| Rate for Payer: Dignity Health Senior |
$1,141.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,141.93
|
| Rate for Payer: Humana Medicare |
$1,141.93
|
| Rate for Payer: IEHP Medi-Cal |
$249.74
|
| Rate for Payer: IEHP Medicare Advantage |
$1,141.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,169.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,347.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,438.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,438.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,256.12
|
| Rate for Payer: TriValley Medical Group Senior |
$1,141.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,712.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,256.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1,141.93
|
|
|
Colpocleisis (Le Fort type)
|
Facility
OP
|
$11,807.68
|
|
|
Service Code
|
CPT 57120
|
| Min. Negotiated Rate |
$948.54 |
| Max. Negotiated Rate |
$11,807.68 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,214.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$6,836.03
|
| Rate for Payer: Dignity Health Senior |
$6,214.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,214.57
|
| Rate for Payer: Humana Medicare |
$6,214.57
|
| Rate for Payer: IEHP Medi-Cal |
$948.54
|
| Rate for Payer: IEHP Medicare Advantage |
$6,214.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,807.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,333.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,830.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7,830.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,836.03
|
| Rate for Payer: TriValley Medical Group Senior |
$6,214.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: Vantage Medical Group Senior |
$6,214.57
|
|
|
Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)
|
Facility
OP
|
$17,938.64
|
|
|
Service Code
|
CPT 57282
|
| Min. Negotiated Rate |
$966.53 |
| Max. Negotiated Rate |
$17,938.64 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14,162.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10,385.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9,441.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14,162.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,385.53
|
| Rate for Payer: Dignity Health Senior |
$9,441.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$9,441.39
|
| Rate for Payer: Humana Medicare |
$9,441.39
|
| Rate for Payer: IEHP Medi-Cal |
$966.53
|
| Rate for Payer: IEHP Medicare Advantage |
$9,441.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17,938.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11,140.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,896.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,896.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$10,385.53
|
| Rate for Payer: TriValley Medical Group Senior |
$9,441.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14,162.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,385.53
|
| Rate for Payer: Vantage Medical Group Senior |
$9,441.39
|
|
|
Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy)
|
Facility
OP
|
$17,938.64
|
|
|
Service Code
|
CPT 57283
|
| Min. Negotiated Rate |
$568.51 |
| Max. Negotiated Rate |
$17,938.64 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14,162.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10,385.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9,441.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14,162.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,385.53
|
| Rate for Payer: Dignity Health Senior |
$9,441.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$9,441.39
|
| Rate for Payer: Humana Medicare |
$9,441.39
|
| Rate for Payer: IEHP Medi-Cal |
$568.51
|
| Rate for Payer: IEHP Medicare Advantage |
$9,441.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17,938.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11,140.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,896.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,896.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$10,385.53
|
| Rate for Payer: TriValley Medical Group Senior |
$9,441.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14,162.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,385.53
|
| Rate for Payer: Vantage Medical Group Senior |
$9,441.39
|
|
|
Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 57454
|
| Min. Negotiated Rate |
$134.38 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$601.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$440.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$400.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$601.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$440.90
|
| Rate for Payer: Dignity Health Senior |
$400.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$400.82
|
| Rate for Payer: Humana Medicare |
$400.82
|
| Rate for Payer: IEHP Medi-Cal |
$134.38
|
| Rate for Payer: IEHP Medicare Advantage |
$400.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$761.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$472.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$505.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$505.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$440.90
|
| Rate for Payer: TriValley Medical Group Senior |
$400.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$601.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$440.90
|
| Rate for Payer: Vantage Medical Group Senior |
$400.82
|
|
|
Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 57421
|
| Min. Negotiated Rate |
$252.30 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,506.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,104.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,004.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,506.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,104.87
|
| Rate for Payer: Dignity Health Senior |
$1,004.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,004.43
|
| Rate for Payer: Humana Medicare |
$1,004.43
|
| Rate for Payer: IEHP Medi-Cal |
$252.30
|
| Rate for Payer: IEHP Medicare Advantage |
$1,004.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,908.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,185.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,265.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,265.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,104.87
|
| Rate for Payer: TriValley Medical Group Senior |
$1,004.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,506.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,104.87
|
| Rate for Payer: Vantage Medical Group Senior |
$1,004.43
|
|
|
Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed;
|
Facility
OP
|
$11,807.68
|
|
|
Service Code
|
CPT 57260
|
| Min. Negotiated Rate |
$1,082.02 |
| Max. Negotiated Rate |
$11,807.68 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,214.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$6,836.03
|
| Rate for Payer: Dignity Health Senior |
$6,214.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,214.57
|
| Rate for Payer: Humana Medicare |
$6,214.57
|
| Rate for Payer: IEHP Medi-Cal |
$1,082.02
|
| Rate for Payer: IEHP Medicare Advantage |
$6,214.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,807.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,333.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,830.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7,830.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,836.03
|
| Rate for Payer: TriValley Medical Group Senior |
$6,214.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: Vantage Medical Group Senior |
$6,214.57
|
|
|
Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with enterocele repair
|
Facility
OP
|
$11,807.68
|
|
|
Service Code
|
CPT 57265
|
| Min. Negotiated Rate |
$1,106.63 |
| Max. Negotiated Rate |
$11,807.68 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,214.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$6,836.03
|
| Rate for Payer: Dignity Health Senior |
$6,214.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,214.57
|
| Rate for Payer: Humana Medicare |
$6,214.57
|
| Rate for Payer: IEHP Medi-Cal |
$1,106.63
|
| Rate for Payer: IEHP Medicare Advantage |
$6,214.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,807.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,333.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,830.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7,830.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,836.03
|
| Rate for Payer: TriValley Medical Group Senior |
$6,214.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: Vantage Medical Group Senior |
$6,214.57
|
|
|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 574030416
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
271
|
| 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: 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
|
|
|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 574030416
|
| Hospital Charge Code |
NDG120589
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| 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 |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| 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 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: Multiplan Commercial |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 574030316
|
| Hospital Charge Code |
NDG211818
|
|
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
|
|
