|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-237-83
|
| Hospital Charge Code |
1712539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Blue Shield of California Commercial |
$28.62
|
| Rate for Payer: Blue Shield of California EPN |
$27.05
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Senior |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.52
|
| Rate for Payer: Heritage Provider Network Senior |
$28.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
OP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0802-1
|
| Hospital Charge Code |
1712539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$81.52 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: Adventist Health Commercial |
$90.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$240.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$382.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$247.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$337.78
|
| Rate for Payer: Blue Shield of California Commercial |
$279.69
|
| Rate for Payer: Blue Shield of California EPN |
$264.37
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$292.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$382.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$382.82
|
| Rate for Payer: Dignity Health Senior |
$382.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$278.79
|
| Rate for Payer: Heritage Provider Network Senior |
$278.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$217.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.60
|
| Rate for Payer: Multiplan Commercial |
$337.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$382.82
|
| Rate for Payer: Vantage Medical Group Senior |
$382.82
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
OP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.66
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Blue Shield of California Commercial |
$28.62
|
| Rate for Payer: Blue Shield of California EPN |
$27.05
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Senior |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.52
|
| Rate for Payer: Heritage Provider Network Senior |
$28.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
IP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$81.52 |
| Max. Negotiated Rate |
$337.78 |
| Rate for Payer: Adventist Health Commercial |
$90.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.41
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$243.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.91
|
| Rate for Payer: Heritage Provider Network Senior |
$304.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.60
|
| Rate for Payer: Multiplan Commercial |
$337.78
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
OP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0801-5
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$81.52 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: Adventist Health Commercial |
$90.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$240.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$382.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$247.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$337.78
|
| Rate for Payer: Blue Shield of California Commercial |
$279.69
|
| Rate for Payer: Blue Shield of California EPN |
$264.37
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$292.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$382.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$382.82
|
| Rate for Payer: Dignity Health Senior |
$382.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$278.79
|
| Rate for Payer: Heritage Provider Network Senior |
$278.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$217.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.60
|
| Rate for Payer: Multiplan Commercial |
$337.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$382.82
|
| Rate for Payer: Vantage Medical Group Senior |
$382.82
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
IP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$81.52 |
| Max. Negotiated Rate |
$337.78 |
| Rate for Payer: Adventist Health Commercial |
$90.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.41
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$243.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.91
|
| Rate for Payer: Heritage Provider Network Senior |
$304.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.60
|
| Rate for Payer: Multiplan Commercial |
$337.78
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
IP
|
$46.08
|
|
|
Service Code
|
NDC 47335-236-83
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.66
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.20
|
| Rate for Payer: Heritage Provider Network Senior |
$31.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
OP
|
$450.38
|
|
|
Service Code
|
NDC 61958-0801-1
|
| Hospital Charge Code |
ERX82307
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$81.52 |
| Max. Negotiated Rate |
$382.82 |
| Rate for Payer: Adventist Health Commercial |
$90.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$240.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$382.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$247.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$337.78
|
| Rate for Payer: Blue Shield of California Commercial |
$279.69
|
| Rate for Payer: Blue Shield of California EPN |
$264.37
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$292.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$382.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$382.82
|
| Rate for Payer: Dignity Health Senior |
$382.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$278.79
|
| Rate for Payer: Heritage Provider Network Senior |
$278.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$217.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$112.60
|
| Rate for Payer: Multiplan Commercial |
$337.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$382.82
|
| Rate for Payer: Vantage Medical Group Senior |
$382.82
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
IP
|
$2.19
|
|
|
Service Code
|
CPT J0278
|
| Hospital Charge Code |
1752069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.19
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$4.73
|
| Rate for Payer: Heritage Provider Network Senior |
$4.98
|
| Rate for Payer: Heritage Provider Network Senior |
$3.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$3.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.46
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
OP
|
$4.65
|
|
|
Service Code
|
CPT J0278
|
| Hospital Charge Code |
1752069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.74
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.25
|
| Rate for Payer: Dignity Health Senior |
$1.86
|
| Rate for Payer: Dignity Health Senior |
$3.95
|
| Rate for Payer: Dignity Health Senior |
$4.08
|
| Rate for Payer: Dignity Health Senior |
$5.94
|
| Rate for Payer: Dignity Health Senior |
$6.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$3.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.01
|
| Rate for Payer: Heritage Provider Network Senior |
$3.40
|
| Rate for Payer: IEHP Medi-Cal |
$8.25
|
| Rate for Payer: IEHP Medi-Cal |
$8.25
|
| Rate for Payer: IEHP Medi-Cal |
$8.25
|
| Rate for Payer: IEHP Medi-Cal |
$8.25
|
| Rate for Payer: IEHP Medi-Cal |
$8.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.25
|
| Rate for Payer: Vantage Medical Group Senior |
$3.95
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$5.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1.86
|
| Rate for Payer: Vantage Medical Group Senior |
$6.25
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
IP
|
$4.65
|
|
|
Service Code
|
CPT J0278
|
| Hospital Charge Code |
1720006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.15
|
| Rate for Payer: Heritage Provider Network Senior |
$4.98
|
| Rate for Payer: Heritage Provider Network Senior |
$3.15
|
| Rate for Payer: Heritage Provider Network Senior |
$3.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.60
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
OP
|
$4.65
|
|
|
Service Code
|
CPT J0278
|
| Hospital Charge Code |
1720006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.74
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.95
|
| Rate for Payer: Dignity Health Senior |
$6.25
|
| Rate for Payer: Dignity Health Senior |
$3.95
|
| Rate for Payer: Dignity Health Senior |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$3.40
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: IEHP Medi-Cal |
$8.25
|
| Rate for Payer: IEHP Medi-Cal |
$8.25
|
| Rate for Payer: IEHP Medi-Cal |
$8.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.25
|
| Rate for Payer: Vantage Medical Group Senior |
$3.95
|
| Rate for Payer: Vantage Medical Group Senior |
$6.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 0574-0292-01
|
| Hospital Charge Code |
1710531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 0574-0292-01
|
| Hospital Charge Code |
1710531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
AMINO ACID INFUSION 7 % INTRAVENOUS SOLUTION [4089055]
|
Facility
OP
|
$315.00
|
|
|
Service Code
|
NDC 9994-0890-55
|
| Hospital Charge Code |
NDC4089055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.02 |
| Max. Negotiated Rate |
$267.75 |
| Rate for Payer: Adventist Health Commercial |
$63.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$168.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$216.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$267.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$173.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$236.25
|
| Rate for Payer: Blue Shield of California Commercial |
$195.62
|
| Rate for Payer: Blue Shield of California EPN |
$184.90
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$267.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$267.75
|
| Rate for Payer: Dignity Health Senior |
$267.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.98
|
| Rate for Payer: Heritage Provider Network Senior |
$194.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$151.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$236.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$267.75
|
| Rate for Payer: Vantage Medical Group Senior |
$267.75
|
|
|
AMINO ACID INFUSION 7 % INTRAVENOUS SOLUTION [4089055]
|
Facility
IP
|
$315.00
|
|
|
Service Code
|
NDC 9994-0890-55
|
| Hospital Charge Code |
NDC4089055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.02 |
| Max. Negotiated Rate |
$236.25 |
| Rate for Payer: Adventist Health Commercial |
$63.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$216.40
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$170.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$213.26
|
| Rate for Payer: Heritage Provider Network Senior |
$213.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$236.25
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
OP
|
$14.18
|
|
|
Service Code
|
NDC 49411-052-08
|
| Hospital Charge Code |
NDG9062
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Adventist Health Commercial |
$2.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.64
|
| Rate for Payer: Blue Shield of California Commercial |
$8.81
|
| Rate for Payer: Blue Shield of California EPN |
$8.32
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.05
|
| Rate for Payer: Dignity Health Senior |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.78
|
| Rate for Payer: Heritage Provider Network Senior |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$10.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.05
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
IP
|
$14.18
|
|
|
Service Code
|
NDC 49411-052-08
|
| Hospital Charge Code |
NDG9062
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$10.64 |
| Rate for Payer: Adventist Health Commercial |
$2.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.74
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.60
|
| Rate for Payer: Heritage Provider Network Senior |
$9.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$10.64
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
CPT S0017
|
| Hospital Charge Code |
1720161
|
|
Hospital Revenue Code
|
636
|
| 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: Cigna of CA HMO/PPO |
$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
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
CPT S0017
|
| Hospital Charge Code |
1720161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$29.78 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.73
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$29.78
|
| Rate for Payer: Blue Shield of California Commercial |
$7.86
|
| Rate for Payer: Blue Shield of California EPN |
$7.86
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| 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 |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: IEHP Medi-Cal |
$18.30
|
| 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: United Healthcare All Other HMO/non HMO |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
OP
|
$14.00
|
|
|
Service Code
|
NDC 70377-102-11
|
| Hospital Charge Code |
1710315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Adventist Health Commercial |
$2.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.50
|
| Rate for Payer: Blue Shield of California Commercial |
$8.69
|
| Rate for Payer: Blue Shield of California EPN |
$8.22
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.90
|
| Rate for Payer: Dignity Health Senior |
$11.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.67
|
| Rate for Payer: Heritage Provider Network Senior |
$8.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$10.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.90
|
| Rate for Payer: Vantage Medical Group Senior |
$11.90
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
IP
|
$14.00
|
|
|
Service Code
|
NDC 70377-102-11
|
| Hospital Charge Code |
1710315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$10.50 |
| Rate for Payer: Adventist Health Commercial |
$2.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.62
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.48
|
| Rate for Payer: Heritage Provider Network Senior |
$9.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$10.50
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
OP
|
$7.16
|
|
|
Service Code
|
NDC 69680-115-30
|
| Hospital Charge Code |
1710315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.37
|
| Rate for Payer: Blue Shield of California Commercial |
$4.45
|
| Rate for Payer: Blue Shield of California EPN |
$4.20
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.09
|
| Rate for Payer: Dignity Health Senior |
$6.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.43
|
| Rate for Payer: Heritage Provider Network Senior |
$4.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.09
|
| Rate for Payer: Vantage Medical Group Senior |
$6.09
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
IP
|
$13.00
|
|
|
Service Code
|
NDC 72205-049-30
|
| Hospital Charge Code |
1710315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.93
|
| Rate for Payer: Cash Price |
$5.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.80
|
| Rate for Payer: Heritage Provider Network Senior |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
OP
|
$13.00
|
|
|
Service Code
|
NDC 72205-049-30
|
| Hospital Charge Code |
1710315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.93
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.75
|
| Rate for Payer: Blue Shield of California Commercial |
$8.07
|
| Rate for Payer: Blue Shield of California EPN |
$7.63
|
| Rate for Payer: Cash Price |
$5.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.05
|
| Rate for Payer: Dignity Health Senior |
$11.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.05
|
| Rate for Payer: Heritage Provider Network Senior |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.05
|
| Rate for Payer: Vantage Medical Group Senior |
$11.05
|
|
