|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.94
|
| Rate for Payer: Dignity Health Senior |
$5.94
|
| Rate for Payer: Dignity Health Senior |
$3.65
|
| Rate for Payer: Dignity Health Senior |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.99
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.72
|
| Rate for Payer: TriValley Medical Group Senior |
$1.72
|
| Rate for Payer: TriValley Medical Group Senior |
$2.80
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.94
|
| Rate for Payer: Vantage Medical Group Senior |
$3.65
|
| Rate for Payer: Vantage Medical Group Senior |
$5.94
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
OP
|
$4.65
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$3.95 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Senior |
$4.08
|
| Rate for Payer: Dignity Health Senior |
$3.83
|
| Rate for Payer: Dignity Health Senior |
$3.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.22
|
| 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 |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Senior |
$1.80
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$1.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$3.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$3.95
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
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 |
$0.90
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.48
|
| 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 |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| 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 |
$1.12
|
| 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 |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.54
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 0574-0292-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.15
|
| 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
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 0574-0292-01
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
|
IP
|
$1.15
|
|
|
Service Code
|
NDC 31722-035-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| 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 Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
|
OP
|
$1.15
|
|
|
Service Code
|
NDC 31722-035-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.98
|
| Rate for Payer: Dignity Health Senior |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Senior |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Senior |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Vantage Medical Group Senior |
$0.98
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| 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: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| 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: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION [403]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
901700025
|
|
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: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 60687-739-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$21.52 |
| Rate for Payer: Adventist Health Commercial |
$5.74
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.43
|
| Rate for Payer: Heritage Provider Network Senior |
$19.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.17
|
| Rate for Payer: Multiplan Commercial |
$21.52
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 70377-102-11
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$7.70
|
| 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
|
$28.70
|
|
|
Service Code
|
NDC 60687-739-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$24.39 |
| Rate for Payer: Adventist Health Commercial |
$5.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.52
|
| Rate for Payer: Blue Shield of California Commercial |
$17.51
|
| Rate for Payer: Blue Shield of California EPN |
$14.01
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.39
|
| Rate for Payer: Dignity Health Senior |
$24.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.77
|
| Rate for Payer: Heritage Provider Network Senior |
$17.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.09
|
| Rate for Payer: Multiplan Commercial |
$21.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.48
|
| Rate for Payer: TriValley Medical Group Senior |
$11.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.39
|
| Rate for Payer: Vantage Medical Group Senior |
$24.39
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$7.16
|
|
|
Service Code
|
NDC 69680-115-30
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.37
|
| Rate for Payer: Blue Shield of California Commercial |
$4.37
|
| Rate for Payer: Blue Shield of California EPN |
$3.49
|
| Rate for Payer: Cash Price |
$3.94
|
| 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 |
$3.42
|
| 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: Molina Healthcare of CA Medi-Cal |
$5.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.01
|
| Rate for Payer: Multiplan Commercial |
$5.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.86
|
| Rate for Payer: TriValley Medical Group Senior |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.09
|
| 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
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 70377-102-11
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$11.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.50
|
| Rate for Payer: Blue Shield of California Commercial |
$8.54
|
| Rate for Payer: Blue Shield of California EPN |
$6.83
|
| Rate for Payer: Cash Price |
$7.70
|
| 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 |
$6.68
|
| 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: Molina Healthcare of CA Medi-Cal |
$9.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.80
|
| Rate for Payer: Multiplan Commercial |
$10.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.60
|
| Rate for Payer: TriValley Medical Group Senior |
$5.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.90
|
| 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
|
$28.70
|
|
|
Service Code
|
NDC 60687-739-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$21.52 |
| Rate for Payer: Adventist Health Commercial |
$5.74
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.43
|
| Rate for Payer: Heritage Provider Network Senior |
$19.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.17
|
| Rate for Payer: Multiplan Commercial |
$21.52
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 60687-739-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$24.39 |
| Rate for Payer: Adventist Health Commercial |
$5.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.52
|
| Rate for Payer: Blue Shield of California Commercial |
$17.51
|
| Rate for Payer: Blue Shield of California EPN |
$14.01
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.39
|
| Rate for Payer: Dignity Health Senior |
$24.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.77
|
| Rate for Payer: Heritage Provider Network Senior |
$17.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.09
|
| Rate for Payer: Multiplan Commercial |
$21.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.48
|
| Rate for Payer: TriValley Medical Group Senior |
$11.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.39
|
| Rate for Payer: Vantage Medical Group Senior |
$24.39
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$7.16
|
|
|
Service Code
|
NDC 69680-115-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.37 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.85
|
| Rate for Payer: Heritage Provider Network Senior |
$4.85
|
| 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
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 72205-049-30
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$11.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.75
|
| Rate for Payer: Blue Shield of California Commercial |
$7.93
|
| Rate for Payer: Blue Shield of California EPN |
$6.34
|
| Rate for Payer: Cash Price |
$7.15
|
| 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 |
$6.20
|
| 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: Molina Healthcare of CA Medi-Cal |
$9.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.10
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.20
|
| Rate for Payer: TriValley Medical Group Senior |
$5.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.05
|
| Rate for Payer: Vantage Medical Group Senior |
$11.05
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 72205-049-30
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$7.15
|
| 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
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION [407]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$34.23 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.23
|
| Rate for Payer: Blue Shield of California Commercial |
$11.13
|
| Rate for Payer: Blue Shield of California EPN |
$11.13
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION CDL ONLY [4084072]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION CDL ONLY [4084072]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$34.23 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.23
|
| Rate for Payer: Blue Shield of California Commercial |
$11.13
|
| Rate for Payer: Blue Shield of California EPN |
$11.13
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION (RAD) [4084071]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION (RAD) [4084071]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$34.23 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.23
|
| Rate for Payer: Blue Shield of California Commercial |
$11.13
|
| Rate for Payer: Blue Shield of California EPN |
$11.13
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
