|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$10.31 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.10
|
| Rate for Payer: Blue Shield of California Commercial |
$7.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.92
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.31
|
| Rate for Payer: Dignity Health Senior |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.51
|
| Rate for Payer: Heritage Provider Network Senior |
$7.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.49
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.31
|
|
|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.21
|
| Rate for Payer: Heritage Provider Network Senior |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$10.31 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.10
|
| Rate for Payer: Blue Shield of California Commercial |
$7.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.92
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.31
|
| Rate for Payer: Dignity Health Senior |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.51
|
| Rate for Payer: Heritage Provider Network Senior |
$7.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.49
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.21
|
| Rate for Payer: Heritage Provider Network Senior |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$10.31 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.10
|
| Rate for Payer: Blue Shield of California Commercial |
$7.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.92
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.31
|
| Rate for Payer: Dignity Health Senior |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.51
|
| Rate for Payer: Heritage Provider Network Senior |
$7.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.49
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$10.31 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.10
|
| Rate for Payer: Blue Shield of California Commercial |
$7.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.92
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.31
|
| Rate for Payer: Dignity Health Senior |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.51
|
| Rate for Payer: Heritage Provider Network Senior |
$7.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.49
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.21
|
| Rate for Payer: Heritage Provider Network Senior |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.21
|
| Rate for Payer: Heritage Provider Network Senior |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.03
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
IP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$11.56 |
| Rate for Payer: Adventist Health Commercial |
$3.08
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.44
|
| Rate for Payer: Heritage Provider Network Senior |
$10.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
OP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$13.11 |
| Rate for Payer: Adventist Health Commercial |
$3.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.56
|
| Rate for Payer: Blue Shield of California Commercial |
$9.41
|
| Rate for Payer: Blue Shield of California EPN |
$7.52
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.11
|
| Rate for Payer: Dignity Health Senior |
$13.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.54
|
| Rate for Payer: Heritage Provider Network Senior |
$9.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.79
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.17
|
| Rate for Payer: TriValley Medical Group Senior |
$6.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.11
|
| Rate for Payer: Vantage Medical Group Senior |
$13.11
|
|
|
APR-DRG 41.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
APR-DRG 2512
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.59
|
|
|
APR-DRG 41.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
APR-DRG 2513
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.77
|
|
|
APR-DRG 41.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
APR-DRG 2514
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.21
|
|
|
APR-DRG 41.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
APR-DRG 2511
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.46
|
|
|
APR-DRG 41.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
APR-DRG 5433
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.88
|
|
|
APR-DRG 41.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
APR-DRG 5432
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.62
|
|
|
APR-DRG 41.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
APR-DRG 5431
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.47
|
|
|
APR-DRG 41.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
APR-DRG 5434
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.93
|
|
|
APR-DRG 41.00: ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
APR-DRG 5642
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
|
|
APR-DRG 41.00: ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
APR-DRG 5643
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.57
|
|
|
APR-DRG 41.00: ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
APR-DRG 5641
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.29
|
|
|
APR-DRG 41.00: ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
APR-DRG 5644
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.78
|
|
|
APR-DRG 41.00: ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
APR-DRG 1933
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.40
|
|
|
APR-DRG 41.00: ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
APR-DRG 1932
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.05
|
|
|
APR-DRG 41.00: ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$2.15
|
|
|
Service Code
|
APR-DRG 1934
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.15
|
|
