|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 50268-068-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 0023-0798-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-184-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 9999-9022-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
NDC 9999-9022-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.14
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: Dignity Health Senior |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1.99
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
OP
|
$3.35
|
|
|
Service Code
|
NDC 0023-0312-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.51
|
| Rate for Payer: Blue Shield of California Commercial |
$2.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.85
|
| Rate for Payer: Dignity Health Senior |
$2.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$2.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Senior |
$1.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.85
|
| Rate for Payer: Vantage Medical Group Senior |
$2.85
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 0904-6488-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
IP
|
$3.35
|
|
|
Service Code
|
NDC 0023-0312-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Senior |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.51
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 0904-6488-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Senior |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 1011902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Senior |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.89
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 1011902239
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.54
|
| Rate for Payer: Blue Shield of California EPN |
$1.23
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.14
|
| Rate for Payer: Dignity Health Senior |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$1.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.01
|
| Rate for Payer: TriValley Medical Group Senior |
$1.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.14
|
| Rate for Payer: Vantage Medical Group Senior |
$2.14
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 0065-8064-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 0065-8064-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
ASCIMINIB 20 MG TABLET [233024]
|
Facility
|
IP
|
$447.30
|
|
|
Service Code
|
NDC 0078-1091-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.96 |
| Max. Negotiated Rate |
$335.48 |
| Rate for Payer: Adventist Health Commercial |
$89.46
|
| Rate for Payer: Cash Price |
$246.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$302.82
|
| Rate for Payer: Heritage Provider Network Senior |
$302.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.83
|
| Rate for Payer: Multiplan Commercial |
$335.48
|
|
|
ASCIMINIB 20 MG TABLET [233024]
|
Facility
|
OP
|
$447.30
|
|
|
Service Code
|
NDC 0078-1091-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.96 |
| Max. Negotiated Rate |
$380.20 |
| Rate for Payer: Adventist Health Commercial |
$89.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$239.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$307.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$380.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$246.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$335.48
|
| Rate for Payer: Blue Shield of California Commercial |
$272.85
|
| Rate for Payer: Blue Shield of California EPN |
$218.28
|
| Rate for Payer: Cash Price |
$246.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$290.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$380.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$380.20
|
| Rate for Payer: Dignity Health Senior |
$380.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$286.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.88
|
| Rate for Payer: Heritage Provider Network Senior |
$276.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$213.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$313.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$313.11
|
| Rate for Payer: Multiplan Commercial |
$335.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$178.92
|
| Rate for Payer: TriValley Medical Group Senior |
$178.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$223.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$223.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$380.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$380.20
|
| Rate for Payer: Vantage Medical Group Senior |
$380.20
|
|
|
ASCIMINIB 40 MG TABLET [233025]
|
Facility
|
IP
|
$447.30
|
|
|
Service Code
|
NDC 0078-1098-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.96 |
| Max. Negotiated Rate |
$335.48 |
| Rate for Payer: Adventist Health Commercial |
$89.46
|
| Rate for Payer: Cash Price |
$246.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$302.82
|
| Rate for Payer: Heritage Provider Network Senior |
$302.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.83
|
| Rate for Payer: Multiplan Commercial |
$335.48
|
|
|
ASCIMINIB 40 MG TABLET [233025]
|
Facility
|
OP
|
$447.30
|
|
|
Service Code
|
NDC 0078-1098-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.96 |
| Max. Negotiated Rate |
$380.20 |
| Rate for Payer: Adventist Health Commercial |
$89.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$239.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$307.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$380.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$246.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$335.48
|
| Rate for Payer: Blue Shield of California Commercial |
$272.85
|
| Rate for Payer: Blue Shield of California EPN |
$218.28
|
| Rate for Payer: Cash Price |
$246.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$290.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$380.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$380.20
|
| Rate for Payer: Dignity Health Senior |
$380.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$286.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.88
|
| Rate for Payer: Heritage Provider Network Senior |
$276.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$213.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$313.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$313.11
|
| Rate for Payer: Multiplan Commercial |
$335.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$178.92
|
| Rate for Payer: TriValley Medical Group Senior |
$178.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$223.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$223.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$380.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$380.20
|
| Rate for Payer: Vantage Medical Group Senior |
$380.20
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL LIQUID [227420]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 6961801854
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL LIQUID [227420]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 6961801854
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL SYRUP [115152]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 5789684216
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL SYRUP [115152]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 5789684216
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION [654]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 67457-118-50
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION [654]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
NDC 67457-118-50
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Senior |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Senior |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
|
