|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 5965149530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.70
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 0378427193
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.68
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.20
|
| Rate for Payer: Heritage Provider Network Senior |
$31.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 0378427193
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.05
|
| Rate for Payer: Blue Shield of California Commercial |
$28.11
|
| Rate for Payer: Blue Shield of California EPN |
$22.49
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.52
|
| Rate for Payer: Heritage Provider Network Senior |
$28.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.43
|
| Rate for Payer: TriValley Medical Group Senior |
$18.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 4733523783
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.05
|
| Rate for Payer: Blue Shield of California Commercial |
$28.11
|
| Rate for Payer: Blue Shield of California EPN |
$22.49
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.52
|
| Rate for Payer: Heritage Provider Network Senior |
$28.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.43
|
| Rate for Payer: TriValley Medical Group Senior |
$18.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 10 MG TABLET [82308]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 4733523783
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.68
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.20
|
| Rate for Payer: Heritage Provider Network Senior |
$31.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$582.30
|
|
|
Service Code
|
NDC 6195808015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$436.73 |
| Rate for Payer: Adventist Health Commercial |
$116.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$375.00
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$314.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$394.22
|
| Rate for Payer: Heritage Provider Network Senior |
$394.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$105.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$145.57
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$582.30
|
|
|
Service Code
|
NDC 6195808015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$494.95 |
| Rate for Payer: Adventist Health Commercial |
$116.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$359.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$494.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$320.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$436.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$291.27
|
| Rate for Payer: Blue Shield of California Commercial |
$355.20
|
| Rate for Payer: Blue Shield of California EPN |
$284.16
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$378.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$494.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$494.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$494.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$372.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$360.44
|
| Rate for Payer: Heritage Provider Network Senior |
$360.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$277.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$105.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$145.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$407.61
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$232.92
|
| Rate for Payer: TriValley Medical Group Senior |
$232.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$291.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$291.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$494.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$494.95
|
| Rate for Payer: Vantage Medical Group Senior |
$494.95
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 5965149430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.70
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$46.08
|
|
|
Service Code
|
NDC 4733523683
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.68
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.20
|
| Rate for Payer: Heritage Provider Network Senior |
$31.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$582.30
|
|
|
Service Code
|
NDC 6195808011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$494.95 |
| Rate for Payer: Adventist Health Commercial |
$116.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$359.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$494.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$320.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$436.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$291.27
|
| Rate for Payer: Blue Shield of California Commercial |
$355.20
|
| Rate for Payer: Blue Shield of California EPN |
$284.16
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$378.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$494.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$494.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$494.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$372.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$360.44
|
| Rate for Payer: Heritage Provider Network Senior |
$360.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$277.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$105.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$145.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$407.61
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$232.92
|
| Rate for Payer: TriValley Medical Group Senior |
$232.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$291.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$291.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$494.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$494.95
|
| Rate for Payer: Vantage Medical Group Senior |
$494.95
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
IP
|
$582.30
|
|
|
Service Code
|
NDC 6195808011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$436.73 |
| Rate for Payer: Adventist Health Commercial |
$116.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$375.00
|
| Rate for Payer: Cash Price |
$262.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$314.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$394.22
|
| Rate for Payer: Heritage Provider Network Senior |
$394.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$105.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$145.57
|
| Rate for Payer: Multiplan Commercial |
$436.73
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$46.08
|
|
|
Service Code
|
NDC 4733523683
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$39.17 |
| Rate for Payer: Adventist Health Commercial |
$9.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.05
|
| Rate for Payer: Blue Shield of California Commercial |
$28.11
|
| Rate for Payer: Blue Shield of California EPN |
$22.49
|
| Rate for Payer: Cash Price |
$20.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.52
|
| Rate for Payer: Heritage Provider Network Senior |
$28.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$21.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.26
|
| Rate for Payer: Multiplan Commercial |
$34.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.43
|
| Rate for Payer: TriValley Medical Group Senior |
$18.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.17
|
| Rate for Payer: Vantage Medical Group Senior |
$39.17
|
|
|
AMBRISENTAN 5 MG TABLET [82307]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 5965149430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.10
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$14.46 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.94
|
| 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 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 |
$3.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.46
|
| 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 |
$2.16
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.22
|
| 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 |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.65
|
| 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 |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.99
|
| Rate for Payer: Heritage Provider Network Senior |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.80
|
| Rate for Payer: TriValley Medical Group Senior |
$2.80
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$1.72
|
| 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 All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.94
|
| 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 Medi-Cal |
$5.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| 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 1,000 MG/4 ML INJECTION SOLUTION [121296]
|
Facility
|
IP
|
$6.99
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.24 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.76
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$1.93
|
| 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: EPIC Health Plan Commercial |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.99
|
| Rate for Payer: Heritage Provider Network Senior |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Foundation Hospitals 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: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.90
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cash Price |
$2.02
|
| 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: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.51
|
| 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 Foundation Hospitals Medi-Cal |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals 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: 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
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [121291]
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
HCPCS J0278
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$14.46 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$3.83
|
| 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 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 |
$3.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.46
|
| 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 |
$2.09
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$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 |
$3.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.83
|
| 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 |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| 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 Foundation Hospitals Commercial |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$1.86
|
| Rate for Payer: TriValley Medical Group Senior |
$1.80
|
| 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 All Other HMO/non HMO |
$1.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| 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 Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.95
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$3.95
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 0574029201
|
| 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: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0574029201
|
| 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 Non-Gatekeeper |
$0.17
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| 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 |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$1.14
|
|
|
Service Code
|
NDC 3172203523
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.97
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.57
|
| 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 |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Senior |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.80
|
| 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 |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.97
|
| Rate for Payer: Vantage Medical Group Senior |
$0.97
|
|
|
AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION [9062]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
NDC 3172203523
|
| 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: Aetna of CA Non-Gatekeeper |
$0.73
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals 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 INTRAVENOUS SOLUTION [403]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
HCPCS J0281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
|
|
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 |
$3.93 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.93
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
AMINOCAPROIC ACID 500 MG TABLET [9063]
|
Facility
|
IP
|
$7.16
|
|
|
Service Code
|
NDC 7037710211
|
| 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: Aetna of CA Non-Gatekeeper |
$4.61
|
| Rate for Payer: Cash Price |
$3.22
|
| 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 Foundation Hospitals 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 7220504930
|
| 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 Non-Gatekeeper |
$8.03
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$6.50
|
| 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 |
$5.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$6.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
