|
ARTIFICIAL TEARS OPHTHALMIC DROPS WRAP [40820640]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 0023079815
|
| 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: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.30
|
| 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 Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
ARTIFICIAL TEARS OPHTHALMIC DROPS WRAP [40820640]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 5789618405
|
| 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 Non-Gatekeeper |
$0.09
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| 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 |
$0.06
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 OPHTHALMIC DROPS WRAP [40820640]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 5026806815
|
| 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 Non-Gatekeeper |
$0.40
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| 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 |
$0.29
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 OPHTHALMIC DROPS WRAP [40820640]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0065042636
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, INCLUDES VALVE SUSPENSION, WHEN PERFORMED; FOR AORTIC DISSECTION
|
Facility
|
OP
|
$15,309.00
|
|
|
Service Code
|
CPT 33858
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,984.00 |
| Max. Negotiated Rate |
$15,309.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15,309.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
|
|
ASCIMINIB 20 MG TABLET [233024]
|
Facility
|
IP
|
$447.30
|
|
|
Service Code
|
NDC 0078109120
|
| 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: Aetna of CA Non-Gatekeeper |
$288.06
|
| Rate for Payer: Cash Price |
$201.28
|
| 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 Foundation Hospitals 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 0078109120
|
| 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 Non-Gatekeeper |
$276.43
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$223.74
|
| 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 |
$201.28
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$213.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$447.30
|
|
|
Service Code
|
NDC 0078109820
|
| 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 Non-Gatekeeper |
$276.43
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$223.74
|
| 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 |
$201.28
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$213.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 0078109820
|
| 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: Aetna of CA Non-Gatekeeper |
$288.06
|
| Rate for Payer: Cash Price |
$201.28
|
| 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 Foundation Hospitals Medi-Cal |
$80.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.83
|
| Rate for Payer: Multiplan Commercial |
$335.48
|
|
|
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 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: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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: Aetna of CA Non-Gatekeeper |
$0.04
|
| 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 Foundation Hospitals 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
|
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 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: Anthem Blue Cross of CA HMO/PPO |
$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 |
$0.01
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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/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: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Foundation Hospitals 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/ML INJECTION SOLUTION [654]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| 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 |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
| 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
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION [654]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.40
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
|
OP
|
$6.42
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.82
|
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California Commercial |
$3.96
|
| Rate for Payer: Blue Shield of California EPN |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$3.13
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.97
|
| Rate for Payer: Heritage Provider Network Senior |
$3.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.49
|
| Rate for Payer: Multiplan Commercial |
$4.87
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.60
|
| Rate for Payer: TriValley Medical Group Senior |
$2.57
|
| Rate for Payer: TriValley Medical Group Senior |
$2.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.52
|
| Rate for Payer: Vantage Medical Group Senior |
$5.52
|
| Rate for Payer: Vantage Medical Group Senior |
$5.46
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
|
IP
|
$6.49
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.87 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.18
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Multiplan Commercial |
$4.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.13
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0904052372
|
| 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: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Foundation Hospitals 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 TABLET [664]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 5789684101
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$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 |
$0.01
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 TABLET [664]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 8770140739
|
| 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 Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0904052360
|
| 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: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Foundation Hospitals 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 TABLET [664]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8770140741
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$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 |
$0.01
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 TABLET [664]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8770140741
|
| 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: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Foundation Hospitals 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 TABLET [664]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 5789684101
|
| 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: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Foundation Hospitals 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 TABLET [664]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0904052372
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$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 |
$0.01
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$0.03
|
|
