|
COLISTIN (COLISTIMETHATE) 150 MG MED NEB SOLUTION [4080399]
|
Facility
|
IP
|
$33.59
|
|
|
Service Code
|
HCPCS J0770
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$25.19 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
|
|
COLISTIN (COLISTIMETHATE) 150 MG MED NEB SOLUTION [4080399]
|
Facility
|
OP
|
$33.60
|
|
|
Service Code
|
HCPCS J0770
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.30
|
| Rate for Payer: Blue Shield of California Commercial |
$28.14
|
| Rate for Payer: Blue Shield of California Commercial |
$28.14
|
| Rate for Payer: Blue Shield of California EPN |
$28.14
|
| Rate for Payer: Blue Shield of California EPN |
$28.14
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: Dignity Health Senior |
$28.55
|
| Rate for Payer: Dignity Health Senior |
$28.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.52
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.44
|
| Rate for Payer: TriValley Medical Group Senior |
$13.44
|
| Rate for Payer: TriValley Medical Group Senior |
$13.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$28.55
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
|
|
COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]
|
Facility
|
IP
|
$33.59
|
|
|
Service Code
|
HCPCS J0770
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$25.19 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
|
|
COLISTIN (COLISTIMETHATE) 37.5 MG CBA/ML SWFI INJ DILUTION [4082134]
|
Facility
|
OP
|
$33.60
|
|
|
Service Code
|
HCPCS J0770
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Adventist Health Commercial |
$6.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.30
|
| Rate for Payer: Blue Shield of California Commercial |
$28.14
|
| Rate for Payer: Blue Shield of California Commercial |
$28.14
|
| Rate for Payer: Blue Shield of California EPN |
$28.14
|
| Rate for Payer: Blue Shield of California EPN |
$28.14
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cash Price |
$18.47
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.56
|
| Rate for Payer: Dignity Health Senior |
$28.55
|
| Rate for Payer: Dignity Health Senior |
$28.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.55
|
| Rate for Payer: Heritage Provider Network Senior |
$15.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.52
|
| Rate for Payer: Multiplan Commercial |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$25.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.44
|
| Rate for Payer: TriValley Medical Group Senior |
$13.44
|
| Rate for Payer: TriValley Medical Group Senior |
$13.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.56
|
| Rate for Payer: Vantage Medical Group Senior |
$28.55
|
| Rate for Payer: Vantage Medical Group Senior |
$28.56
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
IP
|
$10.45
|
|
|
Service Code
|
NDC 9999-9996-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$7.84 |
| Rate for Payer: Adventist Health Commercial |
$2.09
|
| Rate for Payer: Cash Price |
$5.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.07
|
| Rate for Payer: Heritage Provider Network Senior |
$7.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$7.84
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
OP
|
$10.45
|
|
|
Service Code
|
NDC 9999-9996-82
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Adventist Health Commercial |
$2.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.84
|
| Rate for Payer: Blue Shield of California Commercial |
$6.37
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$5.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.88
|
| Rate for Payer: Dignity Health Senior |
$8.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.47
|
| Rate for Payer: Heritage Provider Network Senior |
$6.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.32
|
| Rate for Payer: Multiplan Commercial |
$7.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.18
|
| Rate for Payer: TriValley Medical Group Senior |
$4.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.88
|
| Rate for Payer: Vantage Medical Group Senior |
$8.88
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
IP
|
$12.70
|
|
|
Service Code
|
NDC 50484-010-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$9.53 |
| Rate for Payer: Adventist Health Commercial |
$2.54
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.60
|
| Rate for Payer: Heritage Provider Network Senior |
$8.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$9.53
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
OP
|
$12.70
|
|
|
Service Code
|
NDC 50484-010-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$10.79 |
| Rate for Payer: Adventist Health Commercial |
$2.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.53
|
| Rate for Payer: Blue Shield of California Commercial |
$7.75
|
| Rate for Payer: Blue Shield of California EPN |
$6.20
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.79
|
| Rate for Payer: Dignity Health Senior |
$10.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.86
|
| Rate for Payer: Heritage Provider Network Senior |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.89
|
| Rate for Payer: Multiplan Commercial |
$9.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.08
|
| Rate for Payer: TriValley Medical Group Senior |
$5.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.79
|
| Rate for Payer: Vantage Medical Group Senior |
$10.79
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
IP
|
$12.07
|
|
|
Service Code
|
NDC 50484-010-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$9.05
|
|
|
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT [9682]
|
Facility
|
OP
|
$12.07
|
|
|
Service Code
|
NDC 50484-010-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Adventist Health Commercial |
$2.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.36
|
| Rate for Payer: Blue Shield of California EPN |
$5.89
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.26
|
| Rate for Payer: Dignity Health Senior |
$10.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.47
|
| Rate for Payer: Heritage Provider Network Senior |
$7.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.45
|
| Rate for Payer: Multiplan Commercial |
$9.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.83
|
| Rate for Payer: TriValley Medical Group Senior |
$4.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.26
|
| Rate for Payer: Vantage Medical Group Senior |
$10.26
|
|
|
COLLOIDAL OATMEAL TOPICAL PACKET [81870]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 8137003640
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
COLLOIDAL OATMEAL TOPICAL PACKET [81870]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 8137003640
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| 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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| 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
|
|
|
COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| 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 |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030316
|
| 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: 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 Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030316
|
| 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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| 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 |
$0.02
|
| 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
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0395009416
|
| 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
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030216
|
| 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: 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 Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0395009416
|
| 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
|
|
|
COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030216
|
| 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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| 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 |
$0.02
|
| 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0395009016
|
| 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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| 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 |
$0.02
|
| 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0395009016
|
| 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: 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 Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3172295901
|
| 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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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 |
$0.03
|
| 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 |
$0.02
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| 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 |
$0.02
|
| 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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 3877907448
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 3877907448
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
