|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$5,856.95
|
|
|
Service Code
|
APR-DRG 0822
|
| Min. Negotiated Rate |
$5,856.95 |
| Max. Negotiated Rate |
$5,856.95 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,856.95
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$8,524.27
|
|
|
Service Code
|
APR-DRG 0823
|
| Min. Negotiated Rate |
$8,524.27 |
| Max. Negotiated Rate |
$8,524.27 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,524.27
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$16,841.60
|
|
|
Service Code
|
APR-DRG 0824
|
| Min. Negotiated Rate |
$16,841.60 |
| Max. Negotiated Rate |
$16,841.60 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,841.60
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$4,766.55
|
|
|
Service Code
|
APR-DRG 0821
|
| Min. Negotiated Rate |
$4,766.55 |
| Max. Negotiated Rate |
$4,766.55 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,766.55
|
|
|
EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET [39221]
|
Facility
|
IP
|
$13.67
|
|
|
Service Code
|
NDC 66582-312-31
|
| Hospital Charge Code |
1710951
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$10.25 |
| Rate for Payer: Adventist Health Commercial |
$2.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.39
|
| Rate for Payer: Cash Price |
$6.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.25
|
| Rate for Payer: Heritage Provider Network Senior |
$9.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.42
|
| Rate for Payer: Multiplan Commercial |
$10.25
|
|
|
EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET [39221]
|
Facility
|
OP
|
$13.67
|
|
|
Service Code
|
NDC 66582-312-31
|
| Hospital Charge Code |
1710951
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$11.62 |
| Rate for Payer: Adventist Health Commercial |
$2.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.25
|
| Rate for Payer: Blue Shield of California Commercial |
$8.49
|
| Rate for Payer: Blue Shield of California EPN |
$8.02
|
| Rate for Payer: Cash Price |
$6.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.62
|
| Rate for Payer: Dignity Health Senior |
$11.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.46
|
| Rate for Payer: Heritage Provider Network Senior |
$8.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.42
|
| Rate for Payer: Multiplan Commercial |
$10.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.47
|
| Rate for Payer: TriValley Medical Group Senior |
$5.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.62
|
| Rate for Payer: Vantage Medical Group Senior |
$11.62
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 59651-052-30
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 0781-5690-31
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 0781-5690-31
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 59651-052-30
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$22,366.26
|
|
|
Service Code
|
APR-DRG 0923
|
| Min. Negotiated Rate |
$22,366.26 |
| Max. Negotiated Rate |
$22,366.26 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22,366.26
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$11,081.16
|
|
|
Service Code
|
APR-DRG 0921
|
| Min. Negotiated Rate |
$11,081.16 |
| Max. Negotiated Rate |
$11,081.16 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,081.16
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$14,266.81
|
|
|
Service Code
|
APR-DRG 0922
|
| Min. Negotiated Rate |
$14,266.81 |
| Max. Negotiated Rate |
$14,266.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,266.81
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$43,017.32
|
|
|
Service Code
|
APR-DRG 0924
|
| Min. Negotiated Rate |
$43,017.32 |
| Max. Negotiated Rate |
$43,017.32 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$43,017.32
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 33342-026-07
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Senior |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-95
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 31722-708-30
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 33342-026-07
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-95
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: Dignity Health Senior |
$2.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.10
|
| Rate for Payer: TriValley Medical Group Senior |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2.34
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-25
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 31722-708-30
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Senior |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-25
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: Dignity Health Senior |
$2.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.10
|
| Rate for Payer: TriValley Medical Group Senior |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2.34
|
|
|
FAMOTIDINE 10 MG/ML INJECTION. [4081320]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
CPT S0028
|
| Hospital Charge Code |
1768064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Senior |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
