|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
OP
|
$3.35
|
|
|
Service Code
|
NDC 0023-0312-04
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.51
|
| Rate for Payer: Blue Shield of California Commercial |
$2.08
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.85
|
| Rate for Payer: Dignity Health Senior |
$2.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.85
|
| Rate for Payer: Vantage Medical Group Senior |
$2.85
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
OP
|
$1.85
|
|
|
Service Code
|
NDC 0904-6488-38
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Senior |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
IP
|
$2.34
|
|
|
Service Code
|
NDC 9999-9022-39
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]
|
Facility
OP
|
$0.86
|
|
|
Service Code
|
NDC 0065-8064-01
|
| Hospital Charge Code |
1740326
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]
|
Facility
IP
|
$0.86
|
|
|
Service Code
|
NDC 0065-8064-01
|
| Hospital Charge Code |
1740326
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.5 % EYE DROPS [27980]
|
Facility
OP
|
$2.27
|
|
|
Service Code
|
NDC 0998-0408-15
|
| Hospital Charge Code |
1740176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.5 % EYE DROPS [27980]
|
Facility
IP
|
$2.27
|
|
|
Service Code
|
NDC 0998-0408-15
|
| Hospital Charge Code |
1740176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
Arytenoidectomy or arytenoidopexy, external approach
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 31400
|
| Min. Negotiated Rate |
$242.19 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: IEHP Medi-Cal |
$242.19
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
ASCIMINIB 20 MG TABLET [233024]
|
Facility
OP
|
$402.11
|
|
|
Service Code
|
NDC 0078-1091-20
|
| Hospital Charge Code |
ERX233024
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.78 |
| Max. Negotiated Rate |
$341.79 |
| Rate for Payer: Adventist Health Commercial |
$80.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$214.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$276.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$341.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$221.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$301.58
|
| Rate for Payer: Blue Shield of California Commercial |
$249.71
|
| Rate for Payer: Blue Shield of California EPN |
$236.04
|
| Rate for Payer: Cash Price |
$180.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$261.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.79
|
| Rate for Payer: Dignity Health Senior |
$341.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$248.91
|
| Rate for Payer: Heritage Provider Network Senior |
$248.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$193.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.53
|
| Rate for Payer: Multiplan Commercial |
$301.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.79
|
| Rate for Payer: Vantage Medical Group Senior |
$341.79
|
|
|
ASCIMINIB 20 MG TABLET [233024]
|
Facility
IP
|
$402.11
|
|
|
Service Code
|
NDC 0078-1091-20
|
| Hospital Charge Code |
ERX233024
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.78 |
| Max. Negotiated Rate |
$301.58 |
| Rate for Payer: Adventist Health Commercial |
$80.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$276.25
|
| Rate for Payer: Cash Price |
$180.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$217.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$272.23
|
| Rate for Payer: Heritage Provider Network Senior |
$272.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.53
|
| Rate for Payer: Multiplan Commercial |
$301.58
|
|
|
ASCIMINIB 40 MG TABLET [233025]
|
Facility
OP
|
$402.11
|
|
|
Service Code
|
NDC 0078-1098-20
|
| Hospital Charge Code |
ERX233025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.78 |
| Max. Negotiated Rate |
$341.79 |
| Rate for Payer: Adventist Health Commercial |
$80.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$214.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$276.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$341.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$221.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$301.58
|
| Rate for Payer: Blue Shield of California Commercial |
$249.71
|
| Rate for Payer: Blue Shield of California EPN |
$236.04
|
| Rate for Payer: Cash Price |
$180.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$261.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.79
|
| Rate for Payer: Dignity Health Senior |
$341.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$257.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$248.91
|
| Rate for Payer: Heritage Provider Network Senior |
$248.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$193.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.53
|
| Rate for Payer: Multiplan Commercial |
$301.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.79
|
| Rate for Payer: Vantage Medical Group Senior |
$341.79
|
|
|
ASCIMINIB 40 MG TABLET [233025]
|
Facility
IP
|
$402.11
|
|
|
Service Code
|
NDC 0078-1098-20
|
| Hospital Charge Code |
ERX233025
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$72.78 |
| Max. Negotiated Rate |
$301.58 |
| Rate for Payer: Adventist Health Commercial |
$80.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$276.25
|
| Rate for Payer: Cash Price |
$180.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$217.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$272.23
|
| Rate for Payer: Heritage Provider Network Senior |
$272.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$100.53
|
| Rate for Payer: Multiplan Commercial |
$301.58
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL LIQUID [227420]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 6961801854
|
| Hospital Charge Code |
NDG216878
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| 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 |
$0.03
|
| 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 |
$0.04
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL LIQUID [227420]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 6961801854
|
| Hospital Charge Code |
NDG216878
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| 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 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: Multiplan Commercial |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/5 ML ORAL SYRUP [115152]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 5789684216
|
| Hospital Charge Code |
1719087
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare 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 |
$0.02
|
| 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 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: Multiplan Commercial |
$0.02
|
| 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 |
1719087
|
|
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 Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION [654]
|
Facility
OP
|
$2.17
|
|
|
Service Code
|
NDC 67457-118-50
|
| Hospital Charge Code |
1757957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$1.27
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Senior |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| 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
|
NDC 67457-118-50
|
| Hospital Charge Code |
1757957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.49
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
OP
|
$6.42
|
|
|
Service Code
|
NDC 67157-101-51
|
| Hospital Charge Code |
1757957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.82
|
| Rate for Payer: Blue Shield of California Commercial |
$3.99
|
| Rate for Payer: Blue Shield of California EPN |
$3.77
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.46
|
| Rate for Payer: Dignity Health Senior |
$5.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.97
|
| Rate for Payer: Heritage Provider Network Senior |
$3.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.46
|
| Rate for Payer: Vantage Medical Group Senior |
$5.46
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
OP
|
$6.49
|
|
|
Service Code
|
NDC 67157-101-50
|
| Hospital Charge Code |
1757957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.87
|
| Rate for Payer: Blue Shield of California Commercial |
$4.03
|
| Rate for Payer: Blue Shield of California EPN |
$3.81
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.52
|
| Rate for Payer: Dignity Health Senior |
$5.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.02
|
| Rate for Payer: Heritage Provider Network Senior |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$4.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.52
|
| Rate for Payer: Vantage Medical Group Senior |
$5.52
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
IP
|
$6.42
|
|
|
Service Code
|
NDC 67157-101-51
|
| Hospital Charge Code |
1757957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.41
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.35
|
| Rate for Payer: Heritage Provider Network Senior |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION [221033]
|
Facility
IP
|
$6.49
|
|
|
Service Code
|
NDC 67157-101-50
|
| Hospital Charge Code |
1757957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.87 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.46
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.39
|
| Rate for Payer: Heritage Provider Network Senior |
$4.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$4.87
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET [664]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 8770140739
|
| Hospital Charge Code |
1711030
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare 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: Multiplan Commercial |
$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
OP
|
$0.03
|
|
|
Service Code
|
NDC 5789684101
|
| Hospital Charge Code |
1711030
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare 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 |
$0.02
|
| 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 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: Multiplan Commercial |
$0.02
|
| 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
OP
|
$0.03
|
|
|
Service Code
|
NDC 904052360
|
| Hospital Charge Code |
1711030
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare 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 |
$0.02
|
| 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 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: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
