|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
OP
|
$260.92
|
|
|
Service Code
|
CPT J1300
|
| Hospital Charge Code |
NDG81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$554.42 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$554.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$179.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$282.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$248.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$248.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$370.39
|
| Rate for Payer: Blue Shield of California Commercial |
$221.78
|
| Rate for Payer: Blue Shield of California EPN |
$221.78
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$338.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$248.25
|
| Rate for Payer: Dignity Health Senior |
$248.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.99
|
| Rate for Payer: EPIC Health Plan Medicare |
$225.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.81
|
| Rate for Payer: Heritage Provider Network Senior |
$120.81
|
| Rate for Payer: Humana Medicare |
$225.68
|
| Rate for Payer: IEHP Medi-Cal |
$359.03
|
| Rate for Payer: IEHP Medicare Advantage |
$225.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$428.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$266.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$284.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$284.36
|
| Rate for Payer: Multiplan Commercial |
$195.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$248.25
|
| Rate for Payer: TriValley Medical Group Senior |
$225.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$95.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$87.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$338.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$248.25
|
| Rate for Payer: Vantage Medical Group Senior |
$225.68
|
|
|
EDETATE CALCIUM DISODIUM 200 MG/ML INJECTION SOLUTION [9916]
|
Facility
IP
|
$1,292.51
|
|
|
Service Code
|
CPT J0600
|
| Hospital Charge Code |
NDG9916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.94 |
| Max. Negotiated Rate |
$969.38 |
| Rate for Payer: Adventist Health Commercial |
$258.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$887.95
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$594.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$697.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$875.03
|
| Rate for Payer: Heritage Provider Network Senior |
$875.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$233.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$323.13
|
| Rate for Payer: Multiplan Commercial |
$969.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$471.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$431.83
|
|
|
EDETATE CALCIUM DISODIUM 200 MG/ML INJECTION SOLUTION [9916]
|
Facility
OP
|
$1,292.51
|
|
|
Service Code
|
CPT J0600
|
| Hospital Charge Code |
NDG9916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.21 |
| Max. Negotiated Rate |
$15,733.70 |
| Rate for Payer: Adventist Health Commercial |
$258.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15,733.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$887.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8,065.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,097.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,097.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.21
|
| Rate for Payer: Blue Shield of California Commercial |
$5,493.18
|
| Rate for Payer: Blue Shield of California EPN |
$5,493.18
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cash Price |
$581.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$594.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,678.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,097.75
|
| Rate for Payer: Dignity Health Senior |
$7,097.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$827.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,452.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$598.43
|
| Rate for Payer: Heritage Provider Network Senior |
$598.43
|
| Rate for Payer: Humana Medicare |
$6,452.50
|
| Rate for Payer: IEHP Medicare Advantage |
$6,452.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,259.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$233.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,613.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$323.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,130.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,130.15
|
| Rate for Payer: Multiplan Commercial |
$969.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,097.75
|
| Rate for Payer: TriValley Medical Group Senior |
$6,452.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$471.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$431.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,678.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,097.75
|
| Rate for Payer: Vantage Medical Group Senior |
$6,452.50
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
OP
|
$30.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG222529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.50
|
| Rate for Payer: Blue Shield of California Commercial |
$18.63
|
| Rate for Payer: Blue Shield of California EPN |
$17.61
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.50
|
| Rate for Payer: Dignity Health Senior |
$25.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.89
|
| Rate for Payer: Heritage Provider Network Senior |
$13.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$25.50
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
IP
|
$30.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG222529
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.31
|
| Rate for Payer: Heritage Provider Network Senior |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.02
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
OP
|
$3.20
|
|
|
Service Code
|
NDC 31722-504-30
|
| Hospital Charge Code |
1711878
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California EPN |
$1.88
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
IP
|
$3.20
|
|
|
Service Code
|
NDC 31722-504-30
|
| Hospital Charge Code |
1711878
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.20
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]
|
Facility
IP
|
$9,000.00
|
|
|
Service Code
|
CPT J1449
|
| Hospital Charge Code |
NDG235968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,629.00 |
| Max. Negotiated Rate |
$6,750.00 |
| Rate for Payer: Adventist Health Commercial |
$1,800.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,183.00
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,140.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,860.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,093.00
|
| Rate for Payer: Heritage Provider Network Senior |
$6,093.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,629.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,250.00
|
| Rate for Payer: Multiplan Commercial |
$6,750.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,281.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,006.90
|
|
|
EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]
|
Facility
OP
|
$9,000.00
|
|
|
Service Code
|
CPT J1449
|
| Hospital Charge Code |
NDG235968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.68 |
| Max. Negotiated Rate |
$6,750.00 |
| Rate for Payer: Adventist Health Commercial |
$1,800.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$72.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,183.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$37.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$32.65
|
| Rate for Payer: Blue Shield of California Commercial |
$5,589.00
|
| Rate for Payer: Blue Shield of California EPN |
$5,283.00
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,140.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.65
|
| Rate for Payer: Dignity Health Senior |
$32.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,760.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$29.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,167.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,167.00
|
| Rate for Payer: Humana Medicare |
$29.68
|
| Rate for Payer: IEHP Medi-Cal |
$53.26
|
| Rate for Payer: IEHP Medicare Advantage |
$29.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,629.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,250.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.40
|
| Rate for Payer: Multiplan Commercial |
$6,750.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.65
|
| Rate for Payer: TriValley Medical Group Senior |
$29.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,281.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,006.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.65
|
| Rate for Payer: Vantage Medical Group Senior |
$32.65
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
IP
|
$14,421.01
|
|
|
Service Code
|
APR-DRG 3242
|
| Min. Negotiated Rate |
$14,421.01 |
| Max. Negotiated Rate |
$14,421.01 |
| Rate for Payer: IEHP Medi-Cal |
$14,421.01
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
IP
|
$13,236.09
|
|
|
Service Code
|
APR-DRG 3241
|
| Min. Negotiated Rate |
$13,236.09 |
| Max. Negotiated Rate |
$13,236.09 |
| Rate for Payer: IEHP Medi-Cal |
$13,236.09
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
IP
|
$30,887.55
|
|
|
Service Code
|
APR-DRG 3244
|
| Min. Negotiated Rate |
$30,887.55 |
| Max. Negotiated Rate |
$30,887.55 |
| Rate for Payer: IEHP Medi-Cal |
$30,887.55
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
IP
|
$19,463.16
|
|
|
Service Code
|
APR-DRG 3243
|
| Min. Negotiated Rate |
$19,463.16 |
| Max. Negotiated Rate |
$19,463.16 |
| Rate for Payer: IEHP Medi-Cal |
$19,463.16
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
IP
|
$19,868.07
|
|
|
Service Code
|
APR-DRG 3263
|
| Min. Negotiated Rate |
$19,868.07 |
| Max. Negotiated Rate |
$19,868.07 |
| Rate for Payer: IEHP Medi-Cal |
$19,868.07
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
IP
|
$26,035.43
|
|
|
Service Code
|
APR-DRG 3264
|
| Min. Negotiated Rate |
$26,035.43 |
| Max. Negotiated Rate |
$26,035.43 |
| Rate for Payer: IEHP Medi-Cal |
$26,035.43
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
IP
|
$13,159.49
|
|
|
Service Code
|
APR-DRG 3261
|
| Min. Negotiated Rate |
$13,159.49 |
| Max. Negotiated Rate |
$13,159.49 |
| Rate for Payer: IEHP Medi-Cal |
$13,159.49
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
IP
|
$13,970.33
|
|
|
Service Code
|
APR-DRG 3262
|
| Min. Negotiated Rate |
$13,970.33 |
| Max. Negotiated Rate |
$13,970.33 |
| Rate for Payer: IEHP Medi-Cal |
$13,970.33
|
|
|
ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0338-0179-04
|
| Hospital Charge Code |
1759936
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0338-0179-04
|
| Hospital Charge Code |
1759936
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
1771306
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| 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 |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
1771306
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
