|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]
|
Facility
IP
|
$87.97
|
|
|
Service Code
|
CPT J0457
|
| Hospital Charge Code |
1753314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.92 |
| Max. Negotiated Rate |
$65.98 |
| Rate for Payer: Adventist Health Commercial |
$17.59
|
| Rate for Payer: Adventist Health Commercial |
$15.60
|
| Rate for Payer: Adventist Health Commercial |
$14.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.44
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$39.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.81
|
| Rate for Payer: Heritage Provider Network Senior |
$59.56
|
| Rate for Payer: Heritage Provider Network Senior |
$52.81
|
| Rate for Payer: Heritage Provider Network Senior |
$48.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.84
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$65.98
|
| Rate for Payer: Multiplan Commercial |
$53.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.39
|
|
|
AZTREONAM 2 GRAM SOLUTION FOR INJECTION [9186]
|
Facility
OP
|
$87.97
|
|
|
Service Code
|
CPT J0457
|
| Hospital Charge Code |
1753314
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$65.98 |
| Rate for Payer: Adventist Health Commercial |
$17.59
|
| Rate for Payer: Adventist Health Commercial |
$15.60
|
| Rate for Payer: Adventist Health Commercial |
$14.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.79
|
| Rate for Payer: Blue Shield of California Commercial |
$48.44
|
| Rate for Payer: Blue Shield of California Commercial |
$44.30
|
| Rate for Payer: Blue Shield of California Commercial |
$54.63
|
| Rate for Payer: Blue Shield of California EPN |
$41.88
|
| Rate for Payer: Blue Shield of California EPN |
$45.79
|
| Rate for Payer: Blue Shield of California EPN |
$51.64
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cash Price |
$39.59
|
| Rate for Payer: Cash Price |
$39.59
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.79
|
| Rate for Payer: Dignity Health Senior |
$2.79
|
| Rate for Payer: Dignity Health Senior |
$2.79
|
| Rate for Payer: Dignity Health Senior |
$2.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.66
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.54
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.54
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.73
|
| Rate for Payer: Heritage Provider Network Senior |
$33.03
|
| Rate for Payer: Heritage Provider Network Senior |
$36.11
|
| Rate for Payer: Heritage Provider Network Senior |
$40.73
|
| Rate for Payer: Humana Medicare |
$2.54
|
| Rate for Payer: Humana Medicare |
$2.54
|
| Rate for Payer: Humana Medicare |
$2.54
|
| Rate for Payer: IEHP Medi-Cal |
$10.92
|
| Rate for Payer: IEHP Medi-Cal |
$10.92
|
| Rate for Payer: IEHP Medi-Cal |
$10.92
|
| Rate for Payer: IEHP Medicare Advantage |
$2.54
|
| Rate for Payer: IEHP Medicare Advantage |
$2.54
|
| Rate for Payer: IEHP Medicare Advantage |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.20
|
| Rate for Payer: Multiplan Commercial |
$65.98
|
| Rate for Payer: Multiplan Commercial |
$53.50
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.79
|
| Rate for Payer: TriValley Medical Group Senior |
$2.54
|
| Rate for Payer: TriValley Medical Group Senior |
$2.54
|
| Rate for Payer: TriValley Medical Group Senior |
$2.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.79
|
| Rate for Payer: Vantage Medical Group Senior |
$2.54
|
| Rate for Payer: Vantage Medical Group Senior |
$2.54
|
| Rate for Payer: Vantage Medical Group Senior |
$2.54
|
|
|
AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION [100393]
|
Facility
IP
|
$148.49
|
|
|
Service Code
|
NDC 61958-0901-1
|
| Hospital Charge Code |
NDG100393
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.88 |
| Max. Negotiated Rate |
$111.37 |
| Rate for Payer: Adventist Health Commercial |
$29.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$102.01
|
| Rate for Payer: Cash Price |
$66.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.53
|
| Rate for Payer: Heritage Provider Network Senior |
$100.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.12
|
| Rate for Payer: Multiplan Commercial |
$111.37
|
|
|
AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION [100393]
|
Facility
OP
|
$148.49
|
|
|
Service Code
|
NDC 61958-0901-1
|
| Hospital Charge Code |
NDG100393
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.88 |
| Max. Negotiated Rate |
$126.22 |
| Rate for Payer: Adventist Health Commercial |
$29.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$79.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$102.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$126.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$81.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$111.37
|
| Rate for Payer: Blue Shield of California Commercial |
$92.21
|
| Rate for Payer: Blue Shield of California EPN |
$87.16
|
| Rate for Payer: Cash Price |
$66.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$96.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$126.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$126.22
|
| Rate for Payer: Dignity Health Senior |
$126.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$91.92
|
| Rate for Payer: Heritage Provider Network Senior |
$91.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$71.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.12
|
| Rate for Payer: Multiplan Commercial |
$111.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$126.22
|
| Rate for Payer: Vantage Medical Group Senior |
$126.22
|
|
|
BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]
|
Facility
IP
|
$37.06
|
|
|
Service Code
|
NDC 0574-4022-35
|
| Hospital Charge Code |
1740071
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$27.80 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.46
|
| Rate for Payer: Cash Price |
$16.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.09
|
| Rate for Payer: Heritage Provider Network Senior |
$25.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$27.80
|
|
|
BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]
|
Facility
OP
|
$37.06
|
|
|
Service Code
|
NDC 0574-4022-35
|
| Hospital Charge Code |
1740071
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Adventist Health Commercial |
$7.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.80
|
| Rate for Payer: Blue Shield of California Commercial |
$23.01
|
| Rate for Payer: Blue Shield of California EPN |
$21.75
|
| Rate for Payer: Cash Price |
$16.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.50
|
| Rate for Payer: Dignity Health Senior |
$31.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.94
|
| Rate for Payer: Heritage Provider Network Senior |
$22.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$27.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.50
|
| Rate for Payer: Vantage Medical Group Senior |
$31.50
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 0713-0280-31
|
| Hospital Charge Code |
1743006
|
|
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: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| 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 |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
NDC 45802-060-03
|
| Hospital Charge Code |
1743006
|
|
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: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| 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
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 68001-477-47
|
| Hospital Charge Code |
1743006
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| 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 Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
OP
|
$0.11
|
|
|
Service Code
|
NDC 45802-060-03
|
| Hospital Charge Code |
1743006
|
|
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 |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 |
$0.07
|
| 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 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: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 45802-060-01
|
| Hospital Charge Code |
1719221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 68001-477-47
|
| Hospital Charge Code |
1743006
|
|
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: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| 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 |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 0536-1256-28
|
| Hospital Charge Code |
NDG850B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 0713-0280-31
|
| Hospital Charge Code |
1743006
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| 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 Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 45802-060-01
|
| Hospital Charge Code |
1719221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 0536-1256-28
|
| Hospital Charge Code |
NDG850B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 68001-477-48
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 68001-477-45
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 68001-477-45
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 45802-060-70
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 45802-060-00
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 68001-477-48
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 45802-060-00
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [115118]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 45802-060-70
|
| Hospital Charge Code |
1743769
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [856]
|
Facility
IP
|
$4.77
|
|
|
Service Code
|
NDC 17478-238-35
|
| Hospital Charge Code |
1740295
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.28
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.23
|
| Rate for Payer: Heritage Provider Network Senior |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.58
|
|
