|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM
|
Facility
|
IP
|
$18,153.87
|
|
|
Service Code
|
APR-DRG 0493
|
| Min. Negotiated Rate |
$18,153.87 |
| Max. Negotiated Rate |
$18,153.87 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,153.87
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 0065-0800-50
|
| Hospital Charge Code |
1740393
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 0065-0800-50
|
| Hospital Charge Code |
1740393
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0065-0795-50
|
| Hospital Charge Code |
NDG10781
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0065-0795-50
|
| Hospital Charge Code |
NDG10781
|
|
Hospital Revenue Code
|
250
|
| 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: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care 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: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0065-1795-04
|
| Hospital Charge Code |
NDG10781
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0065-1795-04
|
| Hospital Charge Code |
NDG10781
|
|
Hospital Revenue Code
|
250
|
| 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: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care 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: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 0065-0795-15
|
| Hospital Charge Code |
1740041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 0065-0795-15
|
| Hospital Charge Code |
1740041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: Dignity Health Senior |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.6 EYE [118648]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 59390-175-13
|
| Hospital Charge Code |
NDG118648
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| 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 |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.6 EYE [118648]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 59390-175-13
|
| Hospital Charge Code |
NDG118648
|
|
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 |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 50268-102-11
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.85
|
| Rate for Payer: Dignity Health Senior |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| 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 |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Senior |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1.85
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 0054-0079-28
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Senior |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
NDC 50268-102-13
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.85
|
| Rate for Payer: Dignity Health Senior |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| 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 |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Senior |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1.85
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
NDC 50268-102-11
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 0378-6750-82
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
NDC 50268-102-13
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.50
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.64
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 0054-0079-28
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
BALSALAZIDE 750 MG CAPSULE [29299]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 0378-6750-82
|
| Hospital Charge Code |
1711983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Senior |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 58980-780-50
|
| Hospital Charge Code |
NDG203027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Senior |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Senior |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 58980-780-50
|
| Hospital Charge Code |
NDG203027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.03
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 9468808470
|
| Hospital Charge Code |
ERX37930
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Senior |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
|
|
BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 9468808470
|
| Hospital Charge Code |
ERX37930
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
OP
|
$104.88
|
|
|
Service Code
|
NDC 0002-4732-30
|
| Hospital Charge Code |
ERX225594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$89.15 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$78.66
|
| Rate for Payer: Blue Shield of California Commercial |
$65.13
|
| Rate for Payer: Blue Shield of California EPN |
$61.56
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$68.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.15
|
| Rate for Payer: Dignity Health Senior |
$89.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.92
|
| Rate for Payer: Heritage Provider Network Senior |
$64.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$50.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$78.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.95
|
| Rate for Payer: TriValley Medical Group Senior |
$41.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.15
|
| Rate for Payer: Vantage Medical Group Senior |
$89.15
|
|
|
BARICITINIB 1 MG TABLET [225594]
|
Facility
|
IP
|
$104.88
|
|
|
Service Code
|
NDC 0002-4732-30
|
| Hospital Charge Code |
ERX225594
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$78.66 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.05
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.00
|
| Rate for Payer: Heritage Provider Network Senior |
$71.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$78.66
|
|
