|
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION [21880]
|
Facility
OP
|
$39.56
|
|
|
Service Code
|
CPT J0476
|
| Hospital Charge Code |
1757066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$154.45 |
| Rate for Payer: Adventist Health Commercial |
$7.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$91.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$33.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$29.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$154.45
|
| Rate for Payer: Blue Shield of California Commercial |
$15.36
|
| Rate for Payer: Blue Shield of California EPN |
$15.36
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.63
|
| Rate for Payer: Dignity Health Senior |
$33.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.32
|
| Rate for Payer: Heritage Provider Network Senior |
$18.32
|
| Rate for Payer: IEHP Medi-Cal |
$65.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.89
|
| Rate for Payer: Multiplan Commercial |
$29.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.63
|
| Rate for Payer: Vantage Medical Group Senior |
$33.63
|
|
|
BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0802-46
|
| Hospital Charge Code |
1715278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0802-46
|
| Hospital Charge Code |
1715278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM
|
Facility
IP
|
$16,296.40
|
|
|
Service Code
|
APR-DRG 0492
|
| Min. Negotiated Rate |
$16,296.40 |
| Max. Negotiated Rate |
$16,296.40 |
| Rate for Payer: IEHP Medi-Cal |
$16,296.40
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM
|
Facility
IP
|
$30,387.11
|
|
|
Service Code
|
APR-DRG 0494
|
| Min. Negotiated Rate |
$30,387.11 |
| Max. Negotiated Rate |
$30,387.11 |
| Rate for Payer: IEHP Medi-Cal |
$30,387.11
|
|
|
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: IEHP Medi-Cal |
$18,153.87
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM
|
Facility
IP
|
$8,214.86
|
|
|
Service Code
|
APR-DRG 0491
|
| Min. Negotiated Rate |
$8,214.86 |
| Max. Negotiated Rate |
$8,214.86 |
| Rate for Payer: IEHP Medi-Cal |
$8,214.86
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare 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: 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
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: AlphaCare Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
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
|
$0.08
|
|
|
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: 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
|
|
|
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
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 0065-1795-04
|
| 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: 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
|
|
|
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: 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 |
$0.06
|
| 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: 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
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
|
$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: AlphaCare Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: AlphaCare 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: 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: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare 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: 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: AlphaCare Medical Group Commercial/Exchange |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.20
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1.85
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
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
|
$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
|
|
