|
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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: AlphaCare 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
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DB60ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168ZA
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D164JB
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168JL
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D164ZL
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168K9
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DB68Z3
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DB68ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D160Z9
|
| Min. Negotiated Rate |
$11,586.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,586.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D1647A
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,586.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168KL
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DT74ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DB60Z3
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D164ZB
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168J9
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D1607B
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DQ63ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D168KA
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DB64ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0DB67ZZ
|
| Min. Negotiated Rate |
$17,388.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
|
|
Bariatric Surgery
|
Facility
IP
|
$17,388.00
|
|
|
Service Code
|
ICD 0D164K9
|
| Min. Negotiated Rate |
$10,600.00 |
| Max. Negotiated Rate |
$17,388.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$17,388.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,600.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,586.00
|
|
