|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
IP
|
$0.51
|
|
|
Service Code
|
NDC 0409-3307-03
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
OP
|
$0.73
|
|
|
Service Code
|
NDC 63323-691-30
|
| Hospital Charge Code |
NDG122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
| Rate for Payer: Dignity Health Senior |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Vantage Medical Group Senior |
$0.62
|
|
|
ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]
|
Facility
OP
|
$3.36
|
|
|
Service Code
|
NDC 63323-695-04
|
| Hospital Charge Code |
1781091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Senior |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
IP
|
$4.40
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1721126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.02
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$5.08
|
| Rate for Payer: Heritage Provider Network Senior |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$5.64
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.47
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [38303]
|
Facility
OP
|
$7.52
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1721126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$23.96 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$2.08
|
| Rate for Payer: Blue Shield of California EPN |
$2.08
|
| Rate for Payer: Blue Shield of California EPN |
$2.08
|
| Rate for Payer: Blue Shield of California EPN |
$2.08
|
| Rate for Payer: Blue Shield of California EPN |
$2.08
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.38
|
| Rate for Payer: Dignity Health Senior |
$6.38
|
| Rate for Payer: Dignity Health Senior |
$1.26
|
| Rate for Payer: Dignity Health Senior |
$3.74
|
| Rate for Payer: Dignity Health Senior |
$6.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$3.48
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$5.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.39
|
| Rate for Payer: Vantage Medical Group Senior |
$3.74
|
| Rate for Payer: Vantage Medical Group Senior |
$6.38
|
| Rate for Payer: Vantage Medical Group Senior |
$1.26
|
| Rate for Payer: Vantage Medical Group Senior |
$6.39
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1744013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$23.96 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
IP
|
$4.20
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1781092
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
OP
|
$3.60
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1781092
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$23.96 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$2.24
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.47
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$1.53
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: IEHP Medi-Cal |
$8.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [123]
|
Facility
IP
|
$0.91
|
|
|
Service Code
|
CPT J0132
|
| Hospital Charge Code |
1744013
|
|
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: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE [118614]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 7985404097
|
| Hospital Charge Code |
1710863
|
|
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
|
|
|
ACETYLCYSTEINE 600 MG CAPSULE [118614]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 7985404097
|
| Hospital Charge Code |
1710863
|
|
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
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]
|
Facility
IP
|
$0.35
|
|
|
Service Code
|
NDC 9994-0804-15
|
| Hospital Charge Code |
1715996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 100 MG/ML (10%) [4080415]
|
Facility
OP
|
$0.35
|
|
|
Service Code
|
NDC 9994-0804-15
|
| Hospital Charge Code |
1715996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]
|
Facility
IP
|
$3.84
|
|
|
Service Code
|
NDC 9994-0802-35
|
| Hospital Charge Code |
1715121
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
|
|
ACETYLCYSTEINE ORAL SOLUTION 200 MG/ML (20%) [4080235]
|
Facility
OP
|
$3.84
|
|
|
Service Code
|
NDC 9994-0802-35
|
| Hospital Charge Code |
1715121
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.88
|
| Rate for Payer: Blue Shield of California Commercial |
$2.38
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.26
|
| Rate for Payer: Dignity Health Senior |
$3.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.26
|
|
|
ACETYLCYSTEINE ORAL SOLUTION COMPOUND 50 MG/ML (5%) [4080234]
|
Facility
IP
|
$0.58
|
|
|
Service Code
|
NDC 9994-0802-34
|
| Hospital Charge Code |
1715221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
ACETYLCYSTEINE ORAL SOLUTION COMPOUND 50 MG/ML (5%) [4080234]
|
Facility
OP
|
$0.58
|
|
|
Service Code
|
NDC 9994-0802-34
|
| Hospital Charge Code |
1715221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
ACITRETIN 25 MG CAPSULE [13979]
|
Facility
OP
|
$18.46
|
|
|
Service Code
|
NDC 0115-1753-08
|
| Hospital Charge Code |
ERX13979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$15.69 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.84
|
| Rate for Payer: Blue Shield of California Commercial |
$11.46
|
| Rate for Payer: Blue Shield of California EPN |
$10.84
|
| Rate for Payer: Cash Price |
$8.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.69
|
| Rate for Payer: Dignity Health Senior |
$15.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.43
|
| Rate for Payer: Heritage Provider Network Senior |
$11.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$13.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.69
|
| Rate for Payer: Vantage Medical Group Senior |
$15.69
|
|
|
ACITRETIN 25 MG CAPSULE [13979]
|
Facility
IP
|
$18.46
|
|
|
Service Code
|
NDC 0115-1753-08
|
| Hospital Charge Code |
ERX13979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$13.84 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.68
|
| Rate for Payer: Cash Price |
$8.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.50
|
| Rate for Payer: Heritage Provider Network Senior |
$12.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.62
|
| Rate for Payer: Multiplan Commercial |
$13.84
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [117013]
|
Facility
OP
|
$0.13
|
|
|
Service Code
|
NDC 0574-0521-74
|
| Hospital Charge Code |
1719162
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| 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 |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION [117013]
|
Facility
IP
|
$0.13
|
|
|
Service Code
|
NDC 0574-0521-74
|
| Hospital Charge Code |
1719162
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| 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 Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 66689-201-08
|
| Hospital Charge Code |
1719161
|
|
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
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 0574-0521-76
|
| Hospital Charge Code |
1719161
|
|
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
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0574-0521-76
|
| Hospital Charge Code |
1719161
|
|
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
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 66689-201-08
|
| Hospital Charge Code |
1719161
|
|
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
|
|
