|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]
|
Facility
OP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$32.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.26
|
| Rate for Payer: BCBS Transplant Transplant |
$35.61
|
| Rate for Payer: Blue Shield of California Commercial |
$43.74
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO |
$41.54
|
| Rate for Payer: Cigna of CA PPO |
$41.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.45
|
| Rate for Payer: Dignity Health Media |
$50.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.74
|
| Rate for Payer: Galaxy Health WC |
$50.45
|
| Rate for Payer: Global Benefits Group Commercial |
$35.61
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$44.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.24
|
| Rate for Payer: Multiplan Commercial |
$47.48
|
| Rate for Payer: Networks By Design Commercial |
$29.68
|
| Rate for Payer: Prime Health Services Commercial |
$50.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.68
|
| Rate for Payer: United Healthcare All Other HMO |
$29.68
|
| Rate for Payer: United Healthcare HMO Rider |
$29.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.45
|
| Rate for Payer: Vantage Medical Group Senior |
$50.45
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]
|
Facility
OP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$32.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.26
|
| Rate for Payer: BCBS Transplant Transplant |
$35.61
|
| Rate for Payer: Blue Shield of California Commercial |
$43.74
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO |
$41.54
|
| Rate for Payer: Cigna of CA PPO |
$41.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.45
|
| Rate for Payer: Dignity Health Media |
$50.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.74
|
| Rate for Payer: Galaxy Health WC |
$50.45
|
| Rate for Payer: Global Benefits Group Commercial |
$35.61
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$44.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.24
|
| Rate for Payer: Multiplan Commercial |
$47.48
|
| Rate for Payer: Networks By Design Commercial |
$29.68
|
| Rate for Payer: Prime Health Services Commercial |
$50.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.68
|
| Rate for Payer: United Healthcare All Other HMO |
$29.68
|
| Rate for Payer: United Healthcare HMO Rider |
$29.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.45
|
| Rate for Payer: Vantage Medical Group Senior |
$50.45
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]
|
Facility
IP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.24 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Blue Shield of California Commercial |
$42.26
|
| Rate for Payer: Blue Shield of California EPN |
$30.39
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO |
$41.54
|
| Rate for Payer: Cigna of CA PPO |
$41.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.74
|
| Rate for Payer: Galaxy Health WC |
$50.45
|
| Rate for Payer: Global Benefits Group Commercial |
$35.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.24
|
| Rate for Payer: Multiplan Commercial |
$47.48
|
| Rate for Payer: Networks By Design Commercial |
$29.68
|
| Rate for Payer: Prime Health Services Commercial |
$50.45
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
OP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.11
|
| Rate for Payer: BCBS Transplant Transplant |
$20.26
|
| Rate for Payer: Blue Shield of California Commercial |
$24.88
|
| Rate for Payer: Blue Shield of California EPN |
$19.72
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cigna of CA HMO |
$23.63
|
| Rate for Payer: Cigna of CA PPO |
$23.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.70
|
| Rate for Payer: Dignity Health Media |
$28.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.50
|
| Rate for Payer: Galaxy Health WC |
$28.70
|
| Rate for Payer: Global Benefits Group Commercial |
$20.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$25.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.10
|
| Rate for Payer: Multiplan Commercial |
$27.01
|
| Rate for Payer: Networks By Design Commercial |
$21.94
|
| Rate for Payer: Prime Health Services Commercial |
$28.70
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$20.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.88
|
| Rate for Payer: United Healthcare All Other HMO |
$16.88
|
| Rate for Payer: United Healthcare HMO Rider |
$16.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.70
|
| Rate for Payer: Vantage Medical Group Senior |
$28.70
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
OP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$31.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.60
|
| Rate for Payer: BCBS Transplant Transplant |
$28.80
|
| Rate for Payer: Blue Shield of California Commercial |
$35.38
|
| Rate for Payer: Blue Shield of California EPN |
$28.03
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Media |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Networks By Design Commercial |
$31.20
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Other HMO |
$24.00
|
| Rate for Payer: United Healthcare HMO Rider |
$24.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
IP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Blue Shield of California Commercial |
$57.57
|
| Rate for Payer: Blue Shield of California EPN |
$41.40
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO |
$56.60
|
| Rate for Payer: Cigna of CA PPO |
$56.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.34
|
| Rate for Payer: Galaxy Health WC |
$68.72
|
| Rate for Payer: Global Benefits Group Commercial |
$48.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.40
|
| Rate for Payer: Multiplan Commercial |
$64.68
|
| Rate for Payer: Networks By Design Commercial |
$52.55
|
| Rate for Payer: Prime Health Services Commercial |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
IP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Blue Shield of California Commercial |
$34.18
|
| Rate for Payer: Blue Shield of California EPN |
$24.58
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Networks By Design Commercial |
$31.20
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
IP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-94
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Blue Shield of California Commercial |
$57.57
|
| Rate for Payer: Blue Shield of California EPN |
$41.40
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO |
$56.60
|
| Rate for Payer: Cigna of CA PPO |
$56.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.34
|
| Rate for Payer: Galaxy Health WC |
$68.72
|
| Rate for Payer: Global Benefits Group Commercial |
$48.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.40
|
| Rate for Payer: Multiplan Commercial |
$64.68
|
| Rate for Payer: Networks By Design Commercial |
$52.55
|
| Rate for Payer: Prime Health Services Commercial |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$44.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.17
|
| Rate for Payer: BCBS Transplant Transplant |
$48.51
|
| Rate for Payer: Blue Shield of California Commercial |
$59.59
|
| Rate for Payer: Blue Shield of California EPN |
$47.22
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO |
$56.60
|
| Rate for Payer: Cigna of CA PPO |
$56.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.72
|
| Rate for Payer: Dignity Health Media |
$68.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.34
|
| Rate for Payer: Galaxy Health WC |
$68.72
|
| Rate for Payer: Global Benefits Group Commercial |
$48.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$60.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.40
|
| Rate for Payer: Multiplan Commercial |
$64.68
|
| Rate for Payer: Networks By Design Commercial |
$52.55
|
| Rate for Payer: Prime Health Services Commercial |
$68.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$48.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$48.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$48.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.42
|
| Rate for Payer: United Healthcare All Other HMO |
$40.42
|
| Rate for Payer: United Healthcare HMO Rider |
$40.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$40.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-94
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$44.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.17
|
| Rate for Payer: BCBS Transplant Transplant |
$48.51
|
| Rate for Payer: Blue Shield of California Commercial |
$59.59
|
| Rate for Payer: Blue Shield of California EPN |
$47.22
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO |
$56.60
|
| Rate for Payer: Cigna of CA PPO |
$56.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.72
|
| Rate for Payer: Dignity Health Media |
$68.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.34
|
| Rate for Payer: Galaxy Health WC |
$68.72
|
| Rate for Payer: Global Benefits Group Commercial |
$48.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$60.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.40
|
| Rate for Payer: Multiplan Commercial |
$64.68
|
| Rate for Payer: Networks By Design Commercial |
$52.55
|
| Rate for Payer: Prime Health Services Commercial |
$68.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$48.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$48.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$48.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.42
|
| Rate for Payer: United Healthcare All Other HMO |
$40.42
|
| Rate for Payer: United Healthcare HMO Rider |
$40.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$40.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
IP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Blue Shield of California Commercial |
$24.04
|
| Rate for Payer: Blue Shield of California EPN |
$17.29
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cigna of CA HMO |
$23.63
|
| Rate for Payer: Cigna of CA PPO |
$23.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.50
|
| Rate for Payer: Galaxy Health WC |
$28.70
|
| Rate for Payer: Global Benefits Group Commercial |
$20.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.10
|
| Rate for Payer: Multiplan Commercial |
$27.01
|
| Rate for Payer: Networks By Design Commercial |
$21.94
|
| Rate for Payer: Prime Health Services Commercial |
$28.70
|
|
|
PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [231930]
|
Facility
IP
|
$4,738.00
|
|
|
Service Code
|
CPT A9595
|
| Hospital Charge Code |
ERX231930
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,137.12 |
| Max. Negotiated Rate |
$4,027.30 |
| Rate for Payer: Blue Shield of California Commercial |
$3,373.46
|
| Rate for Payer: Blue Shield of California EPN |
$2,425.86
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,895.20
|
| Rate for Payer: Galaxy Health WC |
$4,027.30
|
| Rate for Payer: Global Benefits Group Commercial |
$2,842.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,160.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,805.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,137.12
|
| Rate for Payer: Multiplan Commercial |
$3,790.40
|
| Rate for Payer: Networks By Design Commercial |
$3,079.70
|
| Rate for Payer: Prime Health Services Commercial |
$4,027.30
|
|
|
PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [231930]
|
Facility
OP
|
$4,738.00
|
|
|
Service Code
|
CPT A9595
|
| Hospital Charge Code |
ERX231930
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$580.35 |
| Max. Negotiated Rate |
$4,027.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,791.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$870.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$638.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$580.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,089.43
|
| Rate for Payer: BCBS Transplant Transplant |
$2,842.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2,800.16
|
| Rate for Payer: Blue Shield of California EPN |
$2,222.12
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: Cigna of CA HMO |
$3,032.32
|
| Rate for Payer: Cigna of CA PPO |
$3,506.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$725.44
|
| Rate for Payer: Dignity Health Media |
$638.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$638.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$783.48
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$580.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$580.35
|
| Rate for Payer: Galaxy Health WC |
$4,027.30
|
| Rate for Payer: Global Benefits Group Commercial |
$2,842.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3,553.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$951.78
|
| Rate for Payer: Heritage Provider Network Transplant |
$951.78
|
| Rate for Payer: IEHP Medi-Cal |
$940.17
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$940.17
|
| Rate for Payer: IEHP Medicare Advantage |
$580.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,160.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,048.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$580.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,137.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$731.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$777.67
|
| Rate for Payer: Multiplan Commercial |
$3,790.40
|
| Rate for Payer: Networks By Design Commercial |
$3,079.70
|
| Rate for Payer: Prime Health Services Commercial |
$4,027.30
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2,842.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,842.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,842.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,369.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2,369.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,369.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,369.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$725.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$638.39
|
| Rate for Payer: Vantage Medical Group Senior |
$638.39
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
OP
|
$5.05
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.01
|
| Rate for Payer: BCBS Transplant Transplant |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.72
|
| Rate for Payer: Blue Shield of California EPN |
$2.95
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$3.54
|
| Rate for Payer: Cigna of CA PPO |
$3.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.29
|
| Rate for Payer: Dignity Health Media |
$4.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.02
|
| Rate for Payer: Galaxy Health WC |
$4.29
|
| Rate for Payer: Global Benefits Group Commercial |
$3.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.04
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Prime Health Services Commercial |
$4.29
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO |
$2.52
|
| Rate for Payer: United Healthcare HMO Rider |
$2.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4.29
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
IP
|
$5.05
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Blue Shield of California Commercial |
$3.60
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$3.54
|
| Rate for Payer: Cigna of CA PPO |
$3.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Galaxy Health WC |
$4.29
|
| Rate for Payer: Global Benefits Group Commercial |
$3.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.04
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Prime Health Services Commercial |
$4.29
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
IP
|
$5.94
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Blue Shield of California Commercial |
$4.23
|
| Rate for Payer: Blue Shield of California EPN |
$3.04
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO |
$4.16
|
| Rate for Payer: Cigna of CA PPO |
$4.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Galaxy Health WC |
$5.05
|
| Rate for Payer: Global Benefits Group Commercial |
$3.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Networks By Design Commercial |
$3.86
|
| Rate for Payer: Prime Health Services Commercial |
$5.05
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
OP
|
$5.94
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.54
|
| Rate for Payer: BCBS Transplant Transplant |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$4.38
|
| Rate for Payer: Blue Shield of California EPN |
$3.47
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO |
$4.16
|
| Rate for Payer: Cigna of CA PPO |
$4.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.05
|
| Rate for Payer: Dignity Health Media |
$5.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.38
|
| Rate for Payer: Galaxy Health WC |
$5.05
|
| Rate for Payer: Global Benefits Group Commercial |
$3.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Networks By Design Commercial |
$3.86
|
| Rate for Payer: Prime Health Services Commercial |
$5.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.97
|
| Rate for Payer: United Healthcare All Other HMO |
$2.97
|
| Rate for Payer: United Healthcare HMO Rider |
$2.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.05
|
| Rate for Payer: Vantage Medical Group Senior |
$5.05
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
OP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.76
|
| Rate for Payer: BCBS Transplant Transplant |
$3.79
|
| Rate for Payer: Blue Shield of California Commercial |
$4.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.69
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.42
|
| Rate for Payer: Cigna of CA PPO |
$4.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Media |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.52
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.16
|
| Rate for Payer: United Healthcare All Other HMO |
$3.16
|
| Rate for Payer: United Healthcare HMO Rider |
$3.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
IP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.42
|
| Rate for Payer: Cigna of CA PPO |
$4.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
IP
|
$6.45
|
|
|
Service Code
|
NDC 61314-204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$5.48 |
| Rate for Payer: Blue Shield of California Commercial |
$4.59
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cigna of CA HMO |
$4.52
|
| Rate for Payer: Cigna of CA PPO |
$4.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.58
|
| Rate for Payer: Galaxy Health WC |
$5.48
|
| Rate for Payer: Global Benefits Group Commercial |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: Multiplan Commercial |
$5.16
|
| Rate for Payer: Networks By Design Commercial |
$4.19
|
| Rate for Payer: Prime Health Services Commercial |
$5.48
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
OP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.62
|
| Rate for Payer: BCBS Transplant Transplant |
$3.64
|
| Rate for Payer: Blue Shield of California Commercial |
$4.47
|
| Rate for Payer: Blue Shield of California EPN |
$3.54
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cigna of CA HMO |
$4.25
|
| Rate for Payer: Cigna of CA PPO |
$4.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.16
|
| Rate for Payer: Dignity Health Media |
$5.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.43
|
| Rate for Payer: Galaxy Health WC |
$5.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$4.86
|
| Rate for Payer: Networks By Design Commercial |
$3.95
|
| Rate for Payer: Prime Health Services Commercial |
$5.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.04
|
| Rate for Payer: United Healthcare All Other HMO |
$3.04
|
| Rate for Payer: United Healthcare HMO Rider |
$3.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
OP
|
$6.45
|
|
|
Service Code
|
NDC 61314-204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$5.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.84
|
| Rate for Payer: BCBS Transplant Transplant |
$3.87
|
| Rate for Payer: Blue Shield of California Commercial |
$4.75
|
| Rate for Payer: Blue Shield of California EPN |
$3.77
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cigna of CA HMO |
$4.52
|
| Rate for Payer: Cigna of CA PPO |
$4.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.48
|
| Rate for Payer: Dignity Health Media |
$5.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.58
|
| Rate for Payer: Galaxy Health WC |
$5.48
|
| Rate for Payer: Global Benefits Group Commercial |
$3.87
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: Multiplan Commercial |
$5.16
|
| Rate for Payer: Networks By Design Commercial |
$4.19
|
| Rate for Payer: Prime Health Services Commercial |
$5.48
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.22
|
| Rate for Payer: United Healthcare All Other HMO |
$3.22
|
| Rate for Payer: United Healthcare HMO Rider |
$3.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Vantage Medical Group Senior |
$5.48
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
OP
|
$6.26
|
|
|
Service Code
|
NDC 17478-224-12
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.73
|
| Rate for Payer: BCBS Transplant Transplant |
$3.76
|
| Rate for Payer: Blue Shield of California Commercial |
$4.61
|
| Rate for Payer: Blue Shield of California EPN |
$3.66
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO |
$4.38
|
| Rate for Payer: Cigna of CA PPO |
$4.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.32
|
| Rate for Payer: Dignity Health Media |
$5.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.50
|
| Rate for Payer: Galaxy Health WC |
$5.32
|
| Rate for Payer: Global Benefits Group Commercial |
$3.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$5.01
|
| Rate for Payer: Networks By Design Commercial |
$4.07
|
| Rate for Payer: Prime Health Services Commercial |
$5.32
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.13
|
| Rate for Payer: United Healthcare All Other HMO |
$3.13
|
| Rate for Payer: United Healthcare HMO Rider |
$3.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.32
|
| Rate for Payer: Vantage Medical Group Senior |
$5.32
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
IP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Blue Shield of California Commercial |
$4.32
|
| Rate for Payer: Blue Shield of California EPN |
$3.11
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cigna of CA HMO |
$4.25
|
| Rate for Payer: Cigna of CA PPO |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: Galaxy Health WC |
$5.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$4.86
|
| Rate for Payer: Networks By Design Commercial |
$3.95
|
| Rate for Payer: Prime Health Services Commercial |
$5.16
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
OP
|
$7.61
|
|
|
Service Code
|
NDC 0998-0204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.53
|
| Rate for Payer: BCBS Transplant Transplant |
$4.57
|
| Rate for Payer: Blue Shield of California Commercial |
$5.61
|
| Rate for Payer: Blue Shield of California EPN |
$4.44
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.47
|
| Rate for Payer: Dignity Health Media |
$6.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.09
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.80
|
| Rate for Payer: United Healthcare All Other HMO |
$3.80
|
| Rate for Payer: United Healthcare HMO Rider |
$3.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Vantage Medical Group Senior |
$6.47
|
|
