|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
901700029
|
|
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: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California Commercial |
$5.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Senior |
$2.88
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Multiplan Commercial |
$5.76
|
| Rate for Payer: Networks By Design Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$3.60
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO |
$1.46
|
| Rate for Payer: United Healthcare HMO Rider |
$1.43
|
| Rate for Payer: United Healthcare HMO Rider |
$2.57
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.31
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.79
|
| Rate for Payer: Blue Shield of California EPN |
$1.79
|
| Rate for Payer: Blue Shield of California EPN |
$1.79
|
| Rate for Payer: Blue Shield of California EPN |
$1.79
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$1.60
|
| Rate for Payer: EPIC Health Plan Senior |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Multiplan Commercial |
$5.76
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: Networks By Design Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$3.60
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO |
$1.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.77
|
| Rate for Payer: United Healthcare HMO Rider |
$2.57
|
| Rate for Payer: United Healthcare HMO Rider |
$1.43
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1.79
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 9994-0804-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 9994-0804-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.46
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 25021-602-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$5.90
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Cash Price |
$4.40
|
| Rate for Payer: Cigna of CA HMO |
$5.60
|
| Rate for Payer: Cigna of CA PPO |
$5.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.20
|
| Rate for Payer: EPIC Health Plan Senior |
$3.20
|
| Rate for Payer: Galaxy Health WC |
$6.80
|
| Rate for Payer: Global Benefits Group Commercial |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: Networks By Design Commercial |
$5.20
|
| Rate for Payer: Prime Health Services Commercial |
$6.80
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
OP
|
$17.67
|
|
|
Service Code
|
NDC 63323-406-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: Adventist Health Commercial |
$3.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.85
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cigna of CA HMO |
$12.37
|
| Rate for Payer: Cigna of CA PPO |
$12.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.07
|
| Rate for Payer: EPIC Health Plan Senior |
$7.07
|
| Rate for Payer: Galaxy Health WC |
$15.02
|
| Rate for Payer: Global Benefits Group Commercial |
$10.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.37
|
| Rate for Payer: Multiplan Commercial |
$14.14
|
| Rate for Payer: Networks By Design Commercial |
$11.49
|
| Rate for Payer: Prime Health Services Commercial |
$15.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.84
|
| Rate for Payer: United Healthcare All Other HMO |
$8.84
|
| Rate for Payer: United Healthcare HMO Rider |
$8.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.02
|
| Rate for Payer: Vantage Medical Group Senior |
$15.02
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 25021-602-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.91
|
| Rate for Payer: Cash Price |
$4.40
|
| Rate for Payer: Cigna of CA HMO |
$5.60
|
| Rate for Payer: Cigna of CA PPO |
$5.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.20
|
| Rate for Payer: EPIC Health Plan Senior |
$3.20
|
| Rate for Payer: Galaxy Health WC |
$6.80
|
| Rate for Payer: Global Benefits Group Commercial |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.60
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: Networks By Design Commercial |
$5.20
|
| Rate for Payer: Prime Health Services Commercial |
$6.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Vantage Medical Group Senior |
$6.80
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
IP
|
$17.67
|
|
|
Service Code
|
NDC 63323-406-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: Adventist Health Commercial |
$3.53
|
| Rate for Payer: Blue Shield of California Commercial |
$13.04
|
| Rate for Payer: Blue Shield of California EPN |
$8.59
|
| Rate for Payer: Cash Price |
$9.72
|
| Rate for Payer: Cigna of CA HMO |
$12.37
|
| Rate for Payer: Cigna of CA PPO |
$12.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.07
|
| Rate for Payer: EPIC Health Plan Senior |
$7.07
|
| Rate for Payer: Galaxy Health WC |
$15.02
|
| Rate for Payer: Global Benefits Group Commercial |
$10.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.24
|
| Rate for Payer: Multiplan Commercial |
$14.14
|
| Rate for Payer: Networks By Design Commercial |
$11.49
|
| Rate for Payer: Prime Health Services Commercial |
$15.02
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
IP
|
$23.48
|
|
|
Service Code
|
NDC 0517-2502-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$19.96 |
| Rate for Payer: Adventist Health Commercial |
$4.70
|
| Rate for Payer: Blue Shield of California Commercial |
$17.33
|
| Rate for Payer: Blue Shield of California EPN |
$11.41
|
| Rate for Payer: Cash Price |
$12.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.39
|
| Rate for Payer: EPIC Health Plan Senior |
$9.39
|
| Rate for Payer: Galaxy Health WC |
$19.96
|
| Rate for Payer: Global Benefits Group Commercial |
$14.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.64
|
| Rate for Payer: Multiplan Commercial |
$18.78
|
| Rate for Payer: Networks By Design Commercial |
$15.26
|
| Rate for Payer: Prime Health Services Commercial |
$19.96
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
OP
|
$23.48
|
|
|
Service Code
|
NDC 0517-2502-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$19.96 |
| Rate for Payer: Adventist Health Commercial |
$4.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.42
|
| Rate for Payer: Cash Price |
$12.92
|
| Rate for Payer: Cigna of CA HMO |
$15.03
|
| Rate for Payer: Cigna of CA PPO |
$17.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.39
|
| Rate for Payer: EPIC Health Plan Senior |
$9.39
|
| Rate for Payer: Galaxy Health WC |
$19.96
|
| Rate for Payer: Global Benefits Group Commercial |
$14.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.44
|
| Rate for Payer: Multiplan Commercial |
$18.78
|
| Rate for Payer: Networks By Design Commercial |
$15.26
|
| Rate for Payer: Prime Health Services Commercial |
$19.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.74
|
| Rate for Payer: United Healthcare All Other HMO |
$11.74
|
| Rate for Payer: United Healthcare HMO Rider |
$11.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.96
|
| Rate for Payer: Vantage Medical Group Senior |
$19.96
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
IP
|
$23.48
|
|
|
Service Code
|
NDC 0517-2502-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$19.96 |
| Rate for Payer: Adventist Health Commercial |
$4.70
|
| Rate for Payer: Blue Shield of California Commercial |
$17.33
|
| Rate for Payer: Blue Shield of California EPN |
$11.41
|
| Rate for Payer: Cash Price |
$12.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.39
|
| Rate for Payer: EPIC Health Plan Senior |
$9.39
|
| Rate for Payer: Galaxy Health WC |
$19.96
|
| Rate for Payer: Global Benefits Group Commercial |
$14.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.64
|
| Rate for Payer: Multiplan Commercial |
$18.78
|
| Rate for Payer: Networks By Design Commercial |
$15.26
|
| Rate for Payer: Prime Health Services Commercial |
$19.96
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
OP
|
$23.48
|
|
|
Service Code
|
NDC 0517-2502-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$19.96 |
| Rate for Payer: Adventist Health Commercial |
$4.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.42
|
| Rate for Payer: Cash Price |
$12.92
|
| Rate for Payer: Cigna of CA HMO |
$15.03
|
| Rate for Payer: Cigna of CA PPO |
$17.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.39
|
| Rate for Payer: EPIC Health Plan Senior |
$9.39
|
| Rate for Payer: Galaxy Health WC |
$19.96
|
| Rate for Payer: Global Benefits Group Commercial |
$14.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.44
|
| Rate for Payer: Multiplan Commercial |
$18.78
|
| Rate for Payer: Networks By Design Commercial |
$15.26
|
| Rate for Payer: Prime Health Services Commercial |
$19.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.74
|
| Rate for Payer: United Healthcare All Other HMO |
$11.74
|
| Rate for Payer: United Healthcare HMO Rider |
$11.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.96
|
| Rate for Payer: Vantage Medical Group Senior |
$19.96
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0395-0413-96
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0904-2533-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0395-0413-96
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904-2533-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 68462-501-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.71
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO |
$3.09
|
| Rate for Payer: Cigna of CA PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: EPIC Health Plan Senior |
$1.76
|
| Rate for Payer: Galaxy Health WC |
$3.75
|
| Rate for Payer: Global Benefits Group Commercial |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.09
|
| Rate for Payer: Multiplan Commercial |
$3.53
|
| Rate for Payer: Networks By Design Commercial |
$2.87
|
| Rate for Payer: Prime Health Services Commercial |
$3.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.21
|
| Rate for Payer: United Healthcare All Other HMO |
$2.21
|
| Rate for Payer: United Healthcare HMO Rider |
$2.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Vantage Medical Group Senior |
$3.75
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 68462-501-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.25
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna of CA HMO |
$3.09
|
| Rate for Payer: Cigna of CA PPO |
$3.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: EPIC Health Plan Senior |
$1.76
|
| Rate for Payer: Galaxy Health WC |
$3.75
|
| Rate for Payer: Global Benefits Group Commercial |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$3.53
|
| Rate for Payer: Networks By Design Commercial |
$2.87
|
| Rate for Payer: Prime Health Services Commercial |
$3.75
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 66993-878-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.70
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cigna of CA HMO |
$4.22
|
| Rate for Payer: Cigna of CA PPO |
$4.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.22
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$3.02
|
| Rate for Payer: United Healthcare HMO Rider |
$3.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 66993-878-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$4.45
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cigna of CA HMO |
$4.22
|
| Rate for Payer: Cigna of CA PPO |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
