|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
OP
|
$3.75
|
|
|
Service Code
|
NDC 7006982408
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.41
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cigna of CA HMO |
$2.62
|
| Rate for Payer: Cigna of CA PPO |
$2.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: EPIC Health Plan Senior |
$1.50
|
| Rate for Payer: Galaxy Health WC |
$3.19
|
| Rate for Payer: Global Benefits Group Commercial |
$2.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.62
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Networks By Design Commercial |
$2.44
|
| Rate for Payer: Prime Health Services Commercial |
$3.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.88
|
| Rate for Payer: United Healthcare All Other HMO |
$1.88
|
| Rate for Payer: United Healthcare HMO Rider |
$1.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.19
|
| Rate for Payer: Vantage Medical Group Senior |
$3.19
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO |
$2.38
|
| Rate for Payer: Cigna of CA PPO |
$2.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: EPIC Health Plan Senior |
$1.36
|
| Rate for Payer: Galaxy Health WC |
$2.89
|
| Rate for Payer: Global Benefits Group Commercial |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.72
|
| Rate for Payer: Networks By Design Commercial |
$2.21
|
| Rate for Payer: Prime Health Services Commercial |
$2.89
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.18
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO |
$2.38
|
| Rate for Payer: Cigna of CA PPO |
$2.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: EPIC Health Plan Senior |
$1.36
|
| Rate for Payer: Galaxy Health WC |
$2.89
|
| Rate for Payer: Global Benefits Group Commercial |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.38
|
| Rate for Payer: Multiplan Commercial |
$2.72
|
| Rate for Payer: Networks By Design Commercial |
$2.21
|
| Rate for Payer: Prime Health Services Commercial |
$2.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1.70
|
| Rate for Payer: United Healthcare HMO Rider |
$1.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.89
|
| Rate for Payer: Vantage Medical Group Senior |
$2.89
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 4612245773
|
| 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 |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| 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
|
IP
|
$6.61
|
|
|
Service Code
|
NDC 7117901860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Adventist Health Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California Commercial |
$3.35
|
| Rate for Payer: Blue Shield of California Commercial |
$5.08
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO |
$4.63
|
| Rate for Payer: Cigna of CA PPO |
$4.63
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: EPIC Health Plan Senior |
$2.64
|
| Rate for Payer: Galaxy Health WC |
$5.62
|
| Rate for Payer: Global Benefits Group Commercial |
$3.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$5.29
|
| Rate for Payer: Networks By Design Commercial |
$4.30
|
| Rate for Payer: Prime Health Services Commercial |
$5.62
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 4612245773
|
| 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: 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 |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| 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
|
OP
|
$6.61
|
|
|
Service Code
|
NDC 7117901860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Adventist Health Commercial |
$1.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO |
$4.63
|
| Rate for Payer: Cigna of CA PPO |
$4.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: EPIC Health Plan Senior |
$2.64
|
| Rate for Payer: Galaxy Health WC |
$5.62
|
| Rate for Payer: Global Benefits Group Commercial |
$3.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$5.29
|
| Rate for Payer: Networks By Design Commercial |
$4.30
|
| Rate for Payer: Prime Health Services Commercial |
$5.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.31
|
| Rate for Payer: United Healthcare All Other HMO |
$3.31
|
| Rate for Payer: United Healthcare HMO Rider |
$3.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.62
|
| Rate for Payer: Vantage Medical Group Senior |
$5.62
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$8.78 |
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| 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: Aetna of CA HMO/PPO |
$8.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.78
|
| 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 |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.62
|
| 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: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.04
|
| 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 |
$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 |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.36
|
| 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 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) 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 |
$3.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$5.54
|
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.48
|
| 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 |
$1.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| 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 Foundation Hospitals Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.25
|
| 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) ORAL (IV FORM) [4080068]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 9994080422
|
| 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 |
$2.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.08
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.36
|
| 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 9994080422
|
| 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 |
$2.57
|
| Rate for Payer: Cash Price |
$1.80
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.36
|
| 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
|
OP
|
$17.67
|
|
|
Service Code
|
NDC 6332340603
|
| 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 |
$11.34
|
| Rate for Payer: Cash Price |
$7.95
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$11.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.43
|
| 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
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 2502160203
|
| 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 |
$4.06
|
| Rate for Payer: Blue Shield of California Commercial |
$6.15
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna of CA HMO |
$5.60
|
| Rate for Payer: Cigna of CA PPO |
$5.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.72
|
| 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
|
$8.00
|
|
|
Service Code
|
NDC 2502160203
|
| 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 |
$5.13
|
| Rate for Payer: Cash Price |
$3.60
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.72
|
| 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 6332340603
|
| 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 |
$13.59
|
| Rate for Payer: Blue Shield of California Commercial |
$8.96
|
| Rate for Payer: Cash Price |
$7.95
|
| Rate for Payer: Cigna of CA HMO |
$12.37
|
| Rate for Payer: Cigna of CA PPO |
$12.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$11.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.43
|
| 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
|
OP
|
$25.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$21.40 |
| Rate for Payer: Adventist Health Commercial |
$5.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.89
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cigna of CA HMO |
$17.63
|
| Rate for Payer: Cigna of CA PPO |
$17.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$21.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$17.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.07
|
| Rate for Payer: EPIC Health Plan Senior |
$10.07
|
| Rate for Payer: Galaxy Health WC |
$21.40
|
| Rate for Payer: Global Benefits Group Commercial |
$15.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.63
|
| Rate for Payer: Multiplan Commercial |
$20.14
|
| Rate for Payer: Networks By Design Commercial |
$12.59
|
| Rate for Payer: Prime Health Services Commercial |
$21.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.45
|
| Rate for Payer: United Healthcare All Other HMO |
$9.20
|
| Rate for Payer: United Healthcare HMO Rider |
$9.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.40
|
| Rate for Payer: Vantage Medical Group Senior |
$21.40
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
IP
|
$25.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$21.40 |
| Rate for Payer: Adventist Health Commercial |
$5.04
|
| Rate for Payer: Blue Shield of California Commercial |
$12.77
|
| Rate for Payer: Blue Shield of California Commercial |
$19.36
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cigna of CA HMO |
$17.63
|
| Rate for Payer: Cigna of CA PPO |
$17.63
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$17.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.07
|
| Rate for Payer: EPIC Health Plan Senior |
$10.07
|
| Rate for Payer: Galaxy Health WC |
$21.40
|
| Rate for Payer: Global Benefits Group Commercial |
$15.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.04
|
| Rate for Payer: Multiplan Commercial |
$20.14
|
| Rate for Payer: Networks By Design Commercial |
$12.59
|
| Rate for Payer: Prime Health Services Commercial |
$21.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.45
|
| Rate for Payer: United Healthcare All Other HMO |
$9.20
|
| Rate for Payer: United Healthcare HMO Rider |
$9.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.25
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0395041396
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0904253321
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$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 Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0395041396
|
| 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 Commercial |
$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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0904253321
|
| 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: 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
|
|
CALASPARGASE PEGOL-MKNL 750 UNIT/ML INTRAVENOUS SOLUTION [225926]
|
Facility
|
IP
|
$7,317.11
|
|
|
Service Code
|
HCPCS J9118
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,463.42 |
| Max. Negotiated Rate |
$6,219.54 |
| Rate for Payer: Adventist Health Commercial |
$1,463.42
|
| Rate for Payer: Blue Shield of California Commercial |
$3,709.77
|
| Rate for Payer: Blue Shield of California Commercial |
$5,626.86
|
| Rate for Payer: Cash Price |
$3,292.70
|
| Rate for Payer: Cigna of CA HMO |
$5,121.98
|
| Rate for Payer: Cigna of CA PPO |
$5,121.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5,121.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,926.84
|
| Rate for Payer: EPIC Health Plan Senior |
$2,926.84
|
| Rate for Payer: Galaxy Health WC |
$6,219.54
|
| Rate for Payer: Global Benefits Group Commercial |
$4,390.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4,646.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,317.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,756.11
|
| Rate for Payer: Multiplan Commercial |
$5,853.69
|
| Rate for Payer: Networks By Design Commercial |
$3,658.55
|
| Rate for Payer: Prime Health Services Commercial |
$6,219.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,746.11
|
| Rate for Payer: United Healthcare All Other HMO |
$2,672.94
|
| Rate for Payer: United Healthcare HMO Rider |
$2,615.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,396.35
|
|
|
CALASPARGASE PEGOL-MKNL 750 UNIT/ML INTRAVENOUS SOLUTION [225926]
|
Facility
|
OP
|
$7,317.11
|
|
|
Service Code
|
HCPCS J9118
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.79 |
| Max. Negotiated Rate |
$6,219.54 |
| Rate for Payer: Adventist Health Commercial |
$1,463.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$150.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$128.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$94.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$165.57
|
| Rate for Payer: Blue Shield of California Commercial |
$86.63
|
| Rate for Payer: Cash Price |
$3,292.70
|
| Rate for Payer: Cash Price |
$3,292.70
|
| Rate for Payer: Cigna of CA HMO |
$5,121.98
|
| Rate for Payer: Cigna of CA PPO |
$5,121.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$128.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$94.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$85.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5,121.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.55
|
| Rate for Payer: EPIC Health Plan Senior |
$94.37
|
| Rate for Payer: Galaxy Health WC |
$6,219.54
|
| Rate for Payer: Global Benefits Group Commercial |
$4,390.27
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$140.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$85.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$85.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4,646.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$155.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$120.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,756.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$108.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$114.96
|
| Rate for Payer: Multiplan Commercial |
$5,853.69
|
| Rate for Payer: Networks By Design Commercial |
$3,658.55
|
| Rate for Payer: Prime Health Services Commercial |
$6,219.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,390.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,390.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,746.11
|
| Rate for Payer: United Healthcare All Other HMO |
$2,672.94
|
| Rate for Payer: United Healthcare HMO Rider |
$2,615.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,396.35
|
| Rate for Payer: Upland Medical Group Pediatric |
$85.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$128.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$94.37
|
| Rate for Payer: Vantage Medical Group Senior |
$85.79
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 6846250165
|
| 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 |
$2.24
|
| Rate for Payer: Blue Shield of California Commercial |
$3.39
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO |
$3.09
|
| Rate for Payer: Cigna of CA PPO |
$3.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.60
|
| 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 CREAM [16034]
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 6846250165
|
| 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 |
$2.83
|
| Rate for Payer: Cash Price |
$1.98
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$2.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.60
|
| 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
|
|
