|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 0409-1660-35
|
| Hospital Charge Code |
NDG201904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 0409-1660-35
|
| Hospital Charge Code |
NDG201904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Distinction Transplant |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Media |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 0409-1660-10
|
| Hospital Charge Code |
NDG201904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
OP
|
$455.94
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX40815157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.01 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$212.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$135.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$118.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$422.75
|
| Rate for Payer: Blue Distinction Transplant |
$273.56
|
| Rate for Payer: Blue Shield of California Commercial |
$336.03
|
| Rate for Payer: Blue Shield of California EPN |
$313.14
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cigna of CA HMO |
$319.16
|
| Rate for Payer: Cigna of CA PPO |
$319.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.01
|
| Rate for Payer: Dignity Health Media |
$108.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.81
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$108.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$108.01
|
| Rate for Payer: Galaxy Health WC |
$387.55
|
| Rate for Payer: Global Benefits Group Commercial |
$273.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$341.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$177.13
|
| Rate for Payer: Heritage Provider Network Transplant |
$177.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$174.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$174.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$108.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$304.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$108.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$144.73
|
| Rate for Payer: Multiplan Commercial |
$364.75
|
| Rate for Payer: Networks By Design Commercial |
$227.97
|
| Rate for Payer: Prime Health Services Commercial |
$387.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$273.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$273.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$227.97
|
| Rate for Payer: United Healthcare All Other HMO |
$227.97
|
| Rate for Payer: United Healthcare HMO Rider |
$227.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$227.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Vantage Medical Group Senior |
$108.01
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
IP
|
$455.94
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX40815157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.43 |
| Max. Negotiated Rate |
$387.55 |
| Rate for Payer: Blue Shield of California Commercial |
$324.63
|
| Rate for Payer: Blue Shield of California EPN |
$233.44
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cigna of CA HMO |
$319.16
|
| Rate for Payer: Cigna of CA PPO |
$319.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$182.38
|
| Rate for Payer: Galaxy Health WC |
$387.55
|
| Rate for Payer: Global Benefits Group Commercial |
$273.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$304.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.43
|
| Rate for Payer: Multiplan Commercial |
$364.75
|
| Rate for Payer: Networks By Design Commercial |
$227.97
|
| Rate for Payer: Prime Health Services Commercial |
$387.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$172.16
|
| Rate for Payer: United Healthcare All Other HMO |
$168.15
|
| Rate for Payer: United Healthcare HMO Rider |
$164.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$150.46
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
OP
|
$329.11
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.99 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$212.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$135.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$118.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$422.75
|
| Rate for Payer: Blue Distinction Transplant |
$197.47
|
| Rate for Payer: Blue Shield of California Commercial |
$242.55
|
| Rate for Payer: Blue Shield of California EPN |
$313.14
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cigna of CA HMO |
$230.38
|
| Rate for Payer: Cigna of CA PPO |
$230.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.01
|
| Rate for Payer: Dignity Health Media |
$108.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.81
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$108.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$108.01
|
| Rate for Payer: Galaxy Health WC |
$279.74
|
| Rate for Payer: Global Benefits Group Commercial |
$197.47
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$246.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$177.13
|
| Rate for Payer: Heritage Provider Network Transplant |
$177.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$174.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$174.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$108.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$108.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$144.73
|
| Rate for Payer: Multiplan Commercial |
$263.29
|
| Rate for Payer: Networks By Design Commercial |
$164.56
|
| Rate for Payer: Prime Health Services Commercial |
$279.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$197.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$197.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$164.56
|
| Rate for Payer: United Healthcare All Other HMO |
$164.56
|
| Rate for Payer: United Healthcare HMO Rider |
$164.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$164.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Vantage Medical Group Senior |
$108.01
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
IP
|
$329.11
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.99 |
| Max. Negotiated Rate |
$279.74 |
| Rate for Payer: Blue Shield of California Commercial |
$234.33
|
| Rate for Payer: Blue Shield of California EPN |
$168.50
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cigna of CA HMO |
$230.38
|
| Rate for Payer: Cigna of CA PPO |
$230.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$131.64
|
| Rate for Payer: Galaxy Health WC |
$279.74
|
| Rate for Payer: Global Benefits Group Commercial |
$197.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.99
|
| Rate for Payer: Multiplan Commercial |
$263.29
|
| Rate for Payer: Networks By Design Commercial |
$164.56
|
| Rate for Payer: Prime Health Services Commercial |
$279.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$124.27
|
| Rate for Payer: United Healthcare All Other HMO |
$121.38
|
| Rate for Payer: United Healthcare HMO Rider |
$118.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$108.61
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION [15157]
|
Facility
|
IP
|
$478.80
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.91 |
| Max. Negotiated Rate |
$406.98 |
| Rate for Payer: Blue Shield of California Commercial |
$340.91
|
| Rate for Payer: Blue Shield of California Commercial |
$468.65
|
| Rate for Payer: Blue Shield of California EPN |
$245.15
|
| Rate for Payer: Blue Shield of California EPN |
$337.00
|
| Rate for Payer: Cash Price |
$215.46
|
| Rate for Payer: Cash Price |
$296.19
|
| Rate for Payer: Cigna of CA HMO |
$335.16
|
| Rate for Payer: Cigna of CA HMO |
$460.75
|
| Rate for Payer: Cigna of CA PPO |
$460.75
|
| Rate for Payer: Cigna of CA PPO |
$335.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$263.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$191.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$263.28
|
| Rate for Payer: Galaxy Health WC |
$406.98
|
| Rate for Payer: Galaxy Health WC |
$559.48
|
| Rate for Payer: Global Benefits Group Commercial |
$394.93
|
| Rate for Payer: Global Benefits Group Commercial |
$287.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$439.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$319.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$250.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$114.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.97
|
| Rate for Payer: Multiplan Commercial |
$383.04
|
| Rate for Payer: Multiplan Commercial |
$526.57
|
| Rate for Payer: Networks By Design Commercial |
$239.40
|
| Rate for Payer: Networks By Design Commercial |
$329.10
|
| Rate for Payer: Prime Health Services Commercial |
$406.98
|
| Rate for Payer: Prime Health Services Commercial |
$559.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$180.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$248.54
|
| Rate for Payer: United Healthcare All Other HMO |
$176.58
|
| Rate for Payer: United Healthcare All Other HMO |
$242.75
|
| Rate for Payer: United Healthcare HMO Rider |
$172.75
|
| Rate for Payer: United Healthcare HMO Rider |
$237.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$158.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$217.21
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION [15157]
|
Facility
|
OP
|
$478.80
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.01 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$212.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$212.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$135.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$135.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$118.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$118.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$422.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$422.75
|
| Rate for Payer: Blue Distinction Transplant |
$394.93
|
| Rate for Payer: Blue Distinction Transplant |
$287.28
|
| Rate for Payer: Blue Shield of California Commercial |
$485.10
|
| Rate for Payer: Blue Shield of California Commercial |
$352.88
|
| Rate for Payer: Blue Shield of California EPN |
$313.14
|
| Rate for Payer: Blue Shield of California EPN |
$313.14
|
| Rate for Payer: Cash Price |
$296.19
|
| Rate for Payer: Cash Price |
$215.46
|
| Rate for Payer: Cash Price |
$296.19
|
| Rate for Payer: Cash Price |
$215.46
|
| Rate for Payer: Cigna of CA HMO |
$460.75
|
| Rate for Payer: Cigna of CA HMO |
$335.16
|
| Rate for Payer: Cigna of CA PPO |
$335.16
|
| Rate for Payer: Cigna of CA PPO |
$460.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.01
|
| Rate for Payer: Dignity Health Media |
$108.01
|
| Rate for Payer: Dignity Health Media |
$108.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.81
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$108.01
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$108.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$108.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$108.01
|
| Rate for Payer: Galaxy Health WC |
$406.98
|
| Rate for Payer: Galaxy Health WC |
$559.48
|
| Rate for Payer: Global Benefits Group Commercial |
$287.28
|
| Rate for Payer: Global Benefits Group Commercial |
$394.93
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$359.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$493.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$177.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$177.13
|
| Rate for Payer: Heritage Provider Network Transplant |
$177.13
|
| Rate for Payer: Heritage Provider Network Transplant |
$177.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$174.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$174.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$174.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$174.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$108.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$108.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$319.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$439.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$250.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$108.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$108.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$114.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$144.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$144.73
|
| Rate for Payer: Multiplan Commercial |
$383.04
|
| Rate for Payer: Multiplan Commercial |
$526.57
|
| Rate for Payer: Networks By Design Commercial |
$329.10
|
| Rate for Payer: Networks By Design Commercial |
$239.40
|
| Rate for Payer: Prime Health Services Commercial |
$406.98
|
| Rate for Payer: Prime Health Services Commercial |
$559.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$394.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$287.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$287.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$394.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$329.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$239.40
|
| Rate for Payer: United Healthcare All Other HMO |
$239.40
|
| Rate for Payer: United Healthcare All Other HMO |
$329.10
|
| Rate for Payer: United Healthcare HMO Rider |
$239.40
|
| Rate for Payer: United Healthcare HMO Rider |
$329.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$329.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$239.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Vantage Medical Group Senior |
$108.01
|
| Rate for Payer: Vantage Medical Group Senior |
$108.01
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0419-28
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0419-18
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Distinction Transplant |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Media |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0065-0416-22
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Distinction Transplant |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Media |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0419-28
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Distinction Transplant |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Media |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0065-0416-22
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 0065-8063-01
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Media |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0419-18
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 0065-0416-63
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 0065-0416-63
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Distinction Transplant |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 0065-8063-01
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]
|
Facility
|
IP
|
$3,466.32
|
|
|
Service Code
|
CPT L8604
|
| Hospital Charge Code |
NDG227990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$831.92 |
| Max. Negotiated Rate |
$12,398.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,398.00
|
| Rate for Payer: Cash Price |
$1,559.84
|
| Rate for Payer: Cash Price |
$1,559.84
|
| Rate for Payer: Cigna of CA HMO |
$2,426.42
|
| Rate for Payer: Cigna of CA PPO |
$2,426.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,386.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,386.53
|
| Rate for Payer: Galaxy Health WC |
$2,946.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2,079.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,312.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,320.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$831.92
|
| Rate for Payer: Multiplan Commercial |
$2,773.06
|
| Rate for Payer: Prime Health Services Commercial |
$2,946.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,308.88
|
| Rate for Payer: United Healthcare All Other HMO |
$1,278.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1,250.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,143.89
|
|
|
DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]
|
Facility
|
OP
|
$3,466.32
|
|
|
Service Code
|
CPT L8604
|
| Hospital Charge Code |
NDG227990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$831.92 |
| Max. Negotiated Rate |
$2,946.37 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,946.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,906.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,906.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,948.07
|
| Rate for Payer: Blue Distinction Transplant |
$2,079.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2,468.02
|
| Rate for Payer: Blue Shield of California EPN |
$1,774.76
|
| Rate for Payer: Cash Price |
$1,559.84
|
| Rate for Payer: Cigna of CA HMO |
$2,426.42
|
| Rate for Payer: Cigna of CA PPO |
$2,426.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,946.37
|
| Rate for Payer: Dignity Health Media |
$2,946.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,946.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,386.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,386.53
|
| Rate for Payer: Galaxy Health WC |
$2,946.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2,079.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,599.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,312.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$831.92
|
| Rate for Payer: Multiplan Commercial |
$2,773.06
|
| Rate for Payer: Networks By Design Commercial |
$1,733.16
|
| Rate for Payer: Prime Health Services Commercial |
$2,946.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,079.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,079.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,733.16
|
| Rate for Payer: United Healthcare All Other HMO |
$1,733.16
|
| Rate for Payer: United Healthcare HMO Rider |
$1,733.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,733.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,946.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,946.37
|
| Rate for Payer: Vantage Medical Group Senior |
$2,946.37
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0853-01
|
| Hospital Charge Code |
1730113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Distinction Transplant |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Media |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0853-01
|
| Hospital Charge Code |
1730113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0831-01
|
| Hospital Charge Code |
1731013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Distinction Transplant |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Media |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 0406-8891-01
|
| Hospital Charge Code |
1731013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Distinction Transplant |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Media |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.52
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
