|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT [3189]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 51672-1264-3
|
| Hospital Charge Code |
1743029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.51
|
| Rate for Payer: Prime Health Services Commercial |
$0.66
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT [3189]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 51672-1264-1
|
| Hospital Charge Code |
1743019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT [3189]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 52565-040-15
|
| Hospital Charge Code |
1743019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| Rate for Payer: Blue Distinction Transplant |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.26
|
| Rate for Payer: Dignity Health Media |
$1.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.26
|
| Rate for Payer: Vantage Medical Group Senior |
$1.26
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT [3189]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 52565-040-15
|
| Hospital Charge Code |
1743019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Blue Shield of California Commercial |
$1.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT [3189]
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 0093-0264-92
|
| Hospital Charge Code |
1743029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Blue Shield of California Commercial |
$3.23
|
| Rate for Payer: Blue Shield of California EPN |
$2.32
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO |
$3.17
|
| Rate for Payer: Cigna of CA PPO |
$3.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: Galaxy Health WC |
$3.85
|
| Rate for Payer: Global Benefits Group Commercial |
$2.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$3.62
|
| Rate for Payer: Networks By Design Commercial |
$2.94
|
| Rate for Payer: Prime Health Services Commercial |
$3.85
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT [3189]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 51672-1264-1
|
| Hospital Charge Code |
1743019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| Rate for Payer: Blue Distinction Transplant |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.26
|
| Rate for Payer: Dignity Health Media |
$1.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.18
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.26
|
| Rate for Payer: Vantage Medical Group Senior |
$1.26
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT [3189]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 51672-1264-3
|
| Hospital Charge Code |
1743029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.46
|
| Rate for Payer: Blue Distinction Transplant |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Media |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.66
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.51
|
| Rate for Payer: Prime Health Services Commercial |
$0.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO |
$0.39
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
FLUOCINONIDE 0.05 % TOPICAL OINTMENT [3189]
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 0093-0264-92
|
| Hospital Charge Code |
1743029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.70
|
| Rate for Payer: Blue Distinction Transplant |
$2.72
|
| Rate for Payer: Blue Shield of California Commercial |
$3.34
|
| Rate for Payer: Blue Shield of California EPN |
$2.65
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO |
$3.17
|
| Rate for Payer: Cigna of CA PPO |
$3.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.85
|
| Rate for Payer: Dignity Health Media |
$3.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.81
|
| Rate for Payer: Galaxy Health WC |
$3.85
|
| Rate for Payer: Global Benefits Group Commercial |
$2.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$3.62
|
| Rate for Payer: Networks By Design Commercial |
$2.94
|
| Rate for Payer: Prime Health Services Commercial |
$3.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.26
|
| Rate for Payer: United Healthcare All Other HMO |
$2.26
|
| Rate for Payer: United Healthcare HMO Rider |
$2.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.85
|
| Rate for Payer: Vantage Medical Group Senior |
$3.85
|
|
|
FLUOCINONIDE 0.05 % TOPICAL SOLUTION [3190]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 51672-1273-2
|
| Hospital Charge Code |
NDG3190
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Blue Distinction Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Media |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
FLUOCINONIDE 0.05 % TOPICAL SOLUTION [3190]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 64980-452-06
|
| Hospital Charge Code |
1743430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
FLUOCINONIDE 0.05 % TOPICAL SOLUTION [3190]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 64980-452-06
|
| Hospital Charge Code |
1743430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Distinction Transplant |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Media |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
FLUOCINONIDE 0.05 % TOPICAL SOLUTION [3190]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 51672-1273-4
|
| Hospital Charge Code |
1743430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Distinction Transplant |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Media |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
FLUOCINONIDE 0.05 % TOPICAL SOLUTION [3190]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 51672-1273-2
|
| Hospital Charge Code |
NDG3190
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
FLUOCINONIDE 0.05 % TOPICAL SOLUTION [3190]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 51672-1273-4
|
| Hospital Charge Code |
1743430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
|
|
FLUORESCEIN 0.6 MG EYE STRIPS [27662]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 17478-403-03
|
| Hospital Charge Code |
ERX27662
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
FLUORESCEIN 0.6 MG EYE STRIPS [27662]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 17478-403-03
|
| Hospital Charge Code |
ERX27662
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
FLUORESCEIN 1 MG EYE STRIPS [27663]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 17238-900-11
|
| Hospital Charge Code |
1740396
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
FLUORESCEIN 1 MG EYE STRIPS [27663]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 17238-900-99
|
| Hospital Charge Code |
1740396
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
FLUORESCEIN 1 MG EYE STRIPS [27663]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 17238-900-99
|
| Hospital Charge Code |
1740396
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
FLUORESCEIN 1 MG EYE STRIPS [27663]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 17238-900-11
|
| Hospital Charge Code |
1740396
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]
|
Facility
|
IP
|
$17.28
|
|
|
Service Code
|
NDC 17478-253-10
|
| Hospital Charge Code |
1720246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.15 |
| Max. Negotiated Rate |
$14.69 |
| Rate for Payer: Blue Shield of California Commercial |
$12.30
|
| Rate for Payer: Blue Shield of California EPN |
$8.85
|
| Rate for Payer: Cash Price |
$7.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.91
|
| Rate for Payer: Galaxy Health WC |
$14.69
|
| Rate for Payer: Global Benefits Group Commercial |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.15
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
| Rate for Payer: Networks By Design Commercial |
$11.23
|
| Rate for Payer: Prime Health Services Commercial |
$14.69
|
|
|
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]
|
Facility
|
IP
|
$12.38
|
|
|
Service Code
|
NDC 0065-0092-65
|
| Hospital Charge Code |
1720246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Blue Shield of California Commercial |
$8.81
|
| Rate for Payer: Blue Shield of California EPN |
$6.34
|
| Rate for Payer: Cash Price |
$5.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.95
|
| Rate for Payer: Galaxy Health WC |
$10.52
|
| Rate for Payer: Global Benefits Group Commercial |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.05
|
| Rate for Payer: Prime Health Services Commercial |
$10.52
|
|
|
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]
|
Facility
|
OP
|
$17.28
|
|
|
Service Code
|
NDC 17478-253-10
|
| Hospital Charge Code |
1720246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.15 |
| Max. Negotiated Rate |
$14.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.30
|
| Rate for Payer: Blue Distinction Transplant |
$10.37
|
| Rate for Payer: Blue Shield of California Commercial |
$12.74
|
| Rate for Payer: Blue Shield of California EPN |
$10.09
|
| Rate for Payer: Cash Price |
$7.78
|
| Rate for Payer: Cigna of CA HMO |
$11.06
|
| Rate for Payer: Cigna of CA PPO |
$12.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.69
|
| Rate for Payer: Dignity Health Media |
$14.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.91
|
| Rate for Payer: Galaxy Health WC |
$14.69
|
| Rate for Payer: Global Benefits Group Commercial |
$10.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.15
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
| Rate for Payer: Networks By Design Commercial |
$11.23
|
| Rate for Payer: Prime Health Services Commercial |
$14.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Other HMO |
$8.64
|
| Rate for Payer: United Healthcare HMO Rider |
$8.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.69
|
| Rate for Payer: Vantage Medical Group Senior |
$14.69
|
|
|
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [10059]
|
Facility
|
OP
|
$12.38
|
|
|
Service Code
|
NDC 0065-0092-65
|
| Hospital Charge Code |
1720246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.38
|
| Rate for Payer: Blue Distinction Transplant |
$7.43
|
| Rate for Payer: Blue Shield of California Commercial |
$9.12
|
| Rate for Payer: Blue Shield of California EPN |
$7.23
|
| Rate for Payer: Cash Price |
$5.57
|
| Rate for Payer: Cigna of CA HMO |
$7.92
|
| Rate for Payer: Cigna of CA PPO |
$9.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.52
|
| Rate for Payer: Dignity Health Media |
$10.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.95
|
| Rate for Payer: Galaxy Health WC |
$10.52
|
| Rate for Payer: Global Benefits Group Commercial |
$7.43
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.05
|
| Rate for Payer: Prime Health Services Commercial |
$10.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.19
|
| Rate for Payer: United Healthcare All Other HMO |
$6.19
|
| Rate for Payer: United Healthcare HMO Rider |
$6.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.52
|
| Rate for Payer: Vantage Medical Group Senior |
$10.52
|
|
|
FLUOROESTRADIOL F-18 148 MBQ/ML TO 3,700 MBQ/ML INTRAVENOUS SOLUTION [229585]
|
Facility
|
OP
|
$4,599.00
|
|
|
Service Code
|
CPT A9591
|
| Hospital Charge Code |
ERX229585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.80 |
| Max. Negotiated Rate |
$3,909.15 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,909.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,529.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,529.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$77.80
|
| Rate for Payer: Blue Distinction Transplant |
$2,759.40
|
| Rate for Payer: Blue Shield of California Commercial |
$3,389.46
|
| Rate for Payer: Blue Shield of California EPN |
$2,685.82
|
| Rate for Payer: Cash Price |
$2,069.55
|
| Rate for Payer: Cash Price |
$2,069.55
|
| Rate for Payer: Cigna of CA HMO |
$3,219.30
|
| Rate for Payer: Cigna of CA PPO |
$3,219.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,909.15
|
| Rate for Payer: Dignity Health Media |
$3,909.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,909.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,839.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,839.60
|
| Rate for Payer: Galaxy Health WC |
$3,909.15
|
| Rate for Payer: Global Benefits Group Commercial |
$2,759.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3,449.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,067.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,103.76
|
| Rate for Payer: Multiplan Commercial |
$3,679.20
|
| Rate for Payer: Networks By Design Commercial |
$2,299.50
|
| Rate for Payer: Prime Health Services Commercial |
$3,909.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,759.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,759.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,299.50
|
| Rate for Payer: United Healthcare All Other HMO |
$2,299.50
|
| Rate for Payer: United Healthcare HMO Rider |
$2,299.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,299.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,909.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,909.15
|
| Rate for Payer: Vantage Medical Group Senior |
$3,909.15
|
|
