|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Blue Shield of California Commercial |
$32.20
|
| Rate for Payer: Blue Shield of California EPN |
$23.15
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.09
|
| Rate for Payer: Galaxy Health WC |
$38.44
|
| Rate for Payer: Global Benefits Group Commercial |
$27.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$36.18
|
| Rate for Payer: Networks By Design Commercial |
$29.39
|
| Rate for Payer: Prime Health Services Commercial |
$38.44
|
|
|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.94
|
| Rate for Payer: Blue Distinction Transplant |
$27.13
|
| Rate for Payer: Blue Shield of California Commercial |
$33.33
|
| Rate for Payer: Blue Shield of California EPN |
$26.41
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO |
$28.94
|
| Rate for Payer: Cigna of CA PPO |
$33.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.44
|
| Rate for Payer: Dignity Health Media |
$38.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.09
|
| Rate for Payer: Galaxy Health WC |
$38.44
|
| Rate for Payer: Global Benefits Group Commercial |
$27.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$33.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$36.18
|
| Rate for Payer: Networks By Design Commercial |
$29.39
|
| Rate for Payer: Prime Health Services Commercial |
$38.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.61
|
| Rate for Payer: United Healthcare All Other HMO |
$22.61
|
| Rate for Payer: United Healthcare HMO Rider |
$22.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.44
|
| Rate for Payer: Vantage Medical Group Senior |
$38.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.94
|
| Rate for Payer: Blue Distinction Transplant |
$27.13
|
| Rate for Payer: Blue Shield of California Commercial |
$33.33
|
| Rate for Payer: Blue Shield of California EPN |
$26.41
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO |
$28.94
|
| Rate for Payer: Cigna of CA PPO |
$33.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.44
|
| Rate for Payer: Dignity Health Media |
$38.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.09
|
| Rate for Payer: Galaxy Health WC |
$38.44
|
| Rate for Payer: Global Benefits Group Commercial |
$27.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$33.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$36.18
|
| Rate for Payer: Networks By Design Commercial |
$29.39
|
| Rate for Payer: Prime Health Services Commercial |
$38.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.61
|
| Rate for Payer: United Healthcare All Other HMO |
$22.61
|
| Rate for Payer: United Healthcare HMO Rider |
$22.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.44
|
| Rate for Payer: Vantage Medical Group Senior |
$38.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Blue Shield of California Commercial |
$32.20
|
| Rate for Payer: Blue Shield of California EPN |
$23.15
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.09
|
| Rate for Payer: Galaxy Health WC |
$38.44
|
| Rate for Payer: Global Benefits Group Commercial |
$27.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$36.18
|
| Rate for Payer: Networks By Design Commercial |
$29.39
|
| Rate for Payer: Prime Health Services Commercial |
$38.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Blue Shield of California Commercial |
$32.20
|
| Rate for Payer: Blue Shield of California EPN |
$23.15
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.09
|
| Rate for Payer: Galaxy Health WC |
$38.44
|
| Rate for Payer: Global Benefits Group Commercial |
$27.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$36.18
|
| Rate for Payer: Networks By Design Commercial |
$29.39
|
| Rate for Payer: Prime Health Services Commercial |
$38.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.94
|
| Rate for Payer: Blue Distinction Transplant |
$27.13
|
| Rate for Payer: Blue Shield of California Commercial |
$33.33
|
| Rate for Payer: Blue Shield of California EPN |
$26.41
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO |
$28.94
|
| Rate for Payer: Cigna of CA PPO |
$33.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.44
|
| Rate for Payer: Dignity Health Media |
$38.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.09
|
| Rate for Payer: Galaxy Health WC |
$38.44
|
| Rate for Payer: Global Benefits Group Commercial |
$27.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$33.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$36.18
|
| Rate for Payer: Networks By Design Commercial |
$29.39
|
| Rate for Payer: Prime Health Services Commercial |
$38.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.61
|
| Rate for Payer: United Healthcare All Other HMO |
$22.61
|
| Rate for Payer: United Healthcare HMO Rider |
$22.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.44
|
| Rate for Payer: Vantage Medical Group Senior |
$38.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-05
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$62.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.20
|
| Rate for Payer: Blue Distinction Transplant |
$57.60
|
| Rate for Payer: Blue Shield of California Commercial |
$70.75
|
| Rate for Payer: Blue Shield of California EPN |
$56.06
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO |
$61.44
|
| Rate for Payer: Cigna of CA PPO |
$71.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.60
|
| Rate for Payer: Dignity Health Media |
$81.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Other HMO |
$48.00
|
| Rate for Payer: United Healthcare HMO Rider |
$48.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$48.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.60
|
| Rate for Payer: Vantage Medical Group Senior |
$81.60
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-00
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Blue Shield of California Commercial |
$68.35
|
| Rate for Payer: Blue Shield of California EPN |
$49.15
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-00
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$62.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.20
|
| Rate for Payer: Blue Distinction Transplant |
$57.60
|
| Rate for Payer: Blue Shield of California Commercial |
$70.75
|
| Rate for Payer: Blue Shield of California EPN |
$56.06
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO |
$61.44
|
| Rate for Payer: Cigna of CA PPO |
$71.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.60
|
| Rate for Payer: Dignity Health Media |
$81.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Other HMO |
$48.00
|
| Rate for Payer: United Healthcare HMO Rider |
$48.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$48.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.60
|
| Rate for Payer: Vantage Medical Group Senior |
$81.60
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-05
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Blue Shield of California Commercial |
$68.35
|
| Rate for Payer: Blue Shield of California EPN |
$49.15
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
|
IP
|
$4,608.00
|
|
|
Service Code
|
CPT A9572
|
| Hospital Charge Code |
ERX13545
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,105.92 |
| Max. Negotiated Rate |
$3,916.80 |
| Rate for Payer: Blue Shield of California Commercial |
$3,280.90
|
| Rate for Payer: Blue Shield of California EPN |
$2,359.30
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,843.20
|
| Rate for Payer: Galaxy Health WC |
$3,916.80
|
| Rate for Payer: Global Benefits Group Commercial |
$2,764.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,073.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,755.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,105.92
|
| Rate for Payer: Multiplan Commercial |
$3,686.40
|
| Rate for Payer: Networks By Design Commercial |
$2,995.20
|
| Rate for Payer: Prime Health Services Commercial |
$3,916.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,739.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1,699.43
|
| Rate for Payer: United Healthcare HMO Rider |
$1,662.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,520.64
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
|
OP
|
$4,608.00
|
|
|
Service Code
|
CPT A9572
|
| Hospital Charge Code |
ERX13545
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,105.92 |
| Max. Negotiated Rate |
$19,199.50 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,916.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,534.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,534.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19,199.50
|
| Rate for Payer: Blue Distinction Transplant |
$2,764.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2,723.33
|
| Rate for Payer: Blue Shield of California EPN |
$2,161.15
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cigna of CA HMO |
$2,949.12
|
| Rate for Payer: Cigna of CA PPO |
$3,409.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,916.80
|
| Rate for Payer: Dignity Health Media |
$3,916.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,916.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,843.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,843.20
|
| Rate for Payer: Galaxy Health WC |
$3,916.80
|
| Rate for Payer: Global Benefits Group Commercial |
$2,764.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3,456.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,073.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,105.92
|
| Rate for Payer: Multiplan Commercial |
$3,686.40
|
| Rate for Payer: Networks By Design Commercial |
$2,995.20
|
| Rate for Payer: Prime Health Services Commercial |
$3,916.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,764.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,764.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,304.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2,304.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,304.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,304.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,916.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,916.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,916.80
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-25
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$89.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$75.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$81.46
|
| Rate for Payer: Blue Distinction Transplant |
$82.03
|
| Rate for Payer: Blue Shield of California Commercial |
$100.76
|
| Rate for Payer: Blue Shield of California EPN |
$79.84
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cigna of CA HMO |
$87.50
|
| Rate for Payer: Cigna of CA PPO |
$101.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$116.21
|
| Rate for Payer: Dignity Health Media |
$116.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$54.69
|
| Rate for Payer: Galaxy Health WC |
$116.21
|
| Rate for Payer: Global Benefits Group Commercial |
$82.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$102.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.81
|
| Rate for Payer: Multiplan Commercial |
$109.38
|
| Rate for Payer: Networks By Design Commercial |
$88.87
|
| Rate for Payer: Prime Health Services Commercial |
$116.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$82.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$82.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.36
|
| Rate for Payer: United Healthcare All Other HMO |
$68.36
|
| Rate for Payer: United Healthcare HMO Rider |
$68.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.21
|
| Rate for Payer: Vantage Medical Group Senior |
$116.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-25
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Blue Shield of California Commercial |
$97.34
|
| Rate for Payer: Blue Shield of California EPN |
$70.00
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.69
|
| Rate for Payer: Galaxy Health WC |
$116.21
|
| Rate for Payer: Global Benefits Group Commercial |
$82.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.81
|
| Rate for Payer: Multiplan Commercial |
$109.38
|
| Rate for Payer: Networks By Design Commercial |
$88.87
|
| Rate for Payer: Prime Health Services Commercial |
$116.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-02
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Blue Shield of California Commercial |
$97.34
|
| Rate for Payer: Blue Shield of California EPN |
$70.00
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.69
|
| Rate for Payer: Galaxy Health WC |
$116.21
|
| Rate for Payer: Global Benefits Group Commercial |
$82.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.81
|
| Rate for Payer: Multiplan Commercial |
$109.38
|
| Rate for Payer: Networks By Design Commercial |
$88.87
|
| Rate for Payer: Prime Health Services Commercial |
$116.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-02
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$89.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$75.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$81.46
|
| Rate for Payer: Blue Distinction Transplant |
$82.03
|
| Rate for Payer: Blue Shield of California Commercial |
$100.76
|
| Rate for Payer: Blue Shield of California EPN |
$79.84
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cigna of CA HMO |
$87.50
|
| Rate for Payer: Cigna of CA PPO |
$101.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$116.21
|
| Rate for Payer: Dignity Health Media |
$116.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$54.69
|
| Rate for Payer: Galaxy Health WC |
$116.21
|
| Rate for Payer: Global Benefits Group Commercial |
$82.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$102.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.81
|
| Rate for Payer: Multiplan Commercial |
$109.38
|
| Rate for Payer: Networks By Design Commercial |
$88.87
|
| Rate for Payer: Prime Health Services Commercial |
$116.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$82.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$82.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.36
|
| Rate for Payer: United Healthcare All Other HMO |
$68.36
|
| Rate for Payer: United Healthcare HMO Rider |
$68.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.21
|
| Rate for Payer: Vantage Medical Group Senior |
$116.21
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
IP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
1753530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.92 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Blue Shield of California Commercial |
$317.19
|
| Rate for Payer: Blue Shield of California EPN |
$228.09
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$297.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.92
|
| Rate for Payer: Multiplan Commercial |
$356.39
|
| Rate for Payer: Networks By Design Commercial |
$289.57
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
OP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
1753530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.92 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$292.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$245.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$265.42
|
| Rate for Payer: Blue Distinction Transplant |
$267.29
|
| Rate for Payer: Blue Shield of California Commercial |
$328.33
|
| Rate for Payer: Blue Shield of California EPN |
$260.17
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: Cigna of CA HMO |
$285.11
|
| Rate for Payer: Cigna of CA PPO |
$329.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.67
|
| Rate for Payer: Dignity Health Media |
$378.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$334.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$297.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.92
|
| Rate for Payer: Multiplan Commercial |
$356.39
|
| Rate for Payer: Networks By Design Commercial |
$289.57
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$267.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$267.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$222.74
|
| Rate for Payer: United Healthcare All Other HMO |
$222.74
|
| Rate for Payer: United Healthcare HMO Rider |
$222.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$222.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.67
|
| Rate for Payer: Vantage Medical Group Senior |
$378.67
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| 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 |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| 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 |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| 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 |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| 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 |
$0.22
|
| Rate for Payer: Dignity Health Media |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.20
|
| 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 |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| 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 |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Distinction Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Distinction Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
1710382
|
|
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
|
|
