|
C1 ESTERASE INHIBITOR, RECOMBINANT 2,100 UNIT INTRAVENOUS SOLUTION [207371]
|
Facility
|
IP
|
$8,724.00
|
|
|
Service Code
|
CPT J0596
|
| Hospital Charge Code |
ERX207371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,093.76 |
| Max. Negotiated Rate |
$7,415.40 |
| Rate for Payer: Blue Shield of California Commercial |
$6,211.49
|
| Rate for Payer: Blue Shield of California EPN |
$4,466.69
|
| Rate for Payer: Cash Price |
$3,925.80
|
| Rate for Payer: Cigna of CA HMO |
$6,106.80
|
| Rate for Payer: Cigna of CA PPO |
$6,106.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,489.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,489.60
|
| Rate for Payer: Galaxy Health WC |
$7,415.40
|
| Rate for Payer: Global Benefits Group Commercial |
$5,234.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,818.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,323.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,093.76
|
| Rate for Payer: Multiplan Commercial |
$6,979.20
|
| Rate for Payer: Networks By Design Commercial |
$4,362.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,415.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,294.18
|
| Rate for Payer: United Healthcare All Other HMO |
$3,217.41
|
| Rate for Payer: United Healthcare HMO Rider |
$3,147.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,878.92
|
|
|
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION [105644]
|
Facility
|
OP
|
$10,772.15
|
|
|
Service Code
|
CPT J9043
|
| Hospital Charge Code |
1755729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.45 |
| Max. Negotiated Rate |
$9,156.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,323.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$263.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$231.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$231.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$287.08
|
| Rate for Payer: Blue Distinction Transplant |
$6,463.29
|
| Rate for Payer: Blue Shield of California Commercial |
$7,939.07
|
| Rate for Payer: Blue Shield of California EPN |
$230.83
|
| Rate for Payer: Cash Price |
$4,847.47
|
| Rate for Payer: Cash Price |
$4,847.47
|
| Rate for Payer: Cigna of CA HMO |
$7,540.50
|
| Rate for Payer: Cigna of CA PPO |
$7,540.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.68
|
| Rate for Payer: Dignity Health Media |
$210.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$284.11
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$210.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$210.45
|
| Rate for Payer: Galaxy Health WC |
$9,156.33
|
| Rate for Payer: Global Benefits Group Commercial |
$6,463.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8,079.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$345.14
|
| Rate for Payer: Heritage Provider Network Transplant |
$345.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$340.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$340.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$210.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,185.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$408.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$210.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,585.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$265.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$282.01
|
| Rate for Payer: Multiplan Commercial |
$8,617.72
|
| Rate for Payer: Networks By Design Commercial |
$5,386.08
|
| Rate for Payer: Prime Health Services Commercial |
$9,156.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6,463.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6,463.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,386.08
|
| Rate for Payer: United Healthcare All Other HMO |
$5,386.08
|
| Rate for Payer: United Healthcare HMO Rider |
$5,386.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,386.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.50
|
| Rate for Payer: Vantage Medical Group Senior |
$210.45
|
|
|
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION [105644]
|
Facility
|
IP
|
$10,772.15
|
|
|
Service Code
|
CPT J9043
|
| Hospital Charge Code |
1755729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,585.32 |
| Max. Negotiated Rate |
$9,156.33 |
| Rate for Payer: Blue Shield of California Commercial |
$7,669.77
|
| Rate for Payer: Blue Shield of California EPN |
$5,515.34
|
| Rate for Payer: Cash Price |
$4,847.47
|
| Rate for Payer: Cigna of CA HMO |
$7,540.50
|
| Rate for Payer: Cigna of CA PPO |
$7,540.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,308.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,308.86
|
| Rate for Payer: Galaxy Health WC |
$9,156.33
|
| Rate for Payer: Global Benefits Group Commercial |
$6,463.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,185.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,104.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,585.32
|
| Rate for Payer: Multiplan Commercial |
$8,617.72
|
| Rate for Payer: Networks By Design Commercial |
$5,386.08
|
| Rate for Payer: Prime Health Services Commercial |
$9,156.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,067.56
|
| Rate for Payer: United Healthcare All Other HMO |
$3,972.77
|
| Rate for Payer: United Healthcare HMO Rider |
$3,886.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,554.81
|
|
|
CABERGOLINE 0.25 MG 1/2 TABLET [4081952]
|
Facility
|
IP
|
$5.59
|
|
|
Service Code
|
NDC 9994-0819-52
|
| Hospital Charge Code |
ERX4081952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Blue Shield of California Commercial |
$3.98
|
| Rate for Payer: Blue Shield of California EPN |
$2.86
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$3.91
|
| Rate for Payer: Cigna of CA PPO |
$3.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.75
|
| Rate for Payer: Global Benefits Group Commercial |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.47
|
| Rate for Payer: Networks By Design Commercial |
$3.63
|
| Rate for Payer: Prime Health Services Commercial |
$4.75
|
|
|
CABERGOLINE 0.25 MG 1/2 TABLET [4081952]
|
Facility
|
OP
|
$5.59
|
|
|
Service Code
|
NDC 9994-0819-52
|
| Hospital Charge Code |
ERX4081952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.33
|
| Rate for Payer: Blue Distinction Transplant |
$3.35
|
| Rate for Payer: Blue Shield of California Commercial |
$4.12
|
| Rate for Payer: Blue Shield of California EPN |
$3.26
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$3.91
|
| Rate for Payer: Cigna of CA PPO |
$3.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.75
|
| Rate for Payer: Dignity Health Media |
$4.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.75
|
| Rate for Payer: Global Benefits Group Commercial |
$3.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.47
|
| Rate for Payer: Networks By Design Commercial |
$3.63
|
| Rate for Payer: Prime Health Services Commercial |
$4.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.80
|
| Rate for Payer: United Healthcare All Other HMO |
$2.80
|
| Rate for Payer: United Healthcare HMO Rider |
$2.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4.75
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
OP
|
$3.75
|
|
|
Service Code
|
NDC 50742-118-08
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.23
|
| Rate for Payer: Blue Distinction Transplant |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$2.76
|
| Rate for Payer: Blue Shield of California EPN |
$2.19
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cigna of CA HMO |
$2.62
|
| Rate for Payer: Cigna of CA PPO |
$2.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.19
|
| Rate for Payer: Dignity Health Media |
$3.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.50
|
| Rate for Payer: Galaxy Health WC |
$3.19
|
| Rate for Payer: Global Benefits Group Commercial |
$2.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Networks By Design Commercial |
$2.44
|
| Rate for Payer: Prime Health Services Commercial |
$3.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.88
|
| Rate for Payer: United Healthcare All Other HMO |
$1.88
|
| Rate for Payer: United Healthcare HMO Rider |
$1.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.19
|
| Rate for Payer: Vantage Medical Group Senior |
$3.19
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
IP
|
$3.75
|
|
|
Service Code
|
NDC 50742-118-08
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Blue Shield of California Commercial |
$2.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cigna of CA HMO |
$2.62
|
| Rate for Payer: Cigna of CA PPO |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Galaxy Health WC |
$3.19
|
| Rate for Payer: Global Benefits Group Commercial |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Networks By Design Commercial |
$2.44
|
| Rate for Payer: Prime Health Services Commercial |
$3.19
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
IP
|
$2.44
|
|
|
Service Code
|
NDC 23155-823-73
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Blue Shield of California Commercial |
$1.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.71
|
| Rate for Payer: Cigna of CA PPO |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.07
|
| Rate for Payer: Global Benefits Group Commercial |
$1.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: Networks By Design Commercial |
$1.59
|
| Rate for Payer: Prime Health Services Commercial |
$2.07
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
OP
|
$2.44
|
|
|
Service Code
|
NDC 23155-823-73
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.45
|
| Rate for Payer: Blue Distinction Transplant |
$1.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.80
|
| Rate for Payer: Blue Shield of California EPN |
$1.42
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.71
|
| Rate for Payer: Cigna of CA PPO |
$1.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.07
|
| Rate for Payer: Dignity Health Media |
$2.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.07
|
| Rate for Payer: Global Benefits Group Commercial |
$1.46
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: Networks By Design Commercial |
$1.59
|
| Rate for Payer: Prime Health Services Commercial |
$2.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO |
$1.22
|
| Rate for Payer: United Healthcare HMO Rider |
$1.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.07
|
| Rate for Payer: Vantage Medical Group Senior |
$2.07
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
1743674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.03
|
| Rate for Payer: Blue Distinction Transplant |
$2.04
|
| Rate for Payer: Blue Shield of California Commercial |
$2.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.99
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO |
$2.38
|
| Rate for Payer: Cigna of CA PPO |
$2.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.89
|
| Rate for Payer: Dignity Health Media |
$2.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.36
|
| Rate for Payer: Galaxy Health WC |
$2.89
|
| Rate for Payer: Global Benefits Group Commercial |
$2.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.72
|
| Rate for Payer: Networks By Design Commercial |
$2.21
|
| Rate for Payer: Prime Health Services Commercial |
$2.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1.70
|
| Rate for Payer: United Healthcare HMO Rider |
$1.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.89
|
| Rate for Payer: Vantage Medical Group Senior |
$2.89
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
1743674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.74
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO |
$2.38
|
| Rate for Payer: Cigna of CA PPO |
$2.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Galaxy Health WC |
$2.89
|
| Rate for Payer: Global Benefits Group Commercial |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.72
|
| Rate for Payer: Networks By Design Commercial |
$2.21
|
| Rate for Payer: Prime Health Services Commercial |
$2.89
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Distinction Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
NDG77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$10.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.35
|
| Rate for Payer: Blue Distinction Transplant |
$4.32
|
| Rate for Payer: Blue Distinction Transplant |
$1.96
|
| Rate for Payer: Blue Distinction Transplant |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$5.31
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA HMO |
$2.28
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.77
|
| Rate for Payer: Dignity Health Media |
$2.77
|
| Rate for Payer: Dignity Health Media |
$3.40
|
| Rate for Payer: Dignity Health Media |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$2.77
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Global Benefits Group Commercial |
$1.96
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$5.76
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$3.60
|
| Rate for Payer: Networks By Design Commercial |
$1.63
|
| Rate for Payer: Networks By Design Commercial |
$2.00
|
| Rate for Payer: Prime Health Services Commercial |
$2.77
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.63
|
| Rate for Payer: United Healthcare All Other HMO |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO |
$2.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.63
|
| Rate for Payer: United Healthcare HMO Rider |
$1.63
|
| Rate for Payer: United Healthcare HMO Rider |
$3.60
|
| Rate for Payer: United Healthcare HMO Rider |
$2.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.77
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.77
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
IP
|
$3.26
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
NDG77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Blue Shield of California Commercial |
$2.32
|
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Blue Shield of California EPN |
$3.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.67
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA HMO |
$2.28
|
| Rate for Payer: Cigna of CA PPO |
$2.28
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$2.77
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Global Benefits Group Commercial |
$1.96
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$2.61
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Multiplan Commercial |
$5.76
|
| Rate for Payer: Networks By Design Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.63
|
| Rate for Payer: Networks By Design Commercial |
$3.60
|
| Rate for Payer: Prime Health Services Commercial |
$2.77
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1.48
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$2.66
|
| Rate for Payer: United Healthcare HMO Rider |
$2.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.18
|
| Rate for Payer: United Healthcare HMO Rider |
$1.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.38
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 9994-0804-22
|
| Hospital Charge Code |
1715184
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.38
|
| Rate for Payer: Blue Distinction Transplant |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$2.95
|
| Rate for Payer: Blue Shield of California EPN |
$2.34
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Media |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 9994-0804-22
|
| Hospital Charge Code |
1715184
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
OP
|
$15.50
|
|
|
Service Code
|
NDC 63323-406-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$13.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.23
|
| Rate for Payer: Blue Distinction Transplant |
$9.30
|
| Rate for Payer: Blue Shield of California Commercial |
$11.42
|
| Rate for Payer: Blue Shield of California EPN |
$9.05
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cigna of CA HMO |
$10.85
|
| Rate for Payer: Cigna of CA PPO |
$10.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.18
|
| Rate for Payer: Dignity Health Media |
$13.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.20
|
| Rate for Payer: Galaxy Health WC |
$13.18
|
| Rate for Payer: Global Benefits Group Commercial |
$9.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$12.40
|
| Rate for Payer: Networks By Design Commercial |
$10.08
|
| Rate for Payer: Prime Health Services Commercial |
$13.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.75
|
| Rate for Payer: United Healthcare All Other HMO |
$7.75
|
| Rate for Payer: United Healthcare HMO Rider |
$7.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.18
|
| Rate for Payer: Vantage Medical Group Senior |
$13.18
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 25021-602-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.77
|
| Rate for Payer: Blue Distinction Transplant |
$4.80
|
| Rate for Payer: Blue Shield of California Commercial |
$5.90
|
| Rate for Payer: Blue Shield of California EPN |
$4.67
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna of CA HMO |
$5.60
|
| Rate for Payer: Cigna of CA PPO |
$5.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.80
|
| Rate for Payer: Dignity Health Media |
$6.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.20
|
| Rate for Payer: Galaxy Health WC |
$6.80
|
| Rate for Payer: Global Benefits Group Commercial |
$4.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: Networks By Design Commercial |
$5.20
|
| Rate for Payer: Prime Health Services Commercial |
$6.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Vantage Medical Group Senior |
$6.80
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
IP
|
$15.50
|
|
|
Service Code
|
NDC 63323-406-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$13.18 |
| Rate for Payer: Blue Shield of California Commercial |
$11.04
|
| Rate for Payer: Blue Shield of California EPN |
$7.94
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cigna of CA HMO |
$10.85
|
| Rate for Payer: Cigna of CA PPO |
$10.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.20
|
| Rate for Payer: Galaxy Health WC |
$13.18
|
| Rate for Payer: Global Benefits Group Commercial |
$9.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$12.40
|
| Rate for Payer: Networks By Design Commercial |
$10.08
|
| Rate for Payer: Prime Health Services Commercial |
$13.18
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 25021-602-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Blue Shield of California Commercial |
$5.70
|
| Rate for Payer: Blue Shield of California EPN |
$4.10
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna of CA HMO |
$5.60
|
| Rate for Payer: Cigna of CA PPO |
$5.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.20
|
| Rate for Payer: Galaxy Health WC |
$6.80
|
| Rate for Payer: Global Benefits Group Commercial |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: Networks By Design Commercial |
$5.20
|
| Rate for Payer: Prime Health Services Commercial |
$6.80
|
|
