|
PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-116-05
|
| Hospital Charge Code |
NDG212681
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-116-06
|
| Hospital Charge Code |
NDG212681
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L [212682]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-117-05
|
| Hospital Charge Code |
NDG212682
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L [212682]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-117-05
|
| Hospital Charge Code |
NDG212682
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
PHOSPHORATED CARBOHYDRATE ORAL SOLUTION [11022]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 1093939933
|
| Hospital Charge Code |
1719016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
PHOSPHORATED CARBOHYDRATE ORAL SOLUTION [11022]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 1093939933
|
| Hospital Charge Code |
1719016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION [6270]
|
Facility
|
OP
|
$46.97
|
|
|
Service Code
|
NDC 17478-510-02
|
| Hospital Charge Code |
1720007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$39.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.98
|
| Rate for Payer: Blue Distinction Transplant |
$28.18
|
| Rate for Payer: Blue Shield of California Commercial |
$34.62
|
| Rate for Payer: Blue Shield of California EPN |
$27.43
|
| Rate for Payer: Cash Price |
$21.14
|
| Rate for Payer: Cigna of CA HMO |
$30.06
|
| Rate for Payer: Cigna of CA PPO |
$34.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.92
|
| Rate for Payer: Dignity Health Media |
$39.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.79
|
| Rate for Payer: Galaxy Health WC |
$39.92
|
| Rate for Payer: Global Benefits Group Commercial |
$28.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$35.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$37.58
|
| Rate for Payer: Networks By Design Commercial |
$30.53
|
| Rate for Payer: Prime Health Services Commercial |
$39.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.48
|
| Rate for Payer: United Healthcare All Other HMO |
$23.48
|
| Rate for Payer: United Healthcare HMO Rider |
$23.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.92
|
| Rate for Payer: Vantage Medical Group Senior |
$39.92
|
|
|
PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION [6270]
|
Facility
|
IP
|
$46.97
|
|
|
Service Code
|
NDC 17478-510-02
|
| Hospital Charge Code |
1720007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$39.92 |
| Rate for Payer: Blue Shield of California Commercial |
$33.44
|
| Rate for Payer: Blue Shield of California EPN |
$24.05
|
| Rate for Payer: Cash Price |
$21.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.79
|
| Rate for Payer: Galaxy Health WC |
$39.92
|
| Rate for Payer: Global Benefits Group Commercial |
$28.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.27
|
| Rate for Payer: Multiplan Commercial |
$37.58
|
| Rate for Payer: Networks By Design Commercial |
$30.53
|
| Rate for Payer: Prime Health Services Commercial |
$39.92
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]
|
Facility
|
OP
|
$51.32
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$43.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$18.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$49.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$43.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.26
|
| Rate for Payer: Blue Distinction Transplant |
$30.79
|
| Rate for Payer: Blue Distinction Transplant |
$35.26
|
| Rate for Payer: Blue Shield of California Commercial |
$37.82
|
| Rate for Payer: Blue Shield of California Commercial |
$43.31
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$26.44
|
| Rate for Payer: Cash Price |
$26.44
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cigna of CA HMO |
$35.92
|
| Rate for Payer: Cigna of CA HMO |
$41.13
|
| Rate for Payer: Cigna of CA PPO |
$35.92
|
| Rate for Payer: Cigna of CA PPO |
$41.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$43.62
|
| Rate for Payer: Dignity Health Media |
$49.95
|
| Rate for Payer: Dignity Health Media |
$43.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$20.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.50
|
| Rate for Payer: Galaxy Health WC |
$43.62
|
| Rate for Payer: Galaxy Health WC |
$49.95
|
| Rate for Payer: Global Benefits Group Commercial |
$35.26
|
| Rate for Payer: Global Benefits Group Commercial |
$30.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$44.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$38.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.32
|
| Rate for Payer: Multiplan Commercial |
$47.01
|
| Rate for Payer: Multiplan Commercial |
$41.06
|
| Rate for Payer: Networks By Design Commercial |
$25.66
|
| Rate for Payer: Networks By Design Commercial |
$29.38
|
| Rate for Payer: Prime Health Services Commercial |
$49.95
|
| Rate for Payer: Prime Health Services Commercial |
$43.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.38
|
| Rate for Payer: United Healthcare All Other HMO |
$29.38
|
| Rate for Payer: United Healthcare All Other HMO |
$25.66
|
| Rate for Payer: United Healthcare HMO Rider |
$29.38
|
| Rate for Payer: United Healthcare HMO Rider |
$25.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$25.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$43.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.95
|
| Rate for Payer: Vantage Medical Group Senior |
$49.95
|
| Rate for Payer: Vantage Medical Group Senior |
$43.62
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]
|
Facility
|
IP
|
$51.32
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$43.62 |
| Rate for Payer: Blue Shield of California Commercial |
$36.54
|
| Rate for Payer: Blue Shield of California Commercial |
$41.84
|
| Rate for Payer: Blue Shield of California EPN |
$26.28
|
| Rate for Payer: Blue Shield of California EPN |
$30.09
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$26.44
|
| Rate for Payer: Cigna of CA HMO |
$35.92
|
| Rate for Payer: Cigna of CA HMO |
$41.13
|
| Rate for Payer: Cigna of CA PPO |
$41.13
|
| Rate for Payer: Cigna of CA PPO |
$35.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$20.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.50
|
| Rate for Payer: Galaxy Health WC |
$43.62
|
| Rate for Payer: Galaxy Health WC |
$49.95
|
| Rate for Payer: Global Benefits Group Commercial |
$35.26
|
| Rate for Payer: Global Benefits Group Commercial |
$30.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.10
|
| Rate for Payer: Multiplan Commercial |
$41.06
|
| Rate for Payer: Multiplan Commercial |
$47.01
|
| Rate for Payer: Networks By Design Commercial |
$25.66
|
| Rate for Payer: Networks By Design Commercial |
$29.38
|
| Rate for Payer: Prime Health Services Commercial |
$43.62
|
| Rate for Payer: Prime Health Services Commercial |
$49.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.19
|
| Rate for Payer: United Healthcare All Other HMO |
$18.93
|
| Rate for Payer: United Healthcare All Other HMO |
$21.67
|
| Rate for Payer: United Healthcare HMO Rider |
$18.52
|
| Rate for Payer: United Healthcare HMO Rider |
$21.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.39
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [110478]
|
Facility
|
OP
|
$11.39
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
NDG110478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$18.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.26
|
| Rate for Payer: Blue Distinction Transplant |
$6.83
|
| Rate for Payer: Blue Shield of California Commercial |
$8.39
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO |
$7.97
|
| Rate for Payer: Cigna of CA PPO |
$7.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.68
|
| Rate for Payer: Dignity Health Media |
$9.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.68
|
| Rate for Payer: Global Benefits Group Commercial |
$6.83
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$9.11
|
| Rate for Payer: Networks By Design Commercial |
$5.70
|
| Rate for Payer: Prime Health Services Commercial |
$9.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.70
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.68
|
| Rate for Payer: Vantage Medical Group Senior |
$9.68
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [110478]
|
Facility
|
IP
|
$11.39
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
NDG110478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$9.68 |
| Rate for Payer: Blue Shield of California Commercial |
$8.11
|
| Rate for Payer: Blue Shield of California EPN |
$5.83
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO |
$7.97
|
| Rate for Payer: Cigna of CA PPO |
$7.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.56
|
| Rate for Payer: Galaxy Health WC |
$9.68
|
| Rate for Payer: Global Benefits Group Commercial |
$6.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$9.11
|
| Rate for Payer: Networks By Design Commercial |
$5.70
|
| Rate for Payer: Prime Health Services Commercial |
$9.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.30
|
| Rate for Payer: United Healthcare All Other HMO |
$4.20
|
| Rate for Payer: United Healthcare HMO Rider |
$4.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.76
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]
|
Facility
|
IP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.24 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Blue Shield of California Commercial |
$42.26
|
| Rate for Payer: Blue Shield of California EPN |
$30.39
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO |
$41.54
|
| Rate for Payer: Cigna of CA PPO |
$41.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.74
|
| Rate for Payer: Galaxy Health WC |
$50.45
|
| Rate for Payer: Global Benefits Group Commercial |
$35.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.24
|
| Rate for Payer: Multiplan Commercial |
$47.48
|
| Rate for Payer: Networks By Design Commercial |
$29.68
|
| Rate for Payer: Prime Health Services Commercial |
$50.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.41
|
| Rate for Payer: United Healthcare All Other HMO |
$21.89
|
| Rate for Payer: United Healthcare HMO Rider |
$21.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.59
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]
|
Facility
|
OP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.26
|
| Rate for Payer: Blue Distinction Transplant |
$35.61
|
| Rate for Payer: Blue Shield of California Commercial |
$43.74
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO |
$41.54
|
| Rate for Payer: Cigna of CA PPO |
$41.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.45
|
| Rate for Payer: Dignity Health Media |
$50.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.74
|
| Rate for Payer: Galaxy Health WC |
$50.45
|
| Rate for Payer: Global Benefits Group Commercial |
$35.61
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$44.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.24
|
| Rate for Payer: Multiplan Commercial |
$47.48
|
| Rate for Payer: Networks By Design Commercial |
$29.68
|
| Rate for Payer: Prime Health Services Commercial |
$50.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.68
|
| Rate for Payer: United Healthcare All Other HMO |
$29.68
|
| Rate for Payer: United Healthcare HMO Rider |
$29.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.45
|
| Rate for Payer: Vantage Medical Group Senior |
$50.45
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]
|
Facility
|
OP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.26
|
| Rate for Payer: Blue Distinction Transplant |
$35.61
|
| Rate for Payer: Blue Shield of California Commercial |
$43.74
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO |
$41.54
|
| Rate for Payer: Cigna of CA PPO |
$41.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.45
|
| Rate for Payer: Dignity Health Media |
$50.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.74
|
| Rate for Payer: Galaxy Health WC |
$50.45
|
| Rate for Payer: Global Benefits Group Commercial |
$35.61
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$44.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.24
|
| Rate for Payer: Multiplan Commercial |
$47.48
|
| Rate for Payer: Networks By Design Commercial |
$29.68
|
| Rate for Payer: Prime Health Services Commercial |
$50.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.68
|
| Rate for Payer: United Healthcare All Other HMO |
$29.68
|
| Rate for Payer: United Healthcare HMO Rider |
$29.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.45
|
| Rate for Payer: Vantage Medical Group Senior |
$50.45
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]
|
Facility
|
IP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.24 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Blue Shield of California Commercial |
$42.26
|
| Rate for Payer: Blue Shield of California EPN |
$30.39
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO |
$41.54
|
| Rate for Payer: Cigna of CA PPO |
$41.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.74
|
| Rate for Payer: Galaxy Health WC |
$50.45
|
| Rate for Payer: Global Benefits Group Commercial |
$35.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.24
|
| Rate for Payer: Multiplan Commercial |
$47.48
|
| Rate for Payer: Networks By Design Commercial |
$29.68
|
| Rate for Payer: Prime Health Services Commercial |
$50.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.41
|
| Rate for Payer: United Healthcare All Other HMO |
$21.89
|
| Rate for Payer: United Healthcare HMO Rider |
$21.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.59
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$31.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.60
|
| Rate for Payer: Blue Distinction Transplant |
$28.80
|
| Rate for Payer: Blue Shield of California Commercial |
$35.38
|
| Rate for Payer: Blue Shield of California EPN |
$28.03
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Media |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.20
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Networks By Design Commercial |
$31.20
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Other HMO |
$24.00
|
| Rate for Payer: United Healthcare HMO Rider |
$24.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-94
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.17
|
| Rate for Payer: Blue Distinction Transplant |
$48.51
|
| Rate for Payer: Blue Shield of California Commercial |
$59.59
|
| Rate for Payer: Blue Shield of California EPN |
$47.22
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO |
$56.60
|
| Rate for Payer: Cigna of CA PPO |
$56.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.72
|
| Rate for Payer: Dignity Health Media |
$68.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.34
|
| Rate for Payer: Galaxy Health WC |
$68.72
|
| Rate for Payer: Global Benefits Group Commercial |
$48.51
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$60.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.40
|
| Rate for Payer: Multiplan Commercial |
$64.68
|
| Rate for Payer: Networks By Design Commercial |
$52.55
|
| Rate for Payer: Prime Health Services Commercial |
$68.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$48.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$48.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.42
|
| Rate for Payer: United Healthcare All Other HMO |
$40.42
|
| Rate for Payer: United Healthcare HMO Rider |
$40.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$40.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Blue Shield of California Commercial |
$24.04
|
| Rate for Payer: Blue Shield of California EPN |
$17.29
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cigna of CA HMO |
$23.63
|
| Rate for Payer: Cigna of CA PPO |
$23.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.50
|
| Rate for Payer: Galaxy Health WC |
$28.70
|
| Rate for Payer: Global Benefits Group Commercial |
$20.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.10
|
| Rate for Payer: Multiplan Commercial |
$27.01
|
| Rate for Payer: Networks By Design Commercial |
$21.94
|
| Rate for Payer: Prime Health Services Commercial |
$28.70
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Blue Shield of California Commercial |
$57.57
|
| Rate for Payer: Blue Shield of California EPN |
$41.40
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO |
$56.60
|
| Rate for Payer: Cigna of CA PPO |
$56.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.34
|
| Rate for Payer: Galaxy Health WC |
$68.72
|
| Rate for Payer: Global Benefits Group Commercial |
$48.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.40
|
| Rate for Payer: Multiplan Commercial |
$64.68
|
| Rate for Payer: Networks By Design Commercial |
$52.55
|
| Rate for Payer: Prime Health Services Commercial |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.11
|
| Rate for Payer: Blue Distinction Transplant |
$20.26
|
| Rate for Payer: Blue Shield of California Commercial |
$24.88
|
| Rate for Payer: Blue Shield of California EPN |
$19.72
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cigna of CA HMO |
$23.63
|
| Rate for Payer: Cigna of CA PPO |
$23.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.70
|
| Rate for Payer: Dignity Health Media |
$28.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$13.50
|
| Rate for Payer: Galaxy Health WC |
$28.70
|
| Rate for Payer: Global Benefits Group Commercial |
$20.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$25.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.10
|
| Rate for Payer: Multiplan Commercial |
$27.01
|
| Rate for Payer: Networks By Design Commercial |
$21.94
|
| Rate for Payer: Prime Health Services Commercial |
$28.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.88
|
| Rate for Payer: United Healthcare All Other HMO |
$16.88
|
| Rate for Payer: United Healthcare HMO Rider |
$16.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.70
|
| Rate for Payer: Vantage Medical Group Senior |
$28.70
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.17
|
| Rate for Payer: Blue Distinction Transplant |
$48.51
|
| Rate for Payer: Blue Shield of California Commercial |
$59.59
|
| Rate for Payer: Blue Shield of California EPN |
$47.22
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO |
$56.60
|
| Rate for Payer: Cigna of CA PPO |
$56.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.72
|
| Rate for Payer: Dignity Health Media |
$68.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.34
|
| Rate for Payer: Galaxy Health WC |
$68.72
|
| Rate for Payer: Global Benefits Group Commercial |
$48.51
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$60.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.40
|
| Rate for Payer: Multiplan Commercial |
$64.68
|
| Rate for Payer: Networks By Design Commercial |
$52.55
|
| Rate for Payer: Prime Health Services Commercial |
$68.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$48.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$48.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.42
|
| Rate for Payer: United Healthcare All Other HMO |
$40.42
|
| Rate for Payer: United Healthcare HMO Rider |
$40.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$40.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Blue Shield of California Commercial |
$34.18
|
| Rate for Payer: Blue Shield of California EPN |
$24.58
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO |
$33.60
|
| Rate for Payer: Cigna of CA PPO |
$33.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: Galaxy Health WC |
$40.80
|
| Rate for Payer: Global Benefits Group Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.52
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Networks By Design Commercial |
$31.20
|
| Rate for Payer: Prime Health Services Commercial |
$40.80
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-94
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.40 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Blue Shield of California Commercial |
$57.57
|
| Rate for Payer: Blue Shield of California EPN |
$41.40
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO |
$56.60
|
| Rate for Payer: Cigna of CA PPO |
$56.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.34
|
| Rate for Payer: Galaxy Health WC |
$68.72
|
| Rate for Payer: Global Benefits Group Commercial |
$48.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.40
|
| Rate for Payer: Multiplan Commercial |
$64.68
|
| Rate for Payer: Networks By Design Commercial |
$52.55
|
| Rate for Payer: Prime Health Services Commercial |
$68.72
|
|
|
PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [231930]
|
Facility
|
IP
|
$4,738.00
|
|
|
Service Code
|
CPT A9595
|
| Hospital Charge Code |
ERX231930
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,137.12 |
| Max. Negotiated Rate |
$4,027.30 |
| Rate for Payer: Blue Shield of California Commercial |
$3,373.46
|
| Rate for Payer: Blue Shield of California EPN |
$2,425.86
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,895.20
|
| Rate for Payer: Galaxy Health WC |
$4,027.30
|
| Rate for Payer: Global Benefits Group Commercial |
$2,842.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,160.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,805.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,137.12
|
| Rate for Payer: Multiplan Commercial |
$3,790.40
|
| Rate for Payer: Networks By Design Commercial |
$3,079.70
|
| Rate for Payer: Prime Health Services Commercial |
$4,027.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,789.07
|
| Rate for Payer: United Healthcare All Other HMO |
$1,747.37
|
| Rate for Payer: United Healthcare HMO Rider |
$1,709.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,563.54
|
|
