|
PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [231930]
|
Facility
|
OP
|
$4,738.00
|
|
|
Service Code
|
CPT A9595
|
| Hospital Charge Code |
ERX231930
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$580.35 |
| Max. Negotiated Rate |
$4,027.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,791.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$870.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$638.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$580.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,089.43
|
| Rate for Payer: Blue Distinction Transplant |
$2,842.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2,800.16
|
| Rate for Payer: Blue Shield of California EPN |
$2,222.12
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: Cigna of CA HMO |
$3,032.32
|
| Rate for Payer: Cigna of CA PPO |
$3,506.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$725.44
|
| Rate for Payer: Dignity Health Media |
$638.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$638.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$783.48
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$580.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$580.35
|
| Rate for Payer: Galaxy Health WC |
$4,027.30
|
| Rate for Payer: Global Benefits Group Commercial |
$2,842.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3,553.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$951.78
|
| Rate for Payer: Heritage Provider Network Transplant |
$951.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$940.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$940.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$580.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,160.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,048.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$580.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,137.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$731.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$777.67
|
| 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: Temecula Valley Physicians Medical Group Commercial |
$2,842.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,842.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,369.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2,369.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,369.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,369.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$725.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$638.39
|
| Rate for Payer: Vantage Medical Group Senior |
$638.39
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$5.94
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.54
|
| Rate for Payer: Blue Distinction Transplant |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$4.38
|
| Rate for Payer: Blue Shield of California EPN |
$3.47
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO |
$4.16
|
| Rate for Payer: Cigna of CA PPO |
$4.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.05
|
| Rate for Payer: Dignity Health Media |
$5.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.38
|
| Rate for Payer: Galaxy Health WC |
$5.05
|
| Rate for Payer: Global Benefits Group Commercial |
$3.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Networks By Design Commercial |
$3.86
|
| Rate for Payer: Prime Health Services Commercial |
$5.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.97
|
| Rate for Payer: United Healthcare All Other HMO |
$2.97
|
| Rate for Payer: United Healthcare HMO Rider |
$2.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.05
|
| Rate for Payer: Vantage Medical Group Senior |
$5.05
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.76
|
| Rate for Payer: Blue Distinction Transplant |
$3.79
|
| Rate for Payer: Blue Shield of California Commercial |
$4.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.69
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.42
|
| Rate for Payer: Cigna of CA PPO |
$4.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Media |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.16
|
| Rate for Payer: United Healthcare All Other HMO |
$3.16
|
| Rate for Payer: United Healthcare HMO Rider |
$3.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$5.05
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.01
|
| Rate for Payer: Blue Distinction Transplant |
$3.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.72
|
| Rate for Payer: Blue Shield of California EPN |
$2.95
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$3.54
|
| Rate for Payer: Cigna of CA PPO |
$3.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.29
|
| Rate for Payer: Dignity Health Media |
$4.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.02
|
| Rate for Payer: Galaxy Health WC |
$4.29
|
| Rate for Payer: Global Benefits Group Commercial |
$3.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.04
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Prime Health Services Commercial |
$4.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO |
$2.52
|
| Rate for Payer: United Healthcare HMO Rider |
$2.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4.29
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.42
|
| Rate for Payer: Cigna of CA PPO |
$4.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$5.05
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Blue Shield of California Commercial |
$3.60
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$3.54
|
| Rate for Payer: Cigna of CA PPO |
$3.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Galaxy Health WC |
$4.29
|
| Rate for Payer: Global Benefits Group Commercial |
$3.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.04
|
| Rate for Payer: Networks By Design Commercial |
$3.28
|
| Rate for Payer: Prime Health Services Commercial |
$4.29
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$5.94
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Blue Shield of California Commercial |
$4.23
|
| Rate for Payer: Blue Shield of California EPN |
$3.04
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO |
$4.16
|
| Rate for Payer: Cigna of CA PPO |
$4.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Galaxy Health WC |
$5.05
|
| Rate for Payer: Global Benefits Group Commercial |
$3.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.75
|
| Rate for Payer: Networks By Design Commercial |
$3.86
|
| Rate for Payer: Prime Health Services Commercial |
$5.05
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
IP
|
$6.26
|
|
|
Service Code
|
NDC 17478-224-12
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Blue Shield of California Commercial |
$4.46
|
| Rate for Payer: Blue Shield of California EPN |
$3.21
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO |
$4.38
|
| Rate for Payer: Cigna of CA PPO |
$4.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.50
|
| Rate for Payer: Galaxy Health WC |
$5.32
|
| Rate for Payer: Global Benefits Group Commercial |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$5.01
|
| Rate for Payer: Networks By Design Commercial |
$4.07
|
| Rate for Payer: Prime Health Services Commercial |
$5.32
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
OP
|
$6.26
|
|
|
Service Code
|
NDC 17478-224-12
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.73
|
| Rate for Payer: Blue Distinction Transplant |
$3.76
|
| Rate for Payer: Blue Shield of California Commercial |
$4.61
|
| Rate for Payer: Blue Shield of California EPN |
$3.66
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO |
$4.38
|
| Rate for Payer: Cigna of CA PPO |
$4.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.32
|
| Rate for Payer: Dignity Health Media |
$5.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.50
|
| Rate for Payer: Galaxy Health WC |
$5.32
|
| Rate for Payer: Global Benefits Group Commercial |
$3.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$5.01
|
| Rate for Payer: Networks By Design Commercial |
$4.07
|
| Rate for Payer: Prime Health Services Commercial |
$5.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.13
|
| Rate for Payer: United Healthcare All Other HMO |
$3.13
|
| Rate for Payer: United Healthcare HMO Rider |
$3.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.32
|
| Rate for Payer: Vantage Medical Group Senior |
$5.32
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
OP
|
$7.61
|
|
|
Service Code
|
NDC 0998-0204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.53
|
| Rate for Payer: Blue Distinction Transplant |
$4.57
|
| Rate for Payer: Blue Shield of California Commercial |
$5.61
|
| Rate for Payer: Blue Shield of California EPN |
$4.44
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.47
|
| Rate for Payer: Dignity Health Media |
$6.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.09
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.80
|
| Rate for Payer: United Healthcare All Other HMO |
$3.80
|
| Rate for Payer: United Healthcare HMO Rider |
$3.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Vantage Medical Group Senior |
$6.47
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
OP
|
$6.45
|
|
|
Service Code
|
NDC 61314-204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$5.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.84
|
| Rate for Payer: Blue Distinction Transplant |
$3.87
|
| Rate for Payer: Blue Shield of California Commercial |
$4.75
|
| Rate for Payer: Blue Shield of California EPN |
$3.77
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cigna of CA HMO |
$4.52
|
| Rate for Payer: Cigna of CA PPO |
$4.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.48
|
| Rate for Payer: Dignity Health Media |
$5.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.58
|
| Rate for Payer: Galaxy Health WC |
$5.48
|
| Rate for Payer: Global Benefits Group Commercial |
$3.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: Multiplan Commercial |
$5.16
|
| Rate for Payer: Networks By Design Commercial |
$4.19
|
| Rate for Payer: Prime Health Services Commercial |
$5.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.22
|
| Rate for Payer: United Healthcare All Other HMO |
$3.22
|
| Rate for Payer: United Healthcare HMO Rider |
$3.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Vantage Medical Group Senior |
$5.48
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
IP
|
$6.45
|
|
|
Service Code
|
NDC 61314-204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$5.48 |
| Rate for Payer: Blue Shield of California Commercial |
$4.59
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cigna of CA HMO |
$4.52
|
| Rate for Payer: Cigna of CA PPO |
$4.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.58
|
| Rate for Payer: Galaxy Health WC |
$5.48
|
| Rate for Payer: Global Benefits Group Commercial |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: Multiplan Commercial |
$5.16
|
| Rate for Payer: Networks By Design Commercial |
$4.19
|
| Rate for Payer: Prime Health Services Commercial |
$5.48
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
IP
|
$7.61
|
|
|
Service Code
|
NDC 0998-0204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Blue Shield of California Commercial |
$5.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.90
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO |
$5.33
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.04
|
| Rate for Payer: Galaxy Health WC |
$6.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.09
|
| Rate for Payer: Networks By Design Commercial |
$4.95
|
| Rate for Payer: Prime Health Services Commercial |
$6.47
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
OP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.62
|
| Rate for Payer: Blue Distinction Transplant |
$3.64
|
| Rate for Payer: Blue Shield of California Commercial |
$4.47
|
| Rate for Payer: Blue Shield of California EPN |
$3.54
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cigna of CA HMO |
$4.25
|
| Rate for Payer: Cigna of CA PPO |
$4.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.16
|
| Rate for Payer: Dignity Health Media |
$5.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.43
|
| Rate for Payer: Galaxy Health WC |
$5.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.64
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$4.86
|
| Rate for Payer: Networks By Design Commercial |
$3.95
|
| Rate for Payer: Prime Health Services Commercial |
$5.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.04
|
| Rate for Payer: United Healthcare All Other HMO |
$3.04
|
| Rate for Payer: United Healthcare HMO Rider |
$3.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
IP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Blue Shield of California Commercial |
$4.32
|
| Rate for Payer: Blue Shield of California EPN |
$3.11
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cigna of CA HMO |
$4.25
|
| Rate for Payer: Cigna of CA PPO |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: Galaxy Health WC |
$5.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$4.86
|
| Rate for Payer: Networks By Design Commercial |
$3.95
|
| Rate for Payer: Prime Health Services Commercial |
$5.16
|
|
|
PILOCARPINE 4 % EYE DROPS [6282]
|
Facility
|
IP
|
$6.36
|
|
|
Service Code
|
NDC 70069-201-01
|
| Hospital Charge Code |
1740061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.26
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna of CA HMO |
$4.45
|
| Rate for Payer: Cigna of CA PPO |
$4.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$5.41
|
| Rate for Payer: Global Benefits Group Commercial |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$5.09
|
| Rate for Payer: Networks By Design Commercial |
$4.13
|
| Rate for Payer: Prime Health Services Commercial |
$5.41
|
|
|
PILOCARPINE 4 % EYE DROPS [6282]
|
Facility
|
OP
|
$6.36
|
|
|
Service Code
|
NDC 70069-201-01
|
| Hospital Charge Code |
1740061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.79
|
| Rate for Payer: Blue Distinction Transplant |
$3.82
|
| Rate for Payer: Blue Shield of California Commercial |
$4.69
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna of CA HMO |
$4.45
|
| Rate for Payer: Cigna of CA PPO |
$4.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.41
|
| Rate for Payer: Dignity Health Media |
$5.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.54
|
| Rate for Payer: Galaxy Health WC |
$5.41
|
| Rate for Payer: Global Benefits Group Commercial |
$3.82
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$5.09
|
| Rate for Payer: Networks By Design Commercial |
$4.13
|
| Rate for Payer: Prime Health Services Commercial |
$5.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.18
|
| Rate for Payer: United Healthcare All Other HMO |
$3.18
|
| Rate for Payer: United Healthcare HMO Rider |
$3.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.41
|
| Rate for Payer: Vantage Medical Group Senior |
$5.41
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-95
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.63
|
| Rate for Payer: Blue Distinction Transplant |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.59
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.91
|
| Rate for Payer: Cigna of CA PPO |
$1.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.32
|
| Rate for Payer: Dignity Health Media |
$2.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.09
|
| Rate for Payer: Galaxy Health WC |
$2.32
|
| Rate for Payer: Global Benefits Group Commercial |
$1.64
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.18
|
| Rate for Payer: Networks By Design Commercial |
$1.77
|
| Rate for Payer: Prime Health Services Commercial |
$2.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.36
|
| Rate for Payer: United Healthcare All Other HMO |
$1.36
|
| Rate for Payer: United Healthcare HMO Rider |
$1.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.32
|
| Rate for Payer: Vantage Medical Group Senior |
$2.32
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-95
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.91
|
| Rate for Payer: Cigna of CA PPO |
$1.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Galaxy Health WC |
$2.32
|
| Rate for Payer: Global Benefits Group Commercial |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.18
|
| Rate for Payer: Networks By Design Commercial |
$1.77
|
| Rate for Payer: Prime Health Services Commercial |
$2.32
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 0527-1313-01
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-25
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.63
|
| Rate for Payer: Blue Distinction Transplant |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.59
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.91
|
| Rate for Payer: Cigna of CA PPO |
$1.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.32
|
| Rate for Payer: Dignity Health Media |
$2.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.09
|
| Rate for Payer: Galaxy Health WC |
$2.32
|
| Rate for Payer: Global Benefits Group Commercial |
$1.64
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.18
|
| Rate for Payer: Networks By Design Commercial |
$1.77
|
| Rate for Payer: Prime Health Services Commercial |
$2.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.36
|
| Rate for Payer: United Healthcare All Other HMO |
$1.36
|
| Rate for Payer: United Healthcare HMO Rider |
$1.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.32
|
| Rate for Payer: Vantage Medical Group Senior |
$2.32
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-25
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.91
|
| Rate for Payer: Cigna of CA PPO |
$1.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Galaxy Health WC |
$2.32
|
| Rate for Payer: Global Benefits Group Commercial |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.18
|
| Rate for Payer: Networks By Design Commercial |
$1.77
|
| Rate for Payer: Prime Health Services Commercial |
$2.32
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 0527-1313-01
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Distinction Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Media |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
PIMECROLIMUS 1 % TOPICAL CREAM [32052]
|
Facility
|
IP
|
$11.96
|
|
|
Service Code
|
NDC 0187-5100-01
|
| Hospital Charge Code |
1743701
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Blue Shield of California Commercial |
$8.52
|
| Rate for Payer: Blue Shield of California EPN |
$6.12
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cigna of CA HMO |
$8.37
|
| Rate for Payer: Cigna of CA PPO |
$8.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.78
|
| Rate for Payer: Galaxy Health WC |
$10.17
|
| Rate for Payer: Global Benefits Group Commercial |
$7.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$9.57
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$10.17
|
|
|
PIMECROLIMUS 1 % TOPICAL CREAM [32052]
|
Facility
|
OP
|
$11.96
|
|
|
Service Code
|
NDC 0187-5100-01
|
| Hospital Charge Code |
1743701
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.13
|
| Rate for Payer: Blue Distinction Transplant |
$7.18
|
| Rate for Payer: Blue Shield of California Commercial |
$8.81
|
| Rate for Payer: Blue Shield of California EPN |
$6.98
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cigna of CA HMO |
$8.37
|
| Rate for Payer: Cigna of CA PPO |
$8.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.17
|
| Rate for Payer: Dignity Health Media |
$10.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.78
|
| Rate for Payer: Galaxy Health WC |
$10.17
|
| Rate for Payer: Global Benefits Group Commercial |
$7.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$9.57
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$10.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.98
|
| Rate for Payer: United Healthcare All Other HMO |
$5.98
|
| Rate for Payer: United Healthcare HMO Rider |
$5.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.17
|
| Rate for Payer: Vantage Medical Group Senior |
$10.17
|
|
