|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$7.80
|
|
|
Service Code
|
NDC 0143-9532-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$7.02 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.58
|
| Rate for Payer: Blue Shield of California Commercial |
$4.77
|
| Rate for Payer: Blue Shield of California EPN |
$3.11
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: Central Health Plan Commercial |
$6.24
|
| Rate for Payer: Cigna of CA HMO |
$4.99
|
| Rate for Payer: Cigna of CA PPO |
$5.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.12
|
| Rate for Payer: EPIC Health Plan Senior |
$3.12
|
| Rate for Payer: Galaxy Health WC |
$6.63
|
| Rate for Payer: Global Benefits Group Commercial |
$4.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.02
|
| Rate for Payer: InnovAge PACE Commercial |
$3.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: Networks By Design Commercial |
$5.07
|
| Rate for Payer: Prime Health Services Commercial |
$6.63
|
| Rate for Payer: Riverside University Health System MISP |
$3.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.90
|
| Rate for Payer: United Healthcare All Other HMO |
$3.90
|
| Rate for Payer: United Healthcare HMO Rider |
$3.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$6.63
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$3.25
|
|
|
Service Code
|
NDC 42023-146-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.91
|
| Rate for Payer: Blue Shield of California Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California EPN |
$1.30
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Central Health Plan Commercial |
$2.60
|
| Rate for Payer: Cigna of CA HMO |
$2.08
|
| Rate for Payer: Cigna of CA PPO |
$2.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: EPIC Health Plan Senior |
$1.30
|
| Rate for Payer: Galaxy Health WC |
$2.76
|
| Rate for Payer: Global Benefits Group Commercial |
$1.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.92
|
| Rate for Payer: InnovAge PACE Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.27
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Networks By Design Commercial |
$2.11
|
| Rate for Payer: Prime Health Services Commercial |
$2.76
|
| Rate for Payer: Riverside University Health System MISP |
$1.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.62
|
| Rate for Payer: United Healthcare All Other HMO |
$1.62
|
| Rate for Payer: United Healthcare HMO Rider |
$1.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.76
|
| Rate for Payer: Vantage Medical Group Senior |
$2.76
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 70860-605-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Central Health Plan Commercial |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$1.29
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: EPIC Health Plan Senior |
$0.81
|
| Rate for Payer: Galaxy Health WC |
$1.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.82
|
| Rate for Payer: InnovAge PACE Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.72
|
| Rate for Payer: Riverside University Health System MISP |
$0.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.01
|
| Rate for Payer: United Healthcare All Other HMO |
$1.01
|
| Rate for Payer: United Healthcare HMO Rider |
$1.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 55150-209-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.89 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$3.34
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Central Health Plan Commercial |
$3.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Senior |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$3.67
|
| Rate for Payer: Global Benefits Group Commercial |
$2.59
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
| Rate for Payer: Networks By Design Commercial |
$2.81
|
| Rate for Payer: Prime Health Services Commercial |
$3.67
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$3.15
|
|
|
Service Code
|
NDC 66794-230-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.59
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Central Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: EPIC Health Plan Senior |
$1.26
|
| Rate for Payer: Galaxy Health WC |
$2.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Networks By Design Commercial |
$2.05
|
| Rate for Payer: Prime Health Services Commercial |
$2.68
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$3.15
|
|
|
Service Code
|
NDC 66794-230-42
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.26
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Central Health Plan Commercial |
$2.52
|
| Rate for Payer: Cigna of CA HMO |
$2.02
|
| Rate for Payer: Cigna of CA PPO |
$2.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: EPIC Health Plan Senior |
$1.26
|
| Rate for Payer: Galaxy Health WC |
$2.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.83
|
| Rate for Payer: InnovAge PACE Commercial |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Networks By Design Commercial |
$2.05
|
| Rate for Payer: Prime Health Services Commercial |
$2.68
|
| Rate for Payer: Riverside University Health System MISP |
$1.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.57
|
| Rate for Payer: United Healthcare All Other HMO |
$1.57
|
| Rate for Payer: United Healthcare HMO Rider |
$1.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2.68
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$2.02
|
|
|
Service Code
|
NDC 70860-605-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Central Health Plan Commercial |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: EPIC Health Plan Senior |
$0.81
|
| Rate for Payer: Galaxy Health WC |
$1.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$1.31
|
| Rate for Payer: Prime Health Services Commercial |
$1.72
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 66794-234-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 66794-234-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: InnovAge PACE Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Riverside University Health System MISP |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 66794-234-44
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 66794-234-44
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: InnovAge PACE Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Riverside University Health System MISP |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 9940-8202-59
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 9940-8202-59
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.37
|
| Rate for Payer: InnovAge PACE Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
OP
|
$455.94
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.09 |
| Max. Negotiated Rate |
$514.51 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Adventist Health Medi-Cal |
$32.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$276.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$514.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$157.91
|
| Rate for Payer: Blue Shield of California Commercial |
$321.82
|
| Rate for Payer: Blue Shield of California EPN |
$292.56
|
| Rate for Payer: Cash Price |
$250.77
|
| Rate for Payer: Cash Price |
$250.77
|
| Rate for Payer: Central Health Plan Commercial |
$364.75
|
| Rate for Payer: Cigna of CA HMO |
$319.16
|
| Rate for Payer: Cigna of CA PPO |
$319.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.31
|
| Rate for Payer: EPIC Health Plan Senior |
$32.09
|
| Rate for Payer: Galaxy Health WC |
$387.55
|
| Rate for Payer: Global Benefits Group Commercial |
$273.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$410.35
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$52.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$80.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.09
|
| Rate for Payer: InnovAge PACE Commercial |
$48.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$304.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$42.99
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: Networks By Design Commercial |
$227.97
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$32.09
|
| Rate for Payer: Prime Health Services Commercial |
$387.55
|
| Rate for Payer: Prime Health Services Medicare |
$34.01
|
| Rate for Payer: Riverside University Health System MISP |
$35.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$273.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$273.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.11
|
| Rate for Payer: United Healthcare All Other HMO |
$166.55
|
| Rate for Payer: United Healthcare HMO Rider |
$162.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$149.32
|
| Rate for Payer: Upland Medical Group Pediatric |
$32.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.29
|
| Rate for Payer: Vantage Medical Group Senior |
$35.29
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
IP
|
$455.94
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.19 |
| Max. Negotiated Rate |
$410.35 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Blue Shield of California Commercial |
$352.44
|
| Rate for Payer: Blue Shield of California EPN |
$229.79
|
| Rate for Payer: Cash Price |
$250.77
|
| Rate for Payer: Central Health Plan Commercial |
$364.75
|
| Rate for Payer: Cigna of CA HMO |
$319.16
|
| Rate for Payer: Cigna of CA PPO |
$319.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.38
|
| Rate for Payer: EPIC Health Plan Senior |
$182.38
|
| Rate for Payer: Galaxy Health WC |
$387.55
|
| Rate for Payer: Global Benefits Group Commercial |
$273.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$410.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$304.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$282.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.19
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: Networks By Design Commercial |
$227.97
|
| Rate for Payer: Prime Health Services Commercial |
$387.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.11
|
| Rate for Payer: United Healthcare All Other HMO |
$166.55
|
| Rate for Payer: United Healthcare HMO Rider |
$162.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$149.32
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
IP
|
$329.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.82 |
| Max. Negotiated Rate |
$296.20 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Blue Shield of California Commercial |
$254.40
|
| Rate for Payer: Blue Shield of California EPN |
$165.87
|
| Rate for Payer: Cash Price |
$181.01
|
| Rate for Payer: Central Health Plan Commercial |
$263.29
|
| Rate for Payer: Cigna of CA HMO |
$230.38
|
| Rate for Payer: Cigna of CA PPO |
$230.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$131.64
|
| Rate for Payer: EPIC Health Plan Senior |
$131.64
|
| Rate for Payer: Galaxy Health WC |
$279.74
|
| Rate for Payer: Global Benefits Group Commercial |
$197.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$296.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.82
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: Networks By Design Commercial |
$164.56
|
| Rate for Payer: Prime Health Services Commercial |
$279.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$123.51
|
| Rate for Payer: United Healthcare All Other HMO |
$120.22
|
| Rate for Payer: United Healthcare HMO Rider |
$117.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$107.78
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
OP
|
$329.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.09 |
| Max. Negotiated Rate |
$514.51 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Adventist Health Medi-Cal |
$32.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$199.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$514.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$157.91
|
| Rate for Payer: Blue Shield of California Commercial |
$321.82
|
| Rate for Payer: Blue Shield of California EPN |
$292.56
|
| Rate for Payer: Cash Price |
$181.01
|
| Rate for Payer: Cash Price |
$181.01
|
| Rate for Payer: Central Health Plan Commercial |
$263.29
|
| Rate for Payer: Cigna of CA HMO |
$230.38
|
| Rate for Payer: Cigna of CA PPO |
$230.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.31
|
| Rate for Payer: EPIC Health Plan Senior |
$32.09
|
| Rate for Payer: Galaxy Health WC |
$279.74
|
| Rate for Payer: Global Benefits Group Commercial |
$197.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$296.20
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$52.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$80.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.09
|
| Rate for Payer: InnovAge PACE Commercial |
$48.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$219.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$125.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$42.99
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: Networks By Design Commercial |
$164.56
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$32.09
|
| Rate for Payer: Prime Health Services Commercial |
$279.74
|
| Rate for Payer: Prime Health Services Medicare |
$34.01
|
| Rate for Payer: Riverside University Health System MISP |
$35.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$197.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$197.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$123.51
|
| Rate for Payer: United Healthcare All Other HMO |
$120.22
|
| Rate for Payer: United Healthcare HMO Rider |
$117.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$107.78
|
| Rate for Payer: Upland Medical Group Pediatric |
$32.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.29
|
| Rate for Payer: Vantage Medical Group Senior |
$35.29
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0065-0416-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 0065-0416-63
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 0065-0416-63
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: InnovAge PACE Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 0065-8063-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 0065-8063-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: InnovAge PACE Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Riverside University Health System MISP |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0065-0416-22
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: InnovAge PACE Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0853-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Central Health Plan Commercial |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: InnovAge PACE Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
| Rate for Payer: Riverside University Health System MISP |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0853-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Central Health Plan Commercial |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
|
