|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 0168-0357-05
|
| Hospital Charge Code |
NDG10434B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.36
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 0168-0357-05
|
| Hospital Charge Code |
NDG10434B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.68
|
| Rate for Payer: Dignity Health Senior |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Senior |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Vantage Medical Group Senior |
$1.68
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 0591-2070-30
|
| Hospital Charge Code |
NDG10434
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: Dignity Health Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Senior |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
Ligamentous reconstruction (augmentation), knee; extra-articular
|
Facility
|
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 27427
|
| Min. Negotiated Rate |
$3,728.00 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,832.38
|
| Rate for Payer: Dignity Health Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,938.53
|
| Rate for Payer: Humana Medicare |
$8,938.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,938.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16,983.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10,547.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,262.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,262.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,832.38
|
| Rate for Payer: TriValley Medical Group Senior |
$8,938.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
Ligation or banding of angioaccess arteriovenous fistula
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 37607
|
| Min. Negotiated Rate |
$425.13 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,380.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,982.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,380.80
|
| Rate for Payer: Dignity Health Senior |
$3,982.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,982.55
|
| Rate for Payer: Humana Medicare |
$3,982.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$425.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,982.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,566.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,699.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,018.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,018.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,380.80
|
| Rate for Payer: TriValley Medical Group Senior |
$3,982.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,973.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,380.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,982.55
|
|
|
Ligation or biopsy, temporal artery
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 37609
|
| Min. Negotiated Rate |
$2,025.69 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: Dignity Health Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,025.69
|
| Rate for Payer: Humana Medicare |
$2,025.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,848.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,390.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,552.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,228.26
|
| Rate for Payer: TriValley Medical Group Senior |
$2,025.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 38564
|
| Min. Negotiated Rate |
$189.34 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,455.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$189.34
|
|
|
Limited pharyngectomy
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 42890
|
| Min. Negotiated Rate |
$1,166.22 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,166.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
LINACLOTIDE 145 MCG CAPSULE [199379]
|
Facility
|
OP
|
$20.61
|
|
|
Service Code
|
NDC 0456-1201-30
|
| Hospital Charge Code |
ERX199379
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$17.52 |
| Rate for Payer: Adventist Health Commercial |
$4.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.46
|
| Rate for Payer: Blue Shield of California Commercial |
$12.80
|
| Rate for Payer: Blue Shield of California EPN |
$12.10
|
| Rate for Payer: Cash Price |
$9.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.52
|
| Rate for Payer: Dignity Health Senior |
$17.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.76
|
| Rate for Payer: Heritage Provider Network Senior |
$12.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.15
|
| Rate for Payer: Multiplan Commercial |
$15.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.24
|
| Rate for Payer: TriValley Medical Group Senior |
$8.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.52
|
| Rate for Payer: Vantage Medical Group Senior |
$17.52
|
|
|
LINACLOTIDE 145 MCG CAPSULE [199379]
|
Facility
|
IP
|
$20.61
|
|
|
Service Code
|
NDC 0456-1201-30
|
| Hospital Charge Code |
ERX199379
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$15.46 |
| Rate for Payer: Adventist Health Commercial |
$4.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.16
|
| Rate for Payer: Cash Price |
$9.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.95
|
| Rate for Payer: Heritage Provider Network Senior |
$13.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.15
|
| Rate for Payer: Multiplan Commercial |
$15.46
|
|
|
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [28225]
|
Facility
|
OP
|
$5.46
|
|
|
Service Code
|
NDC 0009-5136-01
|
| Hospital Charge Code |
1715979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Adventist Health Commercial |
$1.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.10
|
| Rate for Payer: Blue Shield of California Commercial |
$3.39
|
| Rate for Payer: Blue Shield of California EPN |
$3.21
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.64
|
| Rate for Payer: Dignity Health Senior |
$4.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Senior |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.18
|
| Rate for Payer: TriValley Medical Group Senior |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.64
|
| Rate for Payer: Vantage Medical Group Senior |
$4.64
|
|
|
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [28225]
|
Facility
|
IP
|
$5.46
|
|
|
Service Code
|
NDC 0009-5136-01
|
| Hospital Charge Code |
1715979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Adventist Health Commercial |
$1.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.75
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.70
|
| Rate for Payer: Heritage Provider Network Senior |
$3.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
|
|
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [28225]
|
Facility
|
OP
|
$5.25
|
|
|
Service Code
|
NDC 59762-1308-1
|
| Hospital Charge Code |
1715979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.94
|
| Rate for Payer: Blue Shield of California Commercial |
$3.26
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.46
|
| Rate for Payer: Dignity Health Senior |
$4.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Senior |
$3.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$3.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.10
|
| Rate for Payer: TriValley Medical Group Senior |
$2.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.46
|
| Rate for Payer: Vantage Medical Group Senior |
$4.46
|
|
|
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [28225]
|
Facility
|
IP
|
$5.25
|
|
|
Service Code
|
NDC 59762-1308-1
|
| Hospital Charge Code |
1715979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.61
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.55
|
| Rate for Payer: Heritage Provider Network Senior |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$3.94
|
|
|
LINEZOLID 600 MG/300 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK [210366]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
CPT J2021
|
| Hospital Charge Code |
NDG210366
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
|
|
LINEZOLID 600 MG/300 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK [210366]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
CPT J2021
|
| Hospital Charge Code |
NDG210366
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$49.28 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.16
|
| Rate for Payer: Blue Shield of California Commercial |
$21.57
|
| Rate for Payer: Blue Shield of California EPN |
$21.57
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.07
|
| Rate for Payer: Dignity Health Senior |
$22.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Humana Medicare |
$20.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$38.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.28
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.07
|
| Rate for Payer: Vantage Medical Group Senior |
$20.06
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
OP
|
$7.40
|
|
|
Service Code
|
NDC 60687-309-11
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$6.29 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.55
|
| Rate for Payer: Blue Shield of California Commercial |
$4.60
|
| Rate for Payer: Blue Shield of California EPN |
$4.34
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.29
|
| Rate for Payer: Dignity Health Senior |
$6.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Senior |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$5.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.96
|
| Rate for Payer: TriValley Medical Group Senior |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.29
|
| Rate for Payer: Vantage Medical Group Senior |
$6.29
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
IP
|
$7.40
|
|
|
Service Code
|
NDC 60687-309-21
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.08
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.01
|
| Rate for Payer: Heritage Provider Network Senior |
$5.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$5.55
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
OP
|
$7.43
|
|
|
Service Code
|
NDC 0904-6553-04
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$6.32 |
| Rate for Payer: Adventist Health Commercial |
$1.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.57
|
| Rate for Payer: Blue Shield of California Commercial |
$4.61
|
| Rate for Payer: Blue Shield of California EPN |
$4.36
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.32
|
| Rate for Payer: Dignity Health Senior |
$6.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.60
|
| Rate for Payer: Heritage Provider Network Senior |
$4.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$5.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.32
|
| Rate for Payer: Vantage Medical Group Senior |
$6.32
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 67877-419-33
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
OP
|
$7.40
|
|
|
Service Code
|
NDC 60687-309-21
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$6.29 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.55
|
| Rate for Payer: Blue Shield of California Commercial |
$4.60
|
| Rate for Payer: Blue Shield of California EPN |
$4.34
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.29
|
| Rate for Payer: Dignity Health Senior |
$6.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Senior |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$5.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.96
|
| Rate for Payer: TriValley Medical Group Senior |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.29
|
| Rate for Payer: Vantage Medical Group Senior |
$6.29
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 67877-419-84
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
IP
|
$7.40
|
|
|
Service Code
|
NDC 60687-309-11
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Adventist Health Commercial |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.08
|
| Rate for Payer: Cash Price |
$3.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.01
|
| Rate for Payer: Heritage Provider Network Senior |
$5.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$5.55
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
IP
|
$7.43
|
|
|
Service Code
|
NDC 0904-6553-04
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$5.57 |
| Rate for Payer: Adventist Health Commercial |
$1.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.10
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.03
|
| Rate for Payer: Heritage Provider Network Senior |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$5.57
|
|
|
LINEZOLID 600 MG TABLET [28224]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 67877-419-33
|
| Hospital Charge Code |
1712242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$2.47
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
