|
BUSPIRONE 7.5 MG TABLET [29967]
|
Facility
IP
|
$0.31
|
|
|
Service Code
|
NDC 64380-787-06
|
| Hospital Charge Code |
ERX29967
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
BUSPIRONE 7.5 MG TABLET [29967]
|
Facility
IP
|
$0.31
|
|
|
Service Code
|
NDC 16729-201-01
|
| Hospital Charge Code |
ERX29967
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
BUSPIRONE 7.5 MG TABLET [29967]
|
Facility
OP
|
$0.31
|
|
|
Service Code
|
NDC 16729-201-01
|
| Hospital Charge Code |
ERX29967
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
BUSPIRONE 7.5 MG TABLET [29967]
|
Facility
OP
|
$0.31
|
|
|
Service Code
|
NDC 68382-623-01
|
| Hospital Charge Code |
ERX29967
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
BUSPIRONE 7.5 MG TABLET [29967]
|
Facility
IP
|
$0.31
|
|
|
Service Code
|
NDC 68382-623-01
|
| Hospital Charge Code |
ERX29967
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]
|
Facility
OP
|
$1.08
|
|
|
Service Code
|
NDC 42195-955-10
|
| Hospital Charge Code |
ERX104993
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Senior |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]
|
Facility
IP
|
$1.08
|
|
|
Service Code
|
NDC 42195-955-10
|
| Hospital Charge Code |
ERX104993
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]
|
Facility
OP
|
$1.06
|
|
|
Service Code
|
NDC 70010-044-01
|
| Hospital Charge Code |
ERX104993
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.90
|
| Rate for Payer: Dignity Health Senior |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Vantage Medical Group Senior |
$0.90
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE [104993]
|
Facility
IP
|
$1.06
|
|
|
Service Code
|
NDC 70010-044-01
|
| Hospital Charge Code |
ERX104993
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.73
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE [8922]
|
Facility
OP
|
$1.31
|
|
|
Service Code
|
NDC 0591-3219-01
|
| Hospital Charge Code |
1730054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
BUTALBITAL-ASPIRIN-CAFFEINE 50 MG-325 MG-40 MG CAPSULE [8922]
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 0591-3219-01
|
| Hospital Charge Code |
1730054
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
BUTORPHANOL 10 MG/ML NASAL SPRAY [9335]
|
Facility
IP
|
$27.07
|
|
|
Service Code
|
NDC 60505-0813-1
|
| Hospital Charge Code |
1740276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$20.30 |
| Rate for Payer: Adventist Health Commercial |
$5.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.60
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.33
|
| Rate for Payer: Heritage Provider Network Senior |
$18.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.77
|
| Rate for Payer: Multiplan Commercial |
$20.30
|
|
|
BUTORPHANOL 10 MG/ML NASAL SPRAY [9335]
|
Facility
OP
|
$27.07
|
|
|
Service Code
|
NDC 60505-0813-1
|
| Hospital Charge Code |
1740276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$23.01 |
| Rate for Payer: Adventist Health Commercial |
$5.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$23.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$20.30
|
| Rate for Payer: Blue Shield of California Commercial |
$16.81
|
| Rate for Payer: Blue Shield of California EPN |
$15.89
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.01
|
| Rate for Payer: Dignity Health Senior |
$23.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.76
|
| Rate for Payer: Heritage Provider Network Senior |
$16.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.77
|
| Rate for Payer: Multiplan Commercial |
$20.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.01
|
| Rate for Payer: Vantage Medical Group Senior |
$23.01
|
|
|
BUTORPHANOL 1 MG/ML INJECTION SOLUTION [9333]
|
Facility
IP
|
$7.36
|
|
|
Service Code
|
CPT J0595
|
| Hospital Charge Code |
1720353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.06
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.98
|
| Rate for Payer: Heritage Provider Network Senior |
$4.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$5.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.46
|
|
|
BUTORPHANOL 1 MG/ML INJECTION SOLUTION [9333]
|
Facility
OP
|
$7.36
|
|
|
Service Code
|
CPT J0595
|
| Hospital Charge Code |
1720353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Adventist Health Commercial |
$1.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.05
|
| Rate for Payer: Blue Shield of California Commercial |
$3.52
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.26
|
| Rate for Payer: Dignity Health Senior |
$6.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.41
|
| Rate for Payer: Heritage Provider Network Senior |
$3.41
|
| Rate for Payer: IEHP Medi-Cal |
$11.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$5.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.26
|
| Rate for Payer: Vantage Medical Group Senior |
$6.26
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]
|
Facility
OP
|
$6.34
|
|
|
Service Code
|
CPT J0595
|
| Hospital Charge Code |
1720575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.05
|
| Rate for Payer: Blue Shield of California Commercial |
$3.52
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.39
|
| Rate for Payer: Dignity Health Senior |
$5.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.94
|
| Rate for Payer: Heritage Provider Network Senior |
$2.94
|
| Rate for Payer: IEHP Medi-Cal |
$11.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.39
|
| Rate for Payer: Vantage Medical Group Senior |
$5.39
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
CPT J0595
|
| Hospital Charge Code |
1720351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]
|
Facility
IP
|
$6.34
|
|
|
Service Code
|
CPT J0595
|
| Hospital Charge Code |
1720575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.76 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.36
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.29
|
| Rate for Payer: Heritage Provider Network Senior |
$4.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.12
|
|
|
BUTORPHANOL 2 MG/ML INJECTION SOLUTION [9334]
|
Facility
OP
|
$3.60
|
|
|
Service Code
|
CPT J0595
|
| Hospital Charge Code |
1720351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.05
|
| Rate for Payer: Blue Shield of California Commercial |
$3.52
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: IEHP Medi-Cal |
$11.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
BUTT PASTE OINT (LLUMC) [4080617]
|
Facility
IP
|
$15.00
|
|
|
Service Code
|
NDC 9994-0806-17
|
| Hospital Charge Code |
1743709
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$11.25 |
| Rate for Payer: Adventist Health Commercial |
$3.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.30
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.16
|
| Rate for Payer: Heritage Provider Network Senior |
$10.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$11.25
|
|
|
BUTT PASTE OINT (LLUMC) [4080617]
|
Facility
OP
|
$15.00
|
|
|
Service Code
|
NDC 9994-0806-17
|
| Hospital Charge Code |
1743709
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Adventist Health Commercial |
$3.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.25
|
| Rate for Payer: Blue Shield of California Commercial |
$9.32
|
| Rate for Payer: Blue Shield of California EPN |
$8.80
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.75
|
| Rate for Payer: Dignity Health Senior |
$12.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.28
|
| Rate for Payer: Heritage Provider Network Senior |
$9.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$11.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.75
|
| Rate for Payer: Vantage Medical Group Senior |
$12.75
|
|
|
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT [192162]
|
Facility
IP
|
$4,344.83
|
|
|
Service Code
|
CPT J0597
|
| Hospital Charge Code |
ERX192145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$786.41 |
| Max. Negotiated Rate |
$3,258.62 |
| Rate for Payer: Adventist Health Commercial |
$868.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,984.90
|
| Rate for Payer: Cash Price |
$1,955.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,998.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,346.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,941.45
|
| Rate for Payer: Heritage Provider Network Senior |
$2,941.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$786.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,086.21
|
| Rate for Payer: Multiplan Commercial |
$3,258.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,584.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,451.61
|
|
|
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT [192162]
|
Facility
OP
|
$4,344.83
|
|
|
Service Code
|
CPT J0597
|
| Hospital Charge Code |
ERX192145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.36 |
| Max. Negotiated Rate |
$3,258.62 |
| Rate for Payer: Adventist Health Commercial |
$868.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$158.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,984.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$80.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$70.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$70.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.69
|
| Rate for Payer: Blue Shield of California Commercial |
$69.68
|
| Rate for Payer: Blue Shield of California EPN |
$69.68
|
| Rate for Payer: Cash Price |
$1,955.17
|
| Rate for Payer: Cash Price |
$1,955.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,998.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$70.79
|
| Rate for Payer: Dignity Health Senior |
$70.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,780.69
|
| Rate for Payer: EPIC Health Plan Medicare |
$64.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,011.66
|
| Rate for Payer: Heritage Provider Network Senior |
$2,011.66
|
| Rate for Payer: Humana Medicare |
$64.36
|
| Rate for Payer: IEHP Medi-Cal |
$107.36
|
| Rate for Payer: IEHP Medicare Advantage |
$64.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$122.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$786.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$75.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,086.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$81.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$81.09
|
| Rate for Payer: Multiplan Commercial |
$3,258.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$70.79
|
| Rate for Payer: TriValley Medical Group Senior |
$64.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,584.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,451.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$70.79
|
| Rate for Payer: Vantage Medical Group Senior |
$64.36
|
|
|
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION [196347]
|
Facility
OP
|
$4,344.83
|
|
|
Service Code
|
CPT J0597
|
| Hospital Charge Code |
ERX196347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.36 |
| Max. Negotiated Rate |
$3,258.62 |
| Rate for Payer: Adventist Health Commercial |
$868.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$158.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,984.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$80.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$70.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$70.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.69
|
| Rate for Payer: Blue Shield of California Commercial |
$69.68
|
| Rate for Payer: Blue Shield of California EPN |
$69.68
|
| Rate for Payer: Cash Price |
$1,955.17
|
| Rate for Payer: Cash Price |
$1,955.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,998.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$70.79
|
| Rate for Payer: Dignity Health Senior |
$70.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,780.69
|
| Rate for Payer: EPIC Health Plan Medicare |
$64.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,011.66
|
| Rate for Payer: Heritage Provider Network Senior |
$2,011.66
|
| Rate for Payer: Humana Medicare |
$64.36
|
| Rate for Payer: IEHP Medi-Cal |
$107.36
|
| Rate for Payer: IEHP Medicare Advantage |
$64.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$122.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$786.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$75.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,086.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$81.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$81.09
|
| Rate for Payer: Multiplan Commercial |
$3,258.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$70.79
|
| Rate for Payer: TriValley Medical Group Senior |
$64.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,584.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,451.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$70.79
|
| Rate for Payer: Vantage Medical Group Senior |
$64.36
|
|
|
C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION [196347]
|
Facility
IP
|
$4,344.83
|
|
|
Service Code
|
CPT J0597
|
| Hospital Charge Code |
ERX196347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$786.41 |
| Max. Negotiated Rate |
$3,258.62 |
| Rate for Payer: Adventist Health Commercial |
$868.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,984.90
|
| Rate for Payer: Cash Price |
$1,955.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,998.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,346.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,941.45
|
| Rate for Payer: Heritage Provider Network Senior |
$2,941.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$786.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,086.21
|
| Rate for Payer: Multiplan Commercial |
$3,258.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,584.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,451.61
|
|
