|
C1 ESTERASE INHIBITOR, RECOMBINANT 2,100 UNIT INTRAVENOUS SOLUTION [207371]
|
Facility
OP
|
$8,724.00
|
|
|
Service Code
|
CPT J0596
|
| Hospital Charge Code |
ERX207371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.32 |
| Max. Negotiated Rate |
$6,543.00 |
| Rate for Payer: Adventist Health Commercial |
$1,744.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$82.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,993.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$41.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$36.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.54
|
| Rate for Payer: Blue Shield of California Commercial |
$33.32
|
| Rate for Payer: Blue Shield of California EPN |
$33.32
|
| Rate for Payer: Cash Price |
$3,925.80
|
| Rate for Payer: Cash Price |
$3,925.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,013.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.86
|
| Rate for Payer: Dignity Health Senior |
$36.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,583.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$33.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,039.21
|
| Rate for Payer: Heritage Provider Network Senior |
$4,039.21
|
| Rate for Payer: Humana Medicare |
$33.51
|
| Rate for Payer: IEHP Medi-Cal |
$59.23
|
| Rate for Payer: IEHP Medicare Advantage |
$33.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$63.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,579.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$39.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,181.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$42.22
|
| Rate for Payer: Multiplan Commercial |
$6,543.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$36.86
|
| Rate for Payer: TriValley Medical Group Senior |
$33.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,180.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,914.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.86
|
| Rate for Payer: Vantage Medical Group Senior |
$33.51
|
|
|
C1 ESTERASE INHIBITOR, RECOMBINANT 2,100 UNIT INTRAVENOUS SOLUTION [207371]
|
Facility
IP
|
$8,724.00
|
|
|
Service Code
|
CPT J0596
|
| Hospital Charge Code |
ERX207371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,579.04 |
| Max. Negotiated Rate |
$6,543.00 |
| Rate for Payer: Adventist Health Commercial |
$1,744.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,993.39
|
| Rate for Payer: Cash Price |
$3,925.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,013.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,710.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,906.15
|
| Rate for Payer: Heritage Provider Network Senior |
$5,906.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,579.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,181.00
|
| Rate for Payer: Multiplan Commercial |
$6,543.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,180.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,914.69
|
|
|
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION [105644]
|
Facility
OP
|
$10,772.15
|
|
|
Service Code
|
CPT J9043
|
| Hospital Charge Code |
1755729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.45 |
| Max. Negotiated Rate |
$8,079.11 |
| Rate for Payer: Adventist Health Commercial |
$2,154.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$517.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,400.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$287.84
|
| Rate for Payer: Blue Shield of California Commercial |
$217.88
|
| Rate for Payer: Blue Shield of California EPN |
$217.88
|
| Rate for Payer: Cash Price |
$4,847.47
|
| Rate for Payer: Cash Price |
$4,847.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,955.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$315.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.50
|
| Rate for Payer: Dignity Health Senior |
$231.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,894.18
|
| Rate for Payer: EPIC Health Plan Medicare |
$210.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,987.51
|
| Rate for Payer: Heritage Provider Network Senior |
$4,987.51
|
| Rate for Payer: Humana Medicare |
$210.45
|
| Rate for Payer: IEHP Medi-Cal |
$335.26
|
| Rate for Payer: IEHP Medicare Advantage |
$210.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$399.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,949.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$248.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,693.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$265.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$265.17
|
| Rate for Payer: Multiplan Commercial |
$8,079.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$231.50
|
| Rate for Payer: TriValley Medical Group Senior |
$210.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,927.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,598.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$315.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.50
|
| Rate for Payer: Vantage Medical Group Senior |
$210.45
|
|
|
CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION [105644]
|
Facility
IP
|
$10,772.15
|
|
|
Service Code
|
CPT J9043
|
| Hospital Charge Code |
1755729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,949.76 |
| Max. Negotiated Rate |
$8,079.11 |
| Rate for Payer: Adventist Health Commercial |
$2,154.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,400.47
|
| Rate for Payer: Cash Price |
$4,847.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,955.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,816.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,292.75
|
| Rate for Payer: Heritage Provider Network Senior |
$7,292.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,949.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,693.04
|
| Rate for Payer: Multiplan Commercial |
$8,079.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,927.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,598.98
|
|
|
CABERGOLINE 0.25 MG 1/2 TABLET [4081952]
|
Facility
OP
|
$5.59
|
|
|
Service Code
|
NDC 9994-0819-52
|
| Hospital Charge Code |
ERX4081952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.19
|
| Rate for Payer: Blue Shield of California Commercial |
$3.47
|
| Rate for Payer: Blue Shield of California EPN |
$3.28
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.75
|
| Rate for Payer: Dignity Health Senior |
$4.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4.75
|
|
|
CABERGOLINE 0.25 MG 1/2 TABLET [4081952]
|
Facility
IP
|
$5.59
|
|
|
Service Code
|
NDC 9994-0819-52
|
| Hospital Charge Code |
ERX4081952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.84
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.78
|
| Rate for Payer: Heritage Provider Network Senior |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.19
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
OP
|
$2.44
|
|
|
Service Code
|
NDC 23155-823-73
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.83
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.43
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.07
|
| Rate for Payer: Dignity Health Senior |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.51
|
| Rate for Payer: Heritage Provider Network Senior |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.07
|
| Rate for Payer: Vantage Medical Group Senior |
$2.07
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
IP
|
$2.44
|
|
|
Service Code
|
NDC 23155-823-73
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.68
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Senior |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
IP
|
$3.75
|
|
|
Service Code
|
NDC 50742-118-08
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.58
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.54
|
| Rate for Payer: Heritage Provider Network Senior |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$2.81
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
OP
|
$3.75
|
|
|
Service Code
|
NDC 50742-118-08
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.81
|
| Rate for Payer: Blue Shield of California Commercial |
$2.33
|
| Rate for Payer: Blue Shield of California EPN |
$2.20
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.19
|
| Rate for Payer: Dignity Health Senior |
$3.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.32
|
| Rate for Payer: Heritage Provider Network Senior |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$2.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.19
|
| Rate for Payer: Vantage Medical Group Senior |
$3.19
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
OP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
1743674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.55
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.89
|
| Rate for Payer: Dignity Health Senior |
$2.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.10
|
| Rate for Payer: Heritage Provider Network Senior |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.89
|
| Rate for Payer: Vantage Medical Group Senior |
$2.89
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
IP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
1743674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.34
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
OP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
IP
|
$3.26
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
NDG77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.95
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Senior |
$4.87
|
| Rate for Payer: Heritage Provider Network Senior |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.41
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
OP
|
$7.20
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
NDG77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Senior |
$2.77
|
| Rate for Payer: Dignity Health Senior |
$3.40
|
| Rate for Payer: Dignity Health Senior |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Senior |
$3.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.77
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 9994-0804-22
|
| Hospital Charge Code |
1715184
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 9994-0804-22
|
| Hospital Charge Code |
1715184
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$2.35
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Senior |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.48
|
| Rate for Payer: Heritage Provider Network Senior |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
NDC 25021-602-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.97
|
| Rate for Payer: Blue Shield of California EPN |
$4.70
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.80
|
| Rate for Payer: Dignity Health Senior |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.95
|
| Rate for Payer: Heritage Provider Network Senior |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Vantage Medical Group Senior |
$6.80
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
NDC 25021-602-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.50
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.42
|
| Rate for Payer: Heritage Provider Network Senior |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
IP
|
$15.50
|
|
|
Service Code
|
NDC 63323-406-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$11.62 |
| Rate for Payer: Adventist Health Commercial |
$3.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.65
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.49
|
| Rate for Payer: Heritage Provider Network Senior |
$10.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.62
|
|
