|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
OP
|
$15.50
|
|
|
Service Code
|
NDC 63323-406-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$13.18 |
| Rate for Payer: Adventist Health Commercial |
$3.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.62
|
| Rate for Payer: Blue Shield of California Commercial |
$9.63
|
| Rate for Payer: Blue Shield of California EPN |
$9.10
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.18
|
| Rate for Payer: Dignity Health Senior |
$13.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Senior |
$9.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.47
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.18
|
| Rate for Payer: Vantage Medical Group Senior |
$13.18
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
IP
|
$16.57
|
|
|
Service Code
|
NDC 0517-2502-01
|
| Hospital Charge Code |
1720528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Adventist Health Commercial |
$3.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.22
|
| Rate for Payer: Heritage Provider Network Senior |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
OP
|
$16.57
|
|
|
Service Code
|
NDC 0517-2502-10
|
| Hospital Charge Code |
1720528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$14.08 |
| Rate for Payer: Adventist Health Commercial |
$3.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.43
|
| Rate for Payer: Blue Shield of California Commercial |
$10.29
|
| Rate for Payer: Blue Shield of California EPN |
$9.73
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.08
|
| Rate for Payer: Dignity Health Senior |
$14.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.26
|
| Rate for Payer: Heritage Provider Network Senior |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.08
|
| Rate for Payer: Vantage Medical Group Senior |
$14.08
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
IP
|
$16.57
|
|
|
Service Code
|
NDC 0517-2502-10
|
| Hospital Charge Code |
1720528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Adventist Health Commercial |
$3.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.22
|
| Rate for Payer: Heritage Provider Network Senior |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
OP
|
$16.57
|
|
|
Service Code
|
NDC 0517-2502-01
|
| Hospital Charge Code |
1720528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$14.08 |
| Rate for Payer: Adventist Health Commercial |
$3.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.43
|
| Rate for Payer: Blue Shield of California Commercial |
$10.29
|
| Rate for Payer: Blue Shield of California EPN |
$9.73
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.08
|
| Rate for Payer: Dignity Health Senior |
$14.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.26
|
| Rate for Payer: Heritage Provider Network Senior |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.08
|
| Rate for Payer: Vantage Medical Group Senior |
$14.08
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0395-0413-96
|
| Hospital Charge Code |
NDG78879B
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0904-2533-21
|
| Hospital Charge Code |
NDG78879B
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904-2533-21
|
| Hospital Charge Code |
NDG78879B
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0395-0413-96
|
| Hospital Charge Code |
NDG78879B
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
IP
|
$7.07
|
|
|
Service Code
|
NDC 0781-7117-35
|
| Hospital Charge Code |
1743767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$5.30 |
| Rate for Payer: Adventist Health Commercial |
$1.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.86
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.79
|
| Rate for Payer: Heritage Provider Network Senior |
$4.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.77
|
| Rate for Payer: Multiplan Commercial |
$5.30
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
OP
|
$4.41
|
|
|
Service Code
|
NDC 68462-501-65
|
| Hospital Charge Code |
1743767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.75
|
| Rate for Payer: Dignity Health Senior |
$3.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.73
|
| Rate for Payer: Heritage Provider Network Senior |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Vantage Medical Group Senior |
$3.75
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
OP
|
$7.07
|
|
|
Service Code
|
NDC 0781-7117-35
|
| Hospital Charge Code |
1743767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Adventist Health Commercial |
$1.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.30
|
| Rate for Payer: Blue Shield of California Commercial |
$4.39
|
| Rate for Payer: Blue Shield of California EPN |
$4.15
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.01
|
| Rate for Payer: Dignity Health Senior |
$6.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.38
|
| Rate for Payer: Heritage Provider Network Senior |
$4.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.77
|
| Rate for Payer: Multiplan Commercial |
$5.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.01
|
| Rate for Payer: Vantage Medical Group Senior |
$6.01
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
IP
|
$4.41
|
|
|
Service Code
|
NDC 68462-501-65
|
| Hospital Charge Code |
1743767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.03
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Senior |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]
|
Facility
IP
|
$6.03
|
|
|
Service Code
|
NDC 66993-878-61
|
| Hospital Charge Code |
NDG12244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]
|
Facility
OP
|
$6.03
|
|
|
Service Code
|
NDC 66993-878-61
|
| Hospital Charge Code |
NDG12244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Blue Shield of California EPN |
$3.54
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Senior |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL OINTMENT [70383]
|
Facility
IP
|
$19.82
|
|
|
Service Code
|
NDC 50222-227-81
|
| Hospital Charge Code |
NDG70383
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$14.86 |
| Rate for Payer: Adventist Health Commercial |
$3.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.62
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.42
|
| Rate for Payer: Heritage Provider Network Senior |
$13.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.96
|
| Rate for Payer: Multiplan Commercial |
$14.86
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL OINTMENT [70383]
|
Facility
OP
|
$23.78
|
|
|
Service Code
|
NDC 50222-227-04
|
| Hospital Charge Code |
1743778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$20.21 |
| Rate for Payer: Adventist Health Commercial |
$4.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.84
|
| Rate for Payer: Blue Shield of California Commercial |
$14.77
|
| Rate for Payer: Blue Shield of California EPN |
$13.96
|
| Rate for Payer: Cash Price |
$10.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.21
|
| Rate for Payer: Dignity Health Senior |
$20.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.72
|
| Rate for Payer: Heritage Provider Network Senior |
$14.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$17.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.21
|
| Rate for Payer: Vantage Medical Group Senior |
$20.21
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL OINTMENT [70383]
|
Facility
OP
|
$19.82
|
|
|
Service Code
|
NDC 50222-227-81
|
| Hospital Charge Code |
NDG70383
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Adventist Health Commercial |
$3.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.86
|
| Rate for Payer: Blue Shield of California Commercial |
$12.31
|
| Rate for Payer: Blue Shield of California EPN |
$11.63
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.85
|
| Rate for Payer: Dignity Health Senior |
$16.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.27
|
| Rate for Payer: Heritage Provider Network Senior |
$12.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.96
|
| Rate for Payer: Multiplan Commercial |
$14.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.85
|
| Rate for Payer: Vantage Medical Group Senior |
$16.85
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL OINTMENT [70383]
|
Facility
IP
|
$23.78
|
|
|
Service Code
|
NDC 50222-227-04
|
| Hospital Charge Code |
1743778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$17.84 |
| Rate for Payer: Adventist Health Commercial |
$4.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.34
|
| Rate for Payer: Cash Price |
$10.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.10
|
| Rate for Payer: Heritage Provider Network Senior |
$16.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$17.84
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL SUSPENSION [91914]
|
Facility
IP
|
$25.28
|
|
|
Service Code
|
NDC 50222-501-06
|
| Hospital Charge Code |
NDG91914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$18.96 |
| Rate for Payer: Adventist Health Commercial |
$5.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.37
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.11
|
| Rate for Payer: Heritage Provider Network Senior |
$17.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.32
|
| Rate for Payer: Multiplan Commercial |
$18.96
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL SUSPENSION [91914]
|
Facility
OP
|
$25.28
|
|
|
Service Code
|
NDC 50222-501-06
|
| Hospital Charge Code |
NDG91914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$21.49 |
| Rate for Payer: Adventist Health Commercial |
$5.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.96
|
| Rate for Payer: Blue Shield of California Commercial |
$15.70
|
| Rate for Payer: Blue Shield of California EPN |
$14.84
|
| Rate for Payer: Cash Price |
$11.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.49
|
| Rate for Payer: Dignity Health Senior |
$21.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.65
|
| Rate for Payer: Heritage Provider Network Senior |
$15.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.32
|
| Rate for Payer: Multiplan Commercial |
$18.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.49
|
| Rate for Payer: Vantage Medical Group Senior |
$21.49
|
|
|
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]
|
Facility
IP
|
$24.28
|
|
|
Service Code
|
NDC 60505-0823-6
|
| Hospital Charge Code |
1744077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.39 |
| Max. Negotiated Rate |
$18.21 |
| Rate for Payer: Adventist Health Commercial |
$4.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.68
|
| Rate for Payer: Cash Price |
$10.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.44
|
| Rate for Payer: Heritage Provider Network Senior |
$16.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.07
|
| Rate for Payer: Multiplan Commercial |
$18.21
|
|
|
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]
|
Facility
OP
|
$24.28
|
|
|
Service Code
|
NDC 60505-0823-6
|
| Hospital Charge Code |
1744077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.39 |
| Max. Negotiated Rate |
$20.64 |
| Rate for Payer: Adventist Health Commercial |
$4.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.21
|
| Rate for Payer: Blue Shield of California Commercial |
$15.08
|
| Rate for Payer: Blue Shield of California EPN |
$14.25
|
| Rate for Payer: Cash Price |
$10.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.64
|
| Rate for Payer: Dignity Health Senior |
$20.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.03
|
| Rate for Payer: Heritage Provider Network Senior |
$15.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.07
|
| Rate for Payer: Multiplan Commercial |
$18.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.64
|
| Rate for Payer: Vantage Medical Group Senior |
$20.64
|
|
|
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION [9347]
|
Facility
OP
|
$1,879.26
|
|
|
Service Code
|
CPT J0630
|
| Hospital Charge Code |
1720101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.25 |
| Max. Negotiated Rate |
$3,193.62 |
| Rate for Payer: Adventist Health Commercial |
$375.85
|
| Rate for Payer: Adventist Health Commercial |
$375.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,627.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,627.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,291.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,290.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,336.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,336.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,176.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,176.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,176.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,176.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.25
|
| Rate for Payer: Blue Shield of California Commercial |
$3,193.62
|
| Rate for Payer: Blue Shield of California Commercial |
$3,193.62
|
| Rate for Payer: Blue Shield of California EPN |
$3,193.62
|
| Rate for Payer: Blue Shield of California EPN |
$3,193.62
|
| Rate for Payer: Cash Price |
$845.37
|
| Rate for Payer: Cash Price |
$845.67
|
| Rate for Payer: Cash Price |
$845.37
|
| Rate for Payer: Cash Price |
$845.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$864.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$864.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,604.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,604.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,176.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,176.45
|
| Rate for Payer: Dignity Health Senior |
$1,176.45
|
| Rate for Payer: Dignity Health Senior |
$1,176.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,202.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,202.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,069.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,069.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$869.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$870.10
|
| Rate for Payer: Heritage Provider Network Senior |
$869.79
|
| Rate for Payer: Heritage Provider Network Senior |
$870.10
|
| Rate for Payer: Humana Medicare |
$1,069.50
|
| Rate for Payer: Humana Medicare |
$1,069.50
|
| Rate for Payer: IEHP Medi-Cal |
$1,675.38
|
| Rate for Payer: IEHP Medi-Cal |
$1,675.38
|
| Rate for Payer: IEHP Medicare Advantage |
$1,069.50
|
| Rate for Payer: IEHP Medicare Advantage |
$1,069.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,032.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,032.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$340.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$340.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,262.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,262.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$469.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$469.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,347.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,347.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,347.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,347.57
|
| Rate for Payer: Multiplan Commercial |
$1,409.44
|
| Rate for Payer: Multiplan Commercial |
$1,408.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,176.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,176.45
|
| Rate for Payer: TriValley Medical Group Senior |
$1,069.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1,069.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$685.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$684.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$627.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$627.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,604.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,604.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,176.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,176.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1,069.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1,069.50
|
|
|
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION [9347]
|
Facility
IP
|
$1,879.26
|
|
|
Service Code
|
CPT J0630
|
| Hospital Charge Code |
1720101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$340.15 |
| Max. Negotiated Rate |
$1,409.44 |
| Rate for Payer: Adventist Health Commercial |
$375.85
|
| Rate for Payer: Adventist Health Commercial |
$375.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,290.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,291.05
|
| Rate for Payer: Cash Price |
$845.37
|
| Rate for Payer: Cash Price |
$845.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$864.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$864.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,014.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,014.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,271.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,272.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1,271.81
|
| Rate for Payer: Heritage Provider Network Senior |
$1,272.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$340.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$340.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$469.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$469.65
|
| Rate for Payer: Multiplan Commercial |
$1,408.95
|
| Rate for Payer: Multiplan Commercial |
$1,409.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$685.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$684.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$627.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$627.64
|
|
