|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$60.64 |
| Rate for Payer: Adventist Health Commercial |
$16.17
|
| Rate for Payer: Cash Price |
$44.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.74
|
| Rate for Payer: Heritage Provider Network Senior |
$54.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.21
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$60.64 |
| Rate for Payer: Adventist Health Commercial |
$16.17
|
| Rate for Payer: Cash Price |
$44.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.74
|
| Rate for Payer: Heritage Provider Network Senior |
$54.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.21
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Adventist Health Commercial |
$16.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.64
|
| Rate for Payer: Blue Shield of California Commercial |
$49.32
|
| Rate for Payer: Blue Shield of California EPN |
$39.45
|
| Rate for Payer: Cash Price |
$44.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: Dignity Health Senior |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.05
|
| Rate for Payer: Heritage Provider Network Senior |
$50.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$56.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$56.59
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.34
|
| Rate for Payer: TriValley Medical Group Senior |
$32.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Adventist Health Commercial |
$6.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.32
|
| Rate for Payer: Blue Shield of California Commercial |
$20.59
|
| Rate for Payer: Blue Shield of California EPN |
$16.47
|
| Rate for Payer: Cash Price |
$18.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.70
|
| Rate for Payer: Dignity Health Senior |
$28.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.90
|
| Rate for Payer: Heritage Provider Network Senior |
$20.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.63
|
| Rate for Payer: Multiplan Commercial |
$25.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.50
|
| Rate for Payer: TriValley Medical Group Senior |
$13.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.70
|
| Rate for Payer: Vantage Medical Group Senior |
$28.70
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Blue Shield of California Commercial |
$29.28
|
| Rate for Payer: Blue Shield of California EPN |
$23.42
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Senior |
$40.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.71
|
| Rate for Payer: Heritage Provider Network Senior |
$29.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.60
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.20
|
| Rate for Payer: TriValley Medical Group Senior |
$19.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$25.32 |
| Rate for Payer: Adventist Health Commercial |
$6.75
|
| Rate for Payer: Cash Price |
$18.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.86
|
| Rate for Payer: Heritage Provider Network Senior |
$22.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.44
|
| Rate for Payer: Multiplan Commercial |
$25.32
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$27.01
|
|
|
Service Code
|
NDC 69097-999-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.89 |
| Max. Negotiated Rate |
$20.26 |
| Rate for Payer: Adventist Health Commercial |
$5.40
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.29
|
| Rate for Payer: Heritage Provider Network Senior |
$18.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$20.26
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.50
|
| Rate for Payer: Heritage Provider Network Senior |
$32.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Adventist Health Commercial |
$16.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.64
|
| Rate for Payer: Blue Shield of California Commercial |
$49.32
|
| Rate for Payer: Blue Shield of California EPN |
$39.45
|
| Rate for Payer: Cash Price |
$44.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: Dignity Health Senior |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.05
|
| Rate for Payer: Heritage Provider Network Senior |
$50.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$56.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$56.59
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.34
|
| Rate for Payer: TriValley Medical Group Senior |
$32.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
|
OP
|
$27.01
|
|
|
Service Code
|
NDC 69097-999-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.89 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Adventist Health Commercial |
$5.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.26
|
| Rate for Payer: Blue Shield of California Commercial |
$16.48
|
| Rate for Payer: Blue Shield of California EPN |
$13.18
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.96
|
| Rate for Payer: Dignity Health Senior |
$22.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.72
|
| Rate for Payer: Heritage Provider Network Senior |
$16.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.91
|
| Rate for Payer: Multiplan Commercial |
$20.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.80
|
| Rate for Payer: TriValley Medical Group Senior |
$10.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.96
|
| Rate for Payer: Vantage Medical Group Senior |
$22.96
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$5.04
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Adventist Health Commercial |
$1.01
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.41
|
| Rate for Payer: Heritage Provider Network Senior |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$3.78
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$3.85
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Senior |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.91
|
| Rate for Payer: Heritage Provider Network Senior |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.27
|
| Rate for Payer: Heritage Provider Network Senior |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$5.04
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Adventist Health Commercial |
$1.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.46
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.28
|
| Rate for Payer: Dignity Health Senior |
$4.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.12
|
| Rate for Payer: Heritage Provider Network Senior |
$3.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.53
|
| Rate for Payer: Multiplan Commercial |
$3.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Senior |
$2.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.28
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
OP
|
$5.93
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.45
|
| Rate for Payer: Blue Shield of California Commercial |
$3.62
|
| Rate for Payer: Blue Shield of California EPN |
$2.89
|
| Rate for Payer: Cash Price |
$3.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.04
|
| Rate for Payer: Dignity Health Senior |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.67
|
| Rate for Payer: Heritage Provider Network Senior |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.15
|
| Rate for Payer: Multiplan Commercial |
$4.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Senior |
$2.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.04
|
| Rate for Payer: Vantage Medical Group Senior |
$5.04
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
|
IP
|
$5.93
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$3.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.01
|
| Rate for Payer: Heritage Provider Network Senior |
$4.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$4.45
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
OP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.55
|
| Rate for Payer: Blue Shield of California Commercial |
$3.70
|
| Rate for Payer: Blue Shield of California EPN |
$2.96
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: Dignity Health Senior |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.76
|
| Rate for Payer: Heritage Provider Network Senior |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.25
|
| Rate for Payer: Multiplan Commercial |
$4.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.43
|
| Rate for Payer: TriValley Medical Group Senior |
$2.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
|
IP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.11
|
| Rate for Payer: Heritage Provider Network Senior |
$4.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$4.55
|
|
|
PILOCARPINE 4 % EYE DROPS [6282]
|
Facility
|
IP
|
$6.36
|
|
|
Service Code
|
NDC 70069-201-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.31
|
| Rate for Payer: Heritage Provider Network Senior |
$4.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
|
|
PILOCARPINE 4 % EYE DROPS [6282]
|
Facility
|
OP
|
$6.36
|
|
|
Service Code
|
NDC 70069-201-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.77
|
| Rate for Payer: Blue Shield of California Commercial |
$3.88
|
| Rate for Payer: Blue Shield of California EPN |
$3.10
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.41
|
| Rate for Payer: Dignity Health Senior |
$5.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.94
|
| Rate for Payer: Heritage Provider Network Senior |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.45
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.54
|
| Rate for Payer: TriValley Medical Group Senior |
$2.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.41
|
| Rate for Payer: Vantage Medical Group Senior |
$5.41
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 0527-1313-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 50268-652-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Senior |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.03
|
| Rate for Payer: TriValley Medical Group Senior |
$1.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.32
|
| Rate for Payer: Dignity Health Senior |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.09
|
| Rate for Payer: TriValley Medical Group Senior |
$1.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.32
|
| Rate for Payer: Vantage Medical Group Senior |
$2.32
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 50268-652-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Senior |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.03
|
| Rate for Payer: TriValley Medical Group Senior |
$1.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
