|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [39265]
|
Facility
OP
|
$1.14
|
|
|
Service Code
|
CPT J9045
|
| Hospital Charge Code |
1755740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$254.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.87
|
| Rate for Payer: Blue Shield of California Commercial |
$7.51
|
| Rate for Payer: Blue Shield of California Commercial |
$7.51
|
| Rate for Payer: Blue Shield of California EPN |
$7.51
|
| Rate for Payer: Blue Shield of California EPN |
$7.51
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$0.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: IEHP Medi-Cal |
$12.57
|
| Rate for Payer: IEHP Medi-Cal |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.97
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
IP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-5
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.24
|
| Rate for Payer: Heritage Provider Network Senior |
$120.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
OP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-5
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$150.96 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$94.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$150.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$97.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$133.20
|
| Rate for Payer: Blue Shield of California Commercial |
$110.29
|
| Rate for Payer: Blue Shield of California EPN |
$104.25
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$115.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$150.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$150.96
|
| Rate for Payer: Dignity Health Senior |
$150.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.93
|
| Rate for Payer: Heritage Provider Network Senior |
$109.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$150.96
|
| Rate for Payer: Vantage Medical Group Senior |
$150.96
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
IP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-3
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.24
|
| Rate for Payer: Heritage Provider Network Senior |
$120.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
OP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-58
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.28 |
| Max. Negotiated Rate |
$325.37 |
| Rate for Payer: Adventist Health Commercial |
$76.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$204.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$262.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$325.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$210.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$287.09
|
| Rate for Payer: Blue Shield of California Commercial |
$237.71
|
| Rate for Payer: Blue Shield of California EPN |
$224.70
|
| Rate for Payer: Cash Price |
$172.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$248.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$325.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$325.37
|
| Rate for Payer: Dignity Health Senior |
$325.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$236.95
|
| Rate for Payer: Heritage Provider Network Senior |
$236.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$184.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.70
|
| Rate for Payer: Multiplan Commercial |
$287.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$325.37
|
| Rate for Payer: Vantage Medical Group Senior |
$325.37
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
OP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-11
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.28 |
| Max. Negotiated Rate |
$325.37 |
| Rate for Payer: Adventist Health Commercial |
$76.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$204.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$262.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$325.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$210.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$287.09
|
| Rate for Payer: Blue Shield of California Commercial |
$237.71
|
| Rate for Payer: Blue Shield of California EPN |
$224.70
|
| Rate for Payer: Cash Price |
$172.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$248.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$325.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$325.37
|
| Rate for Payer: Dignity Health Senior |
$325.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$236.95
|
| Rate for Payer: Heritage Provider Network Senior |
$236.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$184.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.70
|
| Rate for Payer: Multiplan Commercial |
$287.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$325.37
|
| Rate for Payer: Vantage Medical Group Senior |
$325.37
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
IP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-11
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.28 |
| Max. Negotiated Rate |
$287.09 |
| Rate for Payer: Adventist Health Commercial |
$76.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$262.98
|
| Rate for Payer: Cash Price |
$172.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$259.15
|
| Rate for Payer: Heritage Provider Network Senior |
$259.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.70
|
| Rate for Payer: Multiplan Commercial |
$287.09
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
IP
|
$382.79
|
|
|
Service Code
|
NDC 43598-698-58
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.28 |
| Max. Negotiated Rate |
$287.09 |
| Rate for Payer: Adventist Health Commercial |
$76.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$262.98
|
| Rate for Payer: Cash Price |
$172.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$259.15
|
| Rate for Payer: Heritage Provider Network Senior |
$259.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.70
|
| Rate for Payer: Multiplan Commercial |
$287.09
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
OP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-3
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$150.96 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$94.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$150.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$97.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$133.20
|
| Rate for Payer: Blue Shield of California Commercial |
$110.29
|
| Rate for Payer: Blue Shield of California EPN |
$104.25
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$115.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$150.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$150.96
|
| Rate for Payer: Dignity Health Senior |
$150.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.93
|
| Rate for Payer: Heritage Provider Network Senior |
$109.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$150.96
|
| Rate for Payer: Vantage Medical Group Senior |
$150.96
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
OP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-1
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$150.96 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$94.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$150.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$97.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$133.20
|
| Rate for Payer: Blue Shield of California Commercial |
$110.29
|
| Rate for Payer: Blue Shield of California EPN |
$104.25
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$115.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$150.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$150.96
|
| Rate for Payer: Dignity Health Senior |
$150.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.93
|
| Rate for Payer: Heritage Provider Network Senior |
$109.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$150.96
|
| Rate for Payer: Vantage Medical Group Senior |
$150.96
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [9413]
|
Facility
IP
|
$177.60
|
|
|
Service Code
|
NDC 81298-5010-1
|
| Hospital Charge Code |
1720386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.24
|
| Rate for Payer: Heritage Provider Network Senior |
$120.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
|
|
CARBOXYMETHYL 0.5 %-GLYCERIN 1 %-POLYSORB 80 0.5 %-PF EYE DROPPERETTE [201979]
|
Facility
IP
|
$0.48
|
|
|
Service Code
|
NDC 0023-4491-30
|
| Hospital Charge Code |
ERX201979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| 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 |
$0.36
|
|
|
CARBOXYMETHYL 0.5 %-GLYCERIN 1 %-POLYSORB 80 0.5 %-PF EYE DROPPERETTE [201979]
|
Facility
OP
|
$0.48
|
|
|
Service Code
|
NDC 0023-4491-30
|
| Hospital Charge Code |
ERX201979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Senior |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| 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 |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
NDC 50268-068-15
|
| Hospital Charge Code |
1740385
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
NDC 0023-0798-15
|
| Hospital Charge Code |
1740385
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
OP
|
$0.61
|
|
|
Service Code
|
NDC 50268-068-15
|
| Hospital Charge Code |
1740385
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Senior |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [111282]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
NDC 0023-0798-15
|
| Hospital Charge Code |
1740385
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [27991]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 0023-0403-30
|
| Hospital Charge Code |
ERX27991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [27991]
|
Facility
OP
|
$0.33
|
|
|
Service Code
|
NDC 0023-0403-50
|
| Hospital Charge Code |
ERX27991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [27991]
|
Facility
IP
|
$0.33
|
|
|
Service Code
|
NDC 0023-0403-50
|
| Hospital Charge Code |
ERX27991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [27991]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 0023-0403-30
|
| Hospital Charge Code |
ERX27991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE [38321]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 0023-4554-30
|
| Hospital Charge Code |
1740288
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE [38321]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 0023-4554-30
|
| Hospital Charge Code |
1740288
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [27992]
|
Facility
OP
|
$0.69
|
|
|
Service Code
|
NDC 0023-9205-15
|
| Hospital Charge Code |
1740305
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Senior |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [27992]
|
Facility
IP
|
$0.69
|
|
|
Service Code
|
NDC 0023-9205-15
|
| Hospital Charge Code |
1740305
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
