|
CHLORPROMAZINE 100 MG TABLET [1654]
|
Facility
|
OP
|
$14.98
|
|
|
Service Code
|
NDC 0904-6895-61
|
| Hospital Charge Code |
1710686
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Adventist Health Commercial |
$3.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.24
|
| Rate for Payer: Blue Shield of California Commercial |
$9.30
|
| Rate for Payer: Blue Shield of California EPN |
$8.79
|
| Rate for Payer: Cash Price |
$6.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.73
|
| Rate for Payer: Dignity Health Senior |
$12.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.27
|
| Rate for Payer: Heritage Provider Network Senior |
$9.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.74
|
| Rate for Payer: Multiplan Commercial |
$11.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.99
|
| Rate for Payer: TriValley Medical Group Senior |
$5.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.73
|
| Rate for Payer: Vantage Medical Group Senior |
$12.73
|
|
|
CHLORPROMAZINE 100 MG TABLET [1654]
|
Facility
|
IP
|
$14.98
|
|
|
Service Code
|
NDC 0904-6895-61
|
| Hospital Charge Code |
1710686
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$11.24 |
| Rate for Payer: Adventist Health Commercial |
$3.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.29
|
| Rate for Payer: Cash Price |
$6.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.14
|
| Rate for Payer: Heritage Provider Network Senior |
$10.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.74
|
| Rate for Payer: Multiplan Commercial |
$11.24
|
|
|
CHLORPROMAZINE 10 MG TABLET [1653]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 68462-861-01
|
| Hospital Charge Code |
1711161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| 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 Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
CHLORPROMAZINE 10 MG TABLET [1653]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 68462-861-01
|
| Hospital Charge Code |
1711161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
CHLORPROMAZINE 10 MG TABLET [1653]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 69238-1054-1
|
| Hospital Charge Code |
1711161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| 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 Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
CHLORPROMAZINE 10 MG TABLET [1653]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 69238-1054-1
|
| Hospital Charge Code |
1711161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]
|
Facility
|
OP
|
$19.86
|
|
|
Service Code
|
CPT J3230
|
| Hospital Charge Code |
1720458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$73.16 |
| Rate for Payer: Adventist Health Commercial |
$3.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$73.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.28
|
| Rate for Payer: Blue Shield of California Commercial |
$46.35
|
| Rate for Payer: Blue Shield of California EPN |
$46.35
|
| Rate for Payer: Cash Price |
$8.94
|
| Rate for Payer: Cash Price |
$8.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.88
|
| Rate for Payer: Dignity Health Senior |
$16.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.20
|
| Rate for Payer: Heritage Provider Network Senior |
$9.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$53.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.57
|
| 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 |
$14.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.94
|
| Rate for Payer: TriValley Medical Group Senior |
$7.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.88
|
| Rate for Payer: Vantage Medical Group Senior |
$16.88
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]
|
Facility
|
IP
|
$19.86
|
|
|
Service Code
|
CPT J3230
|
| Hospital Charge Code |
1720458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$14.90 |
| Rate for Payer: Adventist Health Commercial |
$3.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.64
|
| Rate for Payer: Cash Price |
$8.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.45
|
| Rate for Payer: Heritage Provider Network Senior |
$13.45
|
| 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 |
$14.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.64
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 0527-2962-37
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$4.54
|
|
|
Service Code
|
NDC 0832-0301-00
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.12
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.07
|
| Rate for Payer: Heritage Provider Network Senior |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$3.40
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$7.11
|
|
|
Service Code
|
NDC 60687-430-01
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.88
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.81
|
| Rate for Payer: Heritage Provider Network Senior |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 0527-2962-37
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$7.11
|
|
|
Service Code
|
NDC 60687-430-11
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.88
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.81
|
| Rate for Payer: Heritage Provider Network Senior |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$7.11
|
|
|
Service Code
|
NDC 60687-430-11
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.04
|
| Rate for Payer: Dignity Health Senior |
$6.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.40
|
| Rate for Payer: Heritage Provider Network Senior |
$4.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.84
|
| Rate for Payer: TriValley Medical Group Senior |
$2.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.04
|
| Rate for Payer: Vantage Medical Group Senior |
$6.04
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 68462-862-01
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$4.54
|
|
|
Service Code
|
NDC 0832-0301-00
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$2.82
|
| Rate for Payer: Blue Shield of California EPN |
$2.66
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.86
|
| Rate for Payer: Dignity Health Senior |
$3.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.81
|
| Rate for Payer: Heritage Provider Network Senior |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$3.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.82
|
| Rate for Payer: TriValley Medical Group Senior |
$1.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.86
|
| Rate for Payer: Vantage Medical Group Senior |
$3.86
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 68462-862-01
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: Dignity Health Senior |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Senior |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$7.11
|
|
|
Service Code
|
NDC 60687-430-01
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.04
|
| Rate for Payer: Dignity Health Senior |
$6.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.40
|
| Rate for Payer: Heritage Provider Network Senior |
$4.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.84
|
| Rate for Payer: TriValley Medical Group Senior |
$2.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.04
|
| Rate for Payer: Vantage Medical Group Senior |
$6.04
|
|
|
CHLORPROMAZINE 50 MG TABLET [1657]
|
Facility
|
IP
|
$6.46
|
|
|
Service Code
|
NDC 0832-0302-00
|
| Hospital Charge Code |
1710664
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Adventist Health Commercial |
$1.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.44
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.37
|
| Rate for Payer: Heritage Provider Network Senior |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
|
|
CHLORPROMAZINE 50 MG TABLET [1657]
|
Facility
|
OP
|
$6.46
|
|
|
Service Code
|
NDC 0832-0302-00
|
| Hospital Charge Code |
1710664
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Adventist Health Commercial |
$1.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.84
|
| Rate for Payer: Blue Shield of California Commercial |
$4.01
|
| Rate for Payer: Blue Shield of California EPN |
$3.79
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.49
|
| Rate for Payer: Dignity Health Senior |
$5.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.58
|
| Rate for Payer: TriValley Medical Group Senior |
$2.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.49
|
| Rate for Payer: Vantage Medical Group Senior |
$5.49
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$2.30
|
|
|
Service Code
|
NDC 51079-058-01
|
| Hospital Charge Code |
1710179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
OP
|
$2.70
|
|
|
Service Code
|
NDC 60687-317-11
|
| Hospital Charge Code |
1710179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.30
|
| Rate for Payer: Dignity Health Senior |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| 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: Multiplan Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Senior |
$1.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2.30
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$2.30
|
|
|
Service Code
|
NDC 60687-317-95
|
| Hospital Charge Code |
1710179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$2.30
|
|
|
Service Code
|
NDC 60687-317-25
|
| Hospital Charge Code |
1710179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
OP
|
$2.30
|
|
|
Service Code
|
NDC 60687-317-95
|
| Hospital Charge Code |
1710179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.96
|
| Rate for Payer: Dignity Health Senior |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.42
|
| Rate for Payer: Heritage Provider Network Senior |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Senior |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.96
|
| Rate for Payer: Vantage Medical Group Senior |
$1.96
|
|
