|
OCTREOTIDE,MICROSPHERES 20 MG INTRAMUSCULAR WRAP, LONG-ACTING RELEASE [40824435]
|
Facility
IP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$963.73 |
| Max. Negotiated Rate |
$3,993.34 |
| Rate for Payer: Adventist Health Commercial |
$1,064.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,657.90
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,449.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,875.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,604.65
|
| Rate for Payer: Heritage Provider Network Senior |
$3,604.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$963.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,331.11
|
| Rate for Payer: Multiplan Commercial |
$3,993.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,941.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,778.90
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG INTRAMUSCULR WRAP, LONG-ACTING RELEASE [40824436]
|
Facility
OP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.84 |
| Max. Negotiated Rate |
$5,979.73 |
| Rate for Payer: Adventist Health Commercial |
$1,594.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$517.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,477.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.84
|
| Rate for Payer: Blue Shield of California Commercial |
$217.50
|
| Rate for Payer: Blue Shield of California EPN |
$217.50
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,667.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.91
|
| Rate for Payer: Dignity Health Senior |
$231.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,102.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$210.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,691.49
|
| Rate for Payer: Heritage Provider Network Senior |
$3,691.49
|
| Rate for Payer: Humana Medicare |
$210.83
|
| Rate for Payer: IEHP Medi-Cal |
$335.85
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$400.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,443.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$248.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,993.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$265.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$265.64
|
| Rate for Payer: Multiplan Commercial |
$5,979.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$231.91
|
| Rate for Payer: TriValley Medical Group Senior |
$210.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,906.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,663.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OCTREOTIDE,MICROSPHERES 30 MG INTRAMUSCULR WRAP, LONG-ACTING RELEASE [40824436]
|
Facility
IP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX24436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,443.11 |
| Max. Negotiated Rate |
$5,979.73 |
| Rate for Payer: Adventist Health Commercial |
$1,594.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,477.43
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,667.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,305.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,397.70
|
| Rate for Payer: Heritage Provider Network Senior |
$5,397.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,443.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,993.24
|
| Rate for Payer: Multiplan Commercial |
$5,979.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,906.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,663.77
|
|
|
OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204871]
|
Facility
OP
|
$4,063.93
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.84 |
| Max. Negotiated Rate |
$3,047.95 |
| Rate for Payer: Adventist Health Commercial |
$812.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$517.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,791.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.84
|
| Rate for Payer: Blue Shield of California Commercial |
$217.50
|
| Rate for Payer: Blue Shield of California EPN |
$217.50
|
| Rate for Payer: Cash Price |
$1,828.77
|
| Rate for Payer: Cash Price |
$1,828.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,869.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.91
|
| Rate for Payer: Dignity Health Senior |
$231.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,600.92
|
| Rate for Payer: EPIC Health Plan Medicare |
$210.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,881.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1,881.60
|
| Rate for Payer: Humana Medicare |
$210.83
|
| Rate for Payer: IEHP Medi-Cal |
$335.85
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$400.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$735.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$248.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,015.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$265.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$265.64
|
| Rate for Payer: Multiplan Commercial |
$3,047.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$231.91
|
| Rate for Payer: TriValley Medical Group Senior |
$210.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,481.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,357.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204871]
|
Facility
IP
|
$4,063.93
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$735.57 |
| Max. Negotiated Rate |
$3,047.95 |
| Rate for Payer: Adventist Health Commercial |
$812.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,791.92
|
| Rate for Payer: Cash Price |
$1,828.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,869.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,194.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,751.28
|
| Rate for Payer: Heritage Provider Network Senior |
$2,751.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$735.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,015.98
|
| Rate for Payer: Multiplan Commercial |
$3,047.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,481.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,357.76
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204610]
|
Facility
IP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
1720927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$963.73 |
| Max. Negotiated Rate |
$3,993.34 |
| Rate for Payer: Adventist Health Commercial |
$1,064.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,657.90
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,449.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,875.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,604.65
|
| Rate for Payer: Heritage Provider Network Senior |
$3,604.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$963.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,331.11
|
| Rate for Payer: Multiplan Commercial |
$3,993.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,941.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,778.90
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204610]
|
Facility
OP
|
$5,324.45
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
1720927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.84 |
| Max. Negotiated Rate |
$3,993.34 |
| Rate for Payer: Adventist Health Commercial |
$1,064.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$517.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,657.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.84
|
| Rate for Payer: Blue Shield of California Commercial |
$217.50
|
| Rate for Payer: Blue Shield of California EPN |
$217.50
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,449.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.91
|
| Rate for Payer: Dignity Health Senior |
$231.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,407.65
|
| Rate for Payer: EPIC Health Plan Medicare |
$210.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,465.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2,465.22
|
| Rate for Payer: Humana Medicare |
$210.83
|
| Rate for Payer: IEHP Medi-Cal |
$335.85
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$400.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$963.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$248.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,331.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$265.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$265.64
|
| Rate for Payer: Multiplan Commercial |
$3,993.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$231.91
|
| Rate for Payer: TriValley Medical Group Senior |
$210.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,941.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,778.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204612]
|
Facility
OP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.84 |
| Max. Negotiated Rate |
$5,979.73 |
| Rate for Payer: Adventist Health Commercial |
$1,594.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$517.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,477.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$263.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$231.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$173.84
|
| Rate for Payer: Blue Shield of California Commercial |
$217.50
|
| Rate for Payer: Blue Shield of California EPN |
$217.50
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,667.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$316.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.91
|
| Rate for Payer: Dignity Health Senior |
$231.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,102.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$210.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,691.49
|
| Rate for Payer: Heritage Provider Network Senior |
$3,691.49
|
| Rate for Payer: Humana Medicare |
$210.83
|
| Rate for Payer: IEHP Medi-Cal |
$335.85
|
| Rate for Payer: IEHP Medicare Advantage |
$210.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$400.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,443.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$248.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,993.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$265.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$265.64
|
| Rate for Payer: Multiplan Commercial |
$5,979.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$231.91
|
| Rate for Payer: TriValley Medical Group Senior |
$210.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,906.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,663.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$316.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.91
|
| Rate for Payer: Vantage Medical Group Senior |
$210.83
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [204612]
|
Facility
IP
|
$7,972.97
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
ERX204612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,443.11 |
| Max. Negotiated Rate |
$5,979.73 |
| Rate for Payer: Adventist Health Commercial |
$1,594.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,477.43
|
| Rate for Payer: Cash Price |
$3,587.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,667.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,305.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,397.70
|
| Rate for Payer: Heritage Provider Network Senior |
$5,397.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,443.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,993.24
|
| Rate for Payer: Multiplan Commercial |
$5,979.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,906.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,663.77
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
OP
|
$30.86
|
|
|
Service Code
|
NDC 24208-410-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$26.23 |
| Rate for Payer: Adventist Health Commercial |
$6.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.14
|
| Rate for Payer: Blue Shield of California Commercial |
$19.16
|
| Rate for Payer: Blue Shield of California EPN |
$18.11
|
| Rate for Payer: Cash Price |
$13.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.23
|
| Rate for Payer: Dignity Health Senior |
$26.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.10
|
| Rate for Payer: Heritage Provider Network Senior |
$19.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.72
|
| Rate for Payer: Multiplan Commercial |
$23.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.23
|
| Rate for Payer: Vantage Medical Group Senior |
$26.23
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
OP
|
$15.60
|
|
|
Service Code
|
NDC 50383-025-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.70
|
| Rate for Payer: Blue Shield of California Commercial |
$9.69
|
| Rate for Payer: Blue Shield of California EPN |
$9.16
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.66
|
| Rate for Payer: Heritage Provider Network Senior |
$9.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$13.26
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
IP
|
$15.60
|
|
|
Service Code
|
NDC 60505-0363-1
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.72
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.56
|
| Rate for Payer: Heritage Provider Network Senior |
$10.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
IP
|
$15.60
|
|
|
Service Code
|
NDC 50383-025-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.72
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.56
|
| Rate for Payer: Heritage Provider Network Senior |
$10.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
OP
|
$15.60
|
|
|
Service Code
|
NDC 60505-0363-1
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.70
|
| Rate for Payer: Blue Shield of California Commercial |
$9.69
|
| Rate for Payer: Blue Shield of California EPN |
$9.16
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.66
|
| Rate for Payer: Heritage Provider Network Senior |
$9.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$13.26
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
OP
|
$3.60
|
|
|
Service Code
|
NDC 69238-1615-3
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.24
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
NDC 69238-1615-3
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
OFLOXACIN 0.3 % EAR DROPS [22257]
|
Facility
IP
|
$30.86
|
|
|
Service Code
|
NDC 24208-410-05
|
| Hospital Charge Code |
1740311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$23.14 |
| Rate for Payer: Adventist Health Commercial |
$6.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.20
|
| Rate for Payer: Cash Price |
$13.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.89
|
| Rate for Payer: Heritage Provider Network Senior |
$20.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.72
|
| Rate for Payer: Multiplan Commercial |
$23.14
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
NDC 64980-515-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
OP
|
$4.91
|
|
|
Service Code
|
NDC 24208-434-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Adventist Health Commercial |
$0.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.68
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Blue Shield of California EPN |
$2.88
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.17
|
| Rate for Payer: Dignity Health Senior |
$4.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$3.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4.17
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
OP
|
$3.60
|
|
|
Service Code
|
NDC 64980-515-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.24
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
IP
|
$4.91
|
|
|
Service Code
|
NDC 24208-434-05
|
| Hospital Charge Code |
1740303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Adventist Health Commercial |
$0.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.37
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.32
|
| Rate for Payer: Heritage Provider Network Senior |
$3.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$3.68
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
IP
|
$1.51
|
|
|
Service Code
|
NDC 60505-3276-3
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
IP
|
$1.51
|
|
|
Service Code
|
NDC 59746-307-12
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
OP
|
$1.51
|
|
|
Service Code
|
NDC 49884-321-52
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Senior |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
IP
|
$1.51
|
|
|
Service Code
|
NDC 49884-321-52
|
| Hospital Charge Code |
1712250
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.13
|
|
