|
PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L [212682]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-117-05
|
| Hospital Charge Code |
NDG212682
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PHOSPHATE DIALY SOLN W-OUT CALCIUM,DEX K 4 MEQ-MG 1.5 MEQ-PO4 1 MMOL/L [212682]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-117-05
|
| Hospital Charge Code |
NDG212682
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PHOSPHORATED CARBOHYDRATE ORAL SOLUTION [11022]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 1093939933
|
| Hospital Charge Code |
1719016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PHOSPHORATED CARBOHYDRATE ORAL SOLUTION [11022]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 1093939933
|
| Hospital Charge Code |
1719016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION [6270]
|
Facility
OP
|
$46.97
|
|
|
Service Code
|
NDC 17478-510-02
|
| Hospital Charge Code |
1720007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$39.92 |
| Rate for Payer: Adventist Health Commercial |
$9.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$35.23
|
| Rate for Payer: Blue Shield of California Commercial |
$29.17
|
| Rate for Payer: Blue Shield of California EPN |
$27.57
|
| Rate for Payer: Cash Price |
$21.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.92
|
| Rate for Payer: Dignity Health Senior |
$39.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.07
|
| Rate for Payer: Heritage Provider Network Senior |
$29.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.74
|
| Rate for Payer: Multiplan Commercial |
$35.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.92
|
| Rate for Payer: Vantage Medical Group Senior |
$39.92
|
|
|
PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION [6270]
|
Facility
IP
|
$46.97
|
|
|
Service Code
|
NDC 17478-510-02
|
| Hospital Charge Code |
1720007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$35.23 |
| Rate for Payer: Adventist Health Commercial |
$9.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.27
|
| Rate for Payer: Cash Price |
$21.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.80
|
| Rate for Payer: Heritage Provider Network Senior |
$31.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.74
|
| Rate for Payer: Multiplan Commercial |
$35.23
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]
|
Facility
IP
|
$51.32
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$38.49 |
| Rate for Payer: Adventist Health Commercial |
$10.26
|
| Rate for Payer: Adventist Health Commercial |
$11.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.26
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$26.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.78
|
| Rate for Payer: Heritage Provider Network Senior |
$39.78
|
| Rate for Payer: Heritage Provider Network Senior |
$34.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.69
|
| Rate for Payer: Multiplan Commercial |
$38.49
|
| Rate for Payer: Multiplan Commercial |
$44.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.63
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [11023]
|
Facility
OP
|
$58.76
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$49.95 |
| Rate for Payer: Adventist Health Commercial |
$11.75
|
| Rate for Payer: Adventist Health Commercial |
$10.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$43.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$28.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$38.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$5.48
|
| Rate for Payer: Blue Shield of California EPN |
$5.48
|
| Rate for Payer: Blue Shield of California EPN |
$5.48
|
| Rate for Payer: Cash Price |
$26.44
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$26.44
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$43.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$43.62
|
| Rate for Payer: Dignity Health Senior |
$43.62
|
| Rate for Payer: Dignity Health Senior |
$49.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.76
|
| Rate for Payer: Heritage Provider Network Senior |
$27.21
|
| Rate for Payer: Heritage Provider Network Senior |
$23.76
|
| Rate for Payer: IEHP Medi-Cal |
$11.48
|
| Rate for Payer: IEHP Medi-Cal |
$11.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.83
|
| Rate for Payer: Multiplan Commercial |
$38.49
|
| Rate for Payer: Multiplan Commercial |
$44.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$43.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.95
|
| Rate for Payer: Vantage Medical Group Senior |
$43.62
|
| Rate for Payer: Vantage Medical Group Senior |
$49.95
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [110478]
|
Facility
IP
|
$11.39
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
NDG110478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.54 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.82
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.71
|
| Rate for Payer: Heritage Provider Network Senior |
$7.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.81
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [110478]
|
Facility
OP
|
$11.39
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
NDG110478
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.48
|
| Rate for Payer: Blue Shield of California EPN |
$5.48
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.68
|
| Rate for Payer: Dignity Health Senior |
$9.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.27
|
| Rate for Payer: Heritage Provider Network Senior |
$5.27
|
| Rate for Payer: IEHP Medi-Cal |
$11.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$8.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.68
|
| Rate for Payer: Vantage Medical Group Senior |
$9.68
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]
|
Facility
IP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$44.51 |
| Rate for Payer: Adventist Health Commercial |
$11.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.77
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.18
|
| Rate for Payer: Heritage Provider Network Senior |
$40.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$44.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.83
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE [6271]
|
Facility
OP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Adventist Health Commercial |
$11.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.48
|
| Rate for Payer: Blue Shield of California EPN |
$5.48
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.45
|
| Rate for Payer: Dignity Health Senior |
$50.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.48
|
| Rate for Payer: Heritage Provider Network Senior |
$27.48
|
| Rate for Payer: IEHP Medi-Cal |
$11.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$44.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.45
|
| Rate for Payer: Vantage Medical Group Senior |
$50.45
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]
|
Facility
OP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$50.45 |
| Rate for Payer: Adventist Health Commercial |
$11.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.28
|
| Rate for Payer: Blue Shield of California Commercial |
$5.48
|
| Rate for Payer: Blue Shield of California EPN |
$5.48
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.45
|
| Rate for Payer: Dignity Health Senior |
$50.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.48
|
| Rate for Payer: Heritage Provider Network Senior |
$27.48
|
| Rate for Payer: IEHP Medi-Cal |
$11.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$44.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.45
|
| Rate for Payer: Vantage Medical Group Senior |
$50.45
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SYRINGE [4081654]
|
Facility
IP
|
$59.35
|
|
|
Service Code
|
CPT J3430
|
| Hospital Charge Code |
1720082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$44.51 |
| Rate for Payer: Adventist Health Commercial |
$11.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.77
|
| Rate for Payer: Cash Price |
$26.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.18
|
| Rate for Payer: Heritage Provider Network Senior |
$40.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.84
|
| Rate for Payer: Multiplan Commercial |
$44.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.83
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
OP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Adventist Health Commercial |
$6.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.32
|
| Rate for Payer: Blue Shield of California Commercial |
$20.96
|
| Rate for Payer: Blue Shield of California EPN |
$19.82
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.70
|
| Rate for Payer: Dignity Health Senior |
$28.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.90
|
| Rate for Payer: Heritage Provider Network Senior |
$20.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.44
|
| Rate for Payer: Multiplan Commercial |
$25.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.70
|
| Rate for Payer: Vantage Medical Group Senior |
$28.70
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
IP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-94
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$60.64 |
| Rate for Payer: Adventist Health Commercial |
$16.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.54
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.74
|
| Rate for Payer: Heritage Provider Network Senior |
$54.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.21
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-94
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Adventist Health Commercial |
$16.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$44.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$60.64
|
| Rate for Payer: Blue Shield of California Commercial |
$50.21
|
| Rate for Payer: Blue Shield of California EPN |
$47.46
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: Dignity Health Senior |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.05
|
| Rate for Payer: Heritage Provider Network Senior |
$50.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.21
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
IP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.50
|
| Rate for Payer: Heritage Provider Network Senior |
$32.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
OP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$68.72 |
| Rate for Payer: Adventist Health Commercial |
$16.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$68.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$44.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$60.64
|
| Rate for Payer: Blue Shield of California Commercial |
$50.21
|
| Rate for Payer: Blue Shield of California EPN |
$47.46
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.72
|
| Rate for Payer: Dignity Health Senior |
$68.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.05
|
| Rate for Payer: Heritage Provider Network Senior |
$50.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.21
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.72
|
| Rate for Payer: Vantage Medical Group Senior |
$68.72
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
IP
|
$80.85
|
|
|
Service Code
|
NDC 60687-381-11
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$60.64 |
| Rate for Payer: Adventist Health Commercial |
$16.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.54
|
| Rate for Payer: Cash Price |
$36.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.74
|
| Rate for Payer: Heritage Provider Network Senior |
$54.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.21
|
| Rate for Payer: Multiplan Commercial |
$60.64
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
IP
|
$33.76
|
|
|
Service Code
|
NDC 70710-1014-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$25.32 |
| Rate for Payer: Adventist Health Commercial |
$6.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.19
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.86
|
| Rate for Payer: Heritage Provider Network Senior |
$22.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.44
|
| Rate for Payer: Multiplan Commercial |
$25.32
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET [11024]
|
Facility
OP
|
$48.00
|
|
|
Service Code
|
NDC 69238-1051-3
|
| Hospital Charge Code |
1710433
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$40.80 |
| Rate for Payer: Adventist Health Commercial |
$9.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$26.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.00
|
| Rate for Payer: Blue Shield of California Commercial |
$29.81
|
| Rate for Payer: Blue Shield of California EPN |
$28.18
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.80
|
| Rate for Payer: Dignity Health Senior |
$40.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.71
|
| Rate for Payer: Heritage Provider Network Senior |
$29.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.80
|
| Rate for Payer: Vantage Medical Group Senior |
$40.80
|
|
|
PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [231930]
|
Facility
OP
|
$4,738.00
|
|
|
Service Code
|
CPT A9595
|
| Hospital Charge Code |
ERX231930
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$580.35 |
| Max. Negotiated Rate |
$3,553.50 |
| Rate for Payer: Adventist Health Commercial |
$947.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,326.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,255.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$870.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$638.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$580.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,092.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.30
|
| Rate for Payer: Blue Shield of California EPN |
$2,781.21
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,079.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$725.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$638.39
|
| Rate for Payer: Dignity Health Senior |
$580.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,032.32
|
| Rate for Payer: EPIC Health Plan Medicare |
$580.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,932.82
|
| Rate for Payer: Heritage Provider Network Senior |
$2,932.82
|
| Rate for Payer: Humana Medicare |
$580.35
|
| Rate for Payer: IEHP Medi-Cal |
$861.06
|
| Rate for Payer: IEHP Medicare Advantage |
$580.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,102.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$857.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$684.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,184.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$731.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$731.24
|
| Rate for Payer: Multiplan Commercial |
$3,553.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$638.39
|
| Rate for Payer: TriValley Medical Group Senior |
$580.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,727.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,582.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$725.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$638.39
|
| Rate for Payer: Vantage Medical Group Senior |
$638.39
|
|
|
PIFLUFOLASTAT F 18 37 MBQ/ML TO 2,960 MBQ/ML (1-80 MCI/ML) IV SOLUTION [231930]
|
Facility
IP
|
$4,738.00
|
|
|
Service Code
|
CPT A9595
|
| Hospital Charge Code |
ERX231930
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$857.58 |
| Max. Negotiated Rate |
$3,553.50 |
| Rate for Payer: Adventist Health Commercial |
$947.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,255.01
|
| Rate for Payer: Cash Price |
$2,132.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,558.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,207.63
|
| Rate for Payer: Heritage Provider Network Senior |
$3,207.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$857.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,184.50
|
| Rate for Payer: Multiplan Commercial |
$3,553.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,727.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,582.97
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
OP
|
$5.94
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.46
|
| Rate for Payer: Blue Shield of California Commercial |
$3.69
|
| Rate for Payer: Blue Shield of California EPN |
$3.49
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.05
|
| Rate for Payer: Dignity Health Senior |
$5.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.68
|
| Rate for Payer: Heritage Provider Network Senior |
$3.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$4.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.05
|
| Rate for Payer: Vantage Medical Group Senior |
$5.05
|
|
