|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
OP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$3.70
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Senior |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.91
|
| Rate for Payer: Heritage Provider Network Senior |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
IP
|
$6.31
|
|
|
Service Code
|
NDC 61314-203-15
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.33
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.27
|
| Rate for Payer: Heritage Provider Network Senior |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
OP
|
$5.94
|
|
|
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
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
IP
|
$5.94
|
|
|
Service Code
|
NDC 70069-181-01
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.08
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.02
|
| Rate for Payer: Heritage Provider Network Senior |
$4.02
|
| 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
|
|
|
PILOCARPINE 1 % EYE DROPS [6279]
|
Facility
OP
|
$5.05
|
|
|
Service Code
|
NDC 69238-1745-8
|
| Hospital Charge Code |
1740073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Adventist Health Commercial |
$1.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.96
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.29
|
| Rate for Payer: Dignity Health Senior |
$4.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.13
|
| Rate for Payer: Heritage Provider Network Senior |
$3.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$3.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4.29
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
IP
|
$7.61
|
|
|
Service Code
|
NDC 0998-0204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$5.71 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.23
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.15
|
| Rate for Payer: Heritage Provider Network Senior |
$5.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
IP
|
$6.45
|
|
|
Service Code
|
NDC 61314-204-15
|
| Hospital Charge Code |
1740090
|
|
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 |
$4.43
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.48
|
| 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 |
$1.61
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
IP
|
$6.26
|
|
|
Service Code
|
NDC 17478-224-12
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Adventist Health Commercial |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.30
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.24
|
| Rate for Payer: Heritage Provider Network Senior |
$4.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$4.70
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
OP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.55
|
| Rate for Payer: Blue Shield of California Commercial |
$3.77
|
| Rate for Payer: Blue Shield of California EPN |
$3.56
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.16
|
| Rate for Payer: Dignity Health Senior |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.76
|
| Rate for Payer: Heritage Provider Network Senior |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$4.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.16
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
OP
|
$7.61
|
|
|
Service Code
|
NDC 0998-0204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Adventist Health Commercial |
$1.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.71
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.47
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.47
|
| Rate for Payer: Dignity Health Senior |
$6.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.71
|
| Rate for Payer: Heritage Provider Network Senior |
$4.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.90
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.47
|
| Rate for Payer: Vantage Medical Group Senior |
$6.47
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
OP
|
$6.45
|
|
|
Service Code
|
NDC 61314-204-15
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$5.48 |
| 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 |
$4.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.55
|
| Rate for Payer: AlphaCare 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 |
$2.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.48
|
| Rate for Payer: Dignity Health Senior |
$5.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.99
|
| Rate for Payer: Heritage Provider Network Senior |
$3.99
|
| 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 |
$1.61
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Vantage Medical Group Senior |
$5.48
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
IP
|
$6.07
|
|
|
Service Code
|
NDC 70069-191-01
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.17
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.11
|
| Rate for Payer: Heritage Provider Network Senior |
$4.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$4.55
|
|
|
PILOCARPINE 2 % EYE DROPS [6280]
|
Facility
OP
|
$6.26
|
|
|
Service Code
|
NDC 17478-224-12
|
| Hospital Charge Code |
1740090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Adventist Health Commercial |
$1.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.70
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.67
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.32
|
| Rate for Payer: Dignity Health Senior |
$5.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Senior |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$4.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.32
|
| Rate for Payer: Vantage Medical Group Senior |
$5.32
|
|
|
PILOCARPINE 4 % EYE DROPS [6282]
|
Facility
IP
|
$6.36
|
|
|
Service Code
|
NDC 70069-201-01
|
| Hospital Charge Code |
1740061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.37
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.31
|
| Rate for Payer: Heritage Provider Network Senior |
$4.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
|
|
PILOCARPINE 4 % EYE DROPS [6282]
|
Facility
OP
|
$6.36
|
|
|
Service Code
|
NDC 70069-201-01
|
| Hospital Charge Code |
1740061
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$5.41 |
| Rate for Payer: Adventist Health Commercial |
$1.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.77
|
| Rate for Payer: Blue Shield of California Commercial |
$3.95
|
| Rate for Payer: Blue Shield of California EPN |
$3.73
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.41
|
| Rate for Payer: Dignity Health Senior |
$5.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.94
|
| Rate for Payer: Heritage Provider Network Senior |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$4.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.41
|
| Rate for Payer: Vantage Medical Group Senior |
$5.41
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
IP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-25
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
IP
|
$0.49
|
|
|
Service Code
|
NDC 0527-1313-01
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
OP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-25
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.32
|
| Rate for Payer: Dignity Health Senior |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.32
|
| Rate for Payer: Vantage Medical Group Senior |
$2.32
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
OP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-95
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.32
|
| Rate for Payer: Dignity Health Senior |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.32
|
| Rate for Payer: Vantage Medical Group Senior |
$2.32
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
IP
|
$2.73
|
|
|
Service Code
|
NDC 68084-928-95
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
|
|
PILOCARPINE 5 MG TABLET [12803]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 0527-1313-01
|
| Hospital Charge Code |
1711692
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
PIMECROLIMUS 1 % TOPICAL CREAM [32052]
|
Facility
IP
|
$11.96
|
|
|
Service Code
|
NDC 0187-5100-01
|
| Hospital Charge Code |
1743701
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Adventist Health Commercial |
$2.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.22
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.10
|
| Rate for Payer: Heritage Provider Network Senior |
$8.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.99
|
| Rate for Payer: Multiplan Commercial |
$8.97
|
|
|
PIMECROLIMUS 1 % TOPICAL CREAM [32052]
|
Facility
OP
|
$11.96
|
|
|
Service Code
|
NDC 0187-5100-01
|
| Hospital Charge Code |
1743701
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Adventist Health Commercial |
$2.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.97
|
| Rate for Payer: Blue Shield of California Commercial |
$7.43
|
| Rate for Payer: Blue Shield of California EPN |
$7.02
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.17
|
| Rate for Payer: Dignity Health Senior |
$10.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.40
|
| Rate for Payer: Heritage Provider Network Senior |
$7.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.99
|
| Rate for Payer: Multiplan Commercial |
$8.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.17
|
| Rate for Payer: Vantage Medical Group Senior |
$10.17
|
|
|
Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15050
|
| Min. Negotiated Rate |
$247.42 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$247.42
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
PIOGLITAZONE 15 MG TABLET [25528]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 0781-5420-92
|
| Hospital Charge Code |
1710878
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
