|
PROPAFENONE 150 MG TABLET [11146]
|
Facility
IP
|
$0.46
|
|
|
Service Code
|
NDC 0591-0582-01
|
| Hospital Charge Code |
1711536
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
PROPAFENONE 150 MG TABLET [11146]
|
Facility
OP
|
$0.46
|
|
|
Service Code
|
NDC 0591-0582-01
|
| Hospital Charge Code |
1711536
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Senior |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
PROPAFENONE 225 MG TABLET [11147]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
NDC 0591-0583-01
|
| Hospital Charge Code |
1711953
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
PROPAFENONE 225 MG TABLET [11147]
|
Facility
OP
|
$0.61
|
|
|
Service Code
|
NDC 0591-0583-01
|
| Hospital Charge Code |
1711953
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Senior |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
PROPAFENONE 225 MG TABLET [11147]
|
Facility
IP
|
$1.25
|
|
|
Service Code
|
NDC 53489-552-01
|
| Hospital Charge Code |
1711953
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.86
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
|
|
PROPAFENONE 225 MG TABLET [11147]
|
Facility
OP
|
$1.25
|
|
|
Service Code
|
NDC 53489-552-01
|
| Hospital Charge Code |
1711953
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.06
|
| Rate for Payer: Dignity Health Senior |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.06
|
|
|
PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]
|
Facility
OP
|
$9.71
|
|
|
Service Code
|
NDC 60687-185-32
|
| Hospital Charge Code |
1710957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.28
|
| Rate for Payer: Blue Shield of California Commercial |
$6.03
|
| Rate for Payer: Blue Shield of California EPN |
$5.70
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.25
|
| Rate for Payer: Dignity Health Senior |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.01
|
| Rate for Payer: Heritage Provider Network Senior |
$6.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.25
|
| Rate for Payer: Vantage Medical Group Senior |
$8.25
|
|
|
PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 64380-184-01
|
| Hospital Charge Code |
1710957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Senior |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]
|
Facility
IP
|
$9.71
|
|
|
Service Code
|
NDC 60687-185-33
|
| Hospital Charge Code |
1710957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.57
|
| Rate for Payer: Heritage Provider Network Senior |
$6.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
|
|
PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 64380-184-01
|
| Hospital Charge Code |
1710957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]
|
Facility
IP
|
$0.98
|
|
|
Service Code
|
NDC 69680-130-60
|
| Hospital Charge Code |
1710957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]
|
Facility
OP
|
$0.98
|
|
|
Service Code
|
NDC 69680-130-60
|
| Hospital Charge Code |
1710957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.83
|
| Rate for Payer: Dignity Health Senior |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Vantage Medical Group Senior |
$0.83
|
|
|
PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]
|
Facility
IP
|
$9.71
|
|
|
Service Code
|
NDC 60687-185-32
|
| Hospital Charge Code |
1710957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.57
|
| Rate for Payer: Heritage Provider Network Senior |
$6.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
|
|
PROPAFENONE ER 225 MG CAPSULE,EXTENDED RELEASE 12 HR [37643]
|
Facility
OP
|
$9.71
|
|
|
Service Code
|
NDC 60687-185-33
|
| Hospital Charge Code |
1710957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.28
|
| Rate for Payer: Blue Shield of California Commercial |
$6.03
|
| Rate for Payer: Blue Shield of California EPN |
$5.70
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.25
|
| Rate for Payer: Dignity Health Senior |
$8.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.01
|
| Rate for Payer: Heritage Provider Network Senior |
$6.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.25
|
| Rate for Payer: Vantage Medical Group Senior |
$8.25
|
|
|
PROPAFENONE ER 325 MG CAPSULE,EXTENDED RELEASE 12 HR [37644]
|
Facility
IP
|
$8.89
|
|
|
Service Code
|
NDC 49884-210-02
|
| Hospital Charge Code |
1710994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$6.67 |
| Rate for Payer: Adventist Health Commercial |
$1.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.11
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Senior |
$6.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$6.67
|
|
|
PROPAFENONE ER 325 MG CAPSULE,EXTENDED RELEASE 12 HR [37644]
|
Facility
OP
|
$8.89
|
|
|
Service Code
|
NDC 49884-210-02
|
| Hospital Charge Code |
1710994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Adventist Health Commercial |
$1.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.67
|
| Rate for Payer: Blue Shield of California Commercial |
$5.52
|
| Rate for Payer: Blue Shield of California EPN |
$5.22
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.56
|
| Rate for Payer: Dignity Health Senior |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.50
|
| Rate for Payer: Heritage Provider Network Senior |
$5.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$6.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.56
|
| Rate for Payer: Vantage Medical Group Senior |
$7.56
|
|
|
PROPARACAINE 0.5 % EYE DROPS [6644]
|
Facility
OP
|
$3.05
|
|
|
Service Code
|
NDC 0998-0016-15
|
| Hospital Charge Code |
1740258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.79
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.59
|
| Rate for Payer: Dignity Health Senior |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.59
|
| Rate for Payer: Vantage Medical Group Senior |
$2.59
|
|
|
PROPARACAINE 0.5 % EYE DROPS [6644]
|
Facility
IP
|
$3.05
|
|
|
Service Code
|
NDC 0998-0016-15
|
| Hospital Charge Code |
1740258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.29
|
|
|
PROPARACAINE 0.5 % EYE DROPS [6644]
|
Facility
IP
|
$2.81
|
|
|
Service Code
|
NDC 24208-730-06
|
| Hospital Charge Code |
1740258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.11 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.93
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
|
|
PROPARACAINE 0.5 % EYE DROPS [6644]
|
Facility
IP
|
$2.81
|
|
|
Service Code
|
NDC 61314-016-01
|
| Hospital Charge Code |
1740258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.11 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.93
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
|
|
PROPARACAINE 0.5 % EYE DROPS [6644]
|
Facility
OP
|
$2.81
|
|
|
Service Code
|
NDC 24208-730-06
|
| Hospital Charge Code |
1740258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.65
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.39
|
| Rate for Payer: Dignity Health Senior |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2.39
|
|
|
PROPARACAINE 0.5 % EYE DROPS [6644]
|
Facility
OP
|
$2.81
|
|
|
Service Code
|
NDC 61314-016-01
|
| Hospital Charge Code |
1740258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.65
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.39
|
| Rate for Payer: Dignity Health Senior |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.74
|
| Rate for Payer: Heritage Provider Network Senior |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2.39
|
|
|
Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage; photocoagulation
|
Facility
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 67145
|
| Min. Negotiated Rate |
$580.79 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,089.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$798.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$726.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,089.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$798.89
|
| Rate for Payer: Dignity Health Senior |
$726.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$726.26
|
| Rate for Payer: Humana Medicare |
$726.26
|
| Rate for Payer: IEHP Medi-Cal |
$580.79
|
| Rate for Payer: IEHP Medicare Advantage |
$726.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,379.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$856.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$915.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$915.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$798.89
|
| Rate for Payer: TriValley Medical Group Senior |
$726.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,089.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$798.89
|
| Rate for Payer: Vantage Medical Group Senior |
$726.26
|
|
|
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [11150]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
CPT J2704
|
| Hospital Charge Code |
NDG11150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: IEHP Medi-Cal |
$7.16
|
| Rate for Payer: IEHP Medi-Cal |
$7.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [11150]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
CPT J2704
|
| Hospital Charge Code |
1720893
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$7.16 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: IEHP Medi-Cal |
$7.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
