|
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION [9525]
|
Facility
IP
|
$0.35
|
|
|
Service Code
|
NDC 65649-311-12
|
| Hospital Charge Code |
1715531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION [9525]
|
Facility
OP
|
$0.35
|
|
|
Service Code
|
NDC 65649-311-12
|
| Hospital Charge Code |
1715531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]
|
Facility
IP
|
$357.24
|
|
|
Service Code
|
CPT J1205
|
| Hospital Charge Code |
1720125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.66 |
| Max. Negotiated Rate |
$267.93 |
| Rate for Payer: Adventist Health Commercial |
$71.45
|
| Rate for Payer: Adventist Health Commercial |
$23.95
|
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Adventist Health Commercial |
$11.69
|
| Rate for Payer: Adventist Health Commercial |
$38.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$245.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$131.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.28
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$160.76
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$26.29
|
| Rate for Payer: Cash Price |
$53.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$88.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$164.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$241.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$129.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.56
|
| Rate for Payer: Heritage Provider Network Senior |
$39.56
|
| Rate for Payer: Heritage Provider Network Senior |
$129.98
|
| Rate for Payer: Heritage Provider Network Senior |
$48.74
|
| Rate for Payer: Heritage Provider Network Senior |
$241.85
|
| Rate for Payer: Heritage Provider Network Senior |
$81.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.61
|
| Rate for Payer: Multiplan Commercial |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$43.82
|
| Rate for Payer: Multiplan Commercial |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$267.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$130.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$70.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$64.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$119.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.06
|
|
|
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]
|
Facility
OP
|
$58.43
|
|
|
Service Code
|
CPT J1205
|
| Hospital Charge Code |
1720125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$298.10 |
| Rate for Payer: Adventist Health Commercial |
$11.69
|
| Rate for Payer: Adventist Health Commercial |
$71.45
|
| Rate for Payer: Adventist Health Commercial |
$38.40
|
| Rate for Payer: Adventist Health Commercial |
$23.95
|
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$298.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$298.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$298.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$298.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$298.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$131.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$245.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$101.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$163.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$303.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$49.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$196.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$65.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$43.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$267.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$144.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$89.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.67
|
| Rate for Payer: Blue Shield of California Commercial |
$106.04
|
| Rate for Payer: Blue Shield of California Commercial |
$106.04
|
| Rate for Payer: Blue Shield of California Commercial |
$106.04
|
| Rate for Payer: Blue Shield of California Commercial |
$106.04
|
| Rate for Payer: Blue Shield of California Commercial |
$106.04
|
| Rate for Payer: Blue Shield of California EPN |
$106.04
|
| Rate for Payer: Blue Shield of California EPN |
$106.04
|
| Rate for Payer: Blue Shield of California EPN |
$106.04
|
| Rate for Payer: Blue Shield of California EPN |
$106.04
|
| Rate for Payer: Blue Shield of California EPN |
$106.04
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$26.29
|
| Rate for Payer: Cash Price |
$160.76
|
| Rate for Payer: Cash Price |
$26.29
|
| Rate for Payer: Cash Price |
$53.89
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$160.76
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$53.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$88.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$164.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$101.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$163.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$303.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$101.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$303.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$163.20
|
| Rate for Payer: Dignity Health Senior |
$101.80
|
| Rate for Payer: Dignity Health Senior |
$49.67
|
| Rate for Payer: Dignity Health Senior |
$61.20
|
| Rate for Payer: Dignity Health Senior |
$163.20
|
| Rate for Payer: Dignity Health Senior |
$303.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$228.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.90
|
| Rate for Payer: Heritage Provider Network Senior |
$88.90
|
| Rate for Payer: Heritage Provider Network Senior |
$55.45
|
| Rate for Payer: Heritage Provider Network Senior |
$33.34
|
| Rate for Payer: Heritage Provider Network Senior |
$165.40
|
| Rate for Payer: Heritage Provider Network Senior |
$27.05
|
| Rate for Payer: IEHP Medi-Cal |
$196.26
|
| Rate for Payer: IEHP Medi-Cal |
$196.26
|
| Rate for Payer: IEHP Medi-Cal |
$196.26
|
| Rate for Payer: IEHP Medi-Cal |
$196.26
|
| Rate for Payer: IEHP Medi-Cal |
$196.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$172.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$92.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.61
|
| Rate for Payer: Multiplan Commercial |
$267.93
|
| Rate for Payer: Multiplan Commercial |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$43.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$130.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$70.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$64.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$119.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$303.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$163.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$101.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$49.67
|
| Rate for Payer: Vantage Medical Group Senior |
$163.20
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$303.65
|
| Rate for Payer: Vantage Medical Group Senior |
$101.80
|
|
|
CHLORPROMAZINE 100 MG TABLET [1654]
|
Facility
IP
|
$14.98
|
|
|
Service Code
|
NDC 0904-6895-61
|
| Hospital Charge Code |
1710686
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$11.24 |
| Rate for Payer: Adventist Health Commercial |
$3.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.29
|
| Rate for Payer: Cash Price |
$6.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.14
|
| Rate for Payer: Heritage Provider Network Senior |
$10.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.74
|
| Rate for Payer: Multiplan Commercial |
$11.24
|
|
|
CHLORPROMAZINE 100 MG TABLET [1654]
|
Facility
OP
|
$14.98
|
|
|
Service Code
|
NDC 0904-6895-61
|
| Hospital Charge Code |
1710686
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Adventist Health Commercial |
$3.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.24
|
| Rate for Payer: Blue Shield of California Commercial |
$9.30
|
| Rate for Payer: Blue Shield of California EPN |
$8.79
|
| Rate for Payer: Cash Price |
$6.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.73
|
| Rate for Payer: Dignity Health Senior |
$12.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.27
|
| Rate for Payer: Heritage Provider Network Senior |
$9.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.74
|
| Rate for Payer: Multiplan Commercial |
$11.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.73
|
| Rate for Payer: Vantage Medical Group Senior |
$12.73
|
|
|
CHLORPROMAZINE 10 MG TABLET [1653]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 68462-861-01
|
| Hospital Charge Code |
1711161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
CHLORPROMAZINE 10 MG TABLET [1653]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 68462-861-01
|
| Hospital Charge Code |
1711161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
CHLORPROMAZINE 10 MG TABLET [1653]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 69238-1054-1
|
| Hospital Charge Code |
1711161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
CHLORPROMAZINE 10 MG TABLET [1653]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 69238-1054-1
|
| Hospital Charge Code |
1711161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]
|
Facility
IP
|
$19.86
|
|
|
Service Code
|
CPT J3230
|
| Hospital Charge Code |
1720458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$14.90 |
| Rate for Payer: Adventist Health Commercial |
$3.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.64
|
| Rate for Payer: Cash Price |
$8.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.45
|
| Rate for Payer: Heritage Provider Network Senior |
$13.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.96
|
| Rate for Payer: Multiplan Commercial |
$14.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.64
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]
|
Facility
OP
|
$19.86
|
|
|
Service Code
|
CPT J3230
|
| Hospital Charge Code |
1720458
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$73.16 |
| Rate for Payer: Adventist Health Commercial |
$3.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$73.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.28
|
| Rate for Payer: Blue Shield of California Commercial |
$46.35
|
| Rate for Payer: Blue Shield of California EPN |
$46.35
|
| Rate for Payer: Cash Price |
$8.94
|
| Rate for Payer: Cash Price |
$8.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.88
|
| Rate for Payer: Dignity Health Senior |
$16.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.20
|
| Rate for Payer: Heritage Provider Network Senior |
$9.20
|
| Rate for Payer: IEHP Medi-Cal |
$53.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.96
|
| Rate for Payer: Multiplan Commercial |
$14.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.88
|
| Rate for Payer: Vantage Medical Group Senior |
$16.88
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
IP
|
$4.54
|
|
|
Service Code
|
NDC 0832-0301-00
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.12
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.07
|
| Rate for Payer: Heritage Provider Network Senior |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$3.40
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
IP
|
$7.11
|
|
|
Service Code
|
NDC 60687-430-11
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.88
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.81
|
| Rate for Payer: Heritage Provider Network Senior |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
IP
|
$7.11
|
|
|
Service Code
|
NDC 60687-430-01
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.88
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.81
|
| Rate for Payer: Heritage Provider Network Senior |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
OP
|
$7.11
|
|
|
Service Code
|
NDC 60687-430-11
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.04
|
| Rate for Payer: Dignity Health Senior |
$6.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.40
|
| Rate for Payer: Heritage Provider Network Senior |
$4.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.04
|
| Rate for Payer: Vantage Medical Group Senior |
$6.04
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
OP
|
$4.54
|
|
|
Service Code
|
NDC 0832-0301-00
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$2.82
|
| Rate for Payer: Blue Shield of California EPN |
$2.66
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.86
|
| Rate for Payer: Dignity Health Senior |
$3.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.81
|
| Rate for Payer: Heritage Provider Network Senior |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.86
|
| Rate for Payer: Vantage Medical Group Senior |
$3.86
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
OP
|
$1.20
|
|
|
Service Code
|
NDC 0527-2962-37
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
IP
|
$1.20
|
|
|
Service Code
|
NDC 0527-2962-37
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
OP
|
$7.11
|
|
|
Service Code
|
NDC 60687-430-01
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$4.17
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.04
|
| Rate for Payer: Dignity Health Senior |
$6.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.40
|
| Rate for Payer: Heritage Provider Network Senior |
$4.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.04
|
| Rate for Payer: Vantage Medical Group Senior |
$6.04
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
OP
|
$1.02
|
|
|
Service Code
|
NDC 68462-862-01
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.63
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: Dignity Health Senior |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
IP
|
$1.02
|
|
|
Service Code
|
NDC 68462-862-01
|
| Hospital Charge Code |
1711171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
|
|
CHLORPROMAZINE 50 MG TABLET [1657]
|
Facility
OP
|
$6.46
|
|
|
Service Code
|
NDC 0832-0302-00
|
| Hospital Charge Code |
1710664
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Adventist Health Commercial |
$1.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.49
|
| 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 |
$2.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.49
|
| Rate for Payer: Dignity Health Senior |
$5.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.49
|
| Rate for Payer: Vantage Medical Group Senior |
$5.49
|
|
|
CHLORPROMAZINE 50 MG TABLET [1657]
|
Facility
IP
|
$6.46
|
|
|
Service Code
|
NDC 0832-0302-00
|
| Hospital Charge Code |
1710664
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Adventist Health Commercial |
$1.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.44
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.37
|
| Rate for Payer: Heritage Provider Network Senior |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$4.84
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
IP
|
$2.30
|
|
|
Service Code
|
NDC 60687-317-95
|
| Hospital Charge Code |
1710179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.72
|
|
