|
CHONDROITIN-SOD HYALURON 4 %-3 % (40 MG-30 MG/ML) INTRAOCULAR SYRINGE [28923]
|
Facility
IP
|
$431.64
|
|
|
Service Code
|
NDC 8065183905
|
| Hospital Charge Code |
1720965
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.13 |
| Max. Negotiated Rate |
$323.73 |
| Rate for Payer: Adventist Health Commercial |
$86.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$296.54
|
| Rate for Payer: Cash Price |
$194.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$292.22
|
| Rate for Payer: Heritage Provider Network Senior |
$292.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$78.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.91
|
| Rate for Payer: Multiplan Commercial |
$323.73
|
|
|
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]
|
Facility
IP
|
$2.38
|
|
|
Service Code
|
NDC 0409-4093-01
|
| Hospital Charge Code |
1757538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]
|
Facility
OP
|
$2.38
|
|
|
Service Code
|
NDC 0409-4093-01
|
| Hospital Charge Code |
1757538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: Dignity Health Senior |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
Chromotubation of oviduct, including materials
|
Facility
OP
|
$11,807.68
|
|
|
Service Code
|
CPT 58350
|
| Min. Negotiated Rate |
$226.08 |
| Max. Negotiated Rate |
$11,807.68 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,214.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$6,836.03
|
| Rate for Payer: Dignity Health Senior |
$6,214.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,214.57
|
| Rate for Payer: Humana Medicare |
$6,214.57
|
| Rate for Payer: IEHP Medi-Cal |
$226.08
|
| Rate for Payer: IEHP Medicare Advantage |
$6,214.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11,807.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,333.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,830.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7,830.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$6,836.03
|
| Rate for Payer: TriValley Medical Group Senior |
$6,214.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: Vantage Medical Group Senior |
$6,214.57
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
IP
|
$4,660.09
|
|
|
Service Code
|
APR-DRG 4702
|
| Min. Negotiated Rate |
$4,660.09 |
| Max. Negotiated Rate |
$4,660.09 |
| Rate for Payer: IEHP Medi-Cal |
$4,660.09
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
IP
|
$3,421.45
|
|
|
Service Code
|
APR-DRG 4701
|
| Min. Negotiated Rate |
$3,421.45 |
| Max. Negotiated Rate |
$3,421.45 |
| Rate for Payer: IEHP Medi-Cal |
$3,421.45
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
IP
|
$7,699.50
|
|
|
Service Code
|
APR-DRG 4703
|
| Min. Negotiated Rate |
$7,699.50 |
| Max. Negotiated Rate |
$7,699.50 |
| Rate for Payer: IEHP Medi-Cal |
$7,699.50
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
IP
|
$13,486.81
|
|
|
Service Code
|
APR-DRG 4704
|
| Min. Negotiated Rate |
$13,486.81 |
| Max. Negotiated Rate |
$13,486.81 |
| Rate for Payer: IEHP Medi-Cal |
$13,486.81
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
IP
|
$7,062.77
|
|
|
Service Code
|
APR-DRG 1403
|
| Min. Negotiated Rate |
$7,062.77 |
| Max. Negotiated Rate |
$7,062.77 |
| Rate for Payer: IEHP Medi-Cal |
$7,062.77
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
IP
|
$10,445.41
|
|
|
Service Code
|
APR-DRG 1404
|
| Min. Negotiated Rate |
$10,445.41 |
| Max. Negotiated Rate |
$10,445.41 |
| Rate for Payer: IEHP Medi-Cal |
$10,445.41
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
IP
|
$4,728.74
|
|
|
Service Code
|
APR-DRG 1401
|
| Min. Negotiated Rate |
$4,728.74 |
| Max. Negotiated Rate |
$4,728.74 |
| Rate for Payer: IEHP Medi-Cal |
$4,728.74
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
IP
|
$5,824.12
|
|
|
Service Code
|
APR-DRG 1402
|
| Min. Negotiated Rate |
$5,824.12 |
| Max. Negotiated Rate |
$5,824.12 |
| Rate for Payer: IEHP Medi-Cal |
$5,824.12
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
IP
|
$352.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX227971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.86 |
| Max. Negotiated Rate |
$264.60 |
| Rate for Payer: Adventist Health Commercial |
$70.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$242.37
|
| Rate for Payer: Cash Price |
$158.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$162.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$190.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$238.85
|
| Rate for Payer: Heritage Provider Network Senior |
$238.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.20
|
| Rate for Payer: Multiplan Commercial |
$264.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$128.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$117.87
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
OP
|
$352.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX227971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.86 |
| Max. Negotiated Rate |
$299.88 |
| Rate for Payer: Adventist Health Commercial |
$70.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$188.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$242.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$299.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$194.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$264.60
|
| Rate for Payer: Blue Shield of California Commercial |
$219.09
|
| Rate for Payer: Blue Shield of California EPN |
$207.09
|
| Rate for Payer: Cash Price |
$158.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$162.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.88
|
| Rate for Payer: Dignity Health Senior |
$299.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$225.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$163.35
|
| Rate for Payer: Heritage Provider Network Senior |
$163.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$170.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.20
|
| Rate for Payer: Multiplan Commercial |
$264.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$128.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$117.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.88
|
| Rate for Payer: Vantage Medical Group Senior |
$299.88
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
IP
|
$1.08
|
|
|
Service Code
|
NDC 45802-138-11
|
| Hospital Charge Code |
1743680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
OP
|
$1.08
|
|
|
Service Code
|
NDC 45802-138-11
|
| Hospital Charge Code |
1743680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Senior |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
IP
|
$1.23
|
|
|
Service Code
|
NDC 68462-297-17
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
OP
|
$1.49
|
|
|
Service Code
|
NDC 51672-1318-1
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Senior |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Senior |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
NDC 68462-297-17
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
IP
|
$1.49
|
|
|
Service Code
|
NDC 51672-1318-1
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.02
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Senior |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
OP
|
$6.76
|
|
|
Service Code
|
NDC 50383-419-06
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.75 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.07
|
| Rate for Payer: Blue Shield of California Commercial |
$4.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.97
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.75
|
| Rate for Payer: Dignity Health Senior |
$5.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Vantage Medical Group Senior |
$5.75
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
OP
|
$5.82
|
|
|
Service Code
|
NDC 0713-0317-88
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Adventist Health Commercial |
$1.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.36
|
| Rate for Payer: Blue Shield of California Commercial |
$3.61
|
| Rate for Payer: Blue Shield of California EPN |
$3.42
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.95
|
| Rate for Payer: Dignity Health Senior |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.60
|
| Rate for Payer: Heritage Provider Network Senior |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: Vantage Medical Group Senior |
$4.95
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
IP
|
$6.76
|
|
|
Service Code
|
NDC 50383-419-06
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$5.07 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.64
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Senior |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$5.07
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
IP
|
$5.82
|
|
|
Service Code
|
NDC 0713-0317-88
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Adventist Health Commercial |
$1.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.00
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.14
|
| 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 Medi-Cal |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$4.36
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
IP
|
$24.48
|
|
|
Service Code
|
NDC 9994-0825-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$18.36 |
| Rate for Payer: Adventist Health Commercial |
$4.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.82
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.57
|
| Rate for Payer: Heritage Provider Network Senior |
$16.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.12
|
| Rate for Payer: Multiplan Commercial |
$18.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.18
|
|
