|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
OP
|
$24.48
|
|
|
Service Code
|
NDC 9994-0825-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$20.81 |
| Rate for Payer: Adventist Health Commercial |
$4.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.36
|
| Rate for Payer: Blue Shield of California Commercial |
$15.20
|
| Rate for Payer: Blue Shield of California EPN |
$14.37
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.81
|
| Rate for Payer: Dignity Health Senior |
$20.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.33
|
| Rate for Payer: Heritage Provider Network Senior |
$11.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.80
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.81
|
| Rate for Payer: Vantage Medical Group Senior |
$20.81
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
IP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-61
|
| Hospital Charge Code |
NDC4081161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.74
|
| Rate for Payer: Heritage Provider Network Senior |
$24.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.21
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-61
|
| Hospital Charge Code |
NDC4081161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.06 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Blue Shield of California Commercial |
$22.69
|
| Rate for Payer: Blue Shield of California EPN |
$21.45
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.06
|
| Rate for Payer: Dignity Health Senior |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.92
|
| Rate for Payer: Heritage Provider Network Senior |
$16.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
IP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-92
|
| Hospital Charge Code |
NDC4081092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.74
|
| Rate for Payer: Heritage Provider Network Senior |
$24.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.21
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-92
|
| Hospital Charge Code |
NDC4081092
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.06 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Blue Shield of California Commercial |
$22.69
|
| Rate for Payer: Blue Shield of California EPN |
$21.45
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.06
|
| Rate for Payer: Dignity Health Senior |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.92
|
| Rate for Payer: Heritage Provider Network Senior |
$16.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
|
CIDOFOVIR 3 MG/ML TOPICAL [4081091]
|
Facility
IP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-91
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.74
|
| Rate for Payer: Heritage Provider Network Senior |
$24.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.21
|
|
|
CIDOFOVIR 3 MG/ML TOPICAL [4081091]
|
Facility
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-91
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.06 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Blue Shield of California Commercial |
$22.69
|
| Rate for Payer: Blue Shield of California EPN |
$21.45
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.06
|
| Rate for Payer: Dignity Health Senior |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.92
|
| Rate for Payer: Heritage Provider Network Senior |
$16.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
|
CIDOFOVIR 5 MG/ML TOPICAL [4081159]
|
Facility
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-59
|
| Hospital Charge Code |
NDC4081159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.06 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Blue Shield of California Commercial |
$22.69
|
| Rate for Payer: Blue Shield of California EPN |
$21.45
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.06
|
| Rate for Payer: Dignity Health Senior |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.62
|
| Rate for Payer: Heritage Provider Network Senior |
$22.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
|
CIDOFOVIR 5 MG/ML TOPICAL [4081159]
|
Facility
IP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-59
|
| Hospital Charge Code |
NDC4081159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.74
|
| Rate for Payer: Heritage Provider Network Senior |
$24.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.14
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]
|
Facility
IP
|
$177.60
|
|
|
Service Code
|
CPT J0740
|
| Hospital Charge Code |
1757059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.24
|
| Rate for Payer: Heritage Provider Network Senior |
$120.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$64.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.34
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]
|
Facility
OP
|
$177.60
|
|
|
Service Code
|
CPT J0740
|
| Hospital Charge Code |
1757059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$1,506.78 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,361.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$692.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$609.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$609.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,506.78
|
| Rate for Payer: Blue Shield of California Commercial |
$881.65
|
| Rate for Payer: Blue Shield of California EPN |
$881.65
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cash Price |
$79.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$831.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$609.61
|
| Rate for Payer: Dignity Health Senior |
$609.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.66
|
| Rate for Payer: EPIC Health Plan Medicare |
$554.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.23
|
| Rate for Payer: Heritage Provider Network Senior |
$82.23
|
| Rate for Payer: Humana Medicare |
$554.19
|
| Rate for Payer: IEHP Medi-Cal |
$871.49
|
| Rate for Payer: IEHP Medicare Advantage |
$554.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,052.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$653.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$698.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$698.28
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$609.61
|
| Rate for Payer: TriValley Medical Group Senior |
$554.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$64.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$831.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$609.61
|
| Rate for Payer: Vantage Medical Group Senior |
$554.19
|
|
|
Ciliary body destruction; cyclophotocoagulation, transscleral
|
Facility
OP
|
$5,547.37
|
|
|
Service Code
|
CPT 66710
|
| Min. Negotiated Rate |
$387.97 |
| Max. Negotiated Rate |
$5,547.37 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: Dignity Health Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,919.67
|
| Rate for Payer: Humana Medicare |
$2,919.67
|
| Rate for Payer: IEHP Medi-Cal |
$387.97
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,547.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,445.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,678.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,211.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
CILOSTAZOL 100 MG TABLET [24474]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 0054-0044-21
|
| Hospital Charge Code |
1710971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| 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 |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
CILOSTAZOL 100 MG TABLET [24474]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 0054-0044-29
|
| Hospital Charge Code |
1710971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| 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 |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
CILOSTAZOL 100 MG TABLET [24474]
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 0054-0044-21
|
| Hospital Charge Code |
1710971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| 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 |
$0.32
|
|
|
CILOSTAZOL 100 MG TABLET [24474]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 0093-2064-06
|
| Hospital Charge Code |
1710971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
CILOSTAZOL 100 MG TABLET [24474]
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 0054-0044-29
|
| Hospital Charge Code |
1710971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| 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 |
$0.32
|
|
|
CILOSTAZOL 100 MG TABLET [24474]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 0185-0223-60
|
| Hospital Charge Code |
1710971
|
|
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
|
|
|
CILOSTAZOL 100 MG TABLET [24474]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 0093-2064-06
|
| Hospital Charge Code |
1710971
|
|
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
|
|
|
CILOSTAZOL 100 MG TABLET [24474]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 0185-0223-60
|
| Hospital Charge Code |
1710971
|
|
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
|
|
|
CINACALCET 15 MG PARTIAL TABLET [40820825]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 69097-410-02
|
| Hospital Charge Code |
ERX40820825
|
|
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
|
|
|
CINACALCET 15 MG PARTIAL TABLET [40820825]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 16729-440-10
|
| Hospital Charge Code |
ERX40820825
|
|
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
|
|
|
CINACALCET 15 MG PARTIAL TABLET [40820825]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 16729-440-10
|
| Hospital Charge Code |
ERX40820825
|
|
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
|
|
|
CINACALCET 15 MG PARTIAL TABLET [40820825]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 69097-410-02
|
| Hospital Charge Code |
ERX40820825
|
|
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
|
|
|
CINACALCET 30 MG TABLET [38100]
|
Facility
IP
|
$0.59
|
|
|
Service Code
|
NDC 67877-503-30
|
| Hospital Charge Code |
1710945
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.44 |
| 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 |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| 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 |
$0.44
|
|
