|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$7.23 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.88
|
| Rate for Payer: TriValley Medical Group Senior |
$2.88
|
| Rate for Payer: TriValley Medical Group Senior |
$1.60
|
| Rate for Payer: TriValley Medical Group Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$1.79
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.36
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.98
|
| Rate for Payer: Heritage Provider Network Senior |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.32
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 9994080422
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.58
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 9994080422
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2.44
|
| Rate for Payer: Blue Shield of California EPN |
$1.95
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.48
|
| Rate for Payer: Heritage Provider Network Senior |
$2.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Senior |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
IP
|
$17.67
|
|
|
Service Code
|
NDC 6332340603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$13.25 |
| Rate for Payer: Adventist Health Commercial |
$3.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: Cash Price |
$7.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.96
|
| Rate for Payer: Heritage Provider Network Senior |
$11.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$13.25
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 2502160203
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.88
|
| Rate for Payer: Blue Shield of California EPN |
$3.90
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.95
|
| Rate for Payer: Heritage Provider Network Senior |
$4.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.60
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.20
|
| Rate for Payer: TriValley Medical Group Senior |
$3.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Vantage Medical Group Senior |
$6.80
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 2502160203
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.42
|
| Rate for Payer: Heritage Provider Network Senior |
$5.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
OP
|
$17.67
|
|
|
Service Code
|
NDC 6332340603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: Adventist Health Commercial |
$3.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.84
|
| Rate for Payer: Blue Shield of California Commercial |
$10.78
|
| Rate for Payer: Blue Shield of California EPN |
$8.62
|
| Rate for Payer: Cash Price |
$7.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.94
|
| Rate for Payer: Heritage Provider Network Senior |
$10.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.37
|
| Rate for Payer: Multiplan Commercial |
$13.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.07
|
| Rate for Payer: TriValley Medical Group Senior |
$7.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.02
|
| Rate for Payer: Vantage Medical Group Senior |
$15.02
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
OP
|
$25.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.56 |
| Max. Negotiated Rate |
$21.40 |
| Rate for Payer: Adventist Health Commercial |
$5.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.89
|
| Rate for Payer: Blue Shield of California Commercial |
$15.36
|
| Rate for Payer: Blue Shield of California EPN |
$12.29
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$21.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.66
|
| Rate for Payer: Heritage Provider Network Senior |
$11.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.63
|
| Rate for Payer: Multiplan Commercial |
$18.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.07
|
| Rate for Payer: TriValley Medical Group Senior |
$10.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.40
|
| Rate for Payer: Vantage Medical Group Senior |
$21.40
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
IP
|
$25.18
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.56 |
| Max. Negotiated Rate |
$18.89 |
| Rate for Payer: Adventist Health Commercial |
$5.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.22
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.66
|
| Rate for Payer: Heritage Provider Network Senior |
$11.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.29
|
| Rate for Payer: Multiplan Commercial |
$18.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.34
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904253321
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 0395041396
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0904253321
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 0395041396
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
CALASPARGASE PEGOL-MKNL 750 UNIT/ML INTRAVENOUS SOLUTION [225926]
|
Facility
|
IP
|
$7,317.11
|
|
|
Service Code
|
HCPCS J9118
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,324.40 |
| Max. Negotiated Rate |
$5,487.83 |
| Rate for Payer: Adventist Health Commercial |
$1,463.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,712.22
|
| Rate for Payer: Cash Price |
$3,292.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,365.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,951.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,387.82
|
| Rate for Payer: Heritage Provider Network Senior |
$3,387.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,324.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,829.28
|
| Rate for Payer: Multiplan Commercial |
$5,487.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,643.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,422.70
|
|
|
CALASPARGASE PEGOL-MKNL 750 UNIT/ML INTRAVENOUS SOLUTION [225926]
|
Facility
|
OP
|
$7,317.11
|
|
|
Service Code
|
HCPCS J9118
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.64 |
| Max. Negotiated Rate |
$5,487.83 |
| Rate for Payer: Adventist Health Commercial |
$1,463.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,521.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$128.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$94.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$157.10
|
| Rate for Payer: Blue Shield of California Commercial |
$73.64
|
| Rate for Payer: Blue Shield of California EPN |
$73.64
|
| Rate for Payer: Cash Price |
$3,292.70
|
| Rate for Payer: Cash Price |
$3,292.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,365.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$128.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$94.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$85.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,682.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$85.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,387.82
|
| Rate for Payer: Heritage Provider Network Senior |
$3,387.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$85.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,490.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,324.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$98.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,829.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$114.96
|
| Rate for Payer: Multiplan Commercial |
$5,487.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,926.84
|
| Rate for Payer: TriValley Medical Group Senior |
$2,926.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,643.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,422.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$128.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$94.37
|
| Rate for Payer: Vantage Medical Group Senior |
$85.79
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 6846250165
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.21
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.15
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.73
|
| Rate for Payer: Heritage Provider Network Senior |
$2.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.09
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Senior |
$1.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Vantage Medical Group Senior |
$3.75
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL CREAM [16034]
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 6846250165
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.84
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Senior |
$2.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 6699387861
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.02
|
| Rate for Payer: Blue Shield of California Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.22
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.41
|
| Rate for Payer: TriValley Medical Group Senior |
$2.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
CALCIPOTRIENE 0.005 % TOPICAL OINTMENT [12244]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 6699387861
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.88
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL SUSPENSION [91914]
|
Facility
|
IP
|
$26.04
|
|
|
Service Code
|
NDC 5022250106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.71 |
| Max. Negotiated Rate |
$19.53 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.77
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.63
|
| Rate for Payer: Heritage Provider Network Senior |
$17.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
|
|
CALCIPOTRIENE-BETAMETHASONE 0.005 %-0.064 % TOPICAL SUSPENSION [91914]
|
Facility
|
OP
|
$26.04
|
|
|
Service Code
|
NDC 5022250106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.71 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.03
|
| Rate for Payer: Blue Shield of California Commercial |
$15.88
|
| Rate for Payer: Blue Shield of California EPN |
$12.71
|
| Rate for Payer: Cash Price |
$11.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.12
|
| Rate for Payer: Heritage Provider Network Senior |
$16.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.23
|
| Rate for Payer: Multiplan Commercial |
$19.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.42
|
| Rate for Payer: TriValley Medical Group Senior |
$10.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.13
|
| Rate for Payer: Vantage Medical Group Senior |
$22.13
|
|
|
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]
|
Facility
|
IP
|
$24.28
|
|
|
Service Code
|
NDC 6050508236
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.39 |
| Max. Negotiated Rate |
$18.21 |
| Rate for Payer: Adventist Health Commercial |
$4.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.64
|
| Rate for Payer: Cash Price |
$10.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.44
|
| Rate for Payer: Heritage Provider Network Senior |
$16.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.07
|
| Rate for Payer: Multiplan Commercial |
$18.21
|
|
|
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY [15738]
|
Facility
|
OP
|
$24.28
|
|
|
Service Code
|
NDC 6050508236
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.39 |
| Max. Negotiated Rate |
$20.64 |
| Rate for Payer: Adventist Health Commercial |
$4.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.14
|
| Rate for Payer: Blue Shield of California Commercial |
$14.81
|
| Rate for Payer: Blue Shield of California EPN |
$11.85
|
| Rate for Payer: Cash Price |
$10.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.03
|
| Rate for Payer: Heritage Provider Network Senior |
$15.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.00
|
| Rate for Payer: Multiplan Commercial |
$18.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.71
|
| Rate for Payer: TriValley Medical Group Senior |
$9.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.64
|
| Rate for Payer: Vantage Medical Group Senior |
$20.64
|
|
|
CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION [9347]
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS J0630
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.60 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Adventist Health Commercial |
$72.00
|
| Rate for Payer: Adventist Health Commercial |
$96.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$386.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$231.84
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$165.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$220.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$194.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$259.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$324.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$277.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$222.24
|
| Rate for Payer: Heritage Provider Network Senior |
$222.24
|
| Rate for Payer: Heritage Provider Network Senior |
$166.68
|
| Rate for Payer: Heritage Provider Network Senior |
$277.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$86.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$108.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$65.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$90.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: Multiplan Commercial |
$270.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$130.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$216.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$173.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$119.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.93
|
|
