|
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION [225907]
|
Facility
OP
|
$294.35
|
|
|
Service Code
|
NDC 0078-0883-61
|
| Hospital Charge Code |
NDG225907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.28 |
| Max. Negotiated Rate |
$250.20 |
| Rate for Payer: Adventist Health Commercial |
$58.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$202.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$250.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$161.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$220.76
|
| Rate for Payer: Blue Shield of California Commercial |
$182.79
|
| Rate for Payer: Blue Shield of California EPN |
$172.78
|
| Rate for Payer: Cash Price |
$132.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$135.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$250.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$250.20
|
| Rate for Payer: Dignity Health Senior |
$250.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$188.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$136.28
|
| Rate for Payer: Heritage Provider Network Senior |
$136.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$141.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.59
|
| Rate for Payer: Multiplan Commercial |
$220.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$107.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$98.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$250.20
|
| Rate for Payer: Vantage Medical Group Senior |
$250.20
|
|
|
CRIZOTINIB 250 MG CAPSULE [153216]
|
Facility
OP
|
$423.16
|
|
|
Service Code
|
NDC 0069-8140-20
|
| Hospital Charge Code |
1712554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$76.59 |
| Max. Negotiated Rate |
$359.69 |
| Rate for Payer: Adventist Health Commercial |
$84.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$226.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$290.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$359.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$232.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$317.37
|
| Rate for Payer: Blue Shield of California Commercial |
$262.78
|
| Rate for Payer: Blue Shield of California EPN |
$248.39
|
| Rate for Payer: Cash Price |
$190.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$275.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$359.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$359.69
|
| Rate for Payer: Dignity Health Senior |
$359.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$270.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$261.94
|
| Rate for Payer: Heritage Provider Network Senior |
$261.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$203.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.79
|
| Rate for Payer: Multiplan Commercial |
$317.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$359.69
|
| Rate for Payer: Vantage Medical Group Senior |
$359.69
|
|
|
CRIZOTINIB 250 MG CAPSULE [153216]
|
Facility
IP
|
$423.16
|
|
|
Service Code
|
NDC 0069-8140-20
|
| Hospital Charge Code |
1712554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$76.59 |
| Max. Negotiated Rate |
$317.37 |
| Rate for Payer: Adventist Health Commercial |
$84.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$290.71
|
| Rate for Payer: Cash Price |
$190.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$228.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$286.48
|
| Rate for Payer: Heritage Provider Network Senior |
$286.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$105.79
|
| Rate for Payer: Multiplan Commercial |
$317.37
|
|
|
CROMOLYN 20 MG/2 ML SOLUTION FOR NEBULIZATION [9690]
|
Facility
OP
|
$10.85
|
|
|
Service Code
|
NDC 69784-205-60
|
| Hospital Charge Code |
1781097
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Adventist Health Commercial |
$2.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.14
|
| Rate for Payer: Blue Shield of California Commercial |
$6.74
|
| Rate for Payer: Blue Shield of California EPN |
$6.37
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.22
|
| Rate for Payer: Dignity Health Senior |
$9.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.72
|
| Rate for Payer: Heritage Provider Network Senior |
$6.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.71
|
| Rate for Payer: Multiplan Commercial |
$8.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.22
|
| Rate for Payer: Vantage Medical Group Senior |
$9.22
|
|
|
CROMOLYN 20 MG/2 ML SOLUTION FOR NEBULIZATION [9690]
|
Facility
IP
|
$10.85
|
|
|
Service Code
|
NDC 69784-205-60
|
| Hospital Charge Code |
1781097
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$8.14 |
| Rate for Payer: Adventist Health Commercial |
$2.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.45
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.35
|
| Rate for Payer: Heritage Provider Network Senior |
$7.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.71
|
| Rate for Payer: Multiplan Commercial |
$8.14
|
|
|
CROMOLYN 4 % EYE DROPS [9691]
|
Facility
IP
|
$2.74
|
|
|
Service Code
|
NDC 17478-291-11
|
| Hospital Charge Code |
1744076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
|
|
CROMOLYN 4 % EYE DROPS [9691]
|
Facility
OP
|
$2.74
|
|
|
Service Code
|
NDC 17478-291-11
|
| Hospital Charge Code |
1744076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.33
|
| Rate for Payer: Dignity Health Senior |
$2.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Senior |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.33
|
| Rate for Payer: Vantage Medical Group Senior |
$2.33
|
|
|
CROMOLYN 4 % EYE DROPS [9691]
|
Facility
IP
|
$2.70
|
|
|
Service Code
|
NDC 61314-237-10
|
| Hospital Charge Code |
1744076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.85
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
|
|
CROMOLYN 4 % EYE DROPS [9691]
|
Facility
OP
|
$2.70
|
|
|
Service Code
|
NDC 61314-237-10
|
| Hospital Charge Code |
1744076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.30
|
| Rate for Payer: Dignity Health Senior |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.30
|
| Rate for Payer: Vantage Medical Group Senior |
$2.30
|
|
|
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION [29313]
|
Facility
IP
|
$3,837.60
|
|
|
Service Code
|
CPT J0840
|
| Hospital Charge Code |
1759986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$694.61 |
| Max. Negotiated Rate |
$2,878.20 |
| Rate for Payer: Adventist Health Commercial |
$767.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,636.43
|
| Rate for Payer: Cash Price |
$1,726.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,765.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,072.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,598.06
|
| Rate for Payer: Heritage Provider Network Senior |
$2,598.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$694.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$959.40
|
| Rate for Payer: Multiplan Commercial |
$2,878.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,399.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,282.14
|
|
|
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION [29313]
|
Facility
OP
|
$3,837.60
|
|
|
Service Code
|
CPT J0840
|
| Hospital Charge Code |
1759986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$694.61 |
| Max. Negotiated Rate |
$4,790.22 |
| Rate for Payer: Adventist Health Commercial |
$767.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,790.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,636.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,437.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,144.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,144.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,343.72
|
| Rate for Payer: Blue Shield of California Commercial |
$3,261.96
|
| Rate for Payer: Blue Shield of California EPN |
$3,261.96
|
| Rate for Payer: Cash Price |
$1,726.92
|
| Rate for Payer: Cash Price |
$1,726.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,765.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,924.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,144.91
|
| Rate for Payer: Dignity Health Senior |
$2,144.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,456.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,949.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,776.81
|
| Rate for Payer: Heritage Provider Network Senior |
$1,776.81
|
| Rate for Payer: Humana Medicare |
$1,949.92
|
| Rate for Payer: IEHP Medi-Cal |
$3,048.83
|
| Rate for Payer: IEHP Medicare Advantage |
$1,949.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,704.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$694.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,300.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$959.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,456.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,456.90
|
| Rate for Payer: Multiplan Commercial |
$2,878.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,144.91
|
| Rate for Payer: TriValley Medical Group Senior |
$1,949.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,399.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,282.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,924.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,144.91
|
| Rate for Payer: Vantage Medical Group Senior |
$1,949.92
|
|
|
Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)
|
Facility
OP
|
$21,869.32
|
|
|
Service Code
|
CPT 55873
|
| Min. Negotiated Rate |
$5,245.00 |
| Max. Negotiated Rate |
$21,869.32 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,245.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17,265.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12,661.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11,510.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17,265.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$12,661.19
|
| Rate for Payer: Dignity Health Senior |
$11,510.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$11,510.17
|
| Rate for Payer: Humana Medicare |
$11,510.17
|
| Rate for Payer: IEHP Medicare Advantage |
$11,510.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21,869.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13,582.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14,502.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14,502.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$12,661.19
|
| Rate for Payer: TriValley Medical Group Senior |
$11,510.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17,265.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12,661.19
|
| Rate for Payer: Vantage Medical Group Senior |
$11,510.17
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]
|
Facility
OP
|
$3.15
|
|
|
Service Code
|
NDC 0409-4092-11
|
| Hospital Charge Code |
NDG110358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.68
|
| Rate for Payer: Dignity Health Senior |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2.68
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]
|
Facility
IP
|
$3.15
|
|
|
Service Code
|
NDC 0409-4092-01
|
| Hospital Charge Code |
NDG110358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Senior |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]
|
Facility
OP
|
$3.15
|
|
|
Service Code
|
NDC 0409-4092-01
|
| Hospital Charge Code |
NDG110358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.68
|
| Rate for Payer: Dignity Health Senior |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2.68
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]
|
Facility
IP
|
$3.15
|
|
|
Service Code
|
NDC 0409-4092-11
|
| Hospital Charge Code |
NDG110358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Senior |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]
|
Facility
OP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
ERX110358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.53
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Senior |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| 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 Commercial |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION [110358]
|
Facility
IP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
ERX110358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION
|
Facility
IP
|
$8,510.34
|
|
|
Service Code
|
APR-DRG 0452
|
| Min. Negotiated Rate |
$8,510.34 |
| Max. Negotiated Rate |
$8,510.34 |
| Rate for Payer: IEHP Medi-Cal |
$8,510.34
|
|
|
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION
|
Facility
IP
|
$6,879.71
|
|
|
Service Code
|
APR-DRG 0451
|
| Min. Negotiated Rate |
$6,879.71 |
| Max. Negotiated Rate |
$6,879.71 |
| Rate for Payer: IEHP Medi-Cal |
$6,879.71
|
|
|
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION
|
Facility
IP
|
$11,391.56
|
|
|
Service Code
|
APR-DRG 0453
|
| Min. Negotiated Rate |
$11,391.56 |
| Max. Negotiated Rate |
$11,391.56 |
| Rate for Payer: IEHP Medi-Cal |
$11,391.56
|
|
|
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION
|
Facility
IP
|
$17,124.15
|
|
|
Service Code
|
APR-DRG 0454
|
| Min. Negotiated Rate |
$17,124.15 |
| Max. Negotiated Rate |
$17,124.15 |
| Rate for Payer: IEHP Medi-Cal |
$17,124.15
|
|
|
CVL-NICARDIPINE 20 MG/200 ML PREMIX FOR INTRA-ART/INTRA-CORONARY [4081031]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
NDC 10122-313-10
|
| Hospital Charge Code |
1771308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
CVL-NICARDIPINE 20 MG/200 ML PREMIX FOR INTRA-ART/INTRA-CORONARY [4081031]
|
Facility
OP
|
$0.61
|
|
|
Service Code
|
NDC 10122-313-10
|
| Hospital Charge Code |
1771308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Senior |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
CVL-NITROGLYCERIN 50MG/500ML NS FOR IA/IC BOLUS [4080932]
|
Facility
IP
|
$8.75
|
|
|
Service Code
|
NDC 9994-0809-32
|
| Hospital Charge Code |
NDG4080932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$6.56 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.01
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.92
|
| Rate for Payer: Heritage Provider Network Senior |
$5.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$6.56
|
|
