|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
IP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$11.56 |
| Rate for Payer: Adventist Health Commercial |
$3.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.59
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.44
|
| Rate for Payer: Heritage Provider Network Senior |
$10.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
OP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.30
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Senior |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.92
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.96
|
| Rate for Payer: Heritage Provider Network Senior |
$12.96
|
| Rate for Payer: Humana Medicare |
$1.73
|
| Rate for Payer: IEHP Medi-Cal |
$9.66
|
| Rate for Payer: IEHP Medicare Advantage |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.90
|
| Rate for Payer: TriValley Medical Group Senior |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
IP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.24
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.96
|
| Rate for Payer: Heritage Provider Network Senior |
$18.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.35
|
|
|
Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft
|
Facility
OP
|
$9,652.00
|
|
|
Service Code
|
CPT 66180
|
| Min. Negotiated Rate |
$348.47 |
| Max. Negotiated Rate |
$9,652.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: IEHP Medi-Cal |
$348.47
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft
|
Facility
OP
|
$12,407.40
|
|
|
Service Code
|
CPT 66179
|
| Min. Negotiated Rate |
$4,857.00 |
| Max. Negotiated Rate |
$12,407.40 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,795.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,183.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,530.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,795.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,183.23
|
| Rate for Payer: Dignity Health Senior |
$6,530.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,530.21
|
| Rate for Payer: Humana Medicare |
$6,530.21
|
| Rate for Payer: IEHP Medicare Advantage |
$6,530.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,407.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,705.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,228.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,228.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,183.23
|
| Rate for Payer: TriValley Medical Group Senior |
$6,530.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,795.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,183.23
|
| Rate for Payer: Vantage Medical Group Senior |
$6,530.21
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-64
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$8.44 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.74
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.62
|
| Rate for Payer: Heritage Provider Network Senior |
$7.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-02
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.89
|
| Rate for Payer: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: Dignity Health Senior |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.89
|
| Rate for Payer: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: Dignity Health Senior |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-30
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$8.44 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.74
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.62
|
| Rate for Payer: Heritage Provider Network Senior |
$7.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-30
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.44
|
| Rate for Payer: Blue Shield of California Commercial |
$6.99
|
| Rate for Payer: Blue Shield of California EPN |
$6.61
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.57
|
| Rate for Payer: Dignity Health Senior |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.97
|
| Rate for Payer: Heritage Provider Network Senior |
$6.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.57
|
| Rate for Payer: Vantage Medical Group Senior |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-11
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-11
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.89
|
| Rate for Payer: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: Dignity Health Senior |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Senior |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.44
|
| Rate for Payer: Blue Shield of California Commercial |
$6.99
|
| Rate for Payer: Blue Shield of California EPN |
$6.61
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.57
|
| Rate for Payer: Dignity Health Senior |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.97
|
| Rate for Payer: Heritage Provider Network Senior |
$6.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.57
|
| Rate for Payer: Vantage Medical Group Senior |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$8.44 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.74
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.62
|
| Rate for Payer: Heritage Provider Network Senior |
$7.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-02
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Senior |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-64
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Adventist Health Commercial |
$2.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.44
|
| Rate for Payer: Blue Shield of California Commercial |
$6.99
|
| Rate for Payer: Blue Shield of California EPN |
$6.61
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.57
|
| Rate for Payer: Dignity Health Senior |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.97
|
| Rate for Payer: Heritage Provider Network Senior |
$6.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.82
|
| Rate for Payer: Multiplan Commercial |
$8.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.57
|
| Rate for Payer: Vantage Medical Group Senior |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
|
|
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION [28947]
|
Facility
OP
|
$244.80
|
|
|
Service Code
|
CPT J0883
|
| Hospital Charge Code |
1759990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$183.60 |
| Rate for Payer: Adventist Health Commercial |
$48.96
|
| Rate for Payer: Adventist Health Commercial |
$26.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$168.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.63
|
| Rate for Payer: Blue Shield of California Commercial |
$2.63
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$112.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.34
|
| Rate for Payer: Dignity Health Senior |
$1.34
|
| Rate for Payer: Dignity Health Senior |
$1.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$156.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$83.46
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.22
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$113.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.38
|
| Rate for Payer: Heritage Provider Network Senior |
$60.38
|
| Rate for Payer: Heritage Provider Network Senior |
$113.34
|
| Rate for Payer: Humana Medicare |
$1.22
|
| Rate for Payer: Humana Medicare |
$1.22
|
| Rate for Payer: IEHP Medi-Cal |
$10.70
|
| Rate for Payer: IEHP Medi-Cal |
$10.70
|
| Rate for Payer: IEHP Medicare Advantage |
$1.22
|
| Rate for Payer: IEHP Medicare Advantage |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$183.60
|
| Rate for Payer: Multiplan Commercial |
$97.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$89.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$81.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION [28947]
|
Facility
IP
|
$244.80
|
|
|
Service Code
|
CPT J0883
|
| Hospital Charge Code |
1759990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.31 |
| Max. Negotiated Rate |
$183.60 |
| Rate for Payer: Adventist Health Commercial |
$48.96
|
| Rate for Payer: Adventist Health Commercial |
$26.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$168.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.59
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Cash Price |
$110.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$112.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$132.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.29
|
| Rate for Payer: Heritage Provider Network Senior |
$165.73
|
| Rate for Payer: Heritage Provider Network Senior |
$88.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.60
|
| Rate for Payer: Multiplan Commercial |
$97.81
|
| Rate for Payer: Multiplan Commercial |
$183.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$47.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$89.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$43.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$81.79
|
|
|
ARGININE 25 MG/ML-LYSINE 25 MG/ML IN 0.9 % NACL INTRAVENOUS SOLUTION [223945]
|
Facility
IP
|
$0.45
|
|
|
Service Code
|
NDC 08252-0001-75
|
| Hospital Charge Code |
NDG223945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| 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 |
$0.34
|
|
|
ARGININE 25 MG/ML-LYSINE 25 MG/ML IN 0.9 % NACL INTRAVENOUS SOLUTION [223945]
|
Facility
OP
|
$0.45
|
|
|
Service Code
|
NDC 08252-0001-75
|
| Hospital Charge Code |
NDG223945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| 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 |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| 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 |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Senior |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| 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 |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
