|
CHONDROITIN-SOD HYALURON 3 %-4 %(0.35 ML)1 %(0.4 ML)INTRAOCULAR SYRING [28916]
|
Facility
|
IP
|
$416.85
|
|
|
Service Code
|
NDC 8065183135
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.45 |
| Max. Negotiated Rate |
$312.64 |
| Rate for Payer: Adventist Health Commercial |
$83.37
|
| Rate for Payer: Cash Price |
$229.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$225.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$282.21
|
| Rate for Payer: Heritage Provider Network Senior |
$282.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.21
|
| Rate for Payer: Multiplan Commercial |
$312.64
|
|
|
CHONDROITIN-SOD HYALURON 4 %-3 % (40 MG-30 MG/ML) INTRAOCULAR SYRINGE [28923]
|
Facility
|
IP
|
$475.85
|
|
|
Service Code
|
NDC 8065183905
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.13 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Adventist Health Commercial |
$95.17
|
| Rate for Payer: Cash Price |
$261.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$322.15
|
| Rate for Payer: Heritage Provider Network Senior |
$322.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.96
|
| Rate for Payer: Multiplan Commercial |
$356.89
|
|
|
CHONDROITIN-SOD HYALURON 4 %-3 % (40 MG-30 MG/ML) INTRAOCULAR SYRINGE [28923]
|
Facility
|
OP
|
$475.85
|
|
|
Service Code
|
NDC 8065183905
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.13 |
| Max. Negotiated Rate |
$404.47 |
| Rate for Payer: Adventist Health Commercial |
$95.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$254.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$326.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$404.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$261.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$356.89
|
| Rate for Payer: Blue Shield of California Commercial |
$290.27
|
| Rate for Payer: Blue Shield of California EPN |
$232.21
|
| Rate for Payer: Cash Price |
$261.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$404.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$404.47
|
| Rate for Payer: Dignity Health Senior |
$404.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$309.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$294.55
|
| Rate for Payer: Heritage Provider Network Senior |
$294.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$226.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$333.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$333.10
|
| Rate for Payer: Multiplan Commercial |
$356.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$237.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$237.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$404.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$404.47
|
| Rate for Payer: Vantage Medical Group Senior |
$404.47
|
|
|
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 0409-4093-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.02
|
| Rate for Payer: Dignity Health Senior |
$2.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Senior |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.02
|
| Rate for Payer: Vantage Medical Group Senior |
$2.02
|
|
|
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 0409-4093-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
|
OP
|
$389.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.46 |
| Max. Negotiated Rate |
$330.89 |
| Rate for Payer: Adventist Health Commercial |
$77.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$208.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$267.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$330.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$214.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$291.96
|
| Rate for Payer: Blue Shield of California Commercial |
$237.46
|
| Rate for Payer: Blue Shield of California EPN |
$189.97
|
| Rate for Payer: Cash Price |
$214.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$179.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$330.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$330.89
|
| Rate for Payer: Dignity Health Senior |
$330.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$249.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$180.24
|
| Rate for Payer: Heritage Provider Network Senior |
$180.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$185.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$70.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$272.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$272.50
|
| Rate for Payer: Multiplan Commercial |
$291.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$155.71
|
| Rate for Payer: TriValley Medical Group Senior |
$155.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$140.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$128.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$330.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$330.89
|
| Rate for Payer: Vantage Medical Group Senior |
$330.89
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
|
IP
|
$389.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.46 |
| Max. Negotiated Rate |
$291.96 |
| Rate for Payer: Adventist Health Commercial |
$77.86
|
| Rate for Payer: Cash Price |
$214.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$179.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$210.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$180.24
|
| Rate for Payer: Heritage Provider Network Senior |
$180.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$70.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.32
|
| Rate for Payer: Multiplan Commercial |
$291.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$140.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$128.89
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 45802-138-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 45802-138-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Senior |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 45802-141-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$3.27
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
OP
|
$3.10
|
|
|
Service Code
|
NDC 21922-053-51
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.63
|
| Rate for Payer: Dignity Health Senior |
$2.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.17
|
| Rate for Payer: Multiplan Commercial |
$2.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.24
|
| Rate for Payer: TriValley Medical Group Senior |
$1.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.63
|
| Rate for Payer: Vantage Medical Group Senior |
$2.63
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 45802-141-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.27
|
| Rate for Payer: Blue Shield of California Commercial |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.13
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.71
|
| Rate for Payer: Dignity Health Senior |
$3.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.70
|
| Rate for Payer: Heritage Provider Network Senior |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.05
|
| Rate for Payer: Multiplan Commercial |
$3.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.74
|
| Rate for Payer: TriValley Medical Group Senior |
$1.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Vantage Medical Group Senior |
$3.71
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 21922-053-51
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.10
|
| Rate for Payer: Heritage Provider Network Senior |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.33
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
|
OP
|
$24.48
|
|
|
Service Code
|
NDC 9994-0825-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$20.81 |
| Rate for Payer: Adventist Health Commercial |
$4.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.36
|
| Rate for Payer: Blue Shield of California Commercial |
$14.93
|
| Rate for Payer: Blue Shield of California EPN |
$11.95
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.81
|
| Rate for Payer: Dignity Health Senior |
$20.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.15
|
| Rate for Payer: Heritage Provider Network Senior |
$15.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.14
|
| Rate for Payer: Multiplan Commercial |
$18.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.79
|
| Rate for Payer: TriValley Medical Group Senior |
$9.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.81
|
| Rate for Payer: Vantage Medical Group Senior |
$20.81
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
|
IP
|
$24.48
|
|
|
Service Code
|
NDC 9994-0825-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$18.36 |
| Rate for Payer: Adventist Health Commercial |
$4.90
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.57
|
| Rate for Payer: Heritage Provider Network Senior |
$16.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.12
|
| Rate for Payer: Multiplan Commercial |
$18.36
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 99994-811-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.73
|
| Rate for Payer: Heritage Provider Network Senior |
$24.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 99994-811-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$17.83
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Senior |
$31.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.61
|
| Rate for Payer: Heritage Provider Network Senior |
$22.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.61
|
| Rate for Payer: TriValley Medical Group Senior |
$14.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 99994-811-92
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.73
|
| Rate for Payer: Heritage Provider Network Senior |
$24.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 99994-811-92
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$17.83
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Senior |
$31.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.61
|
| Rate for Payer: Heritage Provider Network Senior |
$22.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.61
|
| Rate for Payer: TriValley Medical Group Senior |
$14.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 3 MG/ML TOPICAL [4081091]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 99994-811-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$17.83
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Senior |
$31.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.61
|
| Rate for Payer: Heritage Provider Network Senior |
$22.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.61
|
| Rate for Payer: TriValley Medical Group Senior |
$14.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 3 MG/ML TOPICAL [4081091]
|
Facility
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 99994-811-91
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.73
|
| Rate for Payer: Heritage Provider Network Senior |
$24.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 5 MG/ML TOPICAL [4081159]
|
Facility
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 99994-811-59
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.73
|
| Rate for Payer: Heritage Provider Network Senior |
$24.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
|
|
CIDOFOVIR 5 MG/ML TOPICAL [4081159]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 99994-811-59
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$19.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Blue Shield of California Commercial |
$22.28
|
| Rate for Payer: Blue Shield of California EPN |
$17.83
|
| Rate for Payer: Cash Price |
$20.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Senior |
$31.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.61
|
| Rate for Payer: Heritage Provider Network Senior |
$22.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$27.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.61
|
| Rate for Payer: TriValley Medical Group Senior |
$14.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]
|
Facility
|
OP
|
$177.60
|
|
|
Service Code
|
HCPCS J0740
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.15 |
| Max. Negotiated Rate |
$2,238.65 |
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Adventist Health Commercial |
$47.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$94.93
|
| Rate for Payer: Aetna of CA Gatekeeper |
$126.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$122.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$163.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$661.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$661.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$582.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$582.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$582.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$582.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,238.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,238.65
|
| Rate for Payer: Blue Shield of California Commercial |
$881.65
|
| Rate for Payer: Blue Shield of California Commercial |
$881.65
|
| Rate for Payer: Blue Shield of California EPN |
$881.65
|
| Rate for Payer: Blue Shield of California EPN |
$881.65
|
| Rate for Payer: Cash Price |
$130.51
|
| Rate for Payer: Cash Price |
$97.68
|
| Rate for Payer: Cash Price |
$130.51
|
| Rate for Payer: Cash Price |
$97.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$661.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$661.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$582.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$582.31
|
| Rate for Payer: Dignity Health Senior |
$582.31
|
| Rate for Payer: Dignity Health Senior |
$582.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$151.87
|
| Rate for Payer: EPIC Health Plan Medicare |
$529.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$529.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.87
|
| Rate for Payer: Heritage Provider Network Senior |
$82.23
|
| Rate for Payer: Heritage Provider Network Senior |
$109.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$521.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$521.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$529.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$529.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$113.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$84.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$608.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$608.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$667.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$667.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$667.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$667.01
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: Multiplan Commercial |
$177.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$94.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$71.04
|
| Rate for Payer: TriValley Medical Group Senior |
$71.04
|
| Rate for Payer: TriValley Medical Group Senior |
$94.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$64.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$78.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$661.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$661.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$582.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$582.31
|
| Rate for Payer: Vantage Medical Group Senior |
$582.31
|
| Rate for Payer: Vantage Medical Group Senior |
$582.31
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [17378]
|
Facility
|
IP
|
$237.29
|
|
|
Service Code
|
HCPCS J0740
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.95 |
| Max. Negotiated Rate |
$177.97 |
| Rate for Payer: Adventist Health Commercial |
$47.46
|
| Rate for Payer: Adventist Health Commercial |
$35.52
|
| Rate for Payer: Cash Price |
$130.51
|
| Rate for Payer: Cash Price |
$97.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$128.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.87
|
| Rate for Payer: Heritage Provider Network Senior |
$109.87
|
| Rate for Payer: Heritage Provider Network Senior |
$82.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.40
|
| Rate for Payer: Multiplan Commercial |
$133.20
|
| Rate for Payer: Multiplan Commercial |
$177.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$64.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$85.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$78.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.80
|
|
