|
Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 57061
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,296.80
|
| Rate for Payer: Dignity Health Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,906.18
|
| Rate for Payer: Humana Medicare |
$3,906.18
|
| Rate for Payer: IEHP Medi-Cal |
$91.70
|
| Rate for Payer: IEHP Medicare Advantage |
$3,906.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,421.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,609.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,921.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,921.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,296.80
|
| Rate for Payer: TriValley Medical Group Senior |
$3,906.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-14
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$13.14 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.04
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.86
|
| Rate for Payer: Heritage Provider Network Senior |
$11.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-13
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: Dignity Health Senior |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-13
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$13.95
|
|
|
Service Code
|
NDC 0008-1211-50
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Adventist Health Commercial |
$2.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.46
|
| Rate for Payer: Blue Shield of California Commercial |
$8.66
|
| Rate for Payer: Blue Shield of California EPN |
$8.19
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.86
|
| Rate for Payer: Dignity Health Senior |
$11.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.64
|
| Rate for Payer: Heritage Provider Network Senior |
$8.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$10.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.86
|
| Rate for Payer: Vantage Medical Group Senior |
$11.86
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$13.95
|
|
|
Service Code
|
NDC 0008-1211-50
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$10.46 |
| Rate for Payer: Adventist Health Commercial |
$2.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.58
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.44
|
| Rate for Payer: Heritage Provider Network Senior |
$9.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$10.46
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$0.80
|
|
|
Service Code
|
NDC 59762-1211-3
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$0.80
|
|
|
Service Code
|
NDC 59762-1211-3
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-30
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$13.14 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.04
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.86
|
| Rate for Payer: Heritage Provider Network Senior |
$11.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-22
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: Dignity Health Senior |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
IP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-22
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-30
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.14
|
| Rate for Payer: Blue Shield of California Commercial |
$10.88
|
| Rate for Payer: Blue Shield of California EPN |
$10.28
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.89
|
| Rate for Payer: Dignity Health Senior |
$14.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.84
|
| Rate for Payer: Heritage Provider Network Senior |
$10.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.89
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
OP
|
$17.52
|
|
|
Service Code
|
NDC 0008-1211-14
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Adventist Health Commercial |
$3.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$14.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.14
|
| Rate for Payer: Blue Shield of California Commercial |
$10.88
|
| Rate for Payer: Blue Shield of California EPN |
$10.28
|
| Rate for Payer: Cash Price |
$7.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.89
|
| Rate for Payer: Dignity Health Senior |
$14.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.84
|
| Rate for Payer: Heritage Provider Network Senior |
$10.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.38
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.89
|
| Rate for Payer: Vantage Medical Group Senior |
$14.89
|
|
|
DEXAMETH 1 MG-MOXIFLOX 0.5 MG-KETOROLAC 0.4 MG/ML(PF) INTRAOCULAR SOLN [221697]
|
Facility
IP
|
$38.40
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG221697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Adventist Health Commercial |
$7.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.38
|
| Rate for Payer: Cash Price |
$17.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.00
|
| Rate for Payer: Heritage Provider Network Senior |
$26.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.83
|
|
|
DEXAMETH 1 MG-MOXIFLOX 0.5 MG-KETOROLAC 0.4 MG/ML(PF) INTRAOCULAR SOLN [221697]
|
Facility
OP
|
$38.40
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG221697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$32.64 |
| Rate for Payer: Adventist Health Commercial |
$7.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$28.80
|
| Rate for Payer: Blue Shield of California Commercial |
$23.85
|
| Rate for Payer: Blue Shield of California EPN |
$22.54
|
| Rate for Payer: Cash Price |
$17.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.64
|
| Rate for Payer: Dignity Health Senior |
$32.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.78
|
| Rate for Payer: Heritage Provider Network Senior |
$17.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.60
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.64
|
| Rate for Payer: Vantage Medical Group Senior |
$32.64
|
|
|
DEXAMETHASONE 0.1% EYE DROPS. [4082335]
|
Facility
IP
|
$4.03
|
|
|
Service Code
|
NDC 61314-294-05
|
| Hospital Charge Code |
1740106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.77
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.73
|
| Rate for Payer: Heritage Provider Network Senior |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.02
|
|
|
DEXAMETHASONE 0.1% EYE DROPS. [4082335]
|
Facility
OP
|
$19.00
|
|
|
Service Code
|
NDC 0998-0615-05
|
| Hospital Charge Code |
1740106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Adventist Health Commercial |
$3.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.25
|
| Rate for Payer: Blue Shield of California Commercial |
$11.80
|
| Rate for Payer: Blue Shield of California EPN |
$11.15
|
| Rate for Payer: Cash Price |
$8.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.15
|
| Rate for Payer: Dignity Health Senior |
$16.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.76
|
| Rate for Payer: Heritage Provider Network Senior |
$11.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$14.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.15
|
| Rate for Payer: Vantage Medical Group Senior |
$16.15
|
|
|
DEXAMETHASONE 0.1% EYE DROPS. [4082335]
|
Facility
IP
|
$12.94
|
|
|
Service Code
|
NDC 24208-720-02
|
| Hospital Charge Code |
1740106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Adventist Health Commercial |
$2.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.89
|
| Rate for Payer: Cash Price |
$5.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.76
|
| Rate for Payer: Heritage Provider Network Senior |
$8.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.24
|
| Rate for Payer: Multiplan Commercial |
$9.70
|
|
|
DEXAMETHASONE 0.1% EYE DROPS. [4082335]
|
Facility
IP
|
$19.00
|
|
|
Service Code
|
NDC 0998-0615-05
|
| Hospital Charge Code |
1740106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Adventist Health Commercial |
$3.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.05
|
| Rate for Payer: Cash Price |
$8.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.86
|
| Rate for Payer: Heritage Provider Network Senior |
$12.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$14.25
|
|
|
DEXAMETHASONE 0.1% EYE DROPS. [4082335]
|
Facility
OP
|
$12.94
|
|
|
Service Code
|
NDC 24208-720-02
|
| Hospital Charge Code |
1740106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Adventist Health Commercial |
$2.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.70
|
| Rate for Payer: Blue Shield of California Commercial |
$8.04
|
| Rate for Payer: Blue Shield of California EPN |
$7.60
|
| Rate for Payer: Cash Price |
$5.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.00
|
| Rate for Payer: Dignity Health Senior |
$11.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.01
|
| Rate for Payer: Heritage Provider Network Senior |
$8.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.24
|
| Rate for Payer: Multiplan Commercial |
$9.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.00
|
| Rate for Payer: Vantage Medical Group Senior |
$11.00
|
|
|
DEXAMETHASONE 0.1% EYE DROPS. [4082335]
|
Facility
OP
|
$4.03
|
|
|
Service Code
|
NDC 61314-294-05
|
| Hospital Charge Code |
1740106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.43 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.02
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$2.37
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.43
|
| Rate for Payer: Dignity Health Senior |
$3.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.49
|
| Rate for Payer: Heritage Provider Network Senior |
$2.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.43
|
| Rate for Payer: Vantage Medical Group Senior |
$3.43
|
|
|
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION [2320]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
1715664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
|
|
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION [2320]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
1715664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
DEXAMETHASONE 0.5 MG TABLET [2322]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
1710096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
|
|
DEXAMETHASONE 0.5 MG TABLET [2322]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
CPT J8540
|
| Hospital Charge Code |
1710096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
