|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 0409-1660-10
|
| Hospital Charge Code |
NDG201904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
OP
|
$455.94
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX40815157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.53 |
| Max. Negotiated Rate |
$423.86 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$212.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$313.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$135.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$118.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$423.86
|
| Rate for Payer: Blue Shield of California Commercial |
$245.85
|
| Rate for Payer: Blue Shield of California EPN |
$245.85
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.81
|
| Rate for Payer: Dignity Health Senior |
$118.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$291.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$108.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.10
|
| Rate for Payer: Heritage Provider Network Senior |
$211.10
|
| Rate for Payer: Humana Medicare |
$108.01
|
| Rate for Payer: IEHP Medicare Advantage |
$108.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$205.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$82.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$127.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$136.09
|
| Rate for Payer: Multiplan Commercial |
$341.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$118.81
|
| Rate for Payer: TriValley Medical Group Senior |
$108.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$166.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$152.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Vantage Medical Group Senior |
$108.01
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
IP
|
$455.94
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX40815157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.53 |
| Max. Negotiated Rate |
$341.96 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$313.23
|
| Rate for Payer: Cash Price |
$205.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$246.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.67
|
| Rate for Payer: Heritage Provider Network Senior |
$308.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$82.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.98
|
| Rate for Payer: Multiplan Commercial |
$341.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$166.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$152.33
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
OP
|
$329.11
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.57 |
| Max. Negotiated Rate |
$423.86 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$212.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$226.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$135.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$118.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$423.86
|
| Rate for Payer: Blue Shield of California Commercial |
$245.85
|
| Rate for Payer: Blue Shield of California EPN |
$245.85
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.81
|
| Rate for Payer: Dignity Health Senior |
$118.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$210.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$108.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.38
|
| Rate for Payer: Heritage Provider Network Senior |
$152.38
|
| Rate for Payer: Humana Medicare |
$108.01
|
| Rate for Payer: IEHP Medicare Advantage |
$108.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$205.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$127.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$136.09
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$118.81
|
| Rate for Payer: TriValley Medical Group Senior |
$108.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$119.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$109.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Vantage Medical Group Senior |
$108.01
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
IP
|
$329.11
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX15156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.57 |
| Max. Negotiated Rate |
$246.83 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$226.10
|
| Rate for Payer: Cash Price |
$148.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$222.81
|
| Rate for Payer: Heritage Provider Network Senior |
$222.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.28
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$119.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$109.96
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION [15157]
|
Facility
IP
|
$658.21
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.14 |
| Max. Negotiated Rate |
$493.66 |
| Rate for Payer: Adventist Health Commercial |
$131.64
|
| Rate for Payer: Adventist Health Commercial |
$95.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$452.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$328.94
|
| Rate for Payer: Cash Price |
$296.19
|
| Rate for Payer: Cash Price |
$215.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$220.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$258.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$445.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$324.15
|
| Rate for Payer: Heritage Provider Network Senior |
$445.61
|
| Rate for Payer: Heritage Provider Network Senior |
$324.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.55
|
| Rate for Payer: Multiplan Commercial |
$359.10
|
| Rate for Payer: Multiplan Commercial |
$493.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$174.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$239.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$159.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$219.91
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION [15157]
|
Facility
OP
|
$658.21
|
|
|
Service Code
|
CPT J1190
|
| Hospital Charge Code |
ERX15157
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.01 |
| Max. Negotiated Rate |
$493.66 |
| Rate for Payer: Adventist Health Commercial |
$131.64
|
| Rate for Payer: Adventist Health Commercial |
$95.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$212.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$212.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$328.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$452.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$135.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$135.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$118.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$118.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$423.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$423.86
|
| Rate for Payer: Blue Shield of California Commercial |
$245.85
|
| Rate for Payer: Blue Shield of California Commercial |
$245.85
|
| Rate for Payer: Blue Shield of California EPN |
$245.85
|
| Rate for Payer: Blue Shield of California EPN |
$245.85
|
| Rate for Payer: Cash Price |
$296.19
|
| Rate for Payer: Cash Price |
$215.46
|
| Rate for Payer: Cash Price |
$296.19
|
| Rate for Payer: Cash Price |
$215.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$220.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$302.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$118.81
|
| Rate for Payer: Dignity Health Senior |
$118.81
|
| Rate for Payer: Dignity Health Senior |
$118.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$421.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$306.43
|
| Rate for Payer: EPIC Health Plan Medicare |
$108.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$108.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$221.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$304.75
|
| Rate for Payer: Heritage Provider Network Senior |
$304.75
|
| Rate for Payer: Heritage Provider Network Senior |
$221.68
|
| Rate for Payer: Humana Medicare |
$108.01
|
| Rate for Payer: Humana Medicare |
$108.01
|
| Rate for Payer: IEHP Medicare Advantage |
$108.01
|
| Rate for Payer: IEHP Medicare Advantage |
$108.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$205.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$205.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$127.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$127.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$164.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$136.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$136.09
|
| Rate for Payer: Multiplan Commercial |
$359.10
|
| Rate for Payer: Multiplan Commercial |
$493.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$118.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$118.81
|
| Rate for Payer: TriValley Medical Group Senior |
$108.01
|
| Rate for Payer: TriValley Medical Group Senior |
$108.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$174.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$239.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$159.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$219.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$118.81
|
| Rate for Payer: Vantage Medical Group Senior |
$108.01
|
| Rate for Payer: Vantage Medical Group Senior |
$108.01
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 0065-0416-22
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0419-18
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
OP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0419-18
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
IP
|
$0.33
|
|
|
Service Code
|
NDC 0065-8063-01
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
OP
|
$0.33
|
|
|
Service Code
|
NDC 0065-8063-01
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
OP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0419-28
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
NDC 0065-0419-28
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 0065-0416-63
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 0065-0416-63
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 0065-0416-22
|
| Hospital Charge Code |
1740337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]
|
Facility
IP
|
$3,466.32
|
|
|
Service Code
|
CPT L8604
|
| Hospital Charge Code |
NDG227990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$693.26 |
| Max. Negotiated Rate |
$12,173.00 |
| Rate for Payer: Adventist Health Commercial |
$693.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,663.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,381.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,173.00
|
| Rate for Payer: Cash Price |
$1,559.84
|
| Rate for Payer: Cash Price |
$1,559.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,594.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,871.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,346.70
|
| Rate for Payer: Heritage Provider Network Senior |
$2,346.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,733.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,733.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,733.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$866.58
|
| Rate for Payer: Multiplan Commercial |
$2,599.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,263.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,158.10
|
|
|
DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]
|
Facility
OP
|
$3,466.32
|
|
|
Service Code
|
CPT L8604
|
| Hospital Charge Code |
NDG227990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$693.26 |
| Max. Negotiated Rate |
$12,139.00 |
| Rate for Payer: Adventist Health Commercial |
$693.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,663.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,381.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,946.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,906.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,599.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12,139.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,152.58
|
| Rate for Payer: Blue Shield of California EPN |
$2,034.73
|
| Rate for Payer: Cash Price |
$1,559.84
|
| Rate for Payer: Cash Price |
$1,559.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,594.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,946.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,946.37
|
| Rate for Payer: Dignity Health Senior |
$2,946.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,218.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,604.91
|
| Rate for Payer: Heritage Provider Network Senior |
$1,604.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,733.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,733.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,733.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$866.58
|
| Rate for Payer: Multiplan Commercial |
$2,599.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,263.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,158.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,946.37
|
| Rate for Payer: Vantage Medical Group Senior |
$2,946.37
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]
|
Facility
OP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0853-01
|
| Hospital Charge Code |
1730113
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]
|
Facility
IP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0853-01
|
| Hospital Charge Code |
1730113
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
IP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0831-01
|
| Hospital Charge Code |
1731013
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
OP
|
$0.61
|
|
|
Service Code
|
NDC 0406-8891-01
|
| Hospital Charge Code |
1731013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Senior |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
NDC 0406-8891-01
|
| Hospital Charge Code |
1731013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]
|
Facility
OP
|
$0.45
|
|
|
Service Code
|
NDC 0185-0831-01
|
| Hospital Charge Code |
1731013
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
