|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$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
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0574030416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
COMPOUNDING VEHICLE SYRUP NO.23 [222005]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3172295901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$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
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET [9973]
|
Facility
|
OP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1100-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.37
|
| Rate for Payer: Blue Shield of California Commercial |
$5.18
|
| Rate for Payer: Blue Shield of California EPN |
$4.14
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: Dignity Health Senior |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.26
|
| Rate for Payer: Heritage Provider Network Senior |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.40
|
| Rate for Payer: TriValley Medical Group Senior |
$3.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.22
|
| Rate for Payer: Vantage Medical Group Senior |
$7.22
|
|
|
CONJUGATED ESTROGENS 0.3 MG TABLET [9973]
|
Facility
|
IP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1100-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.75
|
| Rate for Payer: Heritage Provider Network Senior |
$5.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]
|
Facility
|
OP
|
$18.43
|
|
|
Service Code
|
NDC 0046-0872-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.82
|
| Rate for Payer: Blue Shield of California Commercial |
$11.24
|
| Rate for Payer: Blue Shield of California EPN |
$8.99
|
| Rate for Payer: Cash Price |
$10.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.67
|
| Rate for Payer: Dignity Health Senior |
$15.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.41
|
| Rate for Payer: Heritage Provider Network Senior |
$11.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.90
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.37
|
| Rate for Payer: TriValley Medical Group Senior |
$7.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.67
|
| Rate for Payer: Vantage Medical Group Senior |
$15.67
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM [9977]
|
Facility
|
IP
|
$18.43
|
|
|
Service Code
|
NDC 0046-0872-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$13.82 |
| Rate for Payer: Adventist Health Commercial |
$3.69
|
| Rate for Payer: Cash Price |
$10.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.48
|
| Rate for Payer: Heritage Provider Network Senior |
$12.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.61
|
| Rate for Payer: Multiplan Commercial |
$13.82
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET [9974]
|
Facility
|
OP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1102-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.37
|
| Rate for Payer: Blue Shield of California Commercial |
$5.18
|
| Rate for Payer: Blue Shield of California EPN |
$4.14
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: Dignity Health Senior |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.26
|
| Rate for Payer: Heritage Provider Network Senior |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.40
|
| Rate for Payer: TriValley Medical Group Senior |
$3.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.22
|
| Rate for Payer: Vantage Medical Group Senior |
$7.22
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET [9974]
|
Facility
|
IP
|
$8.49
|
|
|
Service Code
|
NDC 0046-1102-81
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.75
|
| Rate for Payer: Heritage Provider Network Senior |
$5.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$6.37
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
|
OP
|
$452.26
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.86 |
| Max. Negotiated Rate |
$976.11 |
| Rate for Payer: Adventist Health Commercial |
$90.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$241.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$310.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$488.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$429.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$429.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$976.11
|
| Rate for Payer: Blue Shield of California Commercial |
$375.41
|
| Rate for Payer: Blue Shield of California EPN |
$375.41
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$208.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$488.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$429.82
|
| Rate for Payer: Dignity Health Senior |
$429.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$289.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$390.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$209.40
|
| Rate for Payer: Heritage Provider Network Senior |
$209.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$382.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$390.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$449.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$492.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$492.34
|
| Rate for Payer: Multiplan Commercial |
$339.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$180.90
|
| Rate for Payer: TriValley Medical Group Senior |
$180.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$163.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$149.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$488.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$429.82
|
| Rate for Payer: Vantage Medical Group Senior |
$429.82
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
|
IP
|
$452.26
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.86 |
| Max. Negotiated Rate |
$339.19 |
| Rate for Payer: Adventist Health Commercial |
$90.45
|
| Rate for Payer: Cash Price |
$248.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$208.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$244.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$209.40
|
| Rate for Payer: Heritage Provider Network Senior |
$209.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.06
|
| Rate for Payer: Multiplan Commercial |
$339.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$163.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$149.74
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1.59
|
| Rate for Payer: Blue Shield of California EPN |
$1.27
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Senior |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.82
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.04
|
| Rate for Payer: TriValley Medical Group Senior |
$1.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
COPPER GLUCONATE 2 MG TABLET [112194]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0536143901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
COPPER GLUCONATE 2 MG TABLET [112194]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0536143901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.14
|
| 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
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]
|
Facility
|
IP
|
$96.24
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$72.18 |
| Rate for Payer: Adventist Health Commercial |
$19.25
|
| Rate for Payer: Cash Price |
$52.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.56
|
| Rate for Payer: Heritage Provider Network Senior |
$44.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.06
|
| Rate for Payer: Multiplan Commercial |
$72.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.87
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]
|
Facility
|
OP
|
$96.24
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$207.71 |
| Rate for Payer: Adventist Health Commercial |
$19.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$207.71
|
| Rate for Payer: Blue Shield of California Commercial |
$81.80
|
| Rate for Payer: Blue Shield of California EPN |
$81.80
|
| Rate for Payer: Cash Price |
$52.93
|
| Rate for Payer: Cash Price |
$52.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.80
|
| Rate for Payer: Dignity Health Senior |
$81.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.56
|
| Rate for Payer: Heritage Provider Network Senior |
$44.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$45.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$67.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$67.37
|
| Rate for Payer: Multiplan Commercial |
$72.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.50
|
| Rate for Payer: TriValley Medical Group Senior |
$38.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.80
|
| Rate for Payer: Vantage Medical Group Senior |
$81.80
|
|
|
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION [225907]
|
Facility
|
OP
|
$294.35
|
|
|
Service Code
|
HCPCS J0791
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.28 |
| Max. Negotiated Rate |
$317.66 |
| Rate for Payer: Adventist Health Commercial |
$58.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$157.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$202.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$161.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$142.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$142.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$317.66
|
| Rate for Payer: Blue Shield of California Commercial |
$125.10
|
| Rate for Payer: Blue Shield of California EPN |
$125.10
|
| Rate for Payer: Cash Price |
$161.89
|
| Rate for Payer: Cash Price |
$161.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$135.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$161.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$142.54
|
| Rate for Payer: Dignity Health Senior |
$142.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$188.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$129.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$136.28
|
| Rate for Payer: Heritage Provider Network Senior |
$136.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$129.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$129.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$140.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$149.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$163.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$163.27
|
| Rate for Payer: Multiplan Commercial |
$220.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$117.74
|
| Rate for Payer: TriValley Medical Group Senior |
$117.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$106.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$97.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$161.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$142.54
|
| Rate for Payer: Vantage Medical Group Senior |
$142.54
|
|
|
CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION [225907]
|
Facility
|
IP
|
$294.35
|
|
|
Service Code
|
HCPCS J0791
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.28 |
| Max. Negotiated Rate |
$220.76 |
| Rate for Payer: Adventist Health Commercial |
$58.87
|
| Rate for Payer: Cash Price |
$161.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$135.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$158.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$136.28
|
| Rate for Payer: Heritage Provider Network Senior |
$136.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$73.59
|
| Rate for Payer: Multiplan Commercial |
$220.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$106.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$97.46
|
|
|
CRIZOTINIB 250 MG CAPSULE [153216]
|
Facility
|
OP
|
$475.46
|
|
|
Service Code
|
NDC 0069-8140-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.06 |
| Max. Negotiated Rate |
$404.14 |
| Rate for Payer: Adventist Health Commercial |
$95.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$254.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$326.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$404.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$261.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$356.60
|
| Rate for Payer: Blue Shield of California Commercial |
$290.03
|
| Rate for Payer: Blue Shield of California EPN |
$232.02
|
| Rate for Payer: Cash Price |
$261.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$309.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$404.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$404.14
|
| Rate for Payer: Dignity Health Senior |
$404.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$304.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$294.31
|
| Rate for Payer: Heritage Provider Network Senior |
$294.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$226.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$332.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$332.82
|
| Rate for Payer: Multiplan Commercial |
$356.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$190.18
|
| Rate for Payer: TriValley Medical Group Senior |
$190.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$237.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$237.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$404.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$404.14
|
| Rate for Payer: Vantage Medical Group Senior |
$404.14
|
|
|
CRIZOTINIB 250 MG CAPSULE [153216]
|
Facility
|
IP
|
$475.46
|
|
|
Service Code
|
NDC 0069-8140-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.06 |
| Max. Negotiated Rate |
$356.60 |
| Rate for Payer: Adventist Health Commercial |
$95.09
|
| Rate for Payer: Cash Price |
$261.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$256.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$321.89
|
| Rate for Payer: Heritage Provider Network Senior |
$321.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.86
|
| Rate for Payer: Multiplan Commercial |
$356.60
|
|
|
CROMOLYN 4 % EYE DROPS [9691]
|
Facility
|
IP
|
$2.70
|
|
|
Service Code
|
NDC 61314-237-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
|
|
CROMOLYN 4 % EYE DROPS [9691]
|
Facility
|
OP
|
$2.70
|
|
|
Service Code
|
NDC 61314-237-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.29
|
| Rate for Payer: Dignity Health Senior |
$2.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.89
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.29
|
| Rate for Payer: Vantage Medical Group Senior |
$2.29
|
|
