|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$7.80
|
|
|
Service Code
|
NDC 0143-9532-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.28
|
| Rate for Payer: Heritage Provider Network Senior |
$5.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$2.02
|
|
|
Service Code
|
NDC 70860-605-03
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.37
|
| Rate for Payer: Heritage Provider Network Senior |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$3.15
|
|
|
Service Code
|
NDC 66794-230-42
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Senior |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$3.15
|
|
|
Service Code
|
NDC 66794-230-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.68
|
| Rate for Payer: Dignity Health Senior |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2.68
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 55150-209-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.24
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.67
|
| Rate for Payer: Dignity Health Senior |
$3.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.73
|
| Rate for Payer: TriValley Medical Group Senior |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Vantage Medical Group Senior |
$3.67
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 55150-209-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.24
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$3.25
|
|
|
Service Code
|
NDC 42023-146-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.20
|
| Rate for Payer: Heritage Provider Network Senior |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$7.80
|
|
|
Service Code
|
NDC 0143-9532-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$6.63 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.85
|
| Rate for Payer: Blue Shield of California Commercial |
$4.76
|
| Rate for Payer: Blue Shield of California EPN |
$3.81
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.63
|
| Rate for Payer: Dignity Health Senior |
$6.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.83
|
| Rate for Payer: Heritage Provider Network Senior |
$4.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.12
|
| Rate for Payer: TriValley Medical Group Senior |
$3.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$6.63
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$7.80
|
|
|
Service Code
|
NDC 0143-9532-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$6.63 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.85
|
| Rate for Payer: Blue Shield of California Commercial |
$4.76
|
| Rate for Payer: Blue Shield of California EPN |
$3.81
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.63
|
| Rate for Payer: Dignity Health Senior |
$6.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.83
|
| Rate for Payer: Heritage Provider Network Senior |
$4.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.12
|
| Rate for Payer: TriValley Medical Group Senior |
$3.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$6.63
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$7.80
|
|
|
Service Code
|
NDC 0143-9532-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Cash Price |
$4.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.28
|
| Rate for Payer: Heritage Provider Network Senior |
$5.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 70860-605-41
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Senior |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Senior |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
IP
|
$3.24
|
|
|
Service Code
|
NDC 71288-505-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.19
|
| Rate for Payer: Heritage Provider Network Senior |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.43
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$3.15
|
|
|
Service Code
|
NDC 66794-230-42
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Adventist Health Commercial |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.68
|
| Rate for Payer: Dignity Health Senior |
$2.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.26
|
| Rate for Payer: TriValley Medical Group Senior |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.68
|
| Rate for Payer: Vantage Medical Group Senior |
$2.68
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]
|
Facility
|
OP
|
$3.25
|
|
|
Service Code
|
NDC 42023-146-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.98
|
| Rate for Payer: Blue Shield of California EPN |
$1.59
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.76
|
| Rate for Payer: Dignity Health Senior |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Senior |
$2.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.27
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.30
|
| Rate for Payer: TriValley Medical Group Senior |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.76
|
| Rate for Payer: Vantage Medical Group Senior |
$2.76
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 66794-234-44
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| 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 |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| 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 |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 66794-234-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 66794-234-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| 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 |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| 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 |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 66794-234-44
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 9940-8202-59
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 9940-8202-59
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| 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 Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
IP
|
$455.94
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.53 |
| Max. Negotiated Rate |
$341.95 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Cash Price |
$250.77
|
| 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 |
$211.10
|
| Rate for Payer: Heritage Provider Network Senior |
$211.10
|
| 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 |
$341.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$150.96
|
|
|
DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]
|
Facility
|
OP
|
$455.94
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.09 |
| Max. Negotiated Rate |
$605.99 |
| Rate for Payer: Adventist Health Commercial |
$91.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$243.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$313.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$605.99
|
| Rate for Payer: Blue Shield of California Commercial |
$248.68
|
| Rate for Payer: Blue Shield of California EPN |
$248.68
|
| Rate for Payer: Cash Price |
$250.77
|
| Rate for Payer: Cash Price |
$250.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$209.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.29
|
| Rate for Payer: Dignity Health Senior |
$35.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$291.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$211.10
|
| Rate for Payer: Heritage Provider Network Senior |
$211.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$80.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$217.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$82.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$36.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$40.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$40.43
|
| Rate for Payer: Multiplan Commercial |
$341.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$182.38
|
| Rate for Payer: TriValley Medical Group Senior |
$182.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$150.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.29
|
| Rate for Payer: Vantage Medical Group Senior |
$35.29
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
OP
|
$329.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.09 |
| Max. Negotiated Rate |
$605.99 |
| Rate for Payer: Adventist Health Commercial |
$65.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$175.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$226.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$605.99
|
| Rate for Payer: Blue Shield of California Commercial |
$248.68
|
| Rate for Payer: Blue Shield of California EPN |
$248.68
|
| Rate for Payer: Cash Price |
$181.01
|
| Rate for Payer: Cash Price |
$181.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$151.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.29
|
| Rate for Payer: Dignity Health Senior |
$35.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$210.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.38
|
| Rate for Payer: Heritage Provider Network Senior |
$152.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$80.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$156.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$36.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$40.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$40.43
|
| Rate for Payer: Multiplan Commercial |
$246.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$131.64
|
| Rate for Payer: TriValley Medical Group Senior |
$131.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$118.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.29
|
| Rate for Payer: Vantage Medical Group Senior |
$35.29
|
|
|
DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]
|
Facility
|
IP
|
$329.11
|
|
|
Service Code
|
HCPCS J1190
|
| Hospital Charge Code |
901700025
|
|
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: Cash Price |
$181.01
|
| 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 |
$152.38
|
| Rate for Payer: Heritage Provider Network Senior |
$152.38
|
| 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 |
$118.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$108.97
|
|
|
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 |
901700029
|
|
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: Cash Price |
$0.18
|
| 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
|
|
