|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
IP
|
$0.53
|
|
|
Service Code
|
NDC 59762-0245-3
|
| Hospital Charge Code |
1711717
|
|
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
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
NDC 43547-275-03
|
| Hospital Charge Code |
1711717
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
OP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6477-61
|
| Hospital Charge Code |
1711717
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 13668-102-30
|
| Hospital Charge Code |
1711717
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
DONEPEZIL 5 MG TABLET [18786]
|
Facility
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904-6477-61
|
| Hospital Charge Code |
1711717
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION [2595]
|
Facility
IP
|
$0.86
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
1720516
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
|
|
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION [2595]
|
Facility
OP
|
$0.70
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
1720516
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
1771187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14845]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
1771187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
DOPAMINE 40 MG/50 ML D5.2NS SYRINGE [4080662]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
NDC4080662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
|
|
DOPAMINE 40 MG/50 ML D5.2NS SYRINGE [4080662]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
NDC4080662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14846]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
1771255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14846]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
1771255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
|
|
DOPAMINE 80 MG/50 ML D5.2NS SYRINGE [4080663]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
NDC4080663
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
DOPAMINE 80 MG/50 ML D5.2NS SYRINGE [4080663]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
NDC4080663
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
OP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-40
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$51.45 |
| Rate for Payer: Adventist Health Commercial |
$12.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$45.40
|
| Rate for Payer: Blue Shield of California Commercial |
$37.59
|
| Rate for Payer: Blue Shield of California EPN |
$35.53
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.45
|
| Rate for Payer: Dignity Health Senior |
$51.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.47
|
| Rate for Payer: Heritage Provider Network Senior |
$37.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.13
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.45
|
| Rate for Payer: Vantage Medical Group Senior |
$51.45
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
IP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-40
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$45.40 |
| Rate for Payer: Adventist Health Commercial |
$12.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.58
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.98
|
| Rate for Payer: Heritage Provider Network Senior |
$40.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.13
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
OP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-39
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$51.45 |
| Rate for Payer: Adventist Health Commercial |
$12.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$45.40
|
| Rate for Payer: Blue Shield of California Commercial |
$37.59
|
| Rate for Payer: Blue Shield of California EPN |
$35.53
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.45
|
| Rate for Payer: Dignity Health Senior |
$51.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.47
|
| Rate for Payer: Heritage Provider Network Senior |
$37.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.13
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.45
|
| Rate for Payer: Vantage Medical Group Senior |
$51.45
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
IP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-39
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$45.40 |
| Rate for Payer: Adventist Health Commercial |
$12.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.58
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.98
|
| Rate for Payer: Heritage Provider Network Senior |
$40.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.13
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$29,484.73
|
|
|
Service Code
|
APR-DRG 3042
|
| Min. Negotiated Rate |
$29,484.73 |
| Max. Negotiated Rate |
$29,484.73 |
| Rate for Payer: IEHP Medi-Cal |
$29,484.73
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$61,539.30
|
|
|
Service Code
|
APR-DRG 3044
|
| Min. Negotiated Rate |
$61,539.30 |
| Max. Negotiated Rate |
$61,539.30 |
| Rate for Payer: IEHP Medi-Cal |
$61,539.30
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$41,587.65
|
|
|
Service Code
|
APR-DRG 3043
|
| Min. Negotiated Rate |
$41,587.65 |
| Max. Negotiated Rate |
$41,587.65 |
| Rate for Payer: IEHP Medi-Cal |
$41,587.65
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$24,819.67
|
|
|
Service Code
|
APR-DRG 3041
|
| Min. Negotiated Rate |
$24,819.67 |
| Max. Negotiated Rate |
$24,819.67 |
| Rate for Payer: IEHP Medi-Cal |
$24,819.67
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$36,721.61
|
|
|
Service Code
|
APR-DRG 3031
|
| Min. Negotiated Rate |
$36,721.61 |
| Max. Negotiated Rate |
$36,721.61 |
| Rate for Payer: IEHP Medi-Cal |
$36,721.61
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$44,105.73
|
|
|
Service Code
|
APR-DRG 3032
|
| Min. Negotiated Rate |
$44,105.73 |
| Max. Negotiated Rate |
$44,105.73 |
| Rate for Payer: IEHP Medi-Cal |
$44,105.73
|
|
