|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]
|
Facility
IP
|
$0.59
|
|
|
Service Code
|
NDC 43547-381-03
|
| Hospital Charge Code |
1711841
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 57237-019-30
|
| Hospital Charge Code |
1711841
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| 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 |
$0.30
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 68001-415-04
|
| Hospital Charge Code |
1711841
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 68001-415-04
|
| Hospital Charge Code |
1711841
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| 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 Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
IP
|
$473.79
|
|
|
Service Code
|
NDC 0310-4500-12
|
| Hospital Charge Code |
NDG217071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.76 |
| Max. Negotiated Rate |
$355.34 |
| Rate for Payer: Adventist Health Commercial |
$94.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$325.49
|
| Rate for Payer: Cash Price |
$213.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$255.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$320.76
|
| Rate for Payer: Heritage Provider Network Senior |
$320.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.45
|
| Rate for Payer: Multiplan Commercial |
$355.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.29
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
IP
|
$473.79
|
|
|
Service Code
|
NDC 0310-4611-50
|
| Hospital Charge Code |
NDG217071A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.76 |
| Max. Negotiated Rate |
$355.34 |
| Rate for Payer: Adventist Health Commercial |
$94.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$325.49
|
| Rate for Payer: Cash Price |
$213.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$255.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$320.76
|
| Rate for Payer: Heritage Provider Network Senior |
$320.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.45
|
| Rate for Payer: Multiplan Commercial |
$355.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.29
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
OP
|
$473.79
|
|
|
Service Code
|
NDC 0310-4611-50
|
| Hospital Charge Code |
NDG217071A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.76 |
| Max. Negotiated Rate |
$402.72 |
| Rate for Payer: Adventist Health Commercial |
$94.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$253.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$325.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$402.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$260.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$355.34
|
| Rate for Payer: Blue Shield of California Commercial |
$294.22
|
| Rate for Payer: Blue Shield of California EPN |
$278.11
|
| Rate for Payer: Cash Price |
$213.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$402.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$402.72
|
| Rate for Payer: Dignity Health Senior |
$402.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$219.36
|
| Rate for Payer: Heritage Provider Network Senior |
$219.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$228.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.45
|
| Rate for Payer: Multiplan Commercial |
$355.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$402.72
|
| Rate for Payer: Vantage Medical Group Senior |
$402.72
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
OP
|
$473.79
|
|
|
Service Code
|
NDC 0310-4500-12
|
| Hospital Charge Code |
NDG217071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.76 |
| Max. Negotiated Rate |
$402.72 |
| Rate for Payer: Adventist Health Commercial |
$94.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$253.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$325.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$402.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$260.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$355.34
|
| Rate for Payer: Blue Shield of California Commercial |
$294.22
|
| Rate for Payer: Blue Shield of California EPN |
$278.11
|
| Rate for Payer: Cash Price |
$213.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$402.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$402.72
|
| Rate for Payer: Dignity Health Senior |
$402.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$219.36
|
| Rate for Payer: Heritage Provider Network Senior |
$219.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$228.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.45
|
| Rate for Payer: Multiplan Commercial |
$355.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$172.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$158.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$402.72
|
| Rate for Payer: Vantage Medical Group Senior |
$402.72
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
OP
|
$11.00
|
|
|
Service Code
|
NDC 0173-0712-15
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.25
|
| Rate for Payer: Blue Shield of California Commercial |
$6.83
|
| Rate for Payer: Blue Shield of California EPN |
$6.46
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.35
|
| Rate for Payer: Dignity Health Senior |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.81
|
| Rate for Payer: Heritage Provider Network Senior |
$6.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.35
|
| Rate for Payer: Vantage Medical Group Senior |
$9.35
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
IP
|
$11.00
|
|
|
Service Code
|
NDC 0173-0712-15
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
OP
|
$11.00
|
|
|
Service Code
|
NDC 0173-0712-04
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.35 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.25
|
| Rate for Payer: Blue Shield of California Commercial |
$6.83
|
| Rate for Payer: Blue Shield of California EPN |
$6.46
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.35
|
| Rate for Payer: Dignity Health Senior |
$9.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.81
|
| Rate for Payer: Heritage Provider Network Senior |
$6.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.35
|
| Rate for Payer: Vantage Medical Group Senior |
$9.35
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
IP
|
$11.00
|
|
|
Service Code
|
NDC 0173-0712-04
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.25 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.25
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
IP
|
$0.38
|
|
|
Service Code
|
NDC 42806-549-30
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| 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 |
$0.29
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
OP
|
$0.38
|
|
|
Service Code
|
NDC 42806-549-30
|
| Hospital Charge Code |
1710969
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Senior |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| 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 |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
IP
|
$16,755.04
|
|
|
Service Code
|
APR-DRG 1104
|
| Min. Negotiated Rate |
$16,755.04 |
| Max. Negotiated Rate |
$16,755.04 |
| Rate for Payer: IEHP Medi-Cal |
$16,755.04
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
IP
|
$7,102.57
|
|
|
Service Code
|
APR-DRG 1102
|
| Min. Negotiated Rate |
$7,102.57 |
| Max. Negotiated Rate |
$7,102.57 |
| Rate for Payer: IEHP Medi-Cal |
$7,102.57
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
IP
|
$10,289.21
|
|
|
Service Code
|
APR-DRG 1103
|
| Min. Negotiated Rate |
$10,289.21 |
| Max. Negotiated Rate |
$10,289.21 |
| Rate for Payer: IEHP Medi-Cal |
$10,289.21
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
IP
|
$6,209.15
|
|
|
Service Code
|
APR-DRG 1101
|
| Min. Negotiated Rate |
$6,209.15 |
| Max. Negotiated Rate |
$6,209.15 |
| Rate for Payer: IEHP Medi-Cal |
$6,209.15
|
|
|
EATING DISORDERS
|
Facility
IP
|
$46,859.60
|
|
|
Service Code
|
APR-DRG 7594
|
| Min. Negotiated Rate |
$46,859.60 |
| Max. Negotiated Rate |
$46,859.60 |
| Rate for Payer: IEHP Medi-Cal |
$46,859.60
|
|
|
EATING DISORDERS
|
Facility
IP
|
$8,198.94
|
|
|
Service Code
|
APR-DRG 7592
|
| Min. Negotiated Rate |
$8,198.94 |
| Max. Negotiated Rate |
$8,198.94 |
| Rate for Payer: IEHP Medi-Cal |
$8,198.94
|
|
|
EATING DISORDERS
|
Facility
IP
|
$11,342.81
|
|
|
Service Code
|
APR-DRG 7593
|
| Min. Negotiated Rate |
$11,342.81 |
| Max. Negotiated Rate |
$11,342.81 |
| Rate for Payer: IEHP Medi-Cal |
$11,342.81
|
|
|
EATING DISORDERS
|
Facility
IP
|
$5,239.12
|
|
|
Service Code
|
APR-DRG 7591
|
| Min. Negotiated Rate |
$5,239.12 |
| Max. Negotiated Rate |
$5,239.12 |
| Rate for Payer: IEHP Medi-Cal |
$5,239.12
|
|
|
ECONAZOLE 1 % TOPICAL CREAM [9915]
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 51672-1303-1
|
| Hospital Charge Code |
NDG9915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
|
|
ECONAZOLE 1 % TOPICAL CREAM [9915]
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 51672-1303-1
|
| Hospital Charge Code |
NDG9915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$2.35
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Senior |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.48
|
| Rate for Payer: Heritage Provider Network Senior |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
IP
|
$260.92
|
|
|
Service Code
|
CPT J1300
|
| Hospital Charge Code |
NDG81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$195.69 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$179.25
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$176.64
|
| Rate for Payer: Heritage Provider Network Senior |
$176.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.23
|
| Rate for Payer: Multiplan Commercial |
$195.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$95.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$87.17
|
|
