|
EPCORITAMAB-BYSP 48 MG/0.8 ML SUBCUTANEOUS SOLUTION [238112]
|
Facility
IP
|
$22,838.34
|
|
|
Service Code
|
CPT C9155
|
| Hospital Charge Code |
ERX238112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,133.74 |
| Max. Negotiated Rate |
$17,128.76 |
| Rate for Payer: Adventist Health Commercial |
$4,567.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15,689.94
|
| Rate for Payer: Cash Price |
$10,277.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10,505.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,332.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$15,461.56
|
| Rate for Payer: Heritage Provider Network Senior |
$15,461.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,133.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,709.58
|
| Rate for Payer: Multiplan Commercial |
$17,128.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8,326.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7,630.29
|
|
|
EPCORITAMAB-BYSP 4 MG/0.8 ML SUBCUTANEOUS SOLUTION (MUST DILUTE) [238113]
|
Facility
IP
|
$1,903.20
|
|
|
Service Code
|
CPT C9155
|
| Hospital Charge Code |
ERX238113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$344.48 |
| Max. Negotiated Rate |
$1,427.40 |
| Rate for Payer: Adventist Health Commercial |
$380.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,307.50
|
| Rate for Payer: Cash Price |
$856.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$875.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,027.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,288.47
|
| Rate for Payer: Heritage Provider Network Senior |
$1,288.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$475.80
|
| Rate for Payer: Multiplan Commercial |
$1,427.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$693.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$635.86
|
|
|
EPCORITAMAB-BYSP 4 MG/0.8 ML SUBCUTANEOUS SOLUTION (MUST DILUTE) [238113]
|
Facility
OP
|
$1,903.20
|
|
|
Service Code
|
CPT C9155
|
| Hospital Charge Code |
ERX238113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$344.48 |
| Max. Negotiated Rate |
$1,617.72 |
| Rate for Payer: Adventist Health Commercial |
$380.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,017.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,307.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,617.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,046.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,427.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,181.89
|
| Rate for Payer: Blue Shield of California EPN |
$1,117.18
|
| Rate for Payer: Cash Price |
$856.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$875.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,617.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,617.72
|
| Rate for Payer: Dignity Health Senior |
$1,617.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,218.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$881.18
|
| Rate for Payer: Heritage Provider Network Senior |
$881.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$917.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$475.80
|
| Rate for Payer: Multiplan Commercial |
$1,427.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$693.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$635.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,617.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1,617.72
|
|
|
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE [120232]
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
NDC 70004-604-09
|
| Hospital Charge Code |
1722051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
|
|
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE [120232]
|
Facility
OP
|
$4.76
|
|
|
Service Code
|
NDC 70092-1478-44
|
| Hospital Charge Code |
1722051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.57
|
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.05
|
| Rate for Payer: Dignity Health Senior |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.05
|
| Rate for Payer: Vantage Medical Group Senior |
$4.05
|
|
|
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE [120232]
|
Facility
IP
|
$4.76
|
|
|
Service Code
|
NDC 70092-1478-44
|
| Hospital Charge Code |
1722051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.27
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$3.57
|
|
|
EPHEDRINE (PF) 25 MG/5 ML (5 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE [120232]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 70004-604-09
|
| Hospital Charge Code |
1722051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
IP
|
$2.96
|
|
|
Service Code
|
NDC 51754-4250-3
|
| Hospital Charge Code |
NDG233841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
OP
|
$2.96
|
|
|
Service Code
|
NDC 51754-4250-3
|
| Hospital Charge Code |
NDG233841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.22
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.74
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.52
|
| Rate for Payer: Dignity Health Senior |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| 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 Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.52
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
IP
|
$2.96
|
|
|
Service Code
|
NDC 51754-4250-1
|
| Hospital Charge Code |
NDG233841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
OP
|
$2.96
|
|
|
Service Code
|
NDC 51754-4250-1
|
| Hospital Charge Code |
NDG233841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.22
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.74
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.52
|
| Rate for Payer: Dignity Health Senior |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| 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 Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.52
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
IP
|
$34.85
|
|
|
Service Code
|
NDC 70121-1637-1
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.31 |
| Max. Negotiated Rate |
$26.14 |
| Rate for Payer: Adventist Health Commercial |
$6.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.94
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.59
|
| Rate for Payer: Heritage Provider Network Senior |
$23.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Commercial |
$26.14
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
OP
|
$9.35
|
|
|
Service Code
|
NDC 70700-249-25
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$7.95 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.42
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.01
|
| Rate for Payer: Blue Shield of California Commercial |
$5.81
|
| Rate for Payer: Blue Shield of California EPN |
$5.49
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.95
|
| Rate for Payer: Dignity Health Senior |
$7.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.79
|
| Rate for Payer: Heritage Provider Network Senior |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.95
|
| Rate for Payer: Vantage Medical Group Senior |
$7.95
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
OP
|
$13.37
|
|
|
Service Code
|
NDC 70756-611-82
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.03
|
| Rate for Payer: Blue Shield of California Commercial |
$8.30
|
| Rate for Payer: Blue Shield of California EPN |
$7.85
|
| Rate for Payer: Cash Price |
$6.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: Dignity Health Senior |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.28
|
| Rate for Payer: Heritage Provider Network Senior |
$8.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
OP
|
$34.85
|
|
|
Service Code
|
NDC 70121-1637-1
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.31 |
| Max. Negotiated Rate |
$29.62 |
| Rate for Payer: Adventist Health Commercial |
$6.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$29.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$26.14
|
| Rate for Payer: Blue Shield of California Commercial |
$21.64
|
| Rate for Payer: Blue Shield of California EPN |
$20.46
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.62
|
| Rate for Payer: Dignity Health Senior |
$29.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.57
|
| Rate for Payer: Heritage Provider Network Senior |
$21.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.71
|
| Rate for Payer: Multiplan Commercial |
$26.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.62
|
| Rate for Payer: Vantage Medical Group Senior |
$29.62
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
IP
|
$34.05
|
|
|
Service Code
|
NDC 0781-3269-95
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$25.54 |
| Rate for Payer: Adventist Health Commercial |
$6.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.39
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.05
|
| Rate for Payer: Heritage Provider Network Senior |
$23.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.51
|
| Rate for Payer: Multiplan Commercial |
$25.54
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
IP
|
$56.75
|
|
|
Service Code
|
NDC 70121-1637-7
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.27 |
| Max. Negotiated Rate |
$42.56 |
| Rate for Payer: Adventist Health Commercial |
$11.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.99
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.42
|
| Rate for Payer: Heritage Provider Network Senior |
$38.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.19
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
OP
|
$34.05
|
|
|
Service Code
|
NDC 0781-3269-71
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$28.94 |
| Rate for Payer: Adventist Health Commercial |
$6.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.54
|
| Rate for Payer: Blue Shield of California Commercial |
$21.15
|
| Rate for Payer: Blue Shield of California EPN |
$19.99
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.94
|
| Rate for Payer: Dignity Health Senior |
$28.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.08
|
| Rate for Payer: Heritage Provider Network Senior |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.51
|
| Rate for Payer: Multiplan Commercial |
$25.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.94
|
| Rate for Payer: Vantage Medical Group Senior |
$28.94
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
OP
|
$56.75
|
|
|
Service Code
|
NDC 70121-1637-7
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.27 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Adventist Health Commercial |
$11.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$48.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.56
|
| Rate for Payer: Blue Shield of California Commercial |
$35.24
|
| Rate for Payer: Blue Shield of California EPN |
$33.31
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.24
|
| Rate for Payer: Dignity Health Senior |
$48.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.13
|
| Rate for Payer: Heritage Provider Network Senior |
$35.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.19
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.24
|
| Rate for Payer: Vantage Medical Group Senior |
$48.24
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
IP
|
$13.37
|
|
|
Service Code
|
NDC 70756-611-25
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.19
|
| Rate for Payer: Cash Price |
$6.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.05
|
| Rate for Payer: Heritage Provider Network Senior |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.03
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
OP
|
$34.05
|
|
|
Service Code
|
NDC 0781-3269-95
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$28.94 |
| Rate for Payer: Adventist Health Commercial |
$6.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.54
|
| Rate for Payer: Blue Shield of California Commercial |
$21.15
|
| Rate for Payer: Blue Shield of California EPN |
$19.99
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.94
|
| Rate for Payer: Dignity Health Senior |
$28.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.08
|
| Rate for Payer: Heritage Provider Network Senior |
$21.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.51
|
| Rate for Payer: Multiplan Commercial |
$25.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.94
|
| Rate for Payer: Vantage Medical Group Senior |
$28.94
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
OP
|
$13.37
|
|
|
Service Code
|
NDC 70756-611-25
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.03
|
| Rate for Payer: Blue Shield of California Commercial |
$8.30
|
| Rate for Payer: Blue Shield of California EPN |
$7.85
|
| Rate for Payer: Cash Price |
$6.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.36
|
| Rate for Payer: Dignity Health Senior |
$11.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.28
|
| Rate for Payer: Heritage Provider Network Senior |
$8.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.36
|
| Rate for Payer: Vantage Medical Group Senior |
$11.36
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
IP
|
$34.05
|
|
|
Service Code
|
NDC 0781-3269-71
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$25.54 |
| Rate for Payer: Adventist Health Commercial |
$6.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.39
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.05
|
| Rate for Payer: Heritage Provider Network Senior |
$23.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.51
|
| Rate for Payer: Multiplan Commercial |
$25.54
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
IP
|
$13.37
|
|
|
Service Code
|
NDC 70756-611-82
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Adventist Health Commercial |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.19
|
| Rate for Payer: Cash Price |
$6.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.05
|
| Rate for Payer: Heritage Provider Network Senior |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.34
|
| Rate for Payer: Multiplan Commercial |
$10.03
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
IP
|
$9.35
|
|
|
Service Code
|
NDC 70700-249-25
|
| Hospital Charge Code |
1720234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$7.01 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.42
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.33
|
| Rate for Payer: Heritage Provider Network Senior |
$6.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
|
