|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
OP
|
$2.44
|
|
|
Service Code
|
NDC 23155-823-73
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.83
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.43
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.07
|
| Rate for Payer: Dignity Health Senior |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.51
|
| Rate for Payer: Heritage Provider Network Senior |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Senior |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.07
|
| Rate for Payer: Vantage Medical Group Senior |
$2.07
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
IP
|
$2.44
|
|
|
Service Code
|
NDC 23155-823-73
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.68
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Senior |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$1.83
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
IP
|
$3.75
|
|
|
Service Code
|
NDC 50742-118-08
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.58
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.54
|
| Rate for Payer: Heritage Provider Network Senior |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$2.81
|
|
|
CABERGOLINE 0.5 MG TABLET [19226]
|
Facility
|
OP
|
$3.75
|
|
|
Service Code
|
NDC 50742-118-08
|
| Hospital Charge Code |
1712340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.81
|
| Rate for Payer: Blue Shield of California Commercial |
$2.33
|
| Rate for Payer: Blue Shield of California EPN |
$2.20
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.19
|
| Rate for Payer: Dignity Health Senior |
$3.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.32
|
| Rate for Payer: Heritage Provider Network Senior |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$2.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Senior |
$1.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.19
|
| Rate for Payer: Vantage Medical Group Senior |
$3.19
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
1743674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.34
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
|
|
CADEXOMER IODINE 0.9 % TOPICAL GEL [12858]
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 4056512249
|
| Hospital Charge Code |
1743674
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.55
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.89
|
| Rate for Payer: Dignity Health Senior |
$2.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.10
|
| Rate for Payer: Heritage Provider Network Senior |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$2.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.36
|
| Rate for Payer: TriValley Medical Group Senior |
$1.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.89
|
| Rate for Payer: Vantage Medical Group Senior |
$2.89
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| 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 |
$0.07
|
| 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 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: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 46122-457-73
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| 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
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
1710902
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care 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: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| Hospital Charge Code |
1710902
|
|
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 |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| 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 |
$0.11
|
| 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 |
$0.08
|
| 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 |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 4601701816
|
| Hospital Charge Code |
1710902
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
CAFFEINE 200 MG TABLET [1259]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 4601701840
|
| Hospital Charge Code |
1710902
|
|
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
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
NDG77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.24
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.71
|
| Rate for Payer: Heritage Provider Network Senior |
$2.21
|
| Rate for Payer: Heritage Provider Network Senior |
$4.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.34
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION [77412]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
NDG77412
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Senior |
$2.77
|
| Rate for Payer: Dignity Health Senior |
$3.40
|
| Rate for Payer: Dignity Health Senior |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Senior |
$3.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.51
|
| Rate for Payer: Heritage Provider Network Senior |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$3.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.30
|
| Rate for Payer: TriValley Medical Group Senior |
$1.30
|
| Rate for Payer: TriValley Medical Group Senior |
$2.88
|
| Rate for Payer: TriValley Medical Group Senior |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.77
|
| Rate for Payer: Vantage Medical Group Senior |
$2.77
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 9994-0804-22
|
| Hospital Charge Code |
1715184
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care 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: TriValley Medical Group Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Senior |
$1.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL (IV FORM) [4080068]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 9994-0804-22
|
| Hospital Charge Code |
1715184
|
|
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
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 25021-602-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.97
|
| Rate for Payer: Blue Shield of California EPN |
$4.70
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.80
|
| Rate for Payer: Dignity Health Senior |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.95
|
| Rate for Payer: Heritage Provider Network Senior |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.20
|
| Rate for Payer: TriValley Medical Group Senior |
$3.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Vantage Medical Group Senior |
$6.80
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
OP
|
$15.50
|
|
|
Service Code
|
NDC 63323-406-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$13.18 |
| Rate for Payer: Adventist Health Commercial |
$3.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.62
|
| Rate for Payer: Blue Shield of California Commercial |
$9.63
|
| Rate for Payer: Blue Shield of California EPN |
$9.10
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.18
|
| Rate for Payer: Dignity Health Senior |
$13.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Senior |
$9.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.20
|
| Rate for Payer: TriValley Medical Group Senior |
$6.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.18
|
| Rate for Payer: Vantage Medical Group Senior |
$13.18
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
IP
|
$15.50
|
|
|
Service Code
|
NDC 63323-406-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$11.62 |
| Rate for Payer: Adventist Health Commercial |
$3.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.65
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.49
|
| Rate for Payer: Heritage Provider Network Senior |
$10.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.62
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) ORAL SOLUTION [77411]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 25021-602-03
|
| Hospital Charge Code |
NDG77411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.50
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.42
|
| Rate for Payer: Heritage Provider Network Senior |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
IP
|
$16.57
|
|
|
Service Code
|
NDC 0517-2502-10
|
| Hospital Charge Code |
1720528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Adventist Health Commercial |
$3.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.22
|
| Rate for Payer: Heritage Provider Network Senior |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
IP
|
$16.57
|
|
|
Service Code
|
NDC 0517-2502-01
|
| Hospital Charge Code |
1720528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Adventist Health Commercial |
$3.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.22
|
| Rate for Payer: Heritage Provider Network Senior |
$11.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
OP
|
$16.57
|
|
|
Service Code
|
NDC 0517-2502-01
|
| Hospital Charge Code |
1720528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$14.08 |
| Rate for Payer: Adventist Health Commercial |
$3.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.43
|
| Rate for Payer: Blue Shield of California Commercial |
$10.29
|
| Rate for Payer: Blue Shield of California EPN |
$9.73
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.08
|
| Rate for Payer: Dignity Health Senior |
$14.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.26
|
| Rate for Payer: Heritage Provider Network Senior |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.63
|
| Rate for Payer: TriValley Medical Group Senior |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.08
|
| Rate for Payer: Vantage Medical Group Senior |
$14.08
|
|
|
CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN [1262]
|
Facility
|
OP
|
$16.57
|
|
|
Service Code
|
NDC 0517-2502-10
|
| Hospital Charge Code |
1720528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$14.08 |
| Rate for Payer: Adventist Health Commercial |
$3.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.43
|
| Rate for Payer: Blue Shield of California Commercial |
$10.29
|
| Rate for Payer: Blue Shield of California EPN |
$9.73
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.08
|
| Rate for Payer: Dignity Health Senior |
$14.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.26
|
| Rate for Payer: Heritage Provider Network Senior |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.63
|
| Rate for Payer: TriValley Medical Group Senior |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.08
|
| Rate for Payer: Vantage Medical Group Senior |
$14.08
|
|
|
CALAMINE 8 %-ZINC OXIDE 8 % LOTION [78879]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0904-2533-21
|
| Hospital Charge Code |
NDG78879B
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
