|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.92
|
| Rate for Payer: Blue Shield of California Commercial |
$28.08
|
| Rate for Payer: Blue Shield of California EPN |
$26.54
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.44
|
| Rate for Payer: Dignity Health Senior |
$38.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.99
|
| Rate for Payer: Heritage Provider Network Senior |
$27.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.09
|
| Rate for Payer: TriValley Medical Group Senior |
$18.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.44
|
| Rate for Payer: Vantage Medical Group Senior |
$38.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$33.92 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.61
|
| Rate for Payer: Heritage Provider Network Senior |
$30.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Adventist Health Commercial |
$9.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.92
|
| Rate for Payer: Blue Shield of California Commercial |
$28.08
|
| Rate for Payer: Blue Shield of California EPN |
$26.54
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.44
|
| Rate for Payer: Dignity Health Senior |
$38.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.99
|
| Rate for Payer: Heritage Provider Network Senior |
$27.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.30
|
| Rate for Payer: Multiplan Commercial |
$33.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.09
|
| Rate for Payer: TriValley Medical Group Senior |
$18.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.44
|
| Rate for Payer: Vantage Medical Group Senior |
$38.44
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-05
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.95
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.99
|
| Rate for Payer: Heritage Provider Network Senior |
$64.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-05
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.00
|
| Rate for Payer: Blue Shield of California Commercial |
$59.62
|
| Rate for Payer: Blue Shield of California EPN |
$56.35
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.60
|
| Rate for Payer: Dignity Health Senior |
$81.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.42
|
| Rate for Payer: Heritage Provider Network Senior |
$59.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.40
|
| Rate for Payer: TriValley Medical Group Senior |
$38.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.60
|
| Rate for Payer: Vantage Medical Group Senior |
$81.60
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-00
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.95
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.99
|
| Rate for Payer: Heritage Provider Network Senior |
$64.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-00
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$51.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.00
|
| Rate for Payer: Blue Shield of California Commercial |
$59.62
|
| Rate for Payer: Blue Shield of California EPN |
$56.35
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$62.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.60
|
| Rate for Payer: Dignity Health Senior |
$81.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.42
|
| Rate for Payer: Heritage Provider Network Senior |
$59.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.40
|
| Rate for Payer: TriValley Medical Group Senior |
$38.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.60
|
| Rate for Payer: Vantage Medical Group Senior |
$81.60
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
|
OP
|
$4,608.00
|
|
|
Service Code
|
CPT A9572
|
| Hospital Charge Code |
ERX13545
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$834.05 |
| Max. Negotiated Rate |
$19,250.08 |
| Rate for Payer: Adventist Health Commercial |
$921.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,916.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,534.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,456.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19,250.08
|
| Rate for Payer: Blue Shield of California Commercial |
$2,861.57
|
| Rate for Payer: Blue Shield of California EPN |
$2,704.90
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,995.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,916.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,916.80
|
| Rate for Payer: Dignity Health Senior |
$3,916.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,949.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,852.35
|
| Rate for Payer: Heritage Provider Network Senior |
$2,852.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,221.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$834.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,152.00
|
| Rate for Payer: Multiplan Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,680.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,539.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,916.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,916.80
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
|
IP
|
$4,608.00
|
|
|
Service Code
|
CPT A9572
|
| Hospital Charge Code |
ERX13545
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$834.05 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Adventist Health Commercial |
$921.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,165.70
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,488.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,119.62
|
| Rate for Payer: Heritage Provider Network Senior |
$3,119.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$834.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,152.00
|
| Rate for Payer: Multiplan Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,680.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,539.53
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-25
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Adventist Health Commercial |
$27.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$73.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$75.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$102.54
|
| Rate for Payer: Blue Shield of California Commercial |
$84.90
|
| Rate for Payer: Blue Shield of California EPN |
$80.25
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$88.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$116.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.21
|
| Rate for Payer: Dignity Health Senior |
$116.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.63
|
| Rate for Payer: Heritage Provider Network Senior |
$84.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$65.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.18
|
| Rate for Payer: Multiplan Commercial |
$102.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$54.69
|
| Rate for Payer: TriValley Medical Group Senior |
$54.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.21
|
| Rate for Payer: Vantage Medical Group Senior |
$116.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-02
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Adventist Health Commercial |
$27.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$73.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$75.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$102.54
|
| Rate for Payer: Blue Shield of California Commercial |
$84.90
|
| Rate for Payer: Blue Shield of California EPN |
$80.25
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$88.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$116.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.21
|
| Rate for Payer: Dignity Health Senior |
$116.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.63
|
| Rate for Payer: Heritage Provider Network Senior |
$84.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$65.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.18
|
| Rate for Payer: Multiplan Commercial |
$102.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$54.69
|
| Rate for Payer: TriValley Medical Group Senior |
$54.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.21
|
| Rate for Payer: Vantage Medical Group Senior |
$116.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-02
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$102.54 |
| Rate for Payer: Adventist Health Commercial |
$27.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.93
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.56
|
| Rate for Payer: Heritage Provider Network Senior |
$92.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.18
|
| Rate for Payer: Multiplan Commercial |
$102.54
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-25
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$102.54 |
| Rate for Payer: Adventist Health Commercial |
$27.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.93
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.56
|
| Rate for Payer: Heritage Provider Network Senior |
$92.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.18
|
| Rate for Payer: Multiplan Commercial |
$102.54
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
OP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
1753530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.63 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$238.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$306.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$334.12
|
| Rate for Payer: Blue Shield of California Commercial |
$276.65
|
| Rate for Payer: Blue Shield of California EPN |
$261.50
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$289.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.67
|
| Rate for Payer: Dignity Health Senior |
$378.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$285.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.76
|
| Rate for Payer: Heritage Provider Network Senior |
$275.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$214.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.37
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$178.20
|
| Rate for Payer: TriValley Medical Group Senior |
$178.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.67
|
| Rate for Payer: Vantage Medical Group Senior |
$378.67
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
IP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
1753530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.63 |
| Max. Negotiated Rate |
$334.12 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$306.05
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$301.60
|
| Rate for Payer: Heritage Provider Network Senior |
$301.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.37
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| 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 Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| 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 Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care 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 |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: Dignity Health Senior |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| 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 |
$0.19
|
| 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: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
1710382
|
|
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 |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| 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
|
|
