|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
OP
|
$2.35
|
|
|
Service Code
|
NDC 65162-087-74
|
| Hospital Charge Code |
1715991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.46
|
| Rate for Payer: Blue Shield of California EPN |
$1.38
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.00
|
| Rate for Payer: Dignity Health Senior |
$2.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Senior |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.00
|
| Rate for Payer: Vantage Medical Group Senior |
$2.00
|
|
|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 65162-087-74
|
| Hospital Charge Code |
1715991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
|
|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 31722-006-31
|
| Hospital Charge Code |
1715991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 31722-006-31
|
| Hospital Charge Code |
1715991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
IP
|
$11.36
|
|
|
Service Code
|
NDC 55513-800-60
|
| Hospital Charge Code |
ERX204605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.52 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.69
|
| Rate for Payer: Heritage Provider Network Senior |
$7.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
|
|
IVABRADINE 5 MG TABLET [204605]
|
Facility
|
OP
|
$11.36
|
|
|
Service Code
|
NDC 55513-800-60
|
| Hospital Charge Code |
ERX204605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.66 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.52
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.67
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.66
|
| Rate for Payer: Dignity Health Senior |
$9.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Senior |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.54
|
| Rate for Payer: TriValley Medical Group Senior |
$4.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.66
|
| Rate for Payer: Vantage Medical Group Senior |
$9.66
|
|
|
IVABRADINE 7.5 MG TABLET [204608]
|
Facility
|
OP
|
$11.36
|
|
|
Service Code
|
NDC 55513-810-60
|
| Hospital Charge Code |
ERX204608
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$9.66 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.52
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.67
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.66
|
| Rate for Payer: Dignity Health Senior |
$9.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Senior |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.54
|
| Rate for Payer: TriValley Medical Group Senior |
$4.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.66
|
| Rate for Payer: Vantage Medical Group Senior |
$9.66
|
|
|
IVABRADINE 7.5 MG TABLET [204608]
|
Facility
|
IP
|
$11.36
|
|
|
Service Code
|
NDC 55513-810-60
|
| Hospital Charge Code |
ERX204608
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$8.52 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.69
|
| Rate for Payer: Heritage Provider Network Senior |
$7.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.52
|
|
|
IVERMECTIN 0.5 % LOTION [196318]
|
Facility
|
IP
|
$2.79
|
|
|
Service Code
|
NDC 24338-183-04
|
| Hospital Charge Code |
NDG196318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.92
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.09
|
|
|
IVERMECTIN 0.5 % LOTION [196318]
|
Facility
|
OP
|
$2.79
|
|
|
Service Code
|
NDC 24338-183-04
|
| Hospital Charge Code |
NDG196318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.09
|
| Rate for Payer: Blue Shield of California Commercial |
$1.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.37
|
| Rate for Payer: Dignity Health Senior |
$2.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.12
|
| Rate for Payer: TriValley Medical Group Senior |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.37
|
| Rate for Payer: Vantage Medical Group Senior |
$2.37
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
|
OP
|
$4.97
|
|
|
Service Code
|
NDC 42799-806-01
|
| Hospital Charge Code |
1712490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.73
|
| Rate for Payer: Blue Shield of California Commercial |
$3.09
|
| Rate for Payer: Blue Shield of California EPN |
$2.92
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.22
|
| Rate for Payer: Dignity Health Senior |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.08
|
| Rate for Payer: Heritage Provider Network Senior |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$3.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Senior |
$1.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.22
|
| Rate for Payer: Vantage Medical Group Senior |
$4.22
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 42799-806-01
|
| Hospital Charge Code |
1712490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: Adventist Health Commercial |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.41
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.36
|
| Rate for Payer: Heritage Provider Network Senior |
$3.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$3.73
|
|
|
IXABEPILONE 45 MG INTRAVENOUS SOLUTION [88653]
|
Facility
|
IP
|
$6,645.17
|
|
|
Service Code
|
CPT J9207
|
| Hospital Charge Code |
1755731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,202.78 |
| Max. Negotiated Rate |
$4,983.88 |
| Rate for Payer: Adventist Health Commercial |
$1,329.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,565.23
|
| Rate for Payer: Cash Price |
$2,990.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,056.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,588.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,498.78
|
| Rate for Payer: Heritage Provider Network Senior |
$4,498.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,202.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,661.29
|
| Rate for Payer: Multiplan Commercial |
$4,983.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,422.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,220.15
|
|
|
IXABEPILONE 45 MG INTRAVENOUS SOLUTION [88653]
|
Facility
|
OP
|
$6,645.17
|
|
|
Service Code
|
CPT J9207
|
| Hospital Charge Code |
1755731
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.11 |
| Max. Negotiated Rate |
$4,983.88 |
| Rate for Payer: Adventist Health Commercial |
$1,329.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$314.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,565.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$160.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$140.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$140.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.85
|
| Rate for Payer: Blue Shield of California Commercial |
$120.11
|
| Rate for Payer: Blue Shield of California EPN |
$120.11
|
| Rate for Payer: Cash Price |
$2,990.33
|
| Rate for Payer: Cash Price |
$2,990.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,056.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$192.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$140.88
|
| Rate for Payer: Dignity Health Senior |
$140.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,252.91
|
| Rate for Payer: EPIC Health Plan Medicare |
$128.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,076.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3,076.71
|
| Rate for Payer: Humana Medicare |
$128.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$206.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$128.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$243.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,202.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$151.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,661.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$161.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$161.37
|
| Rate for Payer: Multiplan Commercial |
$4,983.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,658.07
|
| Rate for Payer: TriValley Medical Group Senior |
$2,658.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,422.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,220.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$192.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$140.88
|
| Rate for Payer: Vantage Medical Group Senior |
$128.07
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
NDG111957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| 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 |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
KARAYA GUM TOPICAL POWDER [111957]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 8380007905
|
| Hospital Charge Code |
NDG111957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
Keratoplasty (corneal transplant); endothelial
|
Facility
|
OP
|
$9,792.00
|
|
|
Service Code
|
CPT 65756
|
| Min. Negotiated Rate |
$232.89 |
| Max. Negotiated Rate |
$9,792.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$232.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
|
Facility
|
OP
|
$9,792.00
|
|
|
Service Code
|
CPT 65730
|
| Min. Negotiated Rate |
$1,742.36 |
| Max. Negotiated Rate |
$9,792.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,742.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Keratoplasty (corneal transplant); penetrating (in pseudophakia)
|
Facility
|
OP
|
$9,792.00
|
|
|
Service Code
|
CPT 65755
|
| Min. Negotiated Rate |
$1,742.36 |
| Max. Negotiated Rate |
$9,792.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: Dignity Health Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,080.00
|
| Rate for Payer: Humana Medicare |
$5,080.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,742.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,652.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,994.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,400.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,400.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,588.00
|
| Rate for Payer: TriValley Medical Group Senior |
$5,080.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
Keratoprosthesis
|
Facility
|
OP
|
$29,429.97
|
|
|
Service Code
|
CPT 65770
|
| Min. Negotiated Rate |
$348.47 |
| Max. Negotiated Rate |
$29,429.97 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23,234.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17,038.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15,489.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23,234.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$17,038.41
|
| Rate for Payer: Dignity Health Senior |
$15,489.46
|
| Rate for Payer: EPIC Health Plan Medicare |
$15,489.46
|
| Rate for Payer: Humana Medicare |
$15,489.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$348.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,489.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29,429.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18,277.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19,516.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19,516.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$17,038.41
|
| Rate for Payer: TriValley Medical Group Senior |
$15,489.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23,234.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17,038.41
|
| Rate for Payer: Vantage Medical Group Senior |
$15,489.46
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 0409-2051-05
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-01
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-10
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.90
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.60
|
| Rate for Payer: Dignity Health Senior |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 0143-9509-10
|
| Hospital Charge Code |
1720437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.10
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
|
