|
KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
CPT A9587
|
| Hospital Charge Code |
ERX215477
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$134.56 |
| Max. Negotiated Rate |
$3,060.00 |
| Rate for Payer: Adventist Health Commercial |
$720.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,060.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,980.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,700.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.56
|
| Rate for Payer: Blue Shield of California Commercial |
$2,235.60
|
| Rate for Payer: Blue Shield of California EPN |
$2,113.20
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,060.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,060.00
|
| Rate for Payer: Dignity Health Senior |
$3,060.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,304.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,228.40
|
| Rate for Payer: Heritage Provider Network Senior |
$2,228.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,735.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$651.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$900.00
|
| Rate for Payer: Multiplan Commercial |
$2,700.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,312.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,202.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,060.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,060.00
|
|
|
KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT A9537
|
| Hospital Charge Code |
ERX121131
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$117.82 |
| Rate for Payer: Adventist Health Commercial |
$18.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$76.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$67.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.82
|
| Rate for Payer: Blue Shield of California Commercial |
$55.89
|
| Rate for Payer: Blue Shield of California EPN |
$52.83
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.50
|
| Rate for Payer: Dignity Health Senior |
$76.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.71
|
| Rate for Payer: Heritage Provider Network Senior |
$55.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$70.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$43.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$30.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.50
|
| Rate for Payer: Vantage Medical Group Senior |
$76.50
|
|
|
KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT A9537
|
| Hospital Charge Code |
ERX121131
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$67.50 |
| Rate for Payer: Adventist Health Commercial |
$18.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.83
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.93
|
| Rate for Payer: Heritage Provider Network Senior |
$60.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$30.07
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
|
OP
|
$755.82
|
|
|
Service Code
|
CPT A9520
|
| Hospital Charge Code |
ERX223025
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$642.45 |
| Rate for Payer: Adventist Health Commercial |
$151.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$642.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$415.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$566.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$483.88
|
| Rate for Payer: Blue Shield of California Commercial |
$469.36
|
| Rate for Payer: Blue Shield of California EPN |
$443.67
|
| Rate for Payer: Cash Price |
$340.12
|
| Rate for Payer: Cash Price |
$340.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$491.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$642.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$642.45
|
| Rate for Payer: Dignity Health Senior |
$642.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$483.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$467.85
|
| Rate for Payer: Heritage Provider Network Senior |
$467.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$364.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.96
|
| Rate for Payer: Multiplan Commercial |
$566.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$275.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$252.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$642.45
|
| Rate for Payer: Vantage Medical Group Senior |
$642.45
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
|
IP
|
$755.82
|
|
|
Service Code
|
CPT A9520
|
| Hospital Charge Code |
ERX223025
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$566.86 |
| Rate for Payer: Adventist Health Commercial |
$151.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$519.25
|
| Rate for Payer: Cash Price |
$340.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$408.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$511.69
|
| Rate for Payer: Heritage Provider Network Senior |
$511.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.96
|
| Rate for Payer: Multiplan Commercial |
$566.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$275.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$252.52
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
|
IP
|
$34,595.52
|
|
|
Service Code
|
APR-DRG 3134
|
| Min. Negotiated Rate |
$34,595.52 |
| Max. Negotiated Rate |
$34,595.52 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34,595.52
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
|
IP
|
$15,228.87
|
|
|
Service Code
|
APR-DRG 3132
|
| Min. Negotiated Rate |
$15,228.87 |
| Max. Negotiated Rate |
$15,228.87 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,228.87
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
|
IP
|
$22,218.02
|
|
|
Service Code
|
APR-DRG 3133
|
| Min. Negotiated Rate |
$22,218.02 |
| Max. Negotiated Rate |
$22,218.02 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22,218.02
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
|
IP
|
$11,567.65
|
|
|
Service Code
|
APR-DRG 3131
|
| Min. Negotiated Rate |
$11,567.65 |
| Max. Negotiated Rate |
$11,567.65 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,567.65
|
|
|
K-PHOS NEUTRAL ORAL SUSP CMPD 25 MG/ML (0.1 MEQ/ML) [4080284]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 9994-0802-84
|
| Hospital Charge Code |
1715213
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
K-PHOS NEUTRAL ORAL SUSP CMPD 25 MG/ML (0.1 MEQ/ML) [4080284]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 9994-0802-84
|
| Hospital Charge Code |
1715213
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 0185-0010-01
|
| Hospital Charge Code |
1711384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 68001-381-00
|
| Hospital Charge Code |
1711384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 60687-439-11
|
| Hospital Charge Code |
1711384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 0185-0010-01
|
| Hospital Charge Code |
1711384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 68001-381-00
|
| Hospital Charge Code |
1711384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 60687-439-11
|
| Hospital Charge Code |
1711384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Senior |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 60687-439-01
|
| Hospital Charge Code |
1711384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 60687-439-01
|
| Hospital Charge Code |
1711384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Senior |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 68001-382-00
|
| Hospital Charge Code |
1711385
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Senior |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 68382-799-01
|
| Hospital Charge Code |
1711385
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| 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 |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 68001-382-00
|
| Hospital Charge Code |
1711385
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 68382-799-01
|
| Hospital Charge Code |
1711385
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| 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 |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| 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 |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
LABETALOL 300 MG TABLET [10375]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 68001-383-00
|
| Hospital Charge Code |
1711386
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Senior |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
LABETALOL 300 MG TABLET [10375]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 68001-383-00
|
| Hospital Charge Code |
1711386
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
