|
LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR [93834]
|
Facility
|
OP
|
$10.28
|
|
|
Service Code
|
NDC 50474-598-66
|
| Hospital Charge Code |
1712575
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Adventist Health Commercial |
$2.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.71
|
| Rate for Payer: Blue Shield of California Commercial |
$6.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.03
|
| Rate for Payer: Cash Price |
$4.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.74
|
| Rate for Payer: Dignity Health Senior |
$8.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.36
|
| Rate for Payer: Heritage Provider Network Senior |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.57
|
| Rate for Payer: Multiplan Commercial |
$7.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.11
|
| Rate for Payer: TriValley Medical Group Senior |
$4.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: Vantage Medical Group Senior |
$8.74
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS [10394]
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
NDC 24208-505-05
|
| Hospital Charge Code |
1740221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.95
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.91
|
| Rate for Payer: Heritage Provider Network Senior |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS [10394]
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 24208-505-05
|
| Hospital Charge Code |
1740221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: Adventist Health Commercial |
$0.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.22
|
| Rate for Payer: Blue Shield of California Commercial |
$2.67
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.66
|
| Rate for Payer: Dignity Health Senior |
$3.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.66
|
| Rate for Payer: Heritage Provider Network Senior |
$2.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.72
|
| Rate for Payer: TriValley Medical Group Senior |
$1.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.66
|
| Rate for Payer: Vantage Medical Group Senior |
$3.66
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 70954-140-10
|
| Hospital Charge Code |
1715083
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| 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 |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| 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 Commercial |
$0.17
|
| 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 |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 54482-148-01
|
| Hospital Charge Code |
1715083
|
|
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
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 70954-140-10
|
| Hospital Charge Code |
1715083
|
|
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 |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| 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 Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 54482-148-01
|
| Hospital Charge Code |
1715083
|
|
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
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]
|
Facility
|
OP
|
$8.83
|
|
|
Service Code
|
CPT J1955
|
| Hospital Charge Code |
1764075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$86.76 |
| Rate for Payer: Adventist Health Commercial |
$1.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$86.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$76.05
|
| Rate for Payer: Blue Shield of California Commercial |
$37.51
|
| Rate for Payer: Blue Shield of California EPN |
$37.51
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.51
|
| Rate for Payer: Dignity Health Senior |
$7.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.09
|
| Rate for Payer: Heritage Provider Network Senior |
$4.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$6.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.53
|
| Rate for Payer: TriValley Medical Group Senior |
$3.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.51
|
| Rate for Payer: Vantage Medical Group Senior |
$7.51
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]
|
Facility
|
IP
|
$8.83
|
|
|
Service Code
|
CPT J1955
|
| Hospital Charge Code |
1764075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Adventist Health Commercial |
$1.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.07
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.98
|
| Rate for Payer: Heritage Provider Network Senior |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.21
|
| Rate for Payer: Multiplan Commercial |
$6.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.95
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 54482-144-07
|
| Hospital Charge Code |
1711616
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.21
|
| Rate for Payer: Dignity Health Senior |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.57
|
| Rate for Payer: TriValley Medical Group Senior |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.21
|
| Rate for Payer: Vantage Medical Group Senior |
$1.21
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 54482-144-07
|
| Hospital Charge Code |
1711616
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Senior |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 70954-492-10
|
| Hospital Charge Code |
1711616
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.72
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Senior |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
NDC 70954-492-10
|
| Hospital Charge Code |
1711616
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.89
|
| Rate for Payer: Dignity Health Senior |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Senior |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Senior |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Vantage Medical Group Senior |
$0.89
|
|
|
LEVOFLOXACIN 0.5 % EYE DROPS [28872]
|
Facility
|
IP
|
$27.57
|
|
|
Service Code
|
NDC 17478-106-10
|
| Hospital Charge Code |
NDG28872
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$20.68 |
| Rate for Payer: Adventist Health Commercial |
$5.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.94
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.66
|
| Rate for Payer: Heritage Provider Network Senior |
$18.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.89
|
| Rate for Payer: Multiplan Commercial |
$20.68
|
|
|
LEVOFLOXACIN 0.5 % EYE DROPS [28872]
|
Facility
|
OP
|
$27.57
|
|
|
Service Code
|
NDC 17478-106-10
|
| Hospital Charge Code |
NDG28872
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$23.43 |
| Rate for Payer: Adventist Health Commercial |
$5.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.68
|
| Rate for Payer: Blue Shield of California Commercial |
$17.12
|
| Rate for Payer: Blue Shield of California EPN |
$16.18
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.43
|
| Rate for Payer: Dignity Health Senior |
$23.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.07
|
| Rate for Payer: Heritage Provider Network Senior |
$17.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.89
|
| Rate for Payer: Multiplan Commercial |
$20.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.03
|
| Rate for Payer: TriValley Medical Group Senior |
$11.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Vantage Medical Group Senior |
$23.43
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 50383-286-08
|
| Hospital Charge Code |
NDG39970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Senior |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 50383-286-16
|
| Hospital Charge Code |
1715161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.13
|
| Rate for Payer: Dignity Health Senior |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Senior |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 50383-286-08
|
| Hospital Charge Code |
NDG39970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 50383-286-04
|
| Hospital Charge Code |
NDG39970B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
NDC 50383-286-16
|
| Hospital Charge Code |
1715161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Senior |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 50383-286-04
|
| Hospital Charge Code |
NDG39970B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Senior |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
1753537
|
|
Hospital Revenue Code
|
636
|
| 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: Cigna of CA HMO/PPO |
$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
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
1753537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$39.20 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$39.20
|
| Rate for Payer: Blue Shield of California Commercial |
$8.36
|
| Rate for Payer: Blue Shield of California EPN |
$8.36
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| 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 |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| 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: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
LEVOFLOXACIN 250 MG TABLET [18918]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0904-6351-61
|
| Hospital Charge Code |
1711727
|
|
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
|
|
|
LEVOFLOXACIN 250 MG TABLET [18918]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 65862-536-50
|
| Hospital Charge Code |
1711727
|
|
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 |
$0.26
|
| Rate for Payer: Cash Price |
$0.17
|
| 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
|
|
