|
ACYCLOVIR 200 MG CAPSULE [8969]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
ACYCLOVIR 200 MG CAPSULE [8969]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
ACYCLOVIR 400 MG TABLET [8971]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 72578-082-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.68
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna of CA HMO |
$3.05
|
| Rate for Payer: Cigna of CA PPO |
$3.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: EPIC Health Plan Senior |
$1.74
|
| Rate for Payer: Galaxy Health WC |
$3.71
|
| Rate for Payer: Global Benefits Group Commercial |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.05
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Networks By Design Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.18
|
| Rate for Payer: United Healthcare All Other HMO |
$2.18
|
| Rate for Payer: United Healthcare HMO Rider |
$2.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Vantage Medical Group Senior |
$3.71
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 65162-835-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 65162-835-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
ACYCLOVIR 5 % TOPICAL OINTMENT [8968]
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 72578-082-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$3.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.12
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna of CA HMO |
$3.05
|
| Rate for Payer: Cigna of CA PPO |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: EPIC Health Plan Senior |
$1.74
|
| Rate for Payer: Galaxy Health WC |
$3.71
|
| Rate for Payer: Global Benefits Group Commercial |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Networks By Design Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.71
|
|
|
ACYCLOVIR 800 MG TABLET [8972]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.93
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.55
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
ACYCLOVIR 800 MG TABLET [8972]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.93
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [8974]
|
Facility
|
IP
|
$5.40
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$3.99
|
| Rate for Payer: Blue Shield of California EPN |
$2.62
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| Rate for Payer: Cigna of CA PPO |
$3.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Senior |
$2.16
|
| Rate for Payer: Galaxy Health WC |
$4.59
|
| Rate for Payer: Global Benefits Group Commercial |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$4.32
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.03
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.77
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [8974]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| Rate for Payer: Cigna of CA PPO |
$3.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.16
|
| Rate for Payer: EPIC Health Plan Senior |
$2.16
|
| Rate for Payer: Galaxy Health WC |
$4.59
|
| Rate for Payer: Global Benefits Group Commercial |
$3.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.78
|
| Rate for Payer: Multiplan Commercial |
$4.32
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$4.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.03
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.59
|
| Rate for Payer: Vantage Medical Group Senior |
$4.59
|
| Rate for Payer: Adventist Health Commercial |
$1.08
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cigna of CA HMO |
$1.47
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Galaxy Health WC |
$1.78
|
| Rate for Payer: Galaxy Health WC |
$1.15
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$1.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.15
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.51
|
| Rate for Payer: United Healthcare All Other HMO |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.49
|
| Rate for Payer: United Healthcare HMO Rider |
$0.48
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.78
|
| Rate for Payer: Vantage Medical Group Senior |
$1.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.78
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [23128]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$1.47
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$1.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Galaxy Health WC |
$1.15
|
| Rate for Payer: Galaxy Health WC |
$1.78
|
| Rate for Payer: Global Benefits Group Commercial |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: Networks By Design Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$1.15
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Prime Health Services Commercial |
$1.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.64
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.59
|
|
|
ADAGRASIB 200 MG TABLET [236395]
|
Facility
|
OP
|
$150.62
|
|
|
Service Code
|
NDC 80739-812-18
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.12 |
| Max. Negotiated Rate |
$128.03 |
| Rate for Payer: Adventist Health Commercial |
$30.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$98.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$128.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$82.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$112.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.50
|
| Rate for Payer: Cash Price |
$82.84
|
| Rate for Payer: Cigna of CA HMO |
$105.43
|
| Rate for Payer: Cigna of CA PPO |
$105.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$128.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$128.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$128.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.25
|
| Rate for Payer: EPIC Health Plan Senior |
$60.25
|
| Rate for Payer: Galaxy Health WC |
$128.03
|
| Rate for Payer: Global Benefits Group Commercial |
$90.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$93.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$105.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$105.43
|
| Rate for Payer: Multiplan Commercial |
$120.50
|
| Rate for Payer: Networks By Design Commercial |
$97.90
|
| Rate for Payer: Prime Health Services Commercial |
$128.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$90.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$90.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$75.31
|
| Rate for Payer: United Healthcare All Other HMO |
$75.31
|
| Rate for Payer: United Healthcare HMO Rider |
$75.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$75.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$128.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$128.03
|
| Rate for Payer: Vantage Medical Group Senior |
$128.03
|
|
|
ADAGRASIB 200 MG TABLET [236395]
|
Facility
|
IP
|
$150.62
|
|
|
Service Code
|
NDC 80739-812-18
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.12 |
| Max. Negotiated Rate |
$128.03 |
| Rate for Payer: Adventist Health Commercial |
$30.12
|
| Rate for Payer: Blue Shield of California Commercial |
$111.16
|
| Rate for Payer: Blue Shield of California EPN |
$73.20
|
| Rate for Payer: Cash Price |
$82.84
|
| Rate for Payer: Cigna of CA HMO |
$105.43
|
| Rate for Payer: Cigna of CA PPO |
$105.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.25
|
| Rate for Payer: EPIC Health Plan Senior |
$60.25
|
| Rate for Payer: Galaxy Health WC |
$128.03
|
| Rate for Payer: Global Benefits Group Commercial |
$90.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$93.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.15
|
| Rate for Payer: Multiplan Commercial |
$120.50
|
| Rate for Payer: Networks By Design Commercial |
$97.90
|
| Rate for Payer: Prime Health Services Commercial |
$128.03
|
|
|
ADAPALENE 0.1 % TOPICAL CREAM [21831]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 45802-453-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$4.45
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO |
$4.22
|
| Rate for Payer: Cigna of CA PPO |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
|
ADAPALENE 0.1 % TOPICAL CREAM [21831]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 45802-453-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.70
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cigna of CA HMO |
$4.22
|
| Rate for Payer: Cigna of CA PPO |
$4.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.22
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$3.02
|
| Rate for Payer: United Healthcare HMO Rider |
$3.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
ADENOSINE 300 MCG/ML KIT (NICU) IN NS [4080614]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 9994-0806-14
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.42
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cigna of CA HMO |
$4.61
|
| Rate for Payer: Cigna of CA PPO |
$5.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Senior |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.04
|
| Rate for Payer: Multiplan Commercial |
$5.76
|
| Rate for Payer: Networks By Design Commercial |
$4.68
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO |
$3.60
|
| Rate for Payer: United Healthcare HMO Rider |
$3.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
|
|
ADENOSINE 300 MCG/ML KIT (NICU) IN NS [4080614]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 9994-0806-14
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Senior |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$5.76
|
| Rate for Payer: Networks By Design Commercial |
$4.68
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Networks By Design Commercial |
$3.29
|
| Rate for Payer: Networks By Design Commercial |
$1.80
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Prime Health Services Commercial |
$5.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.47
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO |
$2.40
|
| Rate for Payer: United Healthcare HMO Rider |
$2.35
|
| Rate for Payer: United Healthcare HMO Rider |
$1.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.58
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$5.58
|
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.05
|
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cigna of CA HMO |
$4.60
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$4.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.63
|
| Rate for Payer: EPIC Health Plan Senior |
$2.63
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$5.58
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$3.94
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$4.85
|
| Rate for Payer: Blue Shield of California Commercial |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$3.19
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO |
$4.60
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$4.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.63
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Senior |
$2.63
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Galaxy Health WC |
$5.58
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
| Rate for Payer: Networks By Design Commercial |
$3.29
|
| Rate for Payer: Networks By Design Commercial |
$1.80
|
| Rate for Payer: Prime Health Services Commercial |
$5.58
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.47
|
| Rate for Payer: United Healthcare All Other HMO |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare HMO Rider |
$1.29
|
| Rate for Payer: United Healthcare HMO Rider |
$2.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
|
OP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.05
|
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cigna of CA HMO |
$4.60
|
| Rate for Payer: Cigna of CA PPO |
$4.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.63
|
| Rate for Payer: EPIC Health Plan Senior |
$2.63
|
| Rate for Payer: Galaxy Health WC |
$5.58
|
| Rate for Payer: Global Benefits Group Commercial |
$3.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
| Rate for Payer: Networks By Design Commercial |
$3.29
|
| Rate for Payer: Prime Health Services Commercial |
$5.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.47
|
| Rate for Payer: United Healthcare All Other HMO |
$2.40
|
| Rate for Payer: United Healthcare HMO Rider |
$2.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.58
|
| Rate for Payer: Vantage Medical Group Senior |
$5.58
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California Commercial |
$4.85
|
| Rate for Payer: Blue Shield of California EPN |
$3.19
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cigna of CA HMO |
$4.60
|
| Rate for Payer: Cigna of CA PPO |
$4.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.63
|
| Rate for Payer: EPIC Health Plan Senior |
$2.63
|
| Rate for Payer: Galaxy Health WC |
$5.58
|
| Rate for Payer: Global Benefits Group Commercial |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
| Rate for Payer: Networks By Design Commercial |
$3.29
|
| Rate for Payer: Prime Health Services Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.47
|
| Rate for Payer: United Healthcare All Other HMO |
$2.40
|
| Rate for Payer: United Healthcare HMO Rider |
$2.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.15
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.05
|
| Rate for Payer: Blue Shield of California Commercial |
$2.18
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.29
|
| Rate for Payer: EPIC Health Plan Senior |
$2.29
|
| Rate for Payer: Galaxy Health WC |
$4.86
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.00
|
| Rate for Payer: Multiplan Commercial |
$4.58
|
| Rate for Payer: Networks By Design Commercial |
$2.86
|
| Rate for Payer: Prime Health Services Commercial |
$4.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO |
$2.09
|
| Rate for Payer: United Healthcare HMO Rider |
$2.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Vantage Medical Group Senior |
$4.86
|
|
