|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
NDC 70100-725-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$224.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$257.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$210.64
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Cigna of CA HMO |
$219.52
|
| Rate for Payer: Cigna of CA PPO |
$253.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$291.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$291.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$240.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$240.10
|
| Rate for Payer: Multiplan Commercial |
$274.40
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$205.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$205.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.50
|
| Rate for Payer: United Healthcare All Other HMO |
$171.50
|
| Rate for Payer: United Healthcare HMO Rider |
$171.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$291.55
|
| Rate for Payer: Vantage Medical Group Senior |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 70100-725-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Blue Shield of California Commercial |
$253.13
|
| Rate for Payer: Blue Shield of California EPN |
$166.70
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Multiplan Commercial |
$274.40
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
NDC 70100-825-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$224.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$257.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$210.64
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Cigna of CA HMO |
$219.52
|
| Rate for Payer: Cigna of CA PPO |
$253.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$291.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$291.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$240.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$240.10
|
| Rate for Payer: Multiplan Commercial |
$274.40
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$205.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$205.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.50
|
| Rate for Payer: United Healthcare All Other HMO |
$171.50
|
| Rate for Payer: United Healthcare HMO Rider |
$171.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$291.55
|
| Rate for Payer: Vantage Medical Group Senior |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 70100-825-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Blue Shield of California Commercial |
$253.13
|
| Rate for Payer: Blue Shield of California EPN |
$166.70
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Multiplan Commercial |
$274.40
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
IP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.10 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Blue Shield of California Commercial |
$328.77
|
| Rate for Payer: Blue Shield of California EPN |
$216.51
|
| Rate for Payer: Cash Price |
$245.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: EPIC Health Plan Senior |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$297.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$275.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.92
|
| Rate for Payer: Multiplan Commercial |
$356.39
|
| Rate for Payer: Networks By Design Commercial |
$289.57
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
OP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.10 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$292.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$334.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$273.58
|
| Rate for Payer: Cash Price |
$245.02
|
| Rate for Payer: Cigna of CA HMO |
$285.11
|
| Rate for Payer: Cigna of CA PPO |
$329.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$378.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: EPIC Health Plan Senior |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$297.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$275.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$311.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$311.84
|
| Rate for Payer: Multiplan Commercial |
$356.39
|
| Rate for Payer: Networks By Design Commercial |
$289.57
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$267.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$267.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$222.75
|
| Rate for Payer: United Healthcare All Other HMO |
$222.75
|
| Rate for Payer: United Healthcare HMO Rider |
$222.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$222.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.67
|
| Rate for Payer: Vantage Medical Group Senior |
$378.67
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
901700029
|
|
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: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| 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: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| 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 HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| 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: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.86 |
| Max. Negotiated Rate |
$369.15 |
| Rate for Payer: Adventist Health Commercial |
$86.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$284.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$238.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$325.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$266.70
|
| Rate for Payer: Cash Price |
$238.86
|
| Rate for Payer: Cigna of CA HMO |
$304.00
|
| Rate for Payer: Cigna of CA PPO |
$304.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$369.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.72
|
| Rate for Payer: EPIC Health Plan Senior |
$173.72
|
| Rate for Payer: Galaxy Health WC |
$369.15
|
| Rate for Payer: Global Benefits Group Commercial |
$260.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$268.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$304.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$304.00
|
| Rate for Payer: Multiplan Commercial |
$347.43
|
| Rate for Payer: Networks By Design Commercial |
$282.29
|
| Rate for Payer: Prime Health Services Commercial |
$369.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$260.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$260.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$217.15
|
| Rate for Payer: United Healthcare All Other HMO |
$217.15
|
| Rate for Payer: United Healthcare HMO Rider |
$217.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$217.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.15
|
| Rate for Payer: Vantage Medical Group Senior |
$369.15
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.86 |
| Max. Negotiated Rate |
$369.15 |
| Rate for Payer: Adventist Health Commercial |
$86.86
|
| Rate for Payer: Blue Shield of California Commercial |
$320.51
|
| Rate for Payer: Blue Shield of California EPN |
$211.06
|
| Rate for Payer: Cash Price |
$238.86
|
| Rate for Payer: Cigna of CA HMO |
$304.00
|
| Rate for Payer: Cigna of CA PPO |
$304.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.72
|
| Rate for Payer: EPIC Health Plan Senior |
$173.72
|
| Rate for Payer: Galaxy Health WC |
$369.15
|
| Rate for Payer: Global Benefits Group Commercial |
$260.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$268.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.23
|
| Rate for Payer: Multiplan Commercial |
$347.43
|
| Rate for Payer: Networks By Design Commercial |
$282.29
|
| Rate for Payer: Prime Health Services Commercial |
$369.15
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.52 |
| Max. Negotiated Rate |
$484.50 |
| Rate for Payer: Adventist Health Commercial |
$114.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$373.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$129.03
|
| Rate for Payer: Blue Shield of California Commercial |
$57.00
|
| Rate for Payer: Blue Shield of California EPN |
$57.00
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cigna of CA HMO |
$399.00
|
| Rate for Payer: Cigna of CA PPO |
$399.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$34.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.09
|
| Rate for Payer: EPIC Health Plan Senior |
$31.18
|
| Rate for Payer: Galaxy Health WC |
$484.50
|
| Rate for Payer: Global Benefits Group Commercial |
$342.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$31.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$380.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$31.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$136.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.78
|
| Rate for Payer: Multiplan Commercial |
$456.00
|
| Rate for Payer: Networks By Design Commercial |
$285.00
|
| Rate for Payer: Prime Health Services Commercial |
$484.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$342.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$342.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$213.92
|
| Rate for Payer: United Healthcare All Other HMO |
$208.22
|
| Rate for Payer: United Healthcare HMO Rider |
$203.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$186.68
|
| Rate for Payer: Upland Medical Group Pediatric |
$31.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.30
|
| Rate for Payer: Vantage Medical Group Senior |
$34.30
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
HCPCS J1745
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.00 |
| Max. Negotiated Rate |
$484.50 |
| Rate for Payer: Adventist Health Commercial |
$114.00
|
| Rate for Payer: Blue Shield of California Commercial |
$420.66
|
| Rate for Payer: Blue Shield of California EPN |
$277.02
|
| Rate for Payer: Cash Price |
$313.50
|
| Rate for Payer: Cigna of CA HMO |
$399.00
|
| Rate for Payer: Cigna of CA PPO |
$399.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$228.00
|
| Rate for Payer: EPIC Health Plan Senior |
$228.00
|
| Rate for Payer: Galaxy Health WC |
$484.50
|
| Rate for Payer: Global Benefits Group Commercial |
$342.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$380.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$352.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$136.80
|
| Rate for Payer: Multiplan Commercial |
$456.00
|
| Rate for Payer: Networks By Design Commercial |
$285.00
|
| Rate for Payer: Prime Health Services Commercial |
$484.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$213.92
|
| Rate for Payer: United Healthcare All Other HMO |
$208.22
|
| Rate for Payer: United Healthcare HMO Rider |
$203.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$186.68
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
OP
|
$904.07
|
|
|
Service Code
|
HCPCS Q5104
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$768.46 |
| Rate for Payer: Adventist Health Commercial |
$180.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$592.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$37.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$204.66
|
| Rate for Payer: Blue Shield of California Commercial |
$90.41
|
| Rate for Payer: Blue Shield of California EPN |
$90.41
|
| Rate for Payer: Cash Price |
$497.24
|
| Rate for Payer: Cash Price |
$497.24
|
| Rate for Payer: Cigna of CA HMO |
$632.85
|
| Rate for Payer: Cigna of CA PPO |
$632.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.82
|
| Rate for Payer: EPIC Health Plan Senior |
$25.05
|
| Rate for Payer: Galaxy Health WC |
$768.46
|
| Rate for Payer: Global Benefits Group Commercial |
$542.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$603.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$25.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$31.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.57
|
| Rate for Payer: Multiplan Commercial |
$723.26
|
| Rate for Payer: Networks By Design Commercial |
$452.04
|
| Rate for Payer: Prime Health Services Commercial |
$768.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$542.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$542.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$339.30
|
| Rate for Payer: United Healthcare All Other HMO |
$330.26
|
| Rate for Payer: United Healthcare HMO Rider |
$323.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$296.08
|
| Rate for Payer: Upland Medical Group Pediatric |
$25.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.55
|
| Rate for Payer: Vantage Medical Group Senior |
$27.55
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
IP
|
$904.07
|
|
|
Service Code
|
HCPCS Q5104
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.81 |
| Max. Negotiated Rate |
$768.46 |
| Rate for Payer: Adventist Health Commercial |
$180.81
|
| Rate for Payer: Blue Shield of California Commercial |
$667.20
|
| Rate for Payer: Blue Shield of California EPN |
$439.38
|
| Rate for Payer: Cash Price |
$497.24
|
| Rate for Payer: Cigna of CA HMO |
$632.85
|
| Rate for Payer: Cigna of CA PPO |
$632.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$361.63
|
| Rate for Payer: EPIC Health Plan Senior |
$361.63
|
| Rate for Payer: Galaxy Health WC |
$768.46
|
| Rate for Payer: Global Benefits Group Commercial |
$542.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$603.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$344.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$559.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.98
|
| Rate for Payer: Multiplan Commercial |
$723.26
|
| Rate for Payer: Networks By Design Commercial |
$452.04
|
| Rate for Payer: Prime Health Services Commercial |
$768.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$339.30
|
| Rate for Payer: United Healthcare All Other HMO |
$330.26
|
| Rate for Payer: United Healthcare HMO Rider |
$323.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$296.08
|
|
|
INJ CHEST TUBE W/FIBRINOLYTIC INITIAL DAY
|
Facility
|
IP
|
$1,697.00
|
|
|
Service Code
|
CPT 32561
|
| Hospital Charge Code |
909020046
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$339.40 |
| Max. Negotiated Rate |
$1,442.45 |
| Rate for Payer: Adventist Health Commercial |
$339.40
|
| Rate for Payer: Cash Price |
$763.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$678.80
|
| Rate for Payer: EPIC Health Plan Senior |
$678.80
|
| Rate for Payer: Galaxy Health WC |
$1,442.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1,018.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,131.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$646.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,050.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$407.28
|
| Rate for Payer: Multiplan Commercial |
$1,357.60
|
| Rate for Payer: Networks By Design Commercial |
$1,103.05
|
| Rate for Payer: Prime Health Services Commercial |
$1,442.45
|
|
