|
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 0409-4093-01
|
| Hospital Charge Code |
1757538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Galaxy Health WC |
$2.02
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.90
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.02
|
|
|
Chromotubation of oviduct, including materials
|
Facility
|
OP
|
$10,191.89
|
|
|
Service Code
|
CPT 58350
|
| Min. Negotiated Rate |
$275.35 |
| Max. Negotiated Rate |
$10,191.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,214.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Dignity Health Media |
$6,214.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$6,836.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,389.67
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6,214.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$6,214.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$10,191.89
|
| Rate for Payer: Heritage Provider Network Transplant |
$10,191.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,067.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$10,067.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,214.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$275.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,214.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,830.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,327.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,321.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6,836.03
|
| Rate for Payer: Vantage Medical Group Senior |
$6,214.57
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
|
IP
|
$8,306.90
|
|
|
Service Code
|
APR-DRG 4702
|
| Min. Negotiated Rate |
$6,372.26 |
| Max. Negotiated Rate |
$8,306.90 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,372.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,306.90
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
|
IP
|
$6,098.92
|
|
|
Service Code
|
APR-DRG 4701
|
| Min. Negotiated Rate |
$4,678.52 |
| Max. Negotiated Rate |
$6,098.92 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,678.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,098.92
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
|
IP
|
$13,724.80
|
|
|
Service Code
|
APR-DRG 4703
|
| Min. Negotiated Rate |
$10,528.37 |
| Max. Negotiated Rate |
$13,724.80 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,528.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,724.80
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
|
IP
|
$24,041.02
|
|
|
Service Code
|
APR-DRG 4704
|
| Min. Negotiated Rate |
$18,442.00 |
| Max. Negotiated Rate |
$24,041.02 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,442.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,041.02
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
|
IP
|
$8,429.26
|
|
|
Service Code
|
APR-DRG 1401
|
| Min. Negotiated Rate |
$6,466.13 |
| Max. Negotiated Rate |
$8,429.26 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,466.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,429.26
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
|
IP
|
$18,619.56
|
|
|
Service Code
|
APR-DRG 1404
|
| Min. Negotiated Rate |
$14,283.16 |
| Max. Negotiated Rate |
$18,619.56 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,283.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,619.56
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
|
IP
|
$10,381.83
|
|
|
Service Code
|
APR-DRG 1402
|
| Min. Negotiated Rate |
$7,963.95 |
| Max. Negotiated Rate |
$10,381.83 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,963.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,381.83
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
|
IP
|
$12,589.80
|
|
|
Service Code
|
APR-DRG 1403
|
| Min. Negotiated Rate |
$9,657.70 |
| Max. Negotiated Rate |
$12,589.80 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,657.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,589.80
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
|
IP
|
$352.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX227971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.67 |
| Max. Negotiated Rate |
$299.88 |
| Rate for Payer: Blue Shield of California Commercial |
$251.19
|
| Rate for Payer: Blue Shield of California EPN |
$180.63
|
| Rate for Payer: Cash Price |
$158.76
|
| Rate for Payer: Cigna of CA HMO |
$246.96
|
| Rate for Payer: Cigna of CA PPO |
$246.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$141.12
|
| Rate for Payer: Galaxy Health WC |
$299.88
|
| Rate for Payer: Global Benefits Group Commercial |
$211.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$235.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.67
|
| Rate for Payer: Multiplan Commercial |
$282.24
|
| Rate for Payer: Networks By Design Commercial |
$176.40
|
| Rate for Payer: Prime Health Services Commercial |
$299.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$133.22
|
| Rate for Payer: United Healthcare All Other HMO |
$130.11
|
| Rate for Payer: United Healthcare HMO Rider |
$127.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.42
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
|
OP
|
$352.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX227971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.67 |
| Max. Negotiated Rate |
$299.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$231.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$299.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$194.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$194.04
|
| Rate for Payer: Blue Distinction Transplant |
$211.68
|
| Rate for Payer: Blue Shield of California Commercial |
$260.01
|
| Rate for Payer: Blue Shield of California EPN |
$206.04
|
| Rate for Payer: Cash Price |
$158.76
|
| Rate for Payer: Cigna of CA HMO |
$246.96
|
| Rate for Payer: Cigna of CA PPO |
$246.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$299.88
|
| Rate for Payer: Dignity Health Media |
$299.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$299.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$141.12
|
| Rate for Payer: Galaxy Health WC |
$299.88
|
| Rate for Payer: Global Benefits Group Commercial |
$211.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$264.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$235.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.67
|
| Rate for Payer: Multiplan Commercial |
$282.24
|
| Rate for Payer: Networks By Design Commercial |
$176.40
|
| Rate for Payer: Prime Health Services Commercial |
$299.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$211.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$211.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$176.40
|
| Rate for Payer: United Healthcare All Other HMO |
$176.40
|
| Rate for Payer: United Healthcare HMO Rider |
$176.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$176.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$299.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$299.88
|
| Rate for Payer: Vantage Medical Group Senior |
$299.88
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 45802-138-11
|
| Hospital Charge Code |
1743680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| Rate for Payer: Blue Distinction Transplant |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Media |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO |
$0.54
|
| Rate for Payer: United Healthcare HMO Rider |
$0.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
OP
|
$1.49
|
|
|
Service Code
|
NDC 51672-1318-1
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.89
|
| Rate for Payer: Blue Distinction Transplant |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Media |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.19
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
IP
|
$1.23
|
|
|
Service Code
|
NDC 68462-297-17
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
NDC 51672-1318-1
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.19
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 45802-138-11
|
| Hospital Charge Code |
1743680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Networks By Design Commercial |
$0.70
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
OP
|
$1.23
|
|
|
Service Code
|
NDC 68462-297-17
|
| Hospital Charge Code |
NDG9598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: Blue Distinction Transplant |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Media |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.62
|
| Rate for Payer: United Healthcare HMO Rider |
$0.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
IP
|
$6.76
|
|
|
Service Code
|
NDC 50383-419-06
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$5.75 |
| Rate for Payer: Blue Shield of California Commercial |
$4.81
|
| Rate for Payer: Blue Shield of California EPN |
$3.46
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cigna of CA HMO |
$4.73
|
| Rate for Payer: Cigna of CA PPO |
$4.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: Galaxy Health WC |
$5.75
|
| Rate for Payer: Global Benefits Group Commercial |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$5.41
|
| Rate for Payer: Networks By Design Commercial |
$4.39
|
| Rate for Payer: Prime Health Services Commercial |
$5.75
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
OP
|
$5.82
|
|
|
Service Code
|
NDC 0713-0317-88
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.47
|
| Rate for Payer: Blue Distinction Transplant |
$3.49
|
| Rate for Payer: Blue Shield of California Commercial |
$4.29
|
| Rate for Payer: Blue Shield of California EPN |
$3.40
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cigna of CA HMO |
$4.07
|
| Rate for Payer: Cigna of CA PPO |
$4.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.95
|
| Rate for Payer: Dignity Health Media |
$4.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.33
|
| Rate for Payer: Galaxy Health WC |
$4.95
|
| Rate for Payer: Global Benefits Group Commercial |
$3.49
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.66
|
| Rate for Payer: Networks By Design Commercial |
$3.78
|
| Rate for Payer: Prime Health Services Commercial |
$4.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.91
|
| Rate for Payer: United Healthcare All Other HMO |
$2.91
|
| Rate for Payer: United Healthcare HMO Rider |
$2.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.95
|
| Rate for Payer: Vantage Medical Group Senior |
$4.95
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
OP
|
$6.76
|
|
|
Service Code
|
NDC 50383-419-06
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$5.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.03
|
| Rate for Payer: Blue Distinction Transplant |
$4.06
|
| Rate for Payer: Blue Shield of California Commercial |
$4.98
|
| Rate for Payer: Blue Shield of California EPN |
$3.95
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cigna of CA HMO |
$4.73
|
| Rate for Payer: Cigna of CA PPO |
$4.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.75
|
| Rate for Payer: Dignity Health Media |
$5.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.70
|
| Rate for Payer: Galaxy Health WC |
$5.75
|
| Rate for Payer: Global Benefits Group Commercial |
$4.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$5.41
|
| Rate for Payer: Networks By Design Commercial |
$4.39
|
| Rate for Payer: Prime Health Services Commercial |
$5.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.38
|
| Rate for Payer: United Healthcare All Other HMO |
$3.38
|
| Rate for Payer: United Healthcare HMO Rider |
$3.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Vantage Medical Group Senior |
$5.75
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
IP
|
$5.82
|
|
|
Service Code
|
NDC 0713-0317-88
|
| Hospital Charge Code |
1743748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Blue Shield of California Commercial |
$4.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.98
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cigna of CA HMO |
$4.07
|
| Rate for Payer: Cigna of CA PPO |
$4.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: Galaxy Health WC |
$4.95
|
| Rate for Payer: Global Benefits Group Commercial |
$3.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.66
|
| Rate for Payer: Networks By Design Commercial |
$3.78
|
| Rate for Payer: Prime Health Services Commercial |
$4.95
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
|
IP
|
$24.48
|
|
|
Service Code
|
NDC 9994-0825-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$20.81 |
| Rate for Payer: Blue Shield of California Commercial |
$17.43
|
| Rate for Payer: Blue Shield of California EPN |
$12.53
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cigna of CA HMO |
$17.14
|
| Rate for Payer: Cigna of CA PPO |
$17.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.79
|
| Rate for Payer: Galaxy Health WC |
$20.81
|
| Rate for Payer: Global Benefits Group Commercial |
$14.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.88
|
| Rate for Payer: Multiplan Commercial |
$19.58
|
| Rate for Payer: Networks By Design Commercial |
$12.24
|
| Rate for Payer: Prime Health Services Commercial |
$20.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Other HMO |
$9.03
|
| Rate for Payer: United Healthcare HMO Rider |
$8.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.08
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
|
OP
|
$24.48
|
|
|
Service Code
|
NDC 9994-0825-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$20.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$16.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.59
|
| Rate for Payer: Blue Distinction Transplant |
$14.69
|
| Rate for Payer: Blue Shield of California Commercial |
$18.04
|
| Rate for Payer: Blue Shield of California EPN |
$14.30
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cigna of CA HMO |
$17.14
|
| Rate for Payer: Cigna of CA PPO |
$17.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.81
|
| Rate for Payer: Dignity Health Media |
$20.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.79
|
| Rate for Payer: Galaxy Health WC |
$20.81
|
| Rate for Payer: Global Benefits Group Commercial |
$14.69
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$18.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.88
|
| Rate for Payer: Multiplan Commercial |
$19.58
|
| Rate for Payer: Networks By Design Commercial |
$12.24
|
| Rate for Payer: Prime Health Services Commercial |
$20.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.24
|
| Rate for Payer: United Healthcare All Other HMO |
$12.24
|
| Rate for Payer: United Healthcare HMO Rider |
$12.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.81
|
| Rate for Payer: Vantage Medical Group Senior |
$20.81
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
|
OP
|
$36.54
|
|
|
Service Code
|
NDC 99994-811-61
|
| Hospital Charge Code |
NDC4081161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$31.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.77
|
| Rate for Payer: Blue Distinction Transplant |
$21.92
|
| Rate for Payer: Blue Shield of California Commercial |
$26.93
|
| Rate for Payer: Blue Shield of California EPN |
$21.34
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO |
$25.58
|
| Rate for Payer: Cigna of CA PPO |
$25.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.06
|
| Rate for Payer: Dignity Health Media |
$31.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.62
|
| Rate for Payer: Galaxy Health WC |
$31.06
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$27.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Multiplan Commercial |
$29.23
|
| Rate for Payer: Networks By Design Commercial |
$18.27
|
| Rate for Payer: Prime Health Services Commercial |
$31.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.27
|
| Rate for Payer: United Healthcare All Other HMO |
$18.27
|
| Rate for Payer: United Healthcare HMO Rider |
$18.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.06
|
| Rate for Payer: Vantage Medical Group Senior |
$31.06
|
|
