|
COAGULATION FACTOR IX (RECOMB) 250 UNIT INTRAVENOUS SOLUTION [203435]
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203435
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO |
$1.35
|
| Rate for Payer: Cigna of CA PPO |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.64
|
| Rate for Payer: Global Benefits Group Commercial |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.71
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.64
|
|
|
COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [203439]
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO |
$1.35
|
| Rate for Payer: Cigna of CA PPO |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.64
|
| Rate for Payer: Global Benefits Group Commercial |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.71
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.64
|
|
|
COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [203439]
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$11.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Distinction Transplant |
$1.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.69
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO |
$1.35
|
| Rate for Payer: Cigna of CA PPO |
$1.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Media |
$1.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.75
|
| Rate for Payer: Galaxy Health WC |
$1.64
|
| Rate for Payer: Global Benefits Group Commercial |
$1.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Transplant |
$2.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$2.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.97
|
| Rate for Payer: United Healthcare All Other HMO |
$0.97
|
| Rate for Payer: United Healthcare HMO Rider |
$0.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
COAGULATION FACTOR IX (RECOMB) 500 UNIT INTRAVENOUS SOLUTION [203436]
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$11.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Distinction Transplant |
$1.16
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.69
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO |
$1.35
|
| Rate for Payer: Cigna of CA PPO |
$1.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Media |
$1.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.75
|
| Rate for Payer: Galaxy Health WC |
$1.64
|
| Rate for Payer: Global Benefits Group Commercial |
$1.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Transplant |
$2.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$2.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.97
|
| Rate for Payer: United Healthcare All Other HMO |
$0.97
|
| Rate for Payer: United Healthcare HMO Rider |
$0.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
COAGULATION FACTOR IX (RECOMB) 500 UNIT INTRAVENOUS SOLUTION [203436]
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
CPT J7195
|
| Hospital Charge Code |
ERX203436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna of CA HMO |
$1.35
|
| Rate for Payer: Cigna of CA PPO |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
| Rate for Payer: Galaxy Health WC |
$1.64
|
| Rate for Payer: Global Benefits Group Commercial |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.54
|
| Rate for Payer: Networks By Design Commercial |
$0.97
|
| Rate for Payer: Prime Health Services Commercial |
$1.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.71
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.64
|
|
|
COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION [92853]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Blue Shield of California Commercial |
$2.19
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.23
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.02
|
|
|
COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION [92853]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.76
|
| Rate for Payer: Blue Distinction Transplant |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$2.78
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Media |
$2.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.43
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.98
|
| Rate for Payer: Heritage Provider Network Transplant |
$3.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1.54
|
| Rate for Payer: United Healthcare HMO Rider |
$1.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
|
COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION [92854]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Blue Shield of California Commercial |
$2.19
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.23
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.02
|
|
|
COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION [92854]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.76
|
| Rate for Payer: Blue Distinction Transplant |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$2.78
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Media |
$2.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.43
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.98
|
| Rate for Payer: Heritage Provider Network Transplant |
$3.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1.54
|
| Rate for Payer: United Healthcare HMO Rider |
$1.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
|
COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION [92855]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Blue Shield of California Commercial |
$2.19
|
| Rate for Payer: Blue Shield of California EPN |
$1.58
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.23
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.02
|
|
|
COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION [92855]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.76
|
| Rate for Payer: Blue Distinction Transplant |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$2.78
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Media |
$2.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.43
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.98
|
| Rate for Payer: Heritage Provider Network Transplant |
$3.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$1.54
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1.54
|
| Rate for Payer: United Healthcare HMO Rider |
$1.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
|
COBICISTAT 150 MG TABLET [207759]
|
Facility
|
OP
|
$11.33
|
|
|
Service Code
|
NDC 61958-1401-1
|
| Hospital Charge Code |
ERX207759
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.75
|
| Rate for Payer: Blue Distinction Transplant |
$6.80
|
| Rate for Payer: Blue Shield of California Commercial |
$8.35
|
| Rate for Payer: Blue Shield of California EPN |
$6.62
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna of CA HMO |
$7.93
|
| Rate for Payer: Cigna of CA PPO |
$7.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.63
|
| Rate for Payer: Dignity Health Media |
$9.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.53
|
| Rate for Payer: Galaxy Health WC |
$9.63
|
| Rate for Payer: Global Benefits Group Commercial |
$6.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Commercial |
$9.06
|
| Rate for Payer: Networks By Design Commercial |
$7.36
|
| Rate for Payer: Prime Health Services Commercial |
$9.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.66
|
| Rate for Payer: United Healthcare All Other HMO |
$5.66
|
| Rate for Payer: United Healthcare HMO Rider |
$5.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.63
|
| Rate for Payer: Vantage Medical Group Senior |
$9.63
|
|
|
COBICISTAT 150 MG TABLET [207759]
|
Facility
|
IP
|
$11.33
|
|
|
Service Code
|
NDC 61958-1401-1
|
| Hospital Charge Code |
ERX207759
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Blue Shield of California Commercial |
$8.07
|
| Rate for Payer: Blue Shield of California EPN |
$5.80
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna of CA HMO |
$7.93
|
| Rate for Payer: Cigna of CA PPO |
$7.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.53
|
| Rate for Payer: Galaxy Health WC |
$9.63
|
| Rate for Payer: Global Benefits Group Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Commercial |
$9.06
|
| Rate for Payer: Networks By Design Commercial |
$7.36
|
| Rate for Payer: Prime Health Services Commercial |
$9.63
|
|
|
COCAINE 4 % NASAL SOLUTION [221651]
|
Facility
|
OP
|
$73.50
|
|
|
Service Code
|
CPT C9046
|
| Hospital Charge Code |
1734001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$62.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$40.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.94
|
| Rate for Payer: Blue Distinction Transplant |
$39.69
|
| Rate for Payer: Blue Distinction Transplant |
$44.10
|
| Rate for Payer: Blue Shield of California Commercial |
$54.17
|
| Rate for Payer: Blue Shield of California Commercial |
$48.75
|
| Rate for Payer: Blue Shield of California EPN |
$42.92
|
| Rate for Payer: Blue Shield of California EPN |
$38.63
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cigna of CA HMO |
$51.45
|
| Rate for Payer: Cigna of CA HMO |
$46.30
|
| Rate for Payer: Cigna of CA PPO |
$46.30
|
| Rate for Payer: Cigna of CA PPO |
$51.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.48
|
| Rate for Payer: Dignity Health Media |
$56.23
|
| Rate for Payer: Dignity Health Media |
$62.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$26.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$29.40
|
| Rate for Payer: Galaxy Health WC |
$56.23
|
| Rate for Payer: Galaxy Health WC |
$62.48
|
| Rate for Payer: Global Benefits Group Commercial |
$44.10
|
| Rate for Payer: Global Benefits Group Commercial |
$39.69
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$49.61
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$55.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$49.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.64
|
| Rate for Payer: Multiplan Commercial |
$58.80
|
| Rate for Payer: Multiplan Commercial |
$52.92
|
| Rate for Payer: Networks By Design Commercial |
$33.08
|
| Rate for Payer: Networks By Design Commercial |
$36.75
|
| Rate for Payer: Prime Health Services Commercial |
$62.48
|
| Rate for Payer: Prime Health Services Commercial |
$56.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$44.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$39.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$39.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$44.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.75
|
| Rate for Payer: United Healthcare All Other HMO |
$36.75
|
| Rate for Payer: United Healthcare All Other HMO |
$33.08
|
| Rate for Payer: United Healthcare HMO Rider |
$36.75
|
| Rate for Payer: United Healthcare HMO Rider |
$33.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$56.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.48
|
| Rate for Payer: Vantage Medical Group Senior |
$62.48
|
| Rate for Payer: Vantage Medical Group Senior |
$56.23
|
|
|
COCAINE 4 % NASAL SOLUTION [221651]
|
Facility
|
IP
|
$66.15
|
|
|
Service Code
|
CPT C9046
|
| Hospital Charge Code |
1734001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.88 |
| Max. Negotiated Rate |
$56.23 |
| Rate for Payer: Blue Shield of California Commercial |
$47.10
|
| Rate for Payer: Blue Shield of California Commercial |
$52.33
|
| Rate for Payer: Blue Shield of California EPN |
$33.87
|
| Rate for Payer: Blue Shield of California EPN |
$37.63
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cigna of CA HMO |
$46.30
|
| Rate for Payer: Cigna of CA HMO |
$51.45
|
| Rate for Payer: Cigna of CA PPO |
$51.45
|
| Rate for Payer: Cigna of CA PPO |
$46.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$26.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$29.40
|
| Rate for Payer: Galaxy Health WC |
$56.23
|
| Rate for Payer: Galaxy Health WC |
$62.48
|
| Rate for Payer: Global Benefits Group Commercial |
$44.10
|
| Rate for Payer: Global Benefits Group Commercial |
$39.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$49.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.64
|
| Rate for Payer: Multiplan Commercial |
$52.92
|
| Rate for Payer: Multiplan Commercial |
$58.80
|
| Rate for Payer: Networks By Design Commercial |
$33.08
|
| Rate for Payer: Networks By Design Commercial |
$36.75
|
| Rate for Payer: Prime Health Services Commercial |
$56.23
|
| Rate for Payer: Prime Health Services Commercial |
$62.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$27.75
|
| Rate for Payer: United Healthcare All Other HMO |
$24.40
|
| Rate for Payer: United Healthcare All Other HMO |
$27.11
|
| Rate for Payer: United Healthcare HMO Rider |
$23.87
|
| Rate for Payer: United Healthcare HMO Rider |
$26.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.26
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
|
IP
|
$26,188.69
|
|
|
Service Code
|
APR-DRG 7744
|
| Min. Negotiated Rate |
$20,089.48 |
| Max. Negotiated Rate |
$26,188.69 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,089.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26,188.69
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
|
IP
|
$5,070.32
|
|
|
Service Code
|
APR-DRG 7741
|
| Min. Negotiated Rate |
$3,889.47 |
| Max. Negotiated Rate |
$5,070.32 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,889.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,070.32
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
|
IP
|
$6,145.04
|
|
|
Service Code
|
APR-DRG 7742
|
| Min. Negotiated Rate |
$4,713.89 |
| Max. Negotiated Rate |
$6,145.04 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,713.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,145.04
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
|
IP
|
$11,181.67
|
|
|
Service Code
|
APR-DRG 7743
|
| Min. Negotiated Rate |
$8,577.52 |
| Max. Negotiated Rate |
$11,181.67 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,577.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,181.67
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0121-1775-05
|
| Hospital Charge Code |
NDG78003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 9999-3252-16
|
| Hospital Charge Code |
1716075
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0121-1775-00
|
| Hospital Charge Code |
NDG78003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0121-1775-05
|
| Hospital Charge Code |
NDG78003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 9999-3252-16
|
| Hospital Charge Code |
1716075
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Distinction Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Media |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0121-1775-00
|
| Hospital Charge Code |
NDG78003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
