|
CHROMIUM CHLORIDE 4 MCG/ML INTRAVENOUS SOLUTION [1685]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.09
|
| Rate for Payer: Global Benefits Group Commercial |
$1.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: Networks By Design Commercial |
$1.23
|
| Rate for Payer: Prime Health Services Commercial |
$2.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.92
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2.09
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
|
IP
|
$20,989.17
|
|
|
Service Code
|
APR-DRG 4703
|
| Min. Negotiated Rate |
$16,763.72 |
| Max. Negotiated Rate |
$20,989.17 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,763.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20,989.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18,779.78
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
|
IP
|
$9,881.41
|
|
|
Service Code
|
APR-DRG 4701
|
| Min. Negotiated Rate |
$7,892.12 |
| Max. Negotiated Rate |
$9,881.41 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,892.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9,881.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,841.26
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
|
IP
|
$48,417.09
|
|
|
Service Code
|
APR-DRG 4704
|
| Min. Negotiated Rate |
$38,669.97 |
| Max. Negotiated Rate |
$48,417.09 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$38,669.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$48,417.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$43,320.56
|
|
|
CHRONIC KIDNEY DISEASE
|
Facility
|
IP
|
$12,641.36
|
|
|
Service Code
|
APR-DRG 4702
|
| Min. Negotiated Rate |
$10,096.46 |
| Max. Negotiated Rate |
$12,641.36 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,096.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,641.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,310.69
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
|
IP
|
$18,998.75
|
|
|
Service Code
|
APR-DRG 1403
|
| Min. Negotiated Rate |
$15,174.00 |
| Max. Negotiated Rate |
$18,998.75 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,174.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,998.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16,998.88
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
|
IP
|
$14,180.40
|
|
|
Service Code
|
APR-DRG 1402
|
| Min. Negotiated Rate |
$11,325.66 |
| Max. Negotiated Rate |
$14,180.40 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,325.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14,180.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12,687.73
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
|
IP
|
$41,342.76
|
|
|
Service Code
|
APR-DRG 1404
|
| Min. Negotiated Rate |
$33,019.81 |
| Max. Negotiated Rate |
$41,342.76 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33,019.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41,342.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$36,990.89
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
|
Facility
|
IP
|
$11,809.30
|
|
|
Service Code
|
APR-DRG 1401
|
| Min. Negotiated Rate |
$9,431.90 |
| Max. Negotiated Rate |
$11,809.30 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,431.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,809.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,566.21
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC
|
Facility
|
IP
|
$94,208.52
|
|
|
Service Code
|
MSDRG 191
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$94,208.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$25,556.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$94,208.52
|
| Rate for Payer: EPIC Health Plan Senior |
$62,805.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57,096.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79,934.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76,508.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC
|
Facility
|
IP
|
$98,905.57
|
|
|
Service Code
|
MSDRG 190
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$98,905.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$33,581.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$98,905.57
|
| Rate for Payer: EPIC Health Plan Senior |
$65,937.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59,942.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$83,919.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$80,323.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC
|
Facility
|
IP
|
$90,641.78
|
|
|
Service Code
|
MSDRG 192
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$90,641.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19,462.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$90,641.78
|
| Rate for Payer: EPIC Health Plan Senior |
$60,427.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$54,934.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$76,908.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$73,612.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
|
IP
|
$402.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.58 |
| Max. Negotiated Rate |
$342.47 |
| Rate for Payer: Adventist Health Commercial |
$80.58
|
| Rate for Payer: Blue Shield of California Commercial |
$204.28
|
| Rate for Payer: Blue Shield of California Commercial |
$309.84
|
| Rate for Payer: Cash Price |
$181.31
|
| Rate for Payer: Cigna of CA HMO |
$282.04
|
| Rate for Payer: Cigna of CA PPO |
$282.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$282.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$161.16
|
| Rate for Payer: EPIC Health Plan Senior |
$161.16
|
| Rate for Payer: Galaxy Health WC |
$342.47
|
| Rate for Payer: Global Benefits Group Commercial |
$241.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$255.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$237.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.70
|
| Rate for Payer: Multiplan Commercial |
$322.33
|
| Rate for Payer: Networks By Design Commercial |
$201.46
|
| Rate for Payer: Prime Health Services Commercial |
$342.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$151.21
|
| Rate for Payer: United Healthcare All Other HMO |
$147.18
|
| Rate for Payer: United Healthcare HMO Rider |
$144.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$131.95
|
|
|
C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]
|
Facility
|
OP
|
$402.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.58 |
| Max. Negotiated Rate |
$342.47 |
| Rate for Payer: Adventist Health Commercial |
$80.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$264.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$342.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$221.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$302.18
|
| Rate for Payer: Cash Price |
$181.31
|
| Rate for Payer: Cigna of CA HMO |
$282.04
|
| Rate for Payer: Cigna of CA PPO |
$282.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$342.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$342.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$342.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$282.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$161.16
|
| Rate for Payer: EPIC Health Plan Senior |
$161.16
|
| Rate for Payer: Galaxy Health WC |
$342.47
|
| Rate for Payer: Global Benefits Group Commercial |
$241.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$255.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$237.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$282.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$282.04
|
| Rate for Payer: Multiplan Commercial |
$322.33
|
| Rate for Payer: Networks By Design Commercial |
$201.46
|
| Rate for Payer: Prime Health Services Commercial |
$342.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$241.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$241.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$151.21
|
| Rate for Payer: United Healthcare All Other HMO |
$147.18
|
| Rate for Payer: United Healthcare HMO Rider |
$144.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$131.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$342.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$342.47
|
| Rate for Payer: Vantage Medical Group Senior |
$342.47
|
|
|
CICLOPIROX 0.77 % TOPICAL CREAM [9598]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 4580213811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| 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 |
$0.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| 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 Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Senior |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.76
|
| 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
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 4580213811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Senior |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.64
|
| 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 8 % TOPICAL SOLUTION [27158]
|
Facility
|
OP
|
$3.10
|
|
|
Service Code
|
NDC 2192205351
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.99
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$2.17
|
| Rate for Payer: Cigna of CA PPO |
$2.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.63
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: EPIC Health Plan Senior |
$1.24
|
| Rate for Payer: Galaxy Health WC |
$2.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.17
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
| Rate for Payer: Networks By Design Commercial |
$2.02
|
| Rate for Payer: Prime Health Services Commercial |
$2.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.55
|
| Rate for Payer: United Healthcare All Other HMO |
$1.55
|
| Rate for Payer: United Healthcare HMO Rider |
$1.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.63
|
| Rate for Payer: Vantage Medical Group Senior |
$2.63
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 4580214167
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.80
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna of CA HMO |
$3.05
|
| Rate for Payer: Cigna of CA PPO |
$3.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.71
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: EPIC Health Plan Senior |
$1.74
|
| Rate for Payer: Galaxy Health WC |
$3.71
|
| Rate for Payer: Global Benefits Group Commercial |
$2.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.05
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Networks By Design Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.18
|
| Rate for Payer: United Healthcare All Other HMO |
$2.18
|
| Rate for Payer: United Healthcare HMO Rider |
$2.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.71
|
| Rate for Payer: Vantage Medical Group Senior |
$3.71
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 4580214167
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California Commercial |
$3.35
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cigna of CA HMO |
$3.05
|
| Rate for Payer: Cigna of CA PPO |
$3.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.74
|
| Rate for Payer: EPIC Health Plan Senior |
$1.74
|
| Rate for Payer: Galaxy Health WC |
$3.71
|
| Rate for Payer: Global Benefits Group Commercial |
$2.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.49
|
| Rate for Payer: Networks By Design Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$3.71
|
|
|
CICLOPIROX 8 % TOPICAL SOLUTION [27158]
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 2192205351
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California Commercial |
$2.38
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$2.17
|
| Rate for Payer: Cigna of CA PPO |
$2.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: EPIC Health Plan Senior |
$1.24
|
| Rate for Payer: Galaxy Health WC |
$2.63
|
| Rate for Payer: Global Benefits Group Commercial |
$1.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
| Rate for Payer: Networks By Design Commercial |
$2.02
|
| Rate for Payer: Prime Health Services Commercial |
$2.63
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
|
IP
|
$24.48
|
|
|
Service Code
|
NDC 9994082503
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$20.81 |
| Rate for Payer: Adventist Health Commercial |
$4.90
|
| Rate for Payer: Blue Shield of California Commercial |
$12.41
|
| Rate for Payer: Blue Shield of California Commercial |
$18.83
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$17.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.79
|
| Rate for Payer: EPIC Health Plan Senior |
$9.79
|
| Rate for Payer: Galaxy Health WC |
$20.81
|
| Rate for Payer: Global Benefits Group Commercial |
$14.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.44
|
| 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 |
$15.91
|
| Rate for Payer: Prime Health Services Commercial |
$20.81
|
|
|
CIDOFOVIR 10 MG/ML TOPICAL [4082503]
|
Facility
|
OP
|
$24.48
|
|
|
Service Code
|
NDC 9994082503
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$20.81 |
| Rate for Payer: Adventist Health Commercial |
$4.90
|
| 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 |
$18.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.71
|
| 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 Medi-Cal |
$20.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$17.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.79
|
| Rate for Payer: EPIC Health Plan Senior |
$9.79
|
| Rate for Payer: Galaxy Health WC |
$20.81
|
| Rate for Payer: Global Benefits Group Commercial |
$14.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.14
|
| Rate for Payer: Multiplan Commercial |
$19.58
|
| Rate for Payer: Networks By Design Commercial |
$15.91
|
| 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
|
IP
|
$36.53
|
|
|
Service Code
|
NDC 9999481161
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Blue Shield of California Commercial |
$18.52
|
| Rate for Payer: Blue Shield of California Commercial |
$28.09
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO |
$25.57
|
| Rate for Payer: Cigna of CA PPO |
$25.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.61
|
| Rate for Payer: EPIC Health Plan Senior |
$14.61
|
| Rate for Payer: Galaxy Health WC |
$31.05
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Multiplan Commercial |
$29.22
|
| Rate for Payer: Networks By Design Commercial |
$23.74
|
| Rate for Payer: Prime Health Services Commercial |
$31.05
|
|
|
CIDOFOVIR 15 MG/ML TOPICAL [4081161]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 9999481161
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$23.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO |
$25.57
|
| Rate for Payer: Cigna of CA PPO |
$25.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.61
|
| Rate for Payer: EPIC Health Plan Senior |
$14.61
|
| Rate for Payer: Galaxy Health WC |
$31.05
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$29.22
|
| Rate for Payer: Networks By Design Commercial |
$23.74
|
| Rate for Payer: Prime Health Services Commercial |
$31.05
|
| 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 |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
|
CIDOFOVIR 1 MG/ML TOPICAL [4081092]
|
Facility
|
OP
|
$36.53
|
|
|
Service Code
|
NDC 9999481192
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Adventist Health Commercial |
$7.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$23.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.44
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cigna of CA HMO |
$25.57
|
| Rate for Payer: Cigna of CA PPO |
$25.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.61
|
| Rate for Payer: EPIC Health Plan Senior |
$14.61
|
| Rate for Payer: Galaxy Health WC |
$31.05
|
| Rate for Payer: Global Benefits Group Commercial |
$21.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.57
|
| Rate for Payer: Multiplan Commercial |
$29.22
|
| Rate for Payer: Networks By Design Commercial |
$23.74
|
| Rate for Payer: Prime Health Services Commercial |
$31.05
|
| 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 |
$31.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.05
|
| Rate for Payer: Vantage Medical Group Senior |
$31.05
|
|
