|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 69097-845-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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 |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 68084-753-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 50268-190-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 50268-190-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.41
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 68084-753-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 68084-753-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 29300-413-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 43547-399-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| 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 |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 68084-753-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Senior |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 29300-413-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 43547-399-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 69097-845-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.04
|
| 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
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.57
|
| Rate for Payer: Cigna of CA PPO |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: EPIC Health Plan Senior |
$0.90
|
| Rate for Payer: Galaxy Health WC |
$1.90
|
| Rate for Payer: Global Benefits Group Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Networks By Design Commercial |
$1.46
|
| Rate for Payer: Prime Health Services Commercial |
$1.90
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$15.29
|
|
|
Service Code
|
NDC 0065-0396-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Adventist Health Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California Commercial |
$11.28
|
| Rate for Payer: Blue Shield of California EPN |
$7.43
|
| Rate for Payer: Cash Price |
$8.41
|
| Rate for Payer: Cigna of CA HMO |
$10.70
|
| Rate for Payer: Cigna of CA PPO |
$10.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.12
|
| Rate for Payer: EPIC Health Plan Senior |
$6.12
|
| Rate for Payer: Galaxy Health WC |
$13.00
|
| Rate for Payer: Global Benefits Group Commercial |
$9.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.67
|
| Rate for Payer: Multiplan Commercial |
$12.23
|
| Rate for Payer: Networks By Design Commercial |
$9.94
|
| Rate for Payer: Prime Health Services Commercial |
$13.00
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$15.29
|
|
|
Service Code
|
NDC 0065-0396-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Adventist Health Commercial |
$3.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.39
|
| Rate for Payer: Cash Price |
$8.41
|
| Rate for Payer: Cigna of CA HMO |
$10.70
|
| Rate for Payer: Cigna of CA PPO |
$10.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.12
|
| Rate for Payer: EPIC Health Plan Senior |
$6.12
|
| Rate for Payer: Galaxy Health WC |
$13.00
|
| Rate for Payer: Global Benefits Group Commercial |
$9.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.70
|
| Rate for Payer: Multiplan Commercial |
$12.23
|
| Rate for Payer: Networks By Design Commercial |
$9.94
|
| Rate for Payer: Prime Health Services Commercial |
$13.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.64
|
| Rate for Payer: United Healthcare All Other HMO |
$7.64
|
| Rate for Payer: United Healthcare HMO Rider |
$7.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.00
|
| Rate for Payer: Vantage Medical Group Senior |
$13.00
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$7.17
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: EPIC Health Plan Senior |
$2.87
|
| Rate for Payer: Galaxy Health WC |
$6.09
|
| Rate for Payer: Cigna of CA HMO |
$5.02
|
| Rate for Payer: Cigna of CA PPO |
$5.02
|
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$5.29
|
| Rate for Payer: Blue Shield of California EPN |
$3.48
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Global Benefits Group Commercial |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$5.74
|
| Rate for Payer: Networks By Design Commercial |
$4.66
|
| Rate for Payer: Prime Health Services Commercial |
$6.09
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.38
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.57
|
| Rate for Payer: Cigna of CA PPO |
$1.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: EPIC Health Plan Senior |
$0.90
|
| Rate for Payer: Galaxy Health WC |
$1.90
|
| Rate for Payer: Global Benefits Group Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Networks By Design Commercial |
$1.46
|
| Rate for Payer: Prime Health Services Commercial |
$1.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.12
|
| Rate for Payer: United Healthcare All Other HMO |
$1.12
|
| Rate for Payer: United Healthcare HMO Rider |
$1.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$7.17
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.40
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO |
$5.02
|
| Rate for Payer: Cigna of CA PPO |
$5.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: EPIC Health Plan Senior |
$2.87
|
| Rate for Payer: Galaxy Health WC |
$6.09
|
| Rate for Payer: Global Benefits Group Commercial |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$5.74
|
| Rate for Payer: Networks By Design Commercial |
$4.66
|
| Rate for Payer: Prime Health Services Commercial |
$6.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3.58
|
| Rate for Payer: United Healthcare HMO Rider |
$3.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.09
|
| Rate for Payer: Vantage Medical Group Senior |
$6.09
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS >2 ML [4082025]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.38
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.57
|
| Rate for Payer: Cigna of CA PPO |
$1.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: EPIC Health Plan Senior |
$0.90
|
| Rate for Payer: Galaxy Health WC |
$1.90
|
| Rate for Payer: Global Benefits Group Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Networks By Design Commercial |
$1.46
|
| Rate for Payer: Prime Health Services Commercial |
$1.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.12
|
| Rate for Payer: United Healthcare All Other HMO |
$1.12
|
| Rate for Payer: United Healthcare HMO Rider |
$1.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS >2 ML [4082025]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 61314-396-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna of CA HMO |
$1.57
|
| Rate for Payer: Cigna of CA PPO |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: EPIC Health Plan Senior |
$0.90
|
| Rate for Payer: Galaxy Health WC |
$1.90
|
| Rate for Payer: Global Benefits Group Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: Networks By Design Commercial |
$1.46
|
| Rate for Payer: Prime Health Services Commercial |
$1.90
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]
|
Facility
|
IP
|
$22.21
|
|
|
Service Code
|
NDC 0065-0359-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: Adventist Health Commercial |
$4.44
|
| Rate for Payer: Blue Shield of California Commercial |
$16.39
|
| Rate for Payer: Blue Shield of California EPN |
$10.79
|
| Rate for Payer: Cash Price |
$12.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.88
|
| Rate for Payer: EPIC Health Plan Senior |
$8.88
|
| Rate for Payer: Galaxy Health WC |
$18.88
|
| Rate for Payer: Global Benefits Group Commercial |
$13.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.33
|
| Rate for Payer: Multiplan Commercial |
$17.77
|
| Rate for Payer: Networks By Design Commercial |
$14.44
|
| Rate for Payer: Prime Health Services Commercial |
$18.88
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]
|
Facility
|
OP
|
$22.21
|
|
|
Service Code
|
NDC 0065-0359-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: Adventist Health Commercial |
$4.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$14.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.64
|
| Rate for Payer: Cash Price |
$12.22
|
| Rate for Payer: Cigna of CA HMO |
$14.21
|
| Rate for Payer: Cigna of CA PPO |
$16.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.88
|
| Rate for Payer: EPIC Health Plan Senior |
$8.88
|
| Rate for Payer: Galaxy Health WC |
$18.88
|
| Rate for Payer: Global Benefits Group Commercial |
$13.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.55
|
| Rate for Payer: Multiplan Commercial |
$17.77
|
| Rate for Payer: Networks By Design Commercial |
$14.44
|
| Rate for Payer: Prime Health Services Commercial |
$18.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.11
|
| Rate for Payer: United Healthcare All Other HMO |
$11.11
|
| Rate for Payer: United Healthcare HMO Rider |
$11.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.88
|
| Rate for Payer: Vantage Medical Group Senior |
$18.88
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
|
OP
|
$283.20
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$240.72 |
| Rate for Payer: Adventist Health Commercial |
$56.64
|
| Rate for Payer: Adventist Health Commercial |
$60.72
|
| Rate for Payer: Adventist Health Commercial |
$86.40
|
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$185.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$283.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$199.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$137.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.03
|
| Rate for Payer: Blue Shield of California Commercial |
$2.22
|
| Rate for Payer: Blue Shield of California Commercial |
$2.22
|
| Rate for Payer: Blue Shield of California Commercial |
$2.22
|
| Rate for Payer: Blue Shield of California Commercial |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$155.76
|
| Rate for Payer: Cash Price |
$166.98
|
| Rate for Payer: Cash Price |
$155.76
|
| Rate for Payer: Cash Price |
$166.98
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cigna of CA HMO |
$302.40
|
| Rate for Payer: Cigna of CA HMO |
$147.00
|
| Rate for Payer: Cigna of CA HMO |
$198.24
|
| Rate for Payer: Cigna of CA HMO |
$212.52
|
| Rate for Payer: Cigna of CA PPO |
$302.40
|
| Rate for Payer: Cigna of CA PPO |
$147.00
|
| Rate for Payer: Cigna of CA PPO |
$198.24
|
| Rate for Payer: Cigna of CA PPO |
$212.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$178.50
|
| Rate for Payer: Galaxy Health WC |
$367.20
|
| Rate for Payer: Galaxy Health WC |
$258.06
|
| Rate for Payer: Galaxy Health WC |
$240.72
|
| Rate for Payer: Global Benefits Group Commercial |
$169.92
|
| Rate for Payer: Global Benefits Group Commercial |
$182.16
|
| Rate for Payer: Global Benefits Group Commercial |
$259.20
|
| Rate for Payer: Global Benefits Group Commercial |
$126.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$202.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$288.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$140.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$188.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$226.56
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: Multiplan Commercial |
$242.88
|
| Rate for Payer: Multiplan Commercial |
$345.60
|
| Rate for Payer: Networks By Design Commercial |
$141.60
|
| Rate for Payer: Networks By Design Commercial |
$216.00
|
| Rate for Payer: Networks By Design Commercial |
$105.00
|
| Rate for Payer: Networks By Design Commercial |
$151.80
|
| Rate for Payer: Prime Health Services Commercial |
$367.20
|
| Rate for Payer: Prime Health Services Commercial |
$240.72
|
| Rate for Payer: Prime Health Services Commercial |
$258.06
|
| Rate for Payer: Prime Health Services Commercial |
$178.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$126.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$259.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$182.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$169.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$259.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$126.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$169.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$182.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$113.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$162.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.81
|
| Rate for Payer: United Healthcare All Other HMO |
$103.45
|
| Rate for Payer: United Healthcare All Other HMO |
$76.71
|
| Rate for Payer: United Healthcare All Other HMO |
$157.81
|
| Rate for Payer: United Healthcare All Other HMO |
$110.91
|
| Rate for Payer: United Healthcare HMO Rider |
$108.51
|
| Rate for Payer: United Healthcare HMO Rider |
$75.05
|
| Rate for Payer: United Healthcare HMO Rider |
$154.40
|
| Rate for Payer: United Healthcare HMO Rider |
$101.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$141.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.43
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.62
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.62
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.62
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
|
IP
|
$672.43
|
|
|
Service Code
|
HCPCS J9074
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.49 |
| Max. Negotiated Rate |
$571.57 |
| Rate for Payer: Adventist Health Commercial |
$134.49
|
| Rate for Payer: Blue Shield of California Commercial |
$496.25
|
| Rate for Payer: Blue Shield of California EPN |
$326.80
|
| Rate for Payer: Cash Price |
$369.84
|
| Rate for Payer: Cigna of CA HMO |
$470.70
|
| Rate for Payer: Cigna of CA PPO |
$470.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$268.97
|
| Rate for Payer: EPIC Health Plan Senior |
$268.97
|
| Rate for Payer: Galaxy Health WC |
$571.57
|
| Rate for Payer: Global Benefits Group Commercial |
$403.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$448.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$256.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$416.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$161.38
|
| Rate for Payer: Multiplan Commercial |
$537.94
|
| Rate for Payer: Networks By Design Commercial |
$336.21
|
| Rate for Payer: Prime Health Services Commercial |
$571.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$252.36
|
| Rate for Payer: United Healthcare All Other HMO |
$245.64
|
| Rate for Payer: United Healthcare HMO Rider |
$240.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$220.22
|
|
|
CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]
|
Facility
|
IP
|
$283.20
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.64 |
| Max. Negotiated Rate |
$240.72 |
| Rate for Payer: Adventist Health Commercial |
$56.64
|
| Rate for Payer: Adventist Health Commercial |
$86.40
|
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Adventist Health Commercial |
$60.72
|
| Rate for Payer: Blue Shield of California Commercial |
$154.98
|
| Rate for Payer: Blue Shield of California Commercial |
$318.82
|
| Rate for Payer: Blue Shield of California Commercial |
$224.06
|
| Rate for Payer: Blue Shield of California Commercial |
$209.00
|
| Rate for Payer: Blue Shield of California EPN |
$102.06
|
| Rate for Payer: Blue Shield of California EPN |
$137.64
|
| Rate for Payer: Blue Shield of California EPN |
$147.55
|
| Rate for Payer: Blue Shield of California EPN |
$209.95
|
| Rate for Payer: Cash Price |
$166.98
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$155.76
|
| Rate for Payer: Cigna of CA HMO |
$147.00
|
| Rate for Payer: Cigna of CA HMO |
$212.52
|
| Rate for Payer: Cigna of CA HMO |
$198.24
|
| Rate for Payer: Cigna of CA HMO |
$302.40
|
| Rate for Payer: Cigna of CA PPO |
$302.40
|
| Rate for Payer: Cigna of CA PPO |
$212.52
|
| Rate for Payer: Cigna of CA PPO |
$147.00
|
| Rate for Payer: Cigna of CA PPO |
$198.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.80
|
| Rate for Payer: EPIC Health Plan Senior |
$84.00
|
| Rate for Payer: EPIC Health Plan Senior |
$121.44
|
| Rate for Payer: EPIC Health Plan Senior |
$113.28
|
| Rate for Payer: EPIC Health Plan Senior |
$172.80
|
| Rate for Payer: Galaxy Health WC |
$178.50
|
| Rate for Payer: Galaxy Health WC |
$240.72
|
| Rate for Payer: Galaxy Health WC |
$258.06
|
| Rate for Payer: Galaxy Health WC |
$367.20
|
| Rate for Payer: Global Benefits Group Commercial |
$259.20
|
| Rate for Payer: Global Benefits Group Commercial |
$126.00
|
| Rate for Payer: Global Benefits Group Commercial |
$182.16
|
| Rate for Payer: Global Benefits Group Commercial |
$169.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$202.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$188.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$288.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$140.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$164.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$129.99
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$175.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$187.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$267.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.68
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: Multiplan Commercial |
$242.88
|
| Rate for Payer: Multiplan Commercial |
$226.56
|
| Rate for Payer: Multiplan Commercial |
$345.60
|
| Rate for Payer: Networks By Design Commercial |
$141.60
|
| Rate for Payer: Networks By Design Commercial |
$151.80
|
| Rate for Payer: Networks By Design Commercial |
$216.00
|
| Rate for Payer: Networks By Design Commercial |
$105.00
|
| Rate for Payer: Prime Health Services Commercial |
$258.06
|
| Rate for Payer: Prime Health Services Commercial |
$178.50
|
| Rate for Payer: Prime Health Services Commercial |
$367.20
|
| Rate for Payer: Prime Health Services Commercial |
$240.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$113.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$106.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$162.13
|
| Rate for Payer: United Healthcare All Other HMO |
$103.45
|
| Rate for Payer: United Healthcare All Other HMO |
$157.81
|
| Rate for Payer: United Healthcare All Other HMO |
$110.91
|
| Rate for Payer: United Healthcare All Other HMO |
$76.71
|
| Rate for Payer: United Healthcare HMO Rider |
$101.22
|
| Rate for Payer: United Healthcare HMO Rider |
$75.05
|
| Rate for Payer: United Healthcare HMO Rider |
$154.40
|
| Rate for Payer: United Healthcare HMO Rider |
$108.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$141.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.43
|
|
