|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 57237-019-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE SPRINKLE [225947]
|
Facility
|
IP
|
$8.95
|
|
|
Service Code
|
NDC 47335-619-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.61 |
| Rate for Payer: Adventist Health Commercial |
$1.79
|
| Rate for Payer: Blue Shield of California Commercial |
$6.61
|
| Rate for Payer: Blue Shield of California EPN |
$4.35
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cigna of CA HMO |
$6.26
|
| Rate for Payer: Cigna of CA PPO |
$6.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.58
|
| Rate for Payer: EPIC Health Plan Senior |
$3.58
|
| Rate for Payer: Galaxy Health WC |
$7.61
|
| Rate for Payer: Global Benefits Group Commercial |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: Multiplan Commercial |
$7.16
|
| Rate for Payer: Networks By Design Commercial |
$5.82
|
| Rate for Payer: Prime Health Services Commercial |
$7.61
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE SPRINKLE [225947]
|
Facility
|
OP
|
$8.95
|
|
|
Service Code
|
NDC 47335-619-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.61 |
| Rate for Payer: Adventist Health Commercial |
$1.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.50
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cigna of CA HMO |
$6.26
|
| Rate for Payer: Cigna of CA PPO |
$6.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.58
|
| Rate for Payer: EPIC Health Plan Senior |
$3.58
|
| Rate for Payer: Galaxy Health WC |
$7.61
|
| Rate for Payer: Global Benefits Group Commercial |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.26
|
| Rate for Payer: Multiplan Commercial |
$7.16
|
| Rate for Payer: Networks By Design Commercial |
$5.82
|
| Rate for Payer: Prime Health Services Commercial |
$7.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Other HMO |
$4.47
|
| Rate for Payer: United Healthcare HMO Rider |
$4.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.61
|
| Rate for Payer: Vantage Medical Group Senior |
$7.61
|
|
|
DURLOBACTAM 0.5 GRAM INTRAVENOUS SOLUTION [241588]
|
Facility
|
OP
|
$199.60
|
|
|
Service Code
|
NDC 68547-311-30
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.92 |
| Max. Negotiated Rate |
$169.66 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$169.66
|
| Rate for Payer: Vantage Medical Group Senior |
$169.66
|
| Rate for Payer: Adventist Health Commercial |
$39.92
|
| Rate for Payer: Aetna of CA HMO/PPO |
$130.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$169.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$109.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$149.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.57
|
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: Cigna of CA HMO |
$127.74
|
| Rate for Payer: Cigna of CA PPO |
$147.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$169.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$169.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$169.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.84
|
| Rate for Payer: EPIC Health Plan Senior |
$79.84
|
| Rate for Payer: Galaxy Health WC |
$169.66
|
| Rate for Payer: Global Benefits Group Commercial |
$119.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$133.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$123.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$139.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$139.72
|
| Rate for Payer: Multiplan Commercial |
$159.68
|
| Rate for Payer: Networks By Design Commercial |
$129.74
|
| Rate for Payer: Prime Health Services Commercial |
$169.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$119.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$119.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$99.80
|
| Rate for Payer: United Healthcare All Other HMO |
$99.80
|
| Rate for Payer: United Healthcare HMO Rider |
$99.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$169.66
|
|
|
DURLOBACTAM 0.5 GRAM INTRAVENOUS SOLUTION [241588]
|
Facility
|
IP
|
$199.60
|
|
|
Service Code
|
NDC 68547-311-30
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.92 |
| Max. Negotiated Rate |
$169.66 |
| Rate for Payer: Adventist Health Commercial |
$39.92
|
| Rate for Payer: Blue Shield of California Commercial |
$147.30
|
| Rate for Payer: Blue Shield of California EPN |
$97.01
|
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.84
|
| Rate for Payer: EPIC Health Plan Senior |
$79.84
|
| Rate for Payer: Galaxy Health WC |
$169.66
|
| Rate for Payer: Global Benefits Group Commercial |
$119.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$133.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$123.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.90
|
| Rate for Payer: Multiplan Commercial |
$159.68
|
| Rate for Payer: Networks By Design Commercial |
$129.74
|
| Rate for Payer: Prime Health Services Commercial |
$169.66
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
|
IP
|
$515.36
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.07 |
| Max. Negotiated Rate |
$438.06 |
| Rate for Payer: Adventist Health Commercial |
$103.07
|
| Rate for Payer: Blue Shield of California Commercial |
$380.34
|
| Rate for Payer: Blue Shield of California EPN |
$250.46
|
| Rate for Payer: Cash Price |
$283.45
|
| Rate for Payer: Cigna of CA HMO |
$360.75
|
| Rate for Payer: Cigna of CA PPO |
$360.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.14
|
| Rate for Payer: EPIC Health Plan Senior |
$206.14
|
| Rate for Payer: Galaxy Health WC |
$438.06
|
| Rate for Payer: Global Benefits Group Commercial |
$309.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$343.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$196.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$319.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.69
|
| Rate for Payer: Multiplan Commercial |
$412.29
|
| Rate for Payer: Networks By Design Commercial |
$257.68
|
| Rate for Payer: Prime Health Services Commercial |
$438.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$193.41
|
| Rate for Payer: United Healthcare All Other HMO |
$188.26
|
| Rate for Payer: United Healthcare HMO Rider |
$184.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.78
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [217071]
|
Facility
|
OP
|
$515.36
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.87 |
| Max. Negotiated Rate |
$438.06 |
| Rate for Payer: Adventist Health Commercial |
$103.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$338.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$127.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$93.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$228.75
|
| Rate for Payer: Blue Shield of California Commercial |
$99.07
|
| Rate for Payer: Blue Shield of California EPN |
$99.07
|
| Rate for Payer: Cash Price |
$283.45
|
| Rate for Payer: Cash Price |
$283.45
|
| Rate for Payer: Cigna of CA HMO |
$360.75
|
| Rate for Payer: Cigna of CA PPO |
$360.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$93.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.09
|
| Rate for Payer: EPIC Health Plan Senior |
$85.25
|
| Rate for Payer: Galaxy Health WC |
$438.06
|
| Rate for Payer: Global Benefits Group Commercial |
$309.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$83.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$85.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$343.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$159.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$85.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$107.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$114.23
|
| Rate for Payer: Multiplan Commercial |
$412.29
|
| Rate for Payer: Networks By Design Commercial |
$257.68
|
| Rate for Payer: Prime Health Services Commercial |
$438.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$309.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$309.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$193.41
|
| Rate for Payer: United Healthcare All Other HMO |
$188.26
|
| Rate for Payer: United Healthcare HMO Rider |
$184.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$168.78
|
| Rate for Payer: Upland Medical Group Pediatric |
$85.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$106.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.78
|
| Rate for Payer: Vantage Medical Group Senior |
$93.78
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 31722-131-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 42806-549-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 42806-549-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 31722-131-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51672-1303-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
|
|
ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51672-1303-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.23
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
|
IP
|
$260.92
|
|
|
Service Code
|
HCPCS J1299
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.18 |
| Max. Negotiated Rate |
$221.78 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Blue Shield of California Commercial |
$192.56
|
| Rate for Payer: Blue Shield of California EPN |
$126.81
|
| Rate for Payer: Cash Price |
$143.51
|
| Rate for Payer: Cigna of CA HMO |
$182.64
|
| Rate for Payer: Cigna of CA PPO |
$182.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.37
|
| Rate for Payer: EPIC Health Plan Senior |
$104.37
|
| Rate for Payer: Galaxy Health WC |
$221.78
|
| Rate for Payer: Global Benefits Group Commercial |
$156.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$174.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$161.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.62
|
| Rate for Payer: Multiplan Commercial |
$208.74
|
| Rate for Payer: Networks By Design Commercial |
$130.46
|
| Rate for Payer: Prime Health Services Commercial |
$221.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.92
|
| Rate for Payer: United Healthcare All Other HMO |
$95.31
|
| Rate for Payer: United Healthcare HMO Rider |
$93.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.45
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
|
OP
|
$260.92
|
|
|
Service Code
|
HCPCS J1299
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.77 |
| Max. Negotiated Rate |
$221.78 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$171.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$118.12
|
| Rate for Payer: Cash Price |
$143.51
|
| Rate for Payer: Cash Price |
$143.51
|
| Rate for Payer: Cigna of CA HMO |
$182.64
|
| Rate for Payer: Cigna of CA PPO |
$182.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$49.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.44
|
| Rate for Payer: EPIC Health Plan Senior |
$44.77
|
| Rate for Payer: Galaxy Health WC |
$221.78
|
| Rate for Payer: Global Benefits Group Commercial |
$156.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$44.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$44.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$174.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$82.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$56.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$59.99
|
| Rate for Payer: Multiplan Commercial |
$208.74
|
| Rate for Payer: Networks By Design Commercial |
$130.46
|
| Rate for Payer: Prime Health Services Commercial |
$221.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$156.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$156.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$97.92
|
| Rate for Payer: United Healthcare All Other HMO |
$95.31
|
| Rate for Payer: United Healthcare HMO Rider |
$93.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.45
|
| Rate for Payer: Upland Medical Group Pediatric |
$44.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.25
|
| Rate for Payer: Vantage Medical Group Senior |
$49.25
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Blue Shield of California Commercial |
$22.14
|
| Rate for Payer: Blue Shield of California EPN |
$14.58
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna of CA HMO |
$21.00
|
| Rate for Payer: Cigna of CA PPO |
$21.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.00
|
| Rate for Payer: EPIC Health Plan Senior |
$12.00
|
| Rate for Payer: Galaxy Health WC |
$25.50
|
| Rate for Payer: Global Benefits Group Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$15.00
|
| Rate for Payer: Prime Health Services Commercial |
$25.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.26
|
| Rate for Payer: United Healthcare All Other HMO |
$10.96
|
| Rate for Payer: United Healthcare HMO Rider |
$10.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.82
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.42
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna of CA HMO |
$21.00
|
| Rate for Payer: Cigna of CA PPO |
$21.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.00
|
| Rate for Payer: EPIC Health Plan Senior |
$12.00
|
| Rate for Payer: Galaxy Health WC |
$25.50
|
| Rate for Payer: Global Benefits Group Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: Networks By Design Commercial |
$15.00
|
| Rate for Payer: Prime Health Services Commercial |
$25.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.26
|
| Rate for Payer: United Healthcare All Other HMO |
$10.96
|
| Rate for Payer: United Healthcare HMO Rider |
$10.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$25.50
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 31722-504-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Senior |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 31722-504-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Senior |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
