|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Blue Shield of California Commercial |
$7.99
|
| Rate for Payer: Blue Shield of California EPN |
$5.74
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.68
|
| Rate for Payer: Blue Distinction Transplant |
$6.73
|
| Rate for Payer: Blue Shield of California Commercial |
$8.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.55
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: Dignity Health Media |
$9.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.61
|
| Rate for Payer: United Healthcare All Other HMO |
$5.61
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$45,127.47
|
|
|
Service Code
|
APR-DRG 2334
|
| Min. Negotiated Rate |
$34,617.52 |
| Max. Negotiated Rate |
$45,127.47 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34,617.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45,127.47
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$16,118.97
|
|
|
Service Code
|
APR-DRG 2331
|
| Min. Negotiated Rate |
$12,364.95 |
| Max. Negotiated Rate |
$16,118.97 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,364.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,118.97
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$20,816.88
|
|
|
Service Code
|
APR-DRG 2332
|
| Min. Negotiated Rate |
$15,968.73 |
| Max. Negotiated Rate |
$20,816.88 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,968.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,816.88
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$30,166.55
|
|
|
Service Code
|
APR-DRG 2333
|
| Min. Negotiated Rate |
$23,140.92 |
| Max. Negotiated Rate |
$30,166.55 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23,140.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30,166.55
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$13,072.17
|
|
|
Service Code
|
APR-DRG 2341
|
| Min. Negotiated Rate |
$10,027.73 |
| Max. Negotiated Rate |
$13,072.17 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,027.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,072.17
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$16,883.34
|
|
|
Service Code
|
APR-DRG 2342
|
| Min. Negotiated Rate |
$12,951.30 |
| Max. Negotiated Rate |
$16,883.34 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,951.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,883.34
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$24,823.12
|
|
|
Service Code
|
APR-DRG 2343
|
| Min. Negotiated Rate |
$19,041.95 |
| Max. Negotiated Rate |
$24,823.12 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,041.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,823.12
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$42,273.97
|
|
|
Service Code
|
APR-DRG 2344
|
| Min. Negotiated Rate |
$32,428.59 |
| Max. Negotiated Rate |
$42,273.97 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32,428.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42,273.97
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 15275
|
| Min. Negotiated Rate |
$157.87 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Media |
$2,278.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,736.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,736.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,691.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,691.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$157.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
OP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$13.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.19
|
| Rate for Payer: Blue Distinction Transplant |
$9.25
|
| Rate for Payer: Blue Shield of California Commercial |
$11.36
|
| Rate for Payer: Blue Shield of California EPN |
$9.01
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cigna of CA HMO |
$10.79
|
| Rate for Payer: Cigna of CA PPO |
$10.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.11
|
| Rate for Payer: Dignity Health Media |
$13.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.17
|
| Rate for Payer: Galaxy Health WC |
$13.11
|
| Rate for Payer: Global Benefits Group Commercial |
$9.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.70
|
| Rate for Payer: Multiplan Commercial |
$12.34
|
| Rate for Payer: Networks By Design Commercial |
$10.02
|
| Rate for Payer: Prime Health Services Commercial |
$13.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.71
|
| Rate for Payer: United Healthcare All Other HMO |
$7.71
|
| Rate for Payer: United Healthcare HMO Rider |
$7.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.11
|
| Rate for Payer: Vantage Medical Group Senior |
$13.11
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
IP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$13.11 |
| Rate for Payer: Blue Shield of California Commercial |
$10.98
|
| Rate for Payer: Blue Shield of California EPN |
$7.90
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cigna of CA HMO |
$10.79
|
| Rate for Payer: Cigna of CA PPO |
$10.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: Galaxy Health WC |
$13.11
|
| Rate for Payer: Global Benefits Group Commercial |
$9.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.70
|
| Rate for Payer: Multiplan Commercial |
$12.34
|
| Rate for Payer: Networks By Design Commercial |
$10.02
|
| Rate for Payer: Prime Health Services Commercial |
$13.11
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.25
|
| Rate for Payer: Blue Distinction Transplant |
$16.80
|
| Rate for Payer: Blue Shield of California Commercial |
$20.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.55
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna of CA HMO |
$19.60
|
| Rate for Payer: Cigna of CA PPO |
$19.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.59
|
| Rate for Payer: Dignity Health Media |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$23.80
|
| Rate for Payer: Global Benefits Group Commercial |
$16.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$21.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Transplant |
$2.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$2.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: Networks By Design Commercial |
$14.00
|
| Rate for Payer: Prime Health Services Commercial |
$23.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.00
|
| Rate for Payer: United Healthcare All Other HMO |
$14.00
|
| Rate for Payer: United Healthcare HMO Rider |
$14.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Blue Shield of California Commercial |
$19.94
|
| Rate for Payer: Blue Shield of California EPN |
$14.34
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna of CA HMO |
$19.60
|
| Rate for Payer: Cigna of CA PPO |
$19.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.20
|
| Rate for Payer: Galaxy Health WC |
$23.80
|
| Rate for Payer: Global Benefits Group Commercial |
$16.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.72
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: Networks By Design Commercial |
$14.00
|
| Rate for Payer: Prime Health Services Commercial |
$23.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.57
|
| Rate for Payer: United Healthcare All Other HMO |
$10.33
|
| Rate for Payer: United Healthcare HMO Rider |
$10.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.24
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-64
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.71
|
| Rate for Payer: Blue Distinction Transplant |
$6.76
|
| Rate for Payer: Blue Shield of California Commercial |
$8.30
|
| Rate for Payer: Blue Shield of California EPN |
$6.58
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.57
|
| Rate for Payer: Dignity Health Media |
$9.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$9.01
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.63
|
| Rate for Payer: United Healthcare All Other HMO |
$5.63
|
| Rate for Payer: United Healthcare HMO Rider |
$5.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.57
|
| Rate for Payer: Vantage Medical Group Senior |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.49
|
| Rate for Payer: Blue Distinction Transplant |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Media |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-11
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.29
|
| Rate for Payer: Blue Distinction Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.84
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Media |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.29
|
| Rate for Payer: Blue Distinction Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.84
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Media |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.29
|
| Rate for Payer: Blue Distinction Transplant |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.84
|
| Rate for Payer: Blue Shield of California EPN |
$2.25
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$2.70
|
| Rate for Payer: Cigna of CA PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Media |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO |
$1.92
|
| Rate for Payer: United Healthcare HMO Rider |
$1.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-30
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Blue Shield of California Commercial |
$8.02
|
| Rate for Payer: Blue Shield of California EPN |
$5.77
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$9.01
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$11.26
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
1744128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.71
|
| Rate for Payer: Blue Distinction Transplant |
$6.76
|
| Rate for Payer: Blue Shield of California Commercial |
$8.30
|
| Rate for Payer: Blue Shield of California EPN |
$6.58
|
| Rate for Payer: Cash Price |
$5.07
|
| Rate for Payer: Cigna of CA HMO |
$7.88
|
| Rate for Payer: Cigna of CA PPO |
$7.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.57
|
| Rate for Payer: Dignity Health Media |
$9.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.50
|
| Rate for Payer: Galaxy Health WC |
$9.57
|
| Rate for Payer: Global Benefits Group Commercial |
$6.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$9.01
|
| Rate for Payer: Networks By Design Commercial |
$7.32
|
| Rate for Payer: Prime Health Services Commercial |
$9.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.63
|
| Rate for Payer: United Healthcare All Other HMO |
$5.63
|
| Rate for Payer: United Healthcare HMO Rider |
$5.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.57
|
| Rate for Payer: Vantage Medical Group Senior |
$9.57
|
|
