|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 4280654930
|
| 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 |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| 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 3172213130
|
| 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 |
$0.28
|
| Rate for Payer: Cash Price |
$0.20
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.26
|
| 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
|
|
|
DUTASTERIDE 0.5 MG CAPSULE [34089]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 3172213130
|
| 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 |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.26
|
| 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 4280654930
|
| 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 |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| 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
|
|
|
DYSEQUILIBRIUM
|
Facility
|
IP
|
$92,586.63
|
|
|
Service Code
|
MSDRG 149
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$92,586.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22,785.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$92,586.63
|
| Rate for Payer: EPIC Health Plan Senior |
$61,724.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$56,113.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$78,558.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75,191.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC
|
Facility
|
IP
|
$101,812.16
|
|
|
Service Code
|
MSDRG 147
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$101,812.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$38,546.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$101,812.16
|
| Rate for Payer: EPIC Health Plan Senior |
$67,874.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$61,704.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$86,386.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$82,683.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$116,822.49
|
|
|
Service Code
|
MSDRG 146
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$116,822.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$64,191.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$116,822.49
|
| Rate for Payer: EPIC Health Plan Senior |
$77,881.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$70,801.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$99,122.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$94,874.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$93,394.01
|
|
|
Service Code
|
MSDRG 148
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$93,394.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24,164.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$93,394.01
|
| Rate for Payer: EPIC Health Plan Senior |
$62,262.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$56,602.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79,243.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75,847.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$26,375.82
|
|
|
Service Code
|
APR-DRG 1103
|
| Min. Negotiated Rate |
$21,065.95 |
| Max. Negotiated Rate |
$26,375.82 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21,065.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26,375.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23,599.42
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$58,145.64
|
|
|
Service Code
|
APR-DRG 1104
|
| Min. Negotiated Rate |
$46,440.01 |
| Max. Negotiated Rate |
$58,145.64 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$46,440.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58,145.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52,025.05
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$17,791.45
|
|
|
Service Code
|
APR-DRG 1102
|
| Min. Negotiated Rate |
$14,209.75 |
| Max. Negotiated Rate |
$17,791.45 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,209.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17,791.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15,918.66
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$16,448.19
|
|
|
Service Code
|
APR-DRG 1101
|
| Min. Negotiated Rate |
$13,136.91 |
| Max. Negotiated Rate |
$16,448.19 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,136.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16,448.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14,716.80
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$15,972.52
|
|
|
Service Code
|
APR-DRG 7592
|
| Min. Negotiated Rate |
$12,757.00 |
| Max. Negotiated Rate |
$15,972.52 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,757.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15,972.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14,291.20
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$45,508.61
|
|
|
Service Code
|
APR-DRG 7594
|
| Min. Negotiated Rate |
$36,347.01 |
| Max. Negotiated Rate |
$45,508.61 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36,347.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45,508.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$40,718.23
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$24,788.63
|
|
|
Service Code
|
APR-DRG 7593
|
| Min. Negotiated Rate |
$19,798.29 |
| Max. Negotiated Rate |
$24,788.63 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,798.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24,788.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22,179.31
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$11,730.64
|
|
|
Service Code
|
APR-DRG 7591
|
| Min. Negotiated Rate |
$9,369.08 |
| Max. Negotiated Rate |
$11,730.64 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,369.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,730.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,495.83
|
|
|
ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$643,463.16
|
|
|
Service Code
|
MSDRG 003
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$643,463.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$643,463.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$455,887.08
|
| Rate for Payer: EPIC Health Plan Senior |
$303,924.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$276,295.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$386,813.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$370,235.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 5167213031
|
| 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 |
$1.28
|
| Rate for Payer: Cash Price |
$0.90
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.18
|
| 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
|
|
|
ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 5167213031
|
| 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 |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$1.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.18
|
| 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
|
|
|
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 |
$132.29
|
| Rate for Payer: Blue Shield of California Commercial |
$200.65
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO |
$182.64
|
| Rate for Payer: Cigna of CA PPO |
$182.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$165.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$153.94
|
| 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 |
$44.20 |
| Max. Negotiated Rate |
$281.84 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$281.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$48.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$48.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$111.11
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cash Price |
$117.41
|
| 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 |
$55.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$182.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.93
|
| Rate for Payer: EPIC Health Plan Senior |
$48.62
|
| Rate for Payer: Galaxy Health WC |
$221.78
|
| Rate for Payer: Global Benefits Group Commercial |
$156.55
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$72.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$44.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$44.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$165.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$85.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$61.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$59.23
|
| 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 |
$44.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.62
|
| Rate for Payer: Vantage Medical Group Senior |
$48.62
|
|
|
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 |
$15.21
|
| Rate for Payer: Blue Shield of California Commercial |
$23.07
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO |
$21.00
|
| Rate for Payer: Cigna of CA PPO |
$21.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$19.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.70
|
| 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: Cash Price |
$13.50
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$19.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.70
|
| 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 3172250430
|
| 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 |
$2.05
|
| Rate for Payer: Cash Price |
$1.44
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.24
|
| 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 Foundation Hospitals Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.89
|
| 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 3172250430
|
| 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: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.24
|
| 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 Foundation Hospitals Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.89
|
| 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
|
|
