|
ELRANATAMAB-BCMM 40 MG/ML SUBCUTANEOUS SOLUTION [239200]
|
Facility
|
IP
|
$9,759.06
|
|
|
Service Code
|
HCPCS J1323
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,951.81 |
| Max. Negotiated Rate |
$8,295.20 |
| Rate for Payer: Adventist Health Commercial |
$1,951.81
|
| Rate for Payer: Blue Shield of California Commercial |
$4,947.84
|
| Rate for Payer: Blue Shield of California Commercial |
$7,504.72
|
| Rate for Payer: Cash Price |
$4,391.58
|
| Rate for Payer: Cigna of CA HMO |
$6,831.34
|
| Rate for Payer: Cigna of CA PPO |
$6,831.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6,831.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,903.62
|
| Rate for Payer: EPIC Health Plan Senior |
$3,903.62
|
| Rate for Payer: Galaxy Health WC |
$8,295.20
|
| Rate for Payer: Global Benefits Group Commercial |
$5,855.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6,197.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,757.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,342.17
|
| Rate for Payer: Multiplan Commercial |
$7,807.25
|
| Rate for Payer: Networks By Design Commercial |
$4,879.53
|
| Rate for Payer: Prime Health Services Commercial |
$8,295.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,662.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3,564.98
|
| Rate for Payer: United Healthcare HMO Rider |
$3,487.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,196.09
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
IP
|
$313.06
|
|
|
Service Code
|
NDC 0078068515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.61 |
| Max. Negotiated Rate |
$266.10 |
| Rate for Payer: Adventist Health Commercial |
$62.61
|
| Rate for Payer: Blue Shield of California Commercial |
$158.72
|
| Rate for Payer: Blue Shield of California Commercial |
$240.74
|
| Rate for Payer: Cash Price |
$140.88
|
| Rate for Payer: Cigna of CA HMO |
$219.14
|
| Rate for Payer: Cigna of CA PPO |
$219.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$219.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.22
|
| Rate for Payer: EPIC Health Plan Senior |
$125.22
|
| Rate for Payer: Galaxy Health WC |
$266.10
|
| Rate for Payer: Global Benefits Group Commercial |
$187.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$198.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.13
|
| Rate for Payer: Multiplan Commercial |
$250.45
|
| Rate for Payer: Networks By Design Commercial |
$203.49
|
| Rate for Payer: Prime Health Services Commercial |
$266.10
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
OP
|
$313.06
|
|
|
Service Code
|
NDC 0078068515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.61 |
| Max. Negotiated Rate |
$266.10 |
| Rate for Payer: Adventist Health Commercial |
$62.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$205.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$266.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$172.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$234.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$200.89
|
| Rate for Payer: Cash Price |
$140.88
|
| Rate for Payer: Cigna of CA HMO |
$219.14
|
| Rate for Payer: Cigna of CA PPO |
$219.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$266.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$266.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$266.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$219.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.22
|
| Rate for Payer: EPIC Health Plan Senior |
$125.22
|
| Rate for Payer: Galaxy Health WC |
$266.10
|
| Rate for Payer: Global Benefits Group Commercial |
$187.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$198.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$113.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$184.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$219.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$219.14
|
| Rate for Payer: Multiplan Commercial |
$250.45
|
| Rate for Payer: Networks By Design Commercial |
$203.49
|
| Rate for Payer: Prime Health Services Commercial |
$266.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$187.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$187.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$156.53
|
| Rate for Payer: United Healthcare All Other HMO |
$156.53
|
| Rate for Payer: United Healthcare HMO Rider |
$156.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$156.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$266.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$266.10
|
| Rate for Payer: Vantage Medical Group Senior |
$266.10
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
IP
|
$566.53
|
|
|
Service Code
|
NDC 0078068615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$113.31 |
| Max. Negotiated Rate |
$481.55 |
| Rate for Payer: Adventist Health Commercial |
$113.31
|
| Rate for Payer: Blue Shield of California Commercial |
$287.23
|
| Rate for Payer: Blue Shield of California Commercial |
$435.66
|
| Rate for Payer: Cash Price |
$254.94
|
| Rate for Payer: Cigna of CA HMO |
$396.57
|
| Rate for Payer: Cigna of CA PPO |
$396.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$396.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.61
|
| Rate for Payer: EPIC Health Plan Senior |
$226.61
|
| Rate for Payer: Galaxy Health WC |
$481.55
|
| Rate for Payer: Global Benefits Group Commercial |
$339.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$359.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$334.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.97
|
| Rate for Payer: Multiplan Commercial |
$453.22
|
| Rate for Payer: Networks By Design Commercial |
$368.24
|
| Rate for Payer: Prime Health Services Commercial |
$481.55
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
OP
|
$566.53
|
|
|
Service Code
|
NDC 0078068615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$113.31 |
| Max. Negotiated Rate |
$481.55 |
| Rate for Payer: Adventist Health Commercial |
$113.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$371.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$481.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$311.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$424.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$363.54
|
| Rate for Payer: Cash Price |
$254.94
|
| Rate for Payer: Cigna of CA HMO |
$396.57
|
| Rate for Payer: Cigna of CA PPO |
$396.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$481.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$481.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$481.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$396.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.61
|
| Rate for Payer: EPIC Health Plan Senior |
$226.61
|
| Rate for Payer: Galaxy Health WC |
$481.55
|
| Rate for Payer: Global Benefits Group Commercial |
$339.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$359.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$205.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$334.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$396.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$396.57
|
| Rate for Payer: Multiplan Commercial |
$453.22
|
| Rate for Payer: Networks By Design Commercial |
$368.24
|
| Rate for Payer: Prime Health Services Commercial |
$481.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$339.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$339.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$283.26
|
| Rate for Payer: United Healthcare All Other HMO |
$283.26
|
| Rate for Payer: United Healthcare HMO Rider |
$283.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$283.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$481.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$481.55
|
| Rate for Payer: Vantage Medical Group Senior |
$481.55
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
IP
|
$2,226.60
|
|
|
Service Code
|
HCPCS J9210
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$445.32 |
| Max. Negotiated Rate |
$1,892.61 |
| Rate for Payer: Adventist Health Commercial |
$445.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1,128.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1,712.26
|
| Rate for Payer: Cash Price |
$1,001.97
|
| Rate for Payer: Cigna of CA HMO |
$1,558.62
|
| Rate for Payer: Cigna of CA PPO |
$1,558.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,558.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$890.64
|
| Rate for Payer: EPIC Health Plan Senior |
$890.64
|
| Rate for Payer: Galaxy Health WC |
$1,892.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1,335.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,413.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,313.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$534.38
|
| Rate for Payer: Multiplan Commercial |
$1,781.28
|
| Rate for Payer: Networks By Design Commercial |
$1,113.30
|
| Rate for Payer: Prime Health Services Commercial |
$1,892.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$835.64
|
| Rate for Payer: United Healthcare All Other HMO |
$813.38
|
| Rate for Payer: United Healthcare HMO Rider |
$795.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$729.21
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
OP
|
$2,226.60
|
|
|
Service Code
|
HCPCS J9210
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$392.78 |
| Max. Negotiated Rate |
$2,399.46 |
| Rate for Payer: Adventist Health Commercial |
$445.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,399.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$589.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$432.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$392.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$862.78
|
| Rate for Payer: Blue Shield of California Commercial |
$405.24
|
| Rate for Payer: Cash Price |
$1,001.97
|
| Rate for Payer: Cash Price |
$1,001.97
|
| Rate for Payer: Cigna of CA HMO |
$1,558.62
|
| Rate for Payer: Cigna of CA PPO |
$1,558.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$490.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$432.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$432.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,558.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$648.09
|
| Rate for Payer: EPIC Health Plan Senior |
$432.06
|
| Rate for Payer: Galaxy Health WC |
$1,892.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1,335.96
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$644.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$392.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$392.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,413.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$729.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$549.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$534.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$494.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$526.33
|
| Rate for Payer: Multiplan Commercial |
$1,781.28
|
| Rate for Payer: Networks By Design Commercial |
$1,113.30
|
| Rate for Payer: Prime Health Services Commercial |
$1,892.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,335.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,335.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$835.64
|
| Rate for Payer: United Healthcare All Other HMO |
$813.38
|
| Rate for Payer: United Healthcare HMO Rider |
$795.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$729.21
|
| Rate for Payer: Upland Medical Group Pediatric |
$392.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$490.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$432.06
|
| Rate for Payer: Vantage Medical Group Senior |
$432.06
|
|
|
EMICIZUMAB-KXWH 105 MG/0.7 ML SUBCUTANEOUS SOLUTION [220371]
|
Facility
|
IP
|
$22,742.13
|
|
|
Service Code
|
HCPCS J7170
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,548.43 |
| Max. Negotiated Rate |
$19,330.81 |
| Rate for Payer: Adventist Health Commercial |
$4,548.43
|
| Rate for Payer: Blue Shield of California Commercial |
$11,530.26
|
| Rate for Payer: Blue Shield of California Commercial |
$17,488.70
|
| Rate for Payer: Cash Price |
$10,233.96
|
| Rate for Payer: Cigna of CA HMO |
$15,919.49
|
| Rate for Payer: Cigna of CA PPO |
$15,919.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$15,919.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,096.85
|
| Rate for Payer: EPIC Health Plan Senior |
$9,096.85
|
| Rate for Payer: Galaxy Health WC |
$19,330.81
|
| Rate for Payer: Global Benefits Group Commercial |
$13,645.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$14,441.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,417.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,458.11
|
| Rate for Payer: Multiplan Commercial |
$18,193.70
|
| Rate for Payer: Networks By Design Commercial |
$11,371.07
|
| Rate for Payer: Prime Health Services Commercial |
$19,330.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$8,535.12
|
| Rate for Payer: United Healthcare All Other HMO |
$8,307.70
|
| Rate for Payer: United Healthcare HMO Rider |
$8,128.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,448.05
|
|
|
EMICIZUMAB-KXWH 105 MG/0.7 ML SUBCUTANEOUS SOLUTION [220371]
|
Facility
|
OP
|
$22,742.13
|
|
|
Service Code
|
HCPCS J7170
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.03 |
| Max. Negotiated Rate |
$19,330.81 |
| Rate for Payer: Adventist Health Commercial |
$4,548.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$326.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$63.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$63.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$126.68
|
| Rate for Payer: Blue Shield of California Commercial |
$67.17
|
| Rate for Payer: Cash Price |
$10,233.96
|
| Rate for Payer: Cash Price |
$10,233.96
|
| Rate for Payer: Cigna of CA HMO |
$15,919.49
|
| Rate for Payer: Cigna of CA PPO |
$15,919.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$63.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$15,919.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.75
|
| Rate for Payer: EPIC Health Plan Senior |
$63.83
|
| Rate for Payer: Galaxy Health WC |
$19,330.81
|
| Rate for Payer: Global Benefits Group Commercial |
$13,645.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$95.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$14,441.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$115.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$81.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,458.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$73.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$77.76
|
| Rate for Payer: Multiplan Commercial |
$18,193.70
|
| Rate for Payer: Networks By Design Commercial |
$11,371.07
|
| Rate for Payer: Prime Health Services Commercial |
$19,330.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13,645.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13,645.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$8,535.12
|
| Rate for Payer: United Healthcare All Other HMO |
$8,307.70
|
| Rate for Payer: United Healthcare HMO Rider |
$8,128.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,448.05
|
| Rate for Payer: Upland Medical Group Pediatric |
$58.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.83
|
| Rate for Payer: Vantage Medical Group Senior |
$63.83
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$35.74
|
|
|
Service Code
|
NDC 9819300017
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$30.38 |
| Rate for Payer: Adventist Health Commercial |
$7.15
|
| Rate for Payer: Blue Shield of California Commercial |
$18.12
|
| Rate for Payer: Blue Shield of California Commercial |
$27.48
|
| Rate for Payer: Cash Price |
$16.08
|
| Rate for Payer: Cigna of CA HMO |
$25.02
|
| Rate for Payer: Cigna of CA PPO |
$25.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.30
|
| Rate for Payer: EPIC Health Plan Senior |
$14.30
|
| Rate for Payer: Galaxy Health WC |
$30.38
|
| Rate for Payer: Global Benefits Group Commercial |
$21.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$22.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$28.59
|
| Rate for Payer: Networks By Design Commercial |
$23.23
|
| Rate for Payer: Prime Health Services Commercial |
$30.38
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 9994080770
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 9940877002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.28
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$4.09
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 9819300005
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$3.64
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna of CA HMO |
$3.31
|
| Rate for Payer: Cigna of CA PPO |
$3.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| Rate for Payer: EPIC Health Plan Senior |
$1.89
|
| Rate for Payer: Galaxy Health WC |
$4.02
|
| Rate for Payer: Global Benefits Group Commercial |
$2.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$3.78
|
| Rate for Payer: Networks By Design Commercial |
$3.07
|
| Rate for Payer: Prime Health Services Commercial |
$4.02
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 9994080770
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.16
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO |
$2.35
|
| Rate for Payer: Cigna of CA PPO |
$2.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Senior |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: Networks By Design Commercial |
$2.18
|
| Rate for Payer: Prime Health Services Commercial |
$2.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.68
|
| Rate for Payer: United Healthcare All Other HMO |
$1.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.86
|
| Rate for Payer: Vantage Medical Group Senior |
$2.86
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 9940877002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$2.59
|
| Rate for Payer: Blue Shield of California Commercial |
$3.93
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Senior |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.09
|
| Rate for Payer: Networks By Design Commercial |
$3.32
|
| Rate for Payer: Prime Health Services Commercial |
$4.34
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$35.74
|
|
|
Service Code
|
NDC 9819300017
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$30.38 |
| Rate for Payer: Adventist Health Commercial |
$7.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$23.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.93
|
| Rate for Payer: Cash Price |
$16.08
|
| Rate for Payer: Cigna of CA HMO |
$25.02
|
| Rate for Payer: Cigna of CA PPO |
$25.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.30
|
| Rate for Payer: EPIC Health Plan Senior |
$14.30
|
| Rate for Payer: Galaxy Health WC |
$30.38
|
| Rate for Payer: Global Benefits Group Commercial |
$21.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$22.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.02
|
| Rate for Payer: Multiplan Commercial |
$28.59
|
| Rate for Payer: Networks By Design Commercial |
$23.23
|
| Rate for Payer: Prime Health Services Commercial |
$30.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.87
|
| Rate for Payer: United Healthcare All Other HMO |
$17.87
|
| Rate for Payer: United Healthcare HMO Rider |
$17.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.38
|
| Rate for Payer: Vantage Medical Group Senior |
$30.38
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 9819300005
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Adventist Health Commercial |
$0.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.04
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna of CA HMO |
$3.31
|
| Rate for Payer: Cigna of CA PPO |
$3.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| Rate for Payer: EPIC Health Plan Senior |
$1.89
|
| Rate for Payer: Galaxy Health WC |
$4.02
|
| Rate for Payer: Global Benefits Group Commercial |
$2.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.31
|
| Rate for Payer: Multiplan Commercial |
$3.78
|
| Rate for Payer: Networks By Design Commercial |
$3.07
|
| Rate for Payer: Prime Health Services Commercial |
$4.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.37
|
| Rate for Payer: United Healthcare All Other HMO |
$2.37
|
| Rate for Payer: United Healthcare HMO Rider |
$2.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.02
|
| Rate for Payer: Vantage Medical Group Senior |
$4.02
|
|
|
EMTRICITABINE 200 MG CAPSULE [36252]
|
Facility
|
OP
|
$18.54
|
|
|
Service Code
|
NDC 6909764202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$15.76 |
| Rate for Payer: Adventist Health Commercial |
$3.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.90
|
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Cigna of CA HMO |
$12.98
|
| Rate for Payer: Cigna of CA PPO |
$12.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.76
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.42
|
| Rate for Payer: EPIC Health Plan Senior |
$7.42
|
| Rate for Payer: Galaxy Health WC |
$15.76
|
| Rate for Payer: Global Benefits Group Commercial |
$11.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.98
|
| Rate for Payer: Multiplan Commercial |
$14.83
|
| Rate for Payer: Networks By Design Commercial |
$12.05
|
| Rate for Payer: Prime Health Services Commercial |
$15.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.27
|
| Rate for Payer: United Healthcare All Other HMO |
$9.27
|
| Rate for Payer: United Healthcare HMO Rider |
$9.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.76
|
| Rate for Payer: Vantage Medical Group Senior |
$15.76
|
|
|
EMTRICITABINE 200 MG CAPSULE [36252]
|
Facility
|
OP
|
$19.28
|
|
|
Service Code
|
NDC 6586230130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$16.39 |
| Rate for Payer: Adventist Health Commercial |
$3.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.37
|
| Rate for Payer: Cash Price |
$8.68
|
| Rate for Payer: Cigna of CA HMO |
$13.50
|
| Rate for Payer: Cigna of CA PPO |
$13.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.71
|
| Rate for Payer: EPIC Health Plan Senior |
$7.71
|
| Rate for Payer: Galaxy Health WC |
$16.39
|
| Rate for Payer: Global Benefits Group Commercial |
$11.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$15.42
|
| Rate for Payer: Networks By Design Commercial |
$12.53
|
| Rate for Payer: Prime Health Services Commercial |
$16.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Other HMO |
$9.64
|
| Rate for Payer: United Healthcare HMO Rider |
$9.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.39
|
| Rate for Payer: Vantage Medical Group Senior |
$16.39
|
|
|
EMTRICITABINE 200 MG CAPSULE [36252]
|
Facility
|
IP
|
$19.28
|
|
|
Service Code
|
NDC 6586230130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.86 |
| Max. Negotiated Rate |
$16.39 |
| Rate for Payer: Adventist Health Commercial |
$3.86
|
| Rate for Payer: Blue Shield of California Commercial |
$14.83
|
| Rate for Payer: Blue Shield of California Commercial |
$9.77
|
| Rate for Payer: Cash Price |
$8.68
|
| Rate for Payer: Cigna of CA HMO |
$13.50
|
| Rate for Payer: Cigna of CA PPO |
$13.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.71
|
| Rate for Payer: EPIC Health Plan Senior |
$7.71
|
| Rate for Payer: Galaxy Health WC |
$16.39
|
| Rate for Payer: Global Benefits Group Commercial |
$11.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$15.42
|
| Rate for Payer: Networks By Design Commercial |
$12.53
|
| Rate for Payer: Prime Health Services Commercial |
$16.39
|
|
|
EMTRICITABINE 200 MG CAPSULE [36252]
|
Facility
|
IP
|
$18.54
|
|
|
Service Code
|
NDC 6909764202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$15.76 |
| Rate for Payer: Adventist Health Commercial |
$3.71
|
| Rate for Payer: Blue Shield of California Commercial |
$14.26
|
| Rate for Payer: Blue Shield of California Commercial |
$9.40
|
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Cigna of CA HMO |
$12.98
|
| Rate for Payer: Cigna of CA PPO |
$12.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.42
|
| Rate for Payer: EPIC Health Plan Senior |
$7.42
|
| Rate for Payer: Galaxy Health WC |
$15.76
|
| Rate for Payer: Global Benefits Group Commercial |
$11.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Commercial |
$14.83
|
| Rate for Payer: Networks By Design Commercial |
$12.05
|
| Rate for Payer: Prime Health Services Commercial |
$15.76
|
|
