|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$25,706.30
|
|
|
Service Code
|
APR-DRG 3242
|
| Min. Negotiated Rate |
$19,719.44 |
| Max. Negotiated Rate |
$25,706.30 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,719.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25,706.30
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$34,694.19
|
|
|
Service Code
|
APR-DRG 3243
|
| Min. Negotiated Rate |
$26,614.10 |
| Max. Negotiated Rate |
$34,694.19 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26,614.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34,694.19
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$23,457.55
|
|
|
Service Code
|
APR-DRG 3261
|
| Min. Negotiated Rate |
$17,994.41 |
| Max. Negotiated Rate |
$23,457.55 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17,994.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,457.55
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$24,902.92
|
|
|
Service Code
|
APR-DRG 3262
|
| Min. Negotiated Rate |
$19,103.16 |
| Max. Negotiated Rate |
$24,902.92 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,103.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,902.92
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$35,416.00
|
|
|
Service Code
|
APR-DRG 3263
|
| Min. Negotiated Rate |
$27,167.80 |
| Max. Negotiated Rate |
$35,416.00 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,167.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35,416.00
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$46,409.67
|
|
|
Service Code
|
APR-DRG 3264
|
| Min. Negotiated Rate |
$35,601.10 |
| Max. Negotiated Rate |
$46,409.67 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35,601.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$46,409.67
|
|
|
ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0338-0179-04
|
| Hospital Charge Code |
1759936
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0338-0179-04
|
| Hospital Charge Code |
1759936
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
1771306
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0338-0221-04
|
| Hospital Charge Code |
1771306
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7703-00
|
| Hospital Charge Code |
1771035
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7707-00
|
| Hospital Charge Code |
1759610
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264-7707-00
|
| Hospital Charge Code |
1759610
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELETRIPTAN 20 MG TABLET [34683]
|
Facility
|
IP
|
$92.31
|
|
|
Service Code
|
NDC 0049-2330-45
|
| Hospital Charge Code |
1710964
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.15 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Blue Shield of California Commercial |
$65.72
|
| Rate for Payer: Blue Shield of California EPN |
$47.26
|
| Rate for Payer: Cash Price |
$41.54
|
| Rate for Payer: Cigna of CA HMO |
$64.62
|
| Rate for Payer: Cigna of CA PPO |
$64.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.92
|
| Rate for Payer: Galaxy Health WC |
$78.46
|
| Rate for Payer: Global Benefits Group Commercial |
$55.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.15
|
| Rate for Payer: Multiplan Commercial |
$73.85
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$78.46
|
|
|
ELETRIPTAN 20 MG TABLET [34683]
|
Facility
|
OP
|
$92.31
|
|
|
Service Code
|
NDC 0049-2330-45
|
| Hospital Charge Code |
1710964
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.15 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$60.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$78.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$50.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.00
|
| Rate for Payer: Blue Distinction Transplant |
$55.39
|
| Rate for Payer: Blue Shield of California Commercial |
$68.03
|
| Rate for Payer: Blue Shield of California EPN |
$53.91
|
| Rate for Payer: Cash Price |
$41.54
|
| Rate for Payer: Cigna of CA HMO |
$64.62
|
| Rate for Payer: Cigna of CA PPO |
$64.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.46
|
| Rate for Payer: Dignity Health Media |
$78.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$78.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.92
|
| Rate for Payer: Galaxy Health WC |
$78.46
|
| Rate for Payer: Global Benefits Group Commercial |
$55.39
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$69.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.15
|
| Rate for Payer: Multiplan Commercial |
$73.85
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$78.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$55.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$55.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$46.16
|
| Rate for Payer: United Healthcare All Other HMO |
$46.16
|
| Rate for Payer: United Healthcare HMO Rider |
$46.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$46.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$78.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$78.46
|
| Rate for Payer: Vantage Medical Group Senior |
$78.46
|
|
|
ELETRIPTAN 40 MG TABLET [34684]
|
Facility
|
IP
|
$92.31
|
|
|
Service Code
|
NDC 0049-2340-45
|
| Hospital Charge Code |
1711914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.15 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Blue Shield of California Commercial |
$65.72
|
| Rate for Payer: Blue Shield of California EPN |
$47.26
|
| Rate for Payer: Cash Price |
$41.54
|
| Rate for Payer: Cigna of CA HMO |
$64.62
|
| Rate for Payer: Cigna of CA PPO |
$64.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.92
|
| Rate for Payer: Galaxy Health WC |
$78.46
|
| Rate for Payer: Global Benefits Group Commercial |
$55.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.15
|
| Rate for Payer: Multiplan Commercial |
$73.85
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$78.46
|
|
|
ELETRIPTAN 40 MG TABLET [34684]
|
Facility
|
OP
|
$92.31
|
|
|
Service Code
|
NDC 0049-2340-45
|
| Hospital Charge Code |
1711914
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.15 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$60.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$78.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$50.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.00
|
| Rate for Payer: Blue Distinction Transplant |
$55.39
|
| Rate for Payer: Blue Shield of California Commercial |
$68.03
|
| Rate for Payer: Blue Shield of California EPN |
$53.91
|
| Rate for Payer: Cash Price |
$41.54
|
| Rate for Payer: Cigna of CA HMO |
$64.62
|
| Rate for Payer: Cigna of CA PPO |
$64.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.46
|
| Rate for Payer: Dignity Health Media |
$78.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$78.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.92
|
| Rate for Payer: Galaxy Health WC |
$78.46
|
| Rate for Payer: Global Benefits Group Commercial |
$55.39
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$69.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.15
|
| Rate for Payer: Multiplan Commercial |
$73.85
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$78.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$55.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$55.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$46.16
|
| Rate for Payer: United Healthcare All Other HMO |
$46.16
|
| Rate for Payer: United Healthcare HMO Rider |
$46.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$46.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$78.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$78.46
|
| Rate for Payer: Vantage Medical Group Senior |
$78.46
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
IP
|
$2,573.28
|
|
|
Service Code
|
NDC 0003-2291-11
|
| Hospital Charge Code |
ERX212322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$617.59 |
| Max. Negotiated Rate |
$2,187.29 |
| Rate for Payer: Blue Shield of California Commercial |
$1,832.18
|
| Rate for Payer: Blue Shield of California EPN |
$1,317.52
|
| Rate for Payer: Cash Price |
$1,157.98
|
| Rate for Payer: Cigna of CA HMO |
$1,801.30
|
| Rate for Payer: Cigna of CA PPO |
$1,801.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,029.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,029.31
|
| Rate for Payer: Galaxy Health WC |
$2,187.29
|
| Rate for Payer: Global Benefits Group Commercial |
$1,543.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,716.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$980.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$617.59
|
| Rate for Payer: Multiplan Commercial |
$2,058.62
|
| Rate for Payer: Networks By Design Commercial |
$1,286.64
|
| Rate for Payer: Prime Health Services Commercial |
$2,187.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$971.67
|
| Rate for Payer: United Healthcare All Other HMO |
$949.03
|
| Rate for Payer: United Healthcare HMO Rider |
$928.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$849.18
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION [212322]
|
Facility
|
OP
|
$2,573.28
|
|
|
Service Code
|
NDC 0003-2291-11
|
| Hospital Charge Code |
ERX212322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$617.59 |
| Max. Negotiated Rate |
$2,187.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,687.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,187.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,415.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,415.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,533.16
|
| Rate for Payer: Blue Distinction Transplant |
$1,543.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1,896.51
|
| Rate for Payer: Blue Shield of California EPN |
$1,502.80
|
| Rate for Payer: Cash Price |
$1,157.98
|
| Rate for Payer: Cigna of CA HMO |
$1,801.30
|
| Rate for Payer: Cigna of CA PPO |
$1,801.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,187.29
|
| Rate for Payer: Dignity Health Media |
$2,187.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,187.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,029.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,029.31
|
| Rate for Payer: Galaxy Health WC |
$2,187.29
|
| Rate for Payer: Global Benefits Group Commercial |
$1,543.97
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,929.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,716.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$980.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$617.59
|
| Rate for Payer: Multiplan Commercial |
$2,058.62
|
| Rate for Payer: Networks By Design Commercial |
$1,286.64
|
| Rate for Payer: Prime Health Services Commercial |
$2,187.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,543.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,543.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,286.64
|
| Rate for Payer: United Healthcare All Other HMO |
$1,286.64
|
| Rate for Payer: United Healthcare HMO Rider |
$1,286.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,286.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,187.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,187.29
|
| Rate for Payer: Vantage Medical Group Senior |
$2,187.29
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
OP
|
$3,431.02
|
|
|
Service Code
|
CPT J9176
|
| Hospital Charge Code |
ERX212323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$2,916.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.57
|
| Rate for Payer: Blue Distinction Transplant |
$2,058.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2,528.66
|
| Rate for Payer: Blue Shield of California EPN |
$7.77
|
| Rate for Payer: Cash Price |
$1,543.96
|
| Rate for Payer: Cash Price |
$1,543.96
|
| Rate for Payer: Cigna of CA HMO |
$2,401.71
|
| Rate for Payer: Cigna of CA PPO |
$2,401.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.07
|
| Rate for Payer: Dignity Health Media |
$7.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.38
|
| Rate for Payer: Galaxy Health WC |
$2,916.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2,058.61
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,573.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.10
|
| Rate for Payer: Heritage Provider Network Transplant |
$12.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$11.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,288.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$823.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.89
|
| Rate for Payer: Multiplan Commercial |
$2,744.82
|
| Rate for Payer: Networks By Design Commercial |
$1,715.51
|
| Rate for Payer: Prime Health Services Commercial |
$2,916.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,058.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,058.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,715.51
|
| Rate for Payer: United Healthcare All Other HMO |
$1,715.51
|
| Rate for Payer: United Healthcare HMO Rider |
$1,715.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,715.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.12
|
| Rate for Payer: Vantage Medical Group Senior |
$7.38
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION [212323]
|
Facility
|
IP
|
$3,431.02
|
|
|
Service Code
|
CPT J9176
|
| Hospital Charge Code |
ERX212323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$823.44 |
| Max. Negotiated Rate |
$2,916.37 |
| Rate for Payer: Blue Shield of California Commercial |
$2,442.89
|
| Rate for Payer: Blue Shield of California EPN |
$1,756.68
|
| Rate for Payer: Cash Price |
$1,543.96
|
| Rate for Payer: Cigna of CA HMO |
$2,401.71
|
| Rate for Payer: Cigna of CA PPO |
$2,401.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,372.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,372.41
|
| Rate for Payer: Galaxy Health WC |
$2,916.37
|
| Rate for Payer: Global Benefits Group Commercial |
$2,058.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,288.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,307.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$823.44
|
| Rate for Payer: Multiplan Commercial |
$2,744.82
|
| Rate for Payer: Networks By Design Commercial |
$1,715.51
|
| Rate for Payer: Prime Health Services Commercial |
$2,916.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,295.55
|
| Rate for Payer: United Healthcare All Other HMO |
$1,265.36
|
| Rate for Payer: United Healthcare HMO Rider |
$1,237.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,132.24
|
|
|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
OP
|
$268.39
|
|
|
Service Code
|
NDC 0078-0685-15
|
| Hospital Charge Code |
ERX94579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.41 |
| Max. Negotiated Rate |
$228.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$176.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$147.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$159.91
|
| Rate for Payer: Blue Distinction Transplant |
$161.03
|
| Rate for Payer: Blue Shield of California Commercial |
$197.80
|
| Rate for Payer: Blue Shield of California EPN |
$156.74
|
| Rate for Payer: Cash Price |
$120.78
|
| Rate for Payer: Cigna of CA HMO |
$187.87
|
| Rate for Payer: Cigna of CA PPO |
$187.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.13
|
| Rate for Payer: Dignity Health Media |
$228.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$107.36
|
| Rate for Payer: Galaxy Health WC |
$228.13
|
| Rate for Payer: Global Benefits Group Commercial |
$161.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$201.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.41
|
| Rate for Payer: Multiplan Commercial |
$214.71
|
| Rate for Payer: Networks By Design Commercial |
$174.45
|
| Rate for Payer: Prime Health Services Commercial |
$228.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$161.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$161.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.20
|
| Rate for Payer: United Healthcare All Other HMO |
$134.20
|
| Rate for Payer: United Healthcare HMO Rider |
$134.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.13
|
| Rate for Payer: Vantage Medical Group Senior |
$228.13
|
|
