|
ELTROMBOPAG OLAMINE 25 MG TABLET [94579]
|
Facility
|
IP
|
$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: Blue Shield of California Commercial |
$191.09
|
| Rate for Payer: Blue Shield of California EPN |
$137.42
|
| 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: EPIC Health Plan Commercial |
$107.36
|
| Rate for Payer: Galaxy Health WC |
$228.13
|
| Rate for Payer: Global Benefits Group Commercial |
$161.03
|
| 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
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
IP
|
$485.71
|
|
|
Service Code
|
NDC 0078-0686-15
|
| Hospital Charge Code |
ERX94580
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.57 |
| Max. Negotiated Rate |
$412.85 |
| Rate for Payer: Blue Shield of California Commercial |
$345.83
|
| Rate for Payer: Blue Shield of California EPN |
$248.68
|
| Rate for Payer: Cash Price |
$218.57
|
| Rate for Payer: Cigna of CA HMO |
$340.00
|
| Rate for Payer: Cigna of CA PPO |
$340.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$194.28
|
| Rate for Payer: Galaxy Health WC |
$412.85
|
| Rate for Payer: Global Benefits Group Commercial |
$291.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$323.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$185.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.57
|
| Rate for Payer: Multiplan Commercial |
$388.57
|
| Rate for Payer: Networks By Design Commercial |
$315.71
|
| Rate for Payer: Prime Health Services Commercial |
$412.85
|
|
|
ELTROMBOPAG OLAMINE 50 MG TABLET [94580]
|
Facility
|
OP
|
$485.71
|
|
|
Service Code
|
NDC 0078-0686-15
|
| Hospital Charge Code |
ERX94580
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$116.57 |
| Max. Negotiated Rate |
$412.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$318.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$412.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$267.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$267.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$289.39
|
| Rate for Payer: Blue Distinction Transplant |
$291.43
|
| Rate for Payer: Blue Shield of California Commercial |
$357.97
|
| Rate for Payer: Blue Shield of California EPN |
$283.65
|
| Rate for Payer: Cash Price |
$218.57
|
| Rate for Payer: Cigna of CA HMO |
$340.00
|
| Rate for Payer: Cigna of CA PPO |
$340.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$412.85
|
| Rate for Payer: Dignity Health Media |
$412.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$412.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$194.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$194.28
|
| Rate for Payer: Galaxy Health WC |
$412.85
|
| Rate for Payer: Global Benefits Group Commercial |
$291.43
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$364.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$323.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$185.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$116.57
|
| Rate for Payer: Multiplan Commercial |
$388.57
|
| Rate for Payer: Networks By Design Commercial |
$315.71
|
| Rate for Payer: Prime Health Services Commercial |
$412.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$291.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$291.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$242.86
|
| Rate for Payer: United Healthcare All Other HMO |
$242.86
|
| Rate for Payer: United Healthcare HMO Rider |
$242.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$242.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$412.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$412.85
|
| Rate for Payer: Vantage Medical Group Senior |
$412.85
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
IP
|
$2,026.21
|
|
|
Service Code
|
CPT J9210
|
| Hospital Charge Code |
NDG223872A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$486.29 |
| Max. Negotiated Rate |
$1,722.28 |
| Rate for Payer: Blue Shield of California Commercial |
$1,442.66
|
| Rate for Payer: Blue Shield of California EPN |
$1,037.42
|
| Rate for Payer: Cash Price |
$911.79
|
| Rate for Payer: Cigna of CA HMO |
$1,418.35
|
| Rate for Payer: Cigna of CA PPO |
$1,418.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$810.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$810.48
|
| Rate for Payer: Galaxy Health WC |
$1,722.28
|
| Rate for Payer: Global Benefits Group Commercial |
$1,215.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,351.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$771.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$486.29
|
| Rate for Payer: Multiplan Commercial |
$1,620.97
|
| Rate for Payer: Networks By Design Commercial |
$1,013.10
|
| Rate for Payer: Prime Health Services Commercial |
$1,722.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$765.10
|
| Rate for Payer: United Healthcare All Other HMO |
$747.27
|
| Rate for Payer: United Healthcare HMO Rider |
$731.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$668.65
|
|
|
EMAPALUMAB-LZSG 5 MG/ML INTRAVENOUS SOLUTION [223872]
|
Facility
|
OP
|
$2,026.21
|
|
|
Service Code
|
CPT J9210
|
| Hospital Charge Code |
NDG223872A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$375.66 |
| Max. Negotiated Rate |
$2,362.66 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,362.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$469.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$413.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$413.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$719.81
|
| Rate for Payer: Blue Distinction Transplant |
$1,215.73
|
| Rate for Payer: Blue Shield of California Commercial |
$1,493.32
|
| Rate for Payer: Blue Shield of California EPN |
$405.24
|
| Rate for Payer: Cash Price |
$911.79
|
| Rate for Payer: Cash Price |
$911.79
|
| Rate for Payer: Cigna of CA HMO |
$1,418.35
|
| Rate for Payer: Cigna of CA PPO |
$1,418.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$469.57
|
| Rate for Payer: Dignity Health Media |
$413.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$413.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$507.14
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$375.66
|
| Rate for Payer: EPIC Health Plan Transplant |
$375.66
|
| Rate for Payer: Galaxy Health WC |
$1,722.28
|
| Rate for Payer: Global Benefits Group Commercial |
$1,215.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,519.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$616.08
|
| Rate for Payer: Heritage Provider Network Transplant |
$616.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$608.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$608.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$375.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,351.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$722.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$375.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$486.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$473.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$503.38
|
| Rate for Payer: Multiplan Commercial |
$1,620.97
|
| Rate for Payer: Networks By Design Commercial |
$1,013.10
|
| Rate for Payer: Prime Health Services Commercial |
$1,722.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,215.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,215.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,013.10
|
| Rate for Payer: United Healthcare All Other HMO |
$1,013.10
|
| Rate for Payer: United Healthcare HMO Rider |
$1,013.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,013.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$469.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$413.22
|
| Rate for Payer: Vantage Medical Group Senior |
$413.22
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 0187-5110-45
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Blue Distinction Transplant |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.93
|
| Rate for Payer: Cigna of CA PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.13
|
| Rate for Payer: Dignity Health Media |
$1.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.53
|
| Rate for Payer: Galaxy Health WC |
$1.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
| Rate for Payer: Networks By Design Commercial |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$1.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| 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 |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Distinction Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| 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 Media |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| 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
|
| 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.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
NDC 0187-5110-45
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.93
|
| Rate for Payer: Cigna of CA PPO |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Galaxy Health WC |
$1.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
| Rate for Payer: Networks By Design Commercial |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$1.13
|
|
|
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION [42944]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 5898096012
|
| Hospital Charge Code |
1743698
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| 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: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| 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.69 TOPICAL CREAM [196535]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
NDG196535A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$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: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| 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
|
|
|
EMOLLIENT COMBINATION NO.69 TOPICAL CREAM [196535]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 7214063378
|
| Hospital Charge Code |
NDG196535A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$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 Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| 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
|
| 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
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 98193-00005
|
| Hospital Charge Code |
NDG4080770B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Blue Shield of California Commercial |
$3.37
|
| Rate for Payer: Blue Shield of California EPN |
$2.42
|
| 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: EPIC Health Plan Commercial |
$1.89
|
| Rate for Payer: Galaxy Health WC |
$4.02
|
| Rate for Payer: Global Benefits Group Commercial |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| 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 9994-0807-70
|
| Hospital Charge Code |
1743584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$2.86 |
| 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 |
$1.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.00
|
| Rate for Payer: Blue Distinction Transplant |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.96
|
| 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 Media |
$2.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| 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
|
| 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
|
$35.74
|
|
|
Service Code
|
NDC 98193-000-17
|
| Hospital Charge Code |
NDG4080770
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$30.38 |
| Rate for Payer: Blue Shield of California Commercial |
$25.45
|
| Rate for Payer: Blue Shield of California EPN |
$18.30
|
| 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: EPIC Health Plan Commercial |
$14.30
|
| Rate for Payer: Galaxy Health WC |
$30.38
|
| Rate for Payer: Global Benefits Group Commercial |
$21.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.62
|
| 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
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 99408-770-02
|
| Hospital Charge Code |
1743780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.34 |
| 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 |
$2.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.04
|
| Rate for Payer: Blue Distinction Transplant |
$3.07
|
| Rate for Payer: Blue Shield of California Commercial |
$3.77
|
| Rate for Payer: Blue Shield of California EPN |
$2.98
|
| 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 Media |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| 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
|
| 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
|
$3.36
|
|
|
Service Code
|
NDC 9994-0807-70
|
| Hospital Charge Code |
1743584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.72
|
| 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: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: Galaxy Health WC |
$2.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.28
|
| 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
|
$4.73
|
|
|
Service Code
|
NDC 98193-00005
|
| Hospital Charge Code |
NDG4080770B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.02 |
| 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 |
$2.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.82
|
| Rate for Payer: Blue Distinction Transplant |
$2.84
|
| Rate for Payer: Blue Shield of California Commercial |
$3.49
|
| Rate for Payer: Blue Shield of California EPN |
$2.76
|
| 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 Media |
$4.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.89
|
| Rate for Payer: Galaxy Health WC |
$4.02
|
| Rate for Payer: Global Benefits Group Commercial |
$2.84
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| 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
|
| 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 |
$2.36
|
| Rate for Payer: United Healthcare All Other HMO |
$2.36
|
| Rate for Payer: United Healthcare HMO Rider |
$2.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.36
|
| 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
|
|
|
EMOLLIENTS BAG BALM OINTMENT [4080770]
|
Facility
|
OP
|
$35.74
|
|
|
Service Code
|
NDC 98193-000-17
|
| Hospital Charge Code |
NDG4080770
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$30.38 |
| 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 |
$19.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.29
|
| Rate for Payer: Blue Distinction Transplant |
$21.44
|
| Rate for Payer: Blue Shield of California Commercial |
$26.34
|
| Rate for Payer: Blue Shield of California EPN |
$20.87
|
| 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 Media |
$30.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.30
|
| Rate for Payer: Galaxy Health WC |
$30.38
|
| Rate for Payer: Global Benefits Group Commercial |
$21.44
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$26.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$23.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.62
|
| 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
|
| 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
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 99408-770-02
|
| Hospital Charge Code |
1743780
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Blue Shield of California Commercial |
$3.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.62
|
| 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: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$4.34
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| 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
|
|
|
EMTRICITABINE 200 MG CAPSULE [36252]
|
Facility
|
IP
|
$18.54
|
|
|
Service Code
|
NDC 69097-642-02
|
| Hospital Charge Code |
1711928
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$15.76 |
| Rate for Payer: Blue Shield of California Commercial |
$13.20
|
| Rate for Payer: Blue Shield of California EPN |
$9.49
|
| 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: EPIC Health Plan Commercial |
$7.42
|
| Rate for Payer: Galaxy Health WC |
$15.76
|
| Rate for Payer: Global Benefits Group Commercial |
$11.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.06
|
| 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
|
|
|
EMTRICITABINE 200 MG CAPSULE [36252]
|
Facility
|
OP
|
$18.54
|
|
|
Service Code
|
NDC 69097-642-02
|
| Hospital Charge Code |
1711928
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$15.76 |
| 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 |
$10.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.05
|
| Rate for Payer: Blue Distinction Transplant |
$11.12
|
| Rate for Payer: Blue Shield of California Commercial |
$13.66
|
| Rate for Payer: Blue Shield of California EPN |
$10.83
|
| 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 Media |
$15.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.42
|
| Rate for Payer: Galaxy Health WC |
$15.76
|
| Rate for Payer: Global Benefits Group Commercial |
$11.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$13.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.06
|
| 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
|
| 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-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET [214124]
|
Facility
|
OP
|
$86.37
|
|
|
Service Code
|
NDC 61958-2002-1
|
| Hospital Charge Code |
ERX214124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.73 |
| Max. Negotiated Rate |
$73.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$56.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$73.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$51.46
|
| Rate for Payer: Blue Distinction Transplant |
$51.82
|
| Rate for Payer: Blue Shield of California Commercial |
$63.65
|
| Rate for Payer: Blue Shield of California EPN |
$50.44
|
| Rate for Payer: Cash Price |
$38.87
|
| Rate for Payer: Cigna of CA HMO |
$60.46
|
| Rate for Payer: Cigna of CA PPO |
$60.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$73.41
|
| Rate for Payer: Dignity Health Media |
$73.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$73.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$34.55
|
| Rate for Payer: Galaxy Health WC |
$73.41
|
| Rate for Payer: Global Benefits Group Commercial |
$51.82
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$64.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$57.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.73
|
| Rate for Payer: Multiplan Commercial |
$69.10
|
| Rate for Payer: Networks By Design Commercial |
$56.14
|
| Rate for Payer: Prime Health Services Commercial |
$73.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$51.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$51.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.18
|
| Rate for Payer: United Healthcare All Other HMO |
$43.18
|
| Rate for Payer: United Healthcare HMO Rider |
$43.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$43.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$73.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$73.41
|
| Rate for Payer: Vantage Medical Group Senior |
$73.41
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET [214124]
|
Facility
|
IP
|
$86.37
|
|
|
Service Code
|
NDC 61958-2002-1
|
| Hospital Charge Code |
ERX214124
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.73 |
| Max. Negotiated Rate |
$73.41 |
| Rate for Payer: Blue Shield of California Commercial |
$61.50
|
| Rate for Payer: Blue Shield of California EPN |
$44.22
|
| Rate for Payer: Cash Price |
$38.87
|
| Rate for Payer: Cigna of CA HMO |
$60.46
|
| Rate for Payer: Cigna of CA PPO |
$60.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.55
|
| Rate for Payer: Galaxy Health WC |
$73.41
|
| Rate for Payer: Global Benefits Group Commercial |
$51.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$57.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.73
|
| Rate for Payer: Multiplan Commercial |
$69.10
|
| Rate for Payer: Networks By Design Commercial |
$56.14
|
| Rate for Payer: Prime Health Services Commercial |
$73.41
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [39255]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
CPT J0750
|
| Hospital Charge Code |
1710978
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: Blue Distinction Transplant |
$0.60
|
| Rate for Payer: Blue Distinction Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Media |
$0.85
|
| Rate for Payer: Dignity Health Media |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.40
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.75
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Networks By Design Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.50
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.85
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [39255]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
CPT J0750
|
| Hospital Charge Code |
1710978
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Global Benefits Group Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
|
