|
EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE
|
Facility
|
IP
|
$184,715.98
|
|
|
Service Code
|
MSDRG 790
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$184,715.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$180,183.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$184,715.98
|
| Rate for Payer: EPIC Health Plan Senior |
$123,143.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$111,949.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$156,728.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$150,011.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,809.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,601.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$11,336.16
|
|
|
Service Code
|
APR-DRG 0821
|
| Min. Negotiated Rate |
$9,054.01 |
| Max. Negotiated Rate |
$11,336.16 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,054.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,336.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,142.88
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$20,831.47
|
|
|
Service Code
|
APR-DRG 0823
|
| Min. Negotiated Rate |
$16,637.76 |
| Max. Negotiated Rate |
$20,831.47 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,637.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20,831.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18,638.68
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$14,805.81
|
|
|
Service Code
|
APR-DRG 0822
|
| Min. Negotiated Rate |
$11,825.16 |
| Max. Negotiated Rate |
$14,805.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,825.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14,805.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13,247.30
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$46,654.69
|
|
|
Service Code
|
APR-DRG 0824
|
| Min. Negotiated Rate |
$37,262.36 |
| Max. Negotiated Rate |
$46,654.69 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37,262.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$46,654.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41,743.67
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 6787749030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 5965105230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 5965105290
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 5965105230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 5965105290
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 6787749030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$130,281.33
|
|
|
Service Code
|
APR-DRG 0924
|
| Min. Negotiated Rate |
$104,053.64 |
| Max. Negotiated Rate |
$130,281.33 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$104,053.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$130,281.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$116,567.50
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$54,366.81
|
|
|
Service Code
|
APR-DRG 0923
|
| Min. Negotiated Rate |
$43,421.91 |
| Max. Negotiated Rate |
$54,366.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$43,421.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$54,366.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48,643.99
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$36,306.17
|
|
|
Service Code
|
APR-DRG 0922
|
| Min. Negotiated Rate |
$28,997.16 |
| Max. Negotiated Rate |
$36,306.17 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$28,997.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$36,306.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32,484.47
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$28,673.51
|
|
|
Service Code
|
APR-DRG 0921
|
| Min. Negotiated Rate |
$22,901.08 |
| Max. Negotiated Rate |
$28,673.51 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22,901.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28,673.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25,655.24
|
|
|
FACTOR XIII 1,000 UNIT-1,600 UNIT INTRAVENOUS SOLUTION [108721]
|
Facility
|
IP
|
$15.95
|
|
|
Service Code
|
HCPCS J7180
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$13.56 |
| Rate for Payer: United Healthcare HMO Rider |
$5.70
|
| Rate for Payer: Adventist Health Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$12.27
|
| Rate for Payer: Blue Shield of California Commercial |
$8.09
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Cigna of CA HMO |
$11.16
|
| Rate for Payer: Cigna of CA PPO |
$11.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.38
|
| Rate for Payer: EPIC Health Plan Senior |
$6.38
|
| Rate for Payer: Galaxy Health WC |
$13.56
|
| Rate for Payer: Global Benefits Group Commercial |
$9.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$12.76
|
| Rate for Payer: Networks By Design Commercial |
$7.97
|
| Rate for Payer: Prime Health Services Commercial |
$13.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.99
|
| Rate for Payer: United Healthcare All Other HMO |
$5.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.22
|
|
|
FACTOR XIII 1,000 UNIT-1,600 UNIT INTRAVENOUS SOLUTION [108721]
|
Facility
|
OP
|
$15.95
|
|
|
Service Code
|
HCPCS J7180
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$65.88 |
| Rate for Payer: Adventist Health Commercial |
$3.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$65.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.87
|
| Rate for Payer: Blue Shield of California Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Cigna of CA HMO |
$11.16
|
| Rate for Payer: Cigna of CA PPO |
$11.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.55
|
| Rate for Payer: EPIC Health Plan Senior |
$12.36
|
| Rate for Payer: Galaxy Health WC |
$13.56
|
| Rate for Payer: Global Benefits Group Commercial |
$9.57
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$18.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.06
|
| Rate for Payer: Multiplan Commercial |
$12.76
|
| Rate for Payer: Networks By Design Commercial |
$7.97
|
| Rate for Payer: Prime Health Services Commercial |
$13.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.99
|
| Rate for Payer: United Healthcare All Other HMO |
$5.83
|
| Rate for Payer: United Healthcare HMO Rider |
$5.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.22
|
| Rate for Payer: Upland Medical Group Pediatric |
$11.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.36
|
| Rate for Payer: Vantage Medical Group Senior |
$12.36
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 6068710395
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.76
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.93
|
| Rate for Payer: Cigna of CA PPO |
$1.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Senior |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$2.20
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$2.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.38
|
| Rate for Payer: United Healthcare All Other HMO |
$1.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2.34
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 3334202607
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 3172270830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 6068710395
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.93
|
| Rate for Payer: Cigna of CA PPO |
$1.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Senior |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.20
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$2.34
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 6068710325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.76
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.93
|
| Rate for Payer: Cigna of CA PPO |
$1.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Senior |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$2.20
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$2.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.38
|
| Rate for Payer: United Healthcare All Other HMO |
$1.38
|
| Rate for Payer: United Healthcare HMO Rider |
$1.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2.34
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 3172270830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 6068710325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.93
|
| Rate for Payer: Cigna of CA PPO |
$1.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Senior |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.20
|
| Rate for Payer: Networks By Design Commercial |
$1.79
|
| Rate for Payer: Prime Health Services Commercial |
$2.34
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 3334202607
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
|
