|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$8,496.65
|
|
|
Service Code
|
APR-DRG 0821
|
| Min. Negotiated Rate |
$6,517.82 |
| Max. Negotiated Rate |
$8,496.65 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,517.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,496.65
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$15,195.00
|
|
|
Service Code
|
APR-DRG 0823
|
| Min. Negotiated Rate |
$11,656.17 |
| Max. Negotiated Rate |
$15,195.00 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,656.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,195.00
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$10,440.37
|
|
|
Service Code
|
APR-DRG 0822
|
| Min. Negotiated Rate |
$8,008.86 |
| Max. Negotiated Rate |
$10,440.37 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,008.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,440.37
|
|
|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$30,021.14
|
|
|
Service Code
|
APR-DRG 0824
|
| Min. Negotiated Rate |
$23,029.37 |
| Max. Negotiated Rate |
$30,021.14 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23,029.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30,021.14
|
|
|
EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET [39221]
|
Facility
|
IP
|
$13.67
|
|
|
Service Code
|
NDC 66582-312-31
|
| Hospital Charge Code |
1710951
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.62 |
| Rate for Payer: Blue Shield of California Commercial |
$9.73
|
| Rate for Payer: Blue Shield of California EPN |
$7.00
|
| Rate for Payer: Cash Price |
$6.15
|
| Rate for Payer: Cigna of CA HMO |
$9.57
|
| Rate for Payer: Cigna of CA PPO |
$9.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.47
|
| Rate for Payer: Galaxy Health WC |
$11.62
|
| Rate for Payer: Global Benefits Group Commercial |
$8.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.28
|
| Rate for Payer: Multiplan Commercial |
$10.94
|
| Rate for Payer: Networks By Design Commercial |
$8.89
|
| Rate for Payer: Prime Health Services Commercial |
$11.62
|
|
|
EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET [39221]
|
Facility
|
OP
|
$13.67
|
|
|
Service Code
|
NDC 66582-312-31
|
| Hospital Charge Code |
1710951
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$11.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.14
|
| Rate for Payer: Blue Distinction Transplant |
$8.20
|
| Rate for Payer: Blue Shield of California Commercial |
$10.07
|
| Rate for Payer: Blue Shield of California EPN |
$7.98
|
| Rate for Payer: Cash Price |
$6.15
|
| Rate for Payer: Cigna of CA HMO |
$9.57
|
| Rate for Payer: Cigna of CA PPO |
$9.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.62
|
| Rate for Payer: Dignity Health Media |
$11.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.47
|
| Rate for Payer: Galaxy Health WC |
$11.62
|
| Rate for Payer: Global Benefits Group Commercial |
$8.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.28
|
| Rate for Payer: Multiplan Commercial |
$10.94
|
| Rate for Payer: Networks By Design Commercial |
$8.89
|
| Rate for Payer: Prime Health Services Commercial |
$11.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.84
|
| Rate for Payer: United Healthcare All Other HMO |
$6.84
|
| Rate for Payer: United Healthcare HMO Rider |
$6.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.62
|
| Rate for Payer: Vantage Medical Group Senior |
$11.62
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| 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 |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Distinction Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| 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 Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| 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
|
| 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
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 0781-5690-31
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 0781-5690-31
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Distinction Transplant |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Media |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
EZETIMIBE 10 MG TABLET [34153]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 59651-052-30
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| 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 |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| 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 Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| 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
|
| 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
|
$0.37
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| 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: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| 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
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 59651-052-30
|
| Hospital Charge Code |
1712290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| 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: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| 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
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$19,752.80
|
|
|
Service Code
|
APR-DRG 0921
|
| Min. Negotiated Rate |
$15,152.48 |
| Max. Negotiated Rate |
$19,752.80 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,152.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19,752.80
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$25,431.42
|
|
|
Service Code
|
APR-DRG 0922
|
| Min. Negotiated Rate |
$19,508.58 |
| Max. Negotiated Rate |
$25,431.42 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,508.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25,431.42
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$39,869.16
|
|
|
Service Code
|
APR-DRG 0923
|
| Min. Negotiated Rate |
$30,583.84 |
| Max. Negotiated Rate |
$39,869.16 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30,583.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39,869.16
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$76,680.86
|
|
|
Service Code
|
APR-DRG 0924
|
| Min. Negotiated Rate |
$58,822.30 |
| Max. Negotiated Rate |
$76,680.86 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58,822.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76,680.86
|
|
|
FAMCICLOVIR 500 MG TABLET [13358]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-95
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.41
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.92
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.05
|
| 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 60687-103-95
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.34 |
| 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 |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.64
|
| Rate for Payer: Blue Distinction Transplant |
$1.65
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.92
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.34
|
| Rate for Payer: Dignity Health Media |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.05
|
| 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
|
| 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 31722-708-30
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| 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 |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Distinction Transplant |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| 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 Media |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| 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
|
| 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 60687-103-25
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.41
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.92
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.05
|
| 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 31722-708-30
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| 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: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| 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
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 33342-026-07
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| 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 |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Distinction Transplant |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| 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 Media |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| 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
|
| 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
|
$1.40
|
|
|
Service Code
|
NDC 33342-026-07
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| 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: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| 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
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 60687-103-25
|
| Hospital Charge Code |
1711642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.34 |
| 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 |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.64
|
| Rate for Payer: Blue Distinction Transplant |
$1.65
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO |
$1.92
|
| Rate for Payer: Cigna of CA PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.34
|
| Rate for Payer: Dignity Health Media |
$2.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$2.34
|
| Rate for Payer: Global Benefits Group Commercial |
$1.65
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.05
|
| 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
|
| 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
|
|
|
FAMOTIDINE 10 MG/ML INJECTION. [4081320]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
CPT S0028
|
| Hospital Charge Code |
1768064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| Rate for Payer: Blue Distinction Transplant |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.38
|
| Rate for Payer: Cigna of CA PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Media |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.46
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
